Tag Archives: clinical interview

The Clinical Interview as an Assessment Tool

Chair

The following is another excerpt from a chapter I wrote with my colleagues Roni Johnson and Maegan Rides At The Door. This excerpt focuses on ways in which clinical interviews are used as assessment tools. The full chapter is forthcoming in the Cambridge Handbook of Clinical Assessment and Diagnosis. For more (much more) information on clinical interviewing, see our textbook, creatively titled, Clinical Interviewing, now in its 6th edition. If you’re a professor or college instructor, you can get a free evaluation copy here: https://www.wiley.com/en-us/Clinical+Interviewing%2C+6th+Edition-p-9781119215585

The clinical interview often involves more assessment and less intervention. Interviewing assessment protocols or procedures may not be limited to initial interviews; they can be woven into longer term assessment or therapy encounters. Allen Frances (2013), chair of the DSM-IV task force, recommended that clinicians “be patient,” because accurate psychiatric diagnosis may take “five minutes. . .”  “five hours. . .”  “five months, or even five years” (p. 10).

Four common assessment interviewing procedures are discussed next: (1) the intake interview, (2) the psychodiagnostic interview, (4) mental status examinations, and (4) suicide assessment interviewing.

The Intake Interview

The intake interview is perhaps the most ubiquitous clinical interview; it may be referred to as the initial interview, the first interview, or the psychiatric interview. What follows is an atheoretical intake interview model, along with examples of how theoretical models emphasize or ignore specific interview content.

Broadly speaking, intake interviews focus on three assessment areas: (1) presenting problem, (2) psychosocial history, and (3) current situation and functioning. The manner in which clinicians pursue these goals varies greatly. Exploring the client’s presenting problem could involve a structured diagnostic interview, generation and analysis of a problem list, or clients free associating to their presenting problem. Similarly, the psychosocial history can be a cursory glimpse at past relationships and medical history or a rich and extended examination of the client’s childhood. Gathering information about the client’s current situation and functioning can range from an informal query about the client’s typical day to a formal mental status examination (Yalom, 2002).

Psychodiagnostic Interviewing

The psychodiagnostic interview is a variant of the intake interview. For mental health professionals who embrace the medical model, initial interviews are often diagnostic interviews. The purpose of a psychodiagnostic interview is to establish a psychiatric diagnosis. In turn, the purpose of psychiatric diagnosis is to describe the client’s current condition, prognosis, and guide treatment.

Psychodiagnostic interviewing is controversial. Some clinicians view it as essential to treatment planning and positive treatment outcomes (Frances, 2013). Others view it in ways similar to Carl Rogers (1957), who famously wrote, “I am forced to the conclusion that … diagnostic knowledge is not essential to psychotherapy. It may even be … a colossal waste of time” (pp. 102–103). As with many polarized issues, it can be useful to take a moderate position, recognizing the potential benefits and liabilities of diagnostic interviewing. Benefits include standardization, a clear diagnostic focus, and identification of psychiatric conditions to facilitate clinical research and treatment (Lilienfeld, Smith, & Watts, 2013). Liabilities include extensive training required, substantial time for administration, excess structure and rigidity that restrain experienced clinicians, and questionable reliability and validity, especially in real-world clinical settings (Sommers-Flanagan & Sommers-Flanagan, 2017).

Clinicians who are pursuing diagnostic information may integrate structured or semi-structured diagnostic interviews into an intake process. The research literature is replete with structured and semi-structured diagnostic interviews. Clinicians can choose from broad and comprehensive protocols (e.g., the Structured Clinical Interview for DSM-5 Disorders – Clinician Version; First et al., 2016) to questionnaires focusing on a single diagnosis (e.g., Autism Diagnostic Interview – Revised; Zander et al., 2017). Additionally, some diagnostic interviewing protocols are designed for research purposes, while others help clinicians attain greater diagnostic reliability and validity. Later in this chapter we focus on psychodiagnostic interviewing reliability and validity.

