The CALF interview
Like the Metacognition Assessment Interview (MAI) [
23], the Adult Attachment Interview (AAI), the Psychopathy Checklist [
24], and the Clinical Diagnostic Interview [
25], the CALF is structured, but the interview and interpretation rely primarily on the inference of the underlying processes (contrasts, absence, brevity of explanations, and ability to shift perspectives and to reflect on both emotional, factual and cognitive processes) rather than relying only on the explicit content of the response. The four domains in the LPFS are rated based on the totality of the interview rather than on patient responses to the questions in the corresponding section. For each section, the interviewer has to rate the level of dysfunction by giving a score from 0 to 4, with 0 indicating no impairment and 4 indicating extremely severe impairment.
The CALF opens with questions about general demographics, followed by questions about current problems with mental health and current treatments. The main body of the interview consists of four sections, each of which concerns one of the dimensions in the LPFS, but where some of the questions within each section also provide information on the level of functioning within other domains. Specifically, the CALF prompts patients to talk about the four domains based on their general life situation within the last three to five years.
All sections open with a global question concerning the specific domain, followed by prompts for specific examples and qualifications of the response. All sections conclude with questions about contentment and concerns for the given domain, and whether recent changes, events or periods of higher or lower distress have affected specific areas of functioning within this domain.
Section 1 assesses Self-direction. According to the LPFS, Self-direction concerns the ability to set and pursue realistic and meaningful goals in life. Questions in this section concern the patient’s goals in life, and prompt questions concerning the respondent’s ability to set reasonable goals based on a realistic assessment of personal capacities. Since the pilot testing showed that current life goals may be difficult to evaluate in terms of how realistic they are and how consistently the patient pursues these goals, we included past life goals and how these had been pursued. Following this, the patient is asked about the value and meaning of current and past goals, what has been done to obtain the goals and whether they have been obtained, possible future obstacles, and what the patient can do to overcome these obstacles. Finally, the patient is asked if he or she considers herself to be in control of her life in general, and whether she is satisfied with the goals that he or she is presently pursuing.
Section 2 assesses Intimacy. In the LPFS, Intimacy includes both close relationships and relationships in the community, and is more concerned with the reciprocity and the depth of the relationships than with the size of network of perceived support. In order to identify the degree of reciprocity, this section opens with questions about who the patient sees in daily life and the frequency of contact. Next, the patient is asked to identify a single person who is particularly important and to describe what he or she likes about that person, and then to describe what the other person likes about her. Finally, this section asks about conflicts that have resulted in the discontinuation of social contacts, an area which is also considered in the assessment of the capacity for Empathy.
Section 3 concerns Empathy, which is referred to in the LPFS as the capability to understand and respond adequately to the experiences and motivations of others, and the awareness of how one’s own actions affect others. The section opens with questions about disagreements and who the patient disagrees with. Next, the patient is asked to identify a disagreement with a person, and is asked about the motivations and intentions behind the disagreement (of both those of the patient and the other person), and whether and how the disagreement was resolved. The purpose of these questions is primarily to assess the patient’s capacity for understanding and considering the perspectives and needs of others in a conflict, the ability to understand their reactions, and the ability to learn from disagreements.
Section 4 adds further information concerning the Identity dimension. Usually, responses to the previous sections in the CALF interview are highly salient for the issues covered in the Identity section, because they provide rich information about self-image, self-worth, and the capacity for independent functioning. However, an important aspect of Identity that is not necessarily covered by the previous sections is the patient’s access to and ability to regulate a wide range of emotions. To assess this aspect of Identity, the patient is asked about feelings of sadness, anxiety, anger and pleasure, what triggers these feelings, the intensity and duration of the feeling, and how the patient reacts to the feeling. Finally, the section contains questions about differences between private and public identities.
Statistical analysis
The number of patients included was determined primarily on pragmatic grounds. Hence, a post hoc power analysis was conducted to assess the power to assess correlations which indicated that with a sample size of 34, the power to detect a correlation of 0.50 was 86 % with α = 0.05.
For the dependent variable, the LPFS score, we summed the scores on each of the four domains to yield a number that could range from 0 (no dysfunction) to 12 (maximal dysfunction).
To assess the agreement between interviewer ratings and video-based ratings, one of the ratings from experts who had conducted the video rating of the interview was randomly selected, and the rating from that person was correlated with the interviewer’s rating for Pearson correlations. This was done for the individual rating of each domain, as well as for the sum of the four domains. For each correlation, the 95 % confidence intervals were calculated by using Fisher’s Z transformation.
Further, to assess agreement between different video ratings of the same video, we calculated agreement using intraclass correlations from mixed effects regression models. For these correlations, we report the confidence intervals, and the
p-values based on the assumption that the distribution of the likelihood-ratio test statistic is a 50:50 mixture of
χ2 distributions with k and k + 1° of freedom. All analyses were carried out on Stata 13 for Windows [
26].
The analyses were repeated, so that all analyses were first conducted using only the patient sample, and in a second round, the community individuals were included in the analyses.