Therefore, I’d guess that you are a keen observer and you notice how other people’s actions relate to you. An example might include noticing that other people are laughing and then wondering if maybe they are laughing at you. Also, higher scores on scale 6 are associated with intelligence. So your high score here might mean that on your good days, you are intelligent and sensitive, but on your bad days, days when you’re experiencing lots of stress, you can become touchy and suspicious of others. Does any of this seem to ?t how you see yourself ?” Perhaps more important than the speci?c scores obtained by young clients who complete such questionnaires is the manner in which the tests are administered and feedback is provided. Openness with young clients regarding the purpose of formal assessment procedures and results can facilitate the development of trust. Because assessment procedures, depending on how they are used, can either interfere with or facilitate trust development, select speci?c procedures carefully and present them to clients in an open and honest manner.

Considerations of when, why, and how to administer formal assessments should be informed by graduate training in appraisal, test construction, and diagnosis. With regard to young people, it is especially important to note that formal assessment can have Interviewing Young Clients 327a strong impact on the therapeutic relationship and often does not yield as much information as you might have hoped.

General Considerations for the Body of the Interview When using play or physically interactive strategies with children, think through stated and/or unstated ground rules and be prepared to set limits that ?t within your theoretical framework. In an assessment situation, the fewer rules, the better, as this allows the child more free expression. However, children often test limits. They try leaving the room, tinkering with items on your desk, opening windows, or even placing a call on your phone. More infrequently, they try mild aggression toward you: poking with a tack, spitting a spitball, swearing, and blowing smoke . Rather than having stated rules covering all such potentials, it is better to be prepared to set ?rm limits as needed. Some theoretical orientations prefer to leave all rules unstated; others suggest the statement of one or two basic rules . The most common rule is usually stated something like this: “Billy, you’re welcome to play with things in my of?ce . We don’t have too many rules about playing here, but it’s important that you know my one basic rule: It is not okay to break things or hurt yourself or anyone else with the toys or the art supplies.” Cleaning up and putting things away is also an assessment activity. It is challenging to keep time boundaries that include cleanup time before moving into the closing few minutes of the interview. Doing so provides information about how the child interacts when play is ending. An abrupt shift in attitude toward the toys or game may occur. The emotions directed at the toys may be an important signal about how the child feels about endings. In addition, note behaviors directed toward you. Does the child refuse to cooperate? Does he or she scurry around, cleaning frantically to impress you? Those few cleanup minutes at the session’s end can be very revealing.

Young clients often express criticism and/or sarcasm when asked to participate in traditional assessment . They may resist completing the instruments fully and thoughtfully. Fortunately, there are alternatives to using formal assessment procedures for obtaining information. The following procedures help interviewers gather information, while at the same time, capture client interest and coop322 Interviewing Special Populations Finally, I have a right to be a child. I shouldn’t have to be your spy, your special con?dant, or your mother. Just because you hate to talk to each other, I shouldn’t have to be your personal message courier. I exist because you created me. Therefore, I have a right to be more than a child of divorce. I have a right to be a child whose parents love me more than they’ve come to hate each other.

Note. From “The Divorced Children’s Bill of Rights” [Guest editorial], by J. SommersFlanagan, 2000, Counseling Today, p. 9. Reprinted with permission from the American Counseling Association.

INDIVIDUAL AND CULTURAL HIGHLIGHT 11.2 eration. Because these techniques can facilitate rapport and trust, they usually have a positive effect on cooperation with and validity of subsequent traditional, self report assessments . Using these qualitative information gathering procedures can increase youth cooperation with therapy and provide the interviewer with assessment information.

They are not a replacement for formal assessment procedures, but add a great deal of information and simultaneously enhance the working relationship.

What’s Good about You? A relationship building assessment procedure that provides a rich interpersonal interaction between young clients and counselors is the “What’s good about you?” question and answer game . The procedure also provides useful information regarding child/adolescent self esteem. Initially, it is introduced as a game with speci?c rules: “I want to play a game with you. Here’s how it goes. I’m going to ask you the same question 10 times. The only rule is that you can’t answer the question with the same answer twice. So, I’ll ask you the same question 10 times, but you have to give me 10 different answers.” When playing this game, interviewers ask their young client, “What’s good about you?” . Each client answer is responded to with a “Thank you” and a smile. If the client responds with “I don’t know,” the response is simply written down the ?rst time it is used; but if “I don’t know” is used a second time, the interviewer kindly reminds the client that answers can be used only one time.

INDIVIDUAL AND CULTURAL HIGHLIGHT 11.2send parents to the waiting room with an assignment or questionnaire . If you need a direct interview with parents, young clients can be given drawing assignments or questionnaires to complete in the waiting room. In most cases, it is useful to spend individual time with an adolescent and then to have parents return for 5 to 10 minutes at the end of the time to review therapy or follow up procedures .