The Mental Status Examination

The MSE is a semi-structured interview protocol. MSEs are used to organize, assess, and communicate information about clients’ current mental state (Sommers-Flanagan, 2016; Strub & Black, 1977). To achieve this goal, some clinicians administer a highly structured Mini-Mental State Evaluation (MMSE; Folstein, Folstein, & McHugh, 1975), while others conduct a relatively unstructured assessment interview but then organize their observations into a short mental status report. There are also clinicians who, perhaps in the spirit of Piaget’s semi-clinical interviews, combine the best of both worlds by integrating a few structured MSE questions into a less structured interview process (Sommers-Flanagan & Sommers-Flanagan, 2017).

Although the MSE involves collecting data on diagnostic symptoms, it is not a psychodiagnostic interview. Instead, clinicians collect symptom-related data to communicate information to colleagues about client mental status. Sometimes MSEs are conducted daily or hourly. MSEs are commonly used within medical settings. Knowledge of diagnostic terminology and symptoms is a prerequisite to conducting and reporting on mental status.

Introducing the MSE. When administering an MSE, an explanation or role induction is needed. A clinician might state, “In a few minutes, I’ll start a more formal method of getting … to know you. This process involves me asking you a variety of interesting questions so that I can understand a little more about how your brain works” (Sommers-Flanagan & Sommers-Flanagan, 2017, pp. 580–581).

Common MSE domains. Depending on setting and clinician factors, the MSE may focus on neurological responses or psychiatric symptoms. Nine common domains included in a psychiatric-symptom oriented MSE are

  1. Appearance
  2. Behavior/psychomotor activity
  3. Attitude toward examiner (interviewer)
  4. Affect and mood
  5. Speech and thought
  6. Perceptual disturbances
  7. Orientation and consciousness
  8. Memory and intelligence
  9. Reliability, judgment, and insight.

Given that all assessment processes include error and bias, mental status examiners should base their reports on direct observations and minimize interpretive statements. Special care to cross-check conclusive statements is necessary, especially when writing about clients who are members of traditionally oppressed minority groups (Sommers-Flanagan & Sommers-Flanagan, 2017). Additionally, using multiple assessment data sources (aka triangulation; see Using multiple (collateral) data sources) is essential in situations where patients may have memory problems (e.g., confabulation) or be motivated to over- or underreport symptoms (Suhr, 2015).

MSE reports. MSE reports are typically limited to one paragraph or one page. The content of an MSE report focuses specifically on the previously listed nine domains. Each domain is addressed directly with at least one statement.

Suicide Assessment Interviewing

The clinical interview is the gold standard for suicide assessment and intervention (Sommers-Flanagan, 2018). This statement is true, despite the fact that suicide assessment interviewing is not a particularly reliable or valid method for predicting death by suicide (Large & Ryan, 2014). The problem is that, although standardized written assessments exist, they are not a stand-alone means for predicting or intervening with clients who present with suicide ideation. In every case, when clients endorse suicide ideation on a standardized questionnaire or scale, a clinical interview follow-up is essential. Although other assessment approaches exist, they are only supplementary to the clinical interview. Key principles for conducting suicide assessment interviews are summarized below.

Contemporary suicide assessment principles. Historically, suicide assessment interviewing involved a mental health professional conducting a systematic suicide risk assessment. Over the past two decades, this process has changed considerably. Now, rather than taking an authoritative stance, mental health professionals seek to establish an empathic and collaborative relationship with clients who are suicidal (Jobes, 2016). Also, rather than assuming that suicide ideation indicates psychopathology or suicide risk, clinicians frame suicide ideation as a communication of client distress. Finally, instead of focusing on risk factors and suicide prediction, mental health professionals gather information pertaining to eight superordinate suicide dimensions or drivers and then work with suicidal clients to address these dimensions through a collaborative and therapeutic safety planning process (Jobes, 2016). The eight superordinate suicide dimensions include:

  • Unbearable emotional or psychological distress: Unbearable distress can involve one or many trauma, loss, or emotionally disturbing experiences.
  • Problem-solving impairments: Suicide theory and empirical evidence both point to ways in which depressive states can reduce client problem-solving abilities.
  • Interpersonal disconnection, isolation, or feelings of being a social burden: Joiner (2005) has posited that thwarted belongingness and perceiving oneself as a burden contributes to suicidal conditions.
  • Arousal or agitation: Many different physiological states can increase arousal/agitation and push clients toward using suicide as a solution to their unbearable distress.
  • Hopelessness: Hopelessness is a cognitive variable linked to suicide risk. It can also contribute to problem-solving impairments.
  • Suicide intent and plan: Although suicide ideation is a poor predictor of suicide, when ideation is accompanied by an active suicide plan and suicide intent, the potential of death by suicide is magnified.
  • Desensitization to physical pain and thoughts of death: Fear of death and aversion to physical pain are natural suicide deterrents; when clients lose their fear of death or become desensitized to pain, suicide behaviors can increase.
  • Access to firearms: Availability of a lethal means, in general, and access to firearms, in particular, substantially increase suicide risk.

(For additional information on suicide assessment interviewing and the eight suicide dimensions, see other posts on this site).

The Diagnostic Clinical Interview: Tips and Strategies

CI6 Cover

The clinical interview is 40% assessment, 40% therapy, 25% relational, and 20% technical. What I’m trying to say (other than I wasn’t a math major) is that, as the headwaters from which all counseling and psychotherapy flow, the clinical interview is a flexible tool that many researchers and practitioners use to achieve many different goals. Although I’m a big fan of the clinical interview as a means through which clinicians interpersonally connect with clients to begin therapeutic collaboration, I also recognize that interviews can be a highly structured procedure for collecting data and establishing mental disorder diagnoses.

Recently, I came across a nice “eight minute” diagnostic interviewing article by Allen Frances. Dr. Frances was deeply involved in the development of DSM-IV. Here’s a link to his excellent article: https://pro.psychcentral.com/14-tips-for-the-diagnostic-interview-of-mental-disorders/

Reading the 14 tips from Dr. Frances reminded me of a similar section in our Clinical Interviewing textbook, and so I’ve pasted it below. As always our emphasis is on making sure that technical tasks during an interview don’t overshadow essential relational components. In fact, as I write this, I’m aware that even using the term “relational components” is bad form. It’s bad form because it misses the deep human connection, the non-verbal signals, the first impressions, and the whole interpersonal dance that is de rigueur in every unique clinical encounter. Words cannot adequately express what can and does happen during a clinical interview. Nevertheless, here are a few words from the Clinical Interviewing text anyway. We start with short lists of the advantages and disadvantages of structured diagnostic interviews and then move on to a less structure diagnostic interviewing model. Here’s a link to the 6th edition of Clinical Interviewing on Amazon: https://www.amazon.com/Clinical-Interviewing-John-Sommers-Flanagan/dp/1119215587/ref=sr_1_1?ie=UTF8&qid=1519745757&sr=8-1&keywords=clinical+interviewing+sommers-flanagan

Advantages Associated with Structured Diagnostic Interviewing

Advantages associated with structured diagnostic interviewing include the following:

  • Structured diagnostic interview schedules are standardized. Therapists systematically ask clients a menu of diagnostically relevant questions.
  • Diagnostic interview schedules generally produce a diagnosis, consequently relieving clinicians of subjectively weighing many alternative diagnoses.
  • Diagnostic interview schedules show better diagnostic reliability and validity than less structured methods.
  • Diagnostic interviews are well suited for scientific research. Valid and reliable diagnoses support research on the nature, course, prognosis, and treatment responsiveness of particular disorders.

Structured and semi-structured diagnostic interviews are a part of the scientific foundation of psychology and counseling. Current systems are always in revision; realistically, progress (not a perfect system) is the goal. The diagnostic criteria from DSM-III and -IV and ICD-9 and -10 were improvements on previous versions, and there’s hope that the DSM-5 and ICD-11 will show further improvements in reliability, validity, and clinical utility (Keeley et al., 2016).