THE BODY After obtaining child and parent versions of problem areas and possible treatment goals, it is time to shift to the body of the interview. Depending on developmental and temperamental factors, children are more or less verbal. Therefore, anyone planning to communicate fully and effectively with children must develop and be comfortable with a wide variety of methods. Textbooks, graduate classes, workshops, and even core emphases in graduate programs focus exclusively on assessment and therapy strategies with children. An effective child interviewer is familiar with principles and procedures far beyond what is included in this brief chapter .

User Friendly Assessment and Information Gathering Strategies The purpose of formal assessment or evaluation procedures is to obtain information about client functioning that may be used to make diagnoses and treatment recommendations and/or facilitate therapy . While many mental health professionals use traditional, formal assessment procedures when interviewing children, many do not.

Those who do not sometimes have negative attitudes toward assessment or view formal assessment as interfering with the therapy process and with understanding the “whole life of the child” rather than narrow diagnostic aspects .

Good:Clients who readily admit to having a problem for which an appropriate treatment is required are considered to have good insight. When appropriate, these clients take personal responsibility for modifying their life situation. They can articulate and use nonphysical treatment approaches with minimal help from the therapist. These clients may even be exceptionally creative in formulating ways to address their illness through nonmedical methods.

WHEN TO USE MENTAL STATUS EXAMINATIONS Formal mental status examinations are not appropriate for all clients. A good basic guideline is: Mental status examinations become more necessary as suspected level of client psychopathology increases. If clients appear well adjusted and you are not working in a medical setting, it is unlikely you will need to conduct a full mental status evaluation. However, if you have questions about diagnosis or client psychopathology and you are working in a medical setting, administration of a formal mental status examination is usually routine. R. Rosenthal and Akiskal state: Some individuals who present for outpatient psychotherapy or counseling can be viewed as having “problems of living.” In such cases, the relevant mental status information can be largely gleaned from a well conducted history taking or intake interview …. On the other hand, if the patient appears to be suffering from signi?cant disturbance of mood, perception, thinking, or memory, a formal Mental Status Examination is in order.

The primary exception to Rosenthal and Akiskal’s advice is the multicultural client. Some practitioners suggest that it is nearly always inappropriate to use a traditional mental status examination with a multicultural client . Individual and Cultural Highlight 8.1 is designed to sensitize you to potentially invalid conclusions you might reach when using mental status exams with culturally diverse clients.

Mandates for medical care fail to recognize non medical considerations of value for the patient, in the practice situation, or for society as a whole. There is nothing about the actual operational concepts of value in medicine which sets them apart from general concepts of value and renders them immune to the relevance of non medical concerns. “Disease management” thus ignores the fact that actual people with diseases have outside lives, and they have more to manage than just their diseases.3. There are guidelines and criteria for establishing diagnoses, and protocols for dealing with diseases, but the more rigorous the diagnostic criteria, the fewer patients get the diagnosis. There are no protocols for patients without a conclusive diagnosis. Exacting therapy and exacting diagnosis require each other, leaving everything inexact in a therapeutic no man’s land. As a result, clinicians have a tendency to force their observations to fit pre existing categories rather than to admit the existence of the doubtful and to deal with it as such.

Measurable endpoints and outcomes are never the only outcomes of interventions. Clinicians, however, find their work judged only by whatever it is popular to measure or scrutinize, i.e., “survival” or “disease free interval.” There are always unmeasured consequences of attaining measurable endpoints. Therefore, whatever is scrutinized and judged “improves.” Whatever is temporarily off the screen is neglected in order to pay attention to the spotlighted disease or problem of the day. This is one consequence of ignoring context in assessing value. No clinical action occurs in a vacuum; yet formal standards assume that this is so. In a 38 bed emergency department some standards for “better” care in beds 2 to yield worse care in beds 20 through 38. No event occurring in the life of a patient gets its value solely by itself. All are valued in relation to the life context, and all affect one another, at least potentially. Healthier sometimes means poorer and it can mean sadder and less productive, whenever health standards are developed in isolation from other measures of well being.

Priorities for the use of resources, including time as a resource are determined on empirical grounds using informal, not formal reasoning.

c. There are multiple, conflicting and partly metaphorical concepts of “disease” and “health,” as I will show in Chapter Two.

d. Disease is undoubtedly a radial category with disputable, peripheral members. Its subcategories are often not discrete. Research on how this category is structured within and across various cultures and value systems is to my knowledge lacking.