Disadvantages Associated with Structured Diagnostic Interviewing

There are also disadvantages associated with structured diagnostic interviewing:

  • Many diagnostic interviews require considerable time for administration. For example, the Schedule for Affective Disorders and Schizophrenia for School-Age Children (Puig-Antich, Chambers, & Tabrizi, 1983) may take one to four hours to administer, depending on whether both parent and child are interviewed.
  • Diagnostic interviews don’t allow experienced diagnosticians to take shortcuts. This is cumbersome because experts in psychiatric diagnosis might require less information to accurately diagnose clients than would beginning therapists.
  • Some clinicians complain that diagnostic interviews are too structured and rigid, de-emphasizing rapport building and basic interpersonal communication between client and therapist. Extensive structure may not be acceptable for practitioners who prefer using intuition and who emphasize relationship development.
  • Although structured diagnostic interviews have demonstrated reliability, some clinicians question their validity. All diagnostic interviews are limited and leave out important information about clients’ personal history, personality style, and other contextual variables. As noted earlier, two different therapists may administer the same interview schedule and consistently come up with the same incorrect diagnosis.

Given their time-intensive requirements in combination with the need of mental health providers for time-efficient evaluation, it’s not surprising that diagnostic interviewing procedures are underutilized and sometimes unutilized in clinical practice. Critics contend that even the diagnostic criteria themselves are more oriented toward researchers than clinicians (Phillips et al., 2012):

It is difficult to avoid the conclusion that the diagnostic criteria are mainly useful for researchers, who are obligated to insure a uniform research population. (p. 2)

Researchers and academics are far and away the primary users of contemporary structured diagnostic interviewing procedures.

Less Structured Diagnostic Clinical Interviews

If your goal is to conduct a state-of-the-science diagnostic clinical interview, then you’ll use a structured or semi-structured format. But not all clinicians choose that approach. The features of a less structured approach include the following:

  1. An introduction to the assessment process (aka role induction) characterized by culturally sensitive warmth and active listening. Depending on the situation and clinician preference, clinicians may employ culturally appropriate standardized questionnaires and intake/referral information (for example, MMPI-2-RC; BDI-2; OQ-45).
  2. An extensive review of client problems and associated goals, and a detailed analysis of the client’s primary problem and goal. This could include questions about the client’s symptoms using the ICD-10-CM or DSM-5 as a guide, or a circumscribed, symptom-oriented diagnostic interview protocol (the HAM-D, for example).
  3. A brief discussion of experiences (personal history) relevant to the client’s primary problem, including a history of the presenting problem if such a history hasn’t already been conducted.
  4. If appropriate, a brief mental status examination could be included, but more likely you’ll review the client’s current situation, including his or her social support network, coping skills, physical health, and personal strengths.

Introduction and Role Induction

The goal of developing a diagnosis and treatment plan shouldn’t change the therapist’s interest in the client as a unique individual. After reviewing confidentiality limits, you should introduce diagnostic interviews to clients using a statement similar to the following:

Today, we’ll be working together to try to understand what has been troubling you. This means I want you to talk freely with me, but also, I’ll be asking lots of questions to clarify as precisely as possible what you’ve been experiencing. If we can identify your main concerns, we’ll be able to come up with a plan for resolving them. Does that sound OK to you?

This statement emphasizes collaboration and de-emphasizes pathology. The language “try to understand” and “main concerns” are client-friendly ways of talking about diagnostic issues. This statement is a role induction that educates clients about the interview process.

Beginning therapists often become too structured, excluding client spontaneity, or too unstructured, allowing clients to ramble. Remember to integrate active listening and diagnostic questioning throughout your diagnostic interview.

Reviewing Client Problems

While reviewing client problems, consider the following.

Respect Your Client’s Perspective, but Don’t Automatically Accept Your Client’s Self-Diagnosis as Valid

Diagnostic information is available to the general public. This leads many clients to offer their own diagnosis at the beginning of interviews:

  • I’m so depressed. It’s really getting to me.
  • I think my child has ADHD.
  • I took an online quiz and found out that I’m bipolar.
  • I have a problem with compulsive behavior.
  • My main problem is panic. Whenever I’m in public, I just freeze.

Some diagnostic terminology has been so popularized that its specificity has been lost. This is especially true with the term depression. Many people use the word depression to describe sadness. The astute diagnostician recognizes that depression is a syndrome and not a mood state. When clients report “being depressed,” further questioning about sleep dysfunction, appetite or weight changes, and concentration problems are necessary. Research has shown that using the single question “Are you depressed?” isn’t an adequate substitute for an appropriate diagnostic interview (Kawase et al., 2006; Vahter, Kreegipuu, Talvik, & Gross-Paju, 2007).

Similarly, the lay public overuses the terms compulsive, panic, hyperactive, and bipolar. In diagnostic circles, compulsive behavior generally alerts the clinician to symptoms associated with either obsessive-compulsive disorder or obsessive-compulsive personality disorder. In contrast, many individuals with eating disorders and substance abuse disorders refer to their behaviors as compulsive. Similarly, panic disorder is a specific syndrome in the ICD-10-CM and DSM-5. However, many individuals with social phobias, agoraphobia, or public speaking anxiety refer to panic. Therefore, when clients say they have panic, it should alert you to gather additional information about a range of different anxiety disorders. Finally, diagnostic rates of bipolar disorder in both youth and adults have skyrocketed (Blader & Carlson, 2007; Moreno et al., 2007). As a result, the lay public (and some mental health professionals) quickly attribute irritability and/or mood swings to bipolar disorder. Nevertheless, we recommend using established diagnostic criteria.

Keep Diagnostic Checklists Available

When questioning clients about problems, keep diagnostic criteria in mind, but don’t expect to have perfectly memorized diagnostic criteria from the ICD or DSM systems. Using checklists to aid in recalling specific diagnostic criteria helps. But don’t reduce your diagnostic musing to a simple checklist.

Don’t Expect to Accurately Diagnose Clients after a Single Interview

It’s good to have lofty goals, but in many cases, you won’t be able to assign an accurate diagnosis to a client after a single interview. In fact, you may leave the first interview more confused than when you began. Fear not. The ICD-10-CM and DSM-5 provide practitioners with procedures for handling diagnostic uncertainty. These include the following:

V codes (DSM-5) and Z codes (ICD-10-CM): V codes and Z codes are used to indicate that treatment is focusing on a problem that doesn’t meet diagnostic criteria for a mental disorder.

F99: This code refers to Unspecified Mental Disorder. It’s used when the clinician determines that symptoms are present, but full criteria for a specific mental disorder are not met. Also, the clinician doesn’t specify why the criteria aren’t met.

Provisional diagnosis: When a specific diagnosis is followed by the word provisional in parentheses, it communicates a degree of uncertainty. A provisional diagnosis is a working diagnosis, indicating that additional information may modify the diagnosis. The ICD-10-CM also allows for using the word tentative, meaning there is uncertainty but that “more information is unlikely to become available” (p. 8)

Being uncertain about your client’s diagnosis after an intake interview should be an excellent stimulus for you to do some extra reading before meeting for a second appointment.

Client Personal History

Even when time is limited, social-developmental history information helps ensure accurate diagnosis. For example, the DSM-5 lists numerous disorders that have depressive symptoms as one of their primary features, including (1) persistent depressive disorder, (2) major depressive disorder, (3) various adjustment disorders, (4) bipolar I disorder, (5) bipolar II disorder, and (6) cyclothymic disorder. Many other disorders include depressive symptoms or symptoms that are comorbid with one of the previously listed depressive disorders. Among others, these include (1) posttraumatic stress disorder, (2) generalized anxiety disorder, (3) anorexia nervosa, (4) bulimia nervosa, and (5) conduct disorder. The question is not whether depressive symptoms exist in a particular client but rather which depressive symptoms exist, in what context, and for how long. Without adequate historical information, you can’t discriminate between various depressive disorders and comorbid conditions.

In some cases, accurate diagnosis is directly linked to client history. For example, a panic disorder diagnosis requires information about previous panic attacks. Similarly, posttraumatic stress disorder, by definition, requires a trauma history; and for AD/HD (in DSM-5) and hyperkinetic disorders (in ICD-10-CM), the diagnosis can’t be given unless there is evidence that symptoms existed prior to age twelve (DSM) or age six (ICD-10-CM).

Current Situation

Obtaining information about a client’s current functioning is a standard part of the intake interview. A few significant issues should be reviewed and emphasized.