A preliminary sketch of the “disease” category in Anglo American culture will also come in Chapter Two.

e. The collaborative work of a patient and a caregiver can produce new values and should produce new knowledge for both in any circumstance which is not routine. No patient encounter can be successfully approached as “routine” for long, because novel discovery and mutuality in dialogue generates most of the benefit in any but the most superficial or purely technical relationship. A caring professional must be one whose values are not impervious and who can actually learn from shared experience with the patient.

f. The caregiver patient relationship is both a means and an end. Some actions need to be evaluated partly by how they affect this relationship, because the efficacy of much subsequent work depends on its strength.

This chapter has used the field of medical care to demonstrate how our everyday operational and common sense uses a deeply embedded yet informal semantic architecture. The topography of categories, the variety of image schemas, the multiplicity of metaphors and the plastic nature of scenarios and narratives provides a rich menu of possible alternatives for reasoning about means and ends. These cognitive structures, as opposed to those of formal logic, grow out of full bodied experience not limited to the manipulation of numbers, symbol strings and propositions. Informal reasoning (the lately despised “clinical judgment”) picks and chooses, but not in an arbitrary way, among these structures to apply them in fluid situations.

In reviewing the broad imagistic and metaphorical structure underlying informal means/ends reasoning in medical care we need to highlight its two great divergences from formal logics. First, it is neither arbitrary, in the way that the axioms of different logical systems as well as the entailment rules can be arbitrary. Nor is it any unique privileged system grounded eternally in a realm of reason and taking no measure of the human. It has grown organically out of our fundamental biological and existential embodiment.

We cannot simply set up rules for understanding and reasoning by fiat, nor have we inherited them for all eternity. While cognitive structures are somewhat flexible, it is not possible to depart radically from existing ones. The basic bodily predicament into which we have been thrown is the only starting point, the only jumping off place from which the rest of experience can make any sense and to which it can be referred. We are incarnated in our ways of thinking and it is from within them, not outside of them, that our degrees of freedom will be found.

But secondly, there are those degrees of freedom. Empirical thinking has slack, redundancy, room for ambiguity and even for multiple changing evaluations. It is loose jointed. Metaphors can be selected for aptness. Narratives can be transformed to become more comprehensive or fulfilling. There are no absolute rules forcing us to ride roughshod over variations and subtleties. Empirical reflection never wholly compartmentalizes experience. Novel concerns can be found relevant to the situation at hand. Such empirical and informal reasoning does more justice to many clinical encounters than do formal rules, which try to treat medicine like chess.

Just as situations must be specified, assigned to categories, and dealt with according to category assignment, there must also be a formula for valuation.

Qualities, it is assumed, can be made quantifiable for evaluation. Values need to be fungible, i.e., measurable in terms of common units. Rational acts are those which maximize (and sometimes fairly distribute as well) these value units. The method of assessing value is predetermined and not subject to transformation through any particular professional encounter or experience.

Formal means/ends reasoning is also disembodied. Except for a defined set of considerations, it is context independent. It is grounded in abstract relations which are mutually self generating in an a priori symbolic realm and have nothing to do with the embodied circumstances of cognizing subjects. Emotions need to get out of the way of formal reasoning. So does contingency.

It happens, though, that for clinical reality to be specified and quantified as is claimed possible, it would need to have semantic elements (units of meaning) which could be related in the terms prescribed by this rational syntax, and causation would need to work for such reasoning much like entailment. In the calculus of economic rationality professional problems are compared to games. Such rationality assumes that we already know what winning and losing are. We must also know our present strategic positions and we must know which considerations are part of the game and what ones are not. Finally, we must know what the rules allow. Only if all this were possible would a “rational actor” be in a position to prove which strategies would maximize the chance of winning.

This distinction has become important in assessing how best to resolve clinical problems in medicine. A useful working distinction between formal and informal reasoning closely follows that of Dewey quoted above, between “formal logic” and “actual thinking.” Then, the main body of the chapter outlines work in linguistics and cognitive science which has identified imaginative structures important for the cognition of means/ends problems. The intent is to show how such structures contribute to our multiple senses of causation, and therefore inform diagnostic and treatment actions.

“FORMAL” AS OPPOSED TO “INFORMAL” APPROACHES TO DECISION MAKING Attempts to standardize work in the professions are ever on the increase. The use of standards, of course, rests upon the identification of commonalities among situations and often, indeed, upon forcing them into common molds. Standardization makes use of relatively formal means/ends reasoning. Formal means/ends reasoning requires not only the universalization of particulars but also the quantification of qualities. The standardization project involves applying one or another variant of economic rationality to decision making. All of the varying formulae, however, make similar assumptions about the nature of entities, relations and categories of entities and relations, as well as similar assumptions about the assessment of value and the rules of reason.

Formal means/ends reasoning demands that particular entities must be classifiable according to their essential features, and that entities having the same essential features can be treated in a protocol as identical. Clinical situations amenable to standardization must be replicable ensembles of such entities which can also be treated as identical. Additionally, outcomes of professional work need to be specifiable ensembles which can be classified and thought of generically.