A detailed review of your client’s current situation includes an evaluation of his or her typical day, social support network, coping skills, physical health (if this area hasn’t been covered during a medical history), and personal strengths. Each of these areas can provide information crucial to the diagnostic process.

The Usual or Typical Day

Yalom (2002) has written that he believes an inquiry into the “patient’s daily schedule” is especially revealing. He wrote:

In recent initial interviews this inquiry allowed me to learn of activities I might not otherwise have known for months: two hours a day of computer solitaire; three hours a night in Internet sex chat rooms under a different identity; massive procrastination at work and ensuing shame; a daily schedule so demanding that I was exhausted listening to it; a middle-aged woman’s extended daily (sometimes hourly) phone calls with her father; a gay woman’s long daily phone conversations with an ex-lover whom she disliked but from whom she felt unable to separate. (pp. 208–209)

Asking about the client’s typical day can open up a cache of diagnostically rich data that moves you toward identifying appropriate treatment goals and an associated treatment plan.

Client Social Support Network

In some cases, it can be critical to obtain diagnostic information from people other than the client, especially when interviewing young clients. Parents are often interviewed as part of the diagnostic work-up (see Chapter 13). However, even when interviewing adults, you may need outside information:

Adults can also be unaware of their family histories or details about their own development. Patients with psychosis or personality disorder may not have enough perspective to judge accurately many of their own symptoms. In any of these situations, the history you obtain from people who know your patient well may strongly influence your diagnosis. (Morrison, 2007, p. 203)

Whether you need to interview a collateral informant to obtain diagnostic information should be determined on a case-by-case basis.

Assessment of Client Coping Skills

Client coping skills may be related to diagnosis and can facilitate treatment planning. For example, clients with anxiety disorders frequently use avoidance strategies to reduce anxiety (people with agoraphobia don’t leave their homes; individuals with claustrophobia stay away from enclosed spaces). It’s important to examine whether clients are coping with their problems and moving toward mastery or reacting to problems and exacerbating symptoms and/or restricting themselves from social or vocational activities.

Coping skills also may be assessed by using projective techniques or behavior observation. You might try having clients imagine an especially stressful scenario (sometimes referred to as a simulation) and describe how they would handle it. Behavioral observations may be collected either in an office or in an outside setting (school, home, workplace). Collateral informants also may provide information regarding how clients cope when outside your office.

Physical Examination

Often, a conclusive mental disorder diagnosis can’t be achieved without a medical examination. When interviewing new clients, therapists should inquire about the most recent physical examination results. Some therapists ask for this information on their intake form and discuss it with clients.

Physical and mental states can have powerful and reciprocal influences on each other. For instance, a long-term illness or serious injury can contribute to anxiety and depression. Consider the following options when completing a diagnostic assessment:

  • Gather information about physical examination results.
  • Consult with the client’s primary care physician.
  • Refer clients for a physical examination.

Making sure that potential medical or physical causes or contributors to mental disorders are considered and noted is an ethical mandate.

Client Strengths

Clients who come for professional assistance may have lost sight of their personal strengths and positive qualities. Further, after experiencing an hour-long diagnostic interview, clients may feel even more sad or demoralized. As we’ve mentioned before, especially within the context of suicide assessment interviewing, it’s important to ask clients to identify and elaborate on positive personal qualities throughout the interview, but especially toward the end of an assessment/diagnostic process. For example:

I appreciate your telling me about your problems and symptoms. But I’d also like to hear more about your positive qualities. Like how you’ve managed to be a single parent and go to school and fight off those depressive feelings you’ve been talking about.

Exploring client strengths provides important diagnostic information. Clients who are more depressed and demoralized may not be able to identify their strengths. Nonetheless, be sure to provide support, reassurance, and positive feedback. In addition, as solution-oriented theorists emphasize, don’t forget that diagnosis and assessment procedures can—and should—include a consistent orientation toward the positive. Bertolino and O’Hanlon (2002) stated:

Formal assessment procedures are often viewed solely as a means of uncovering and discovering deficiencies and deviancies with clients and their lives. However, as we’ve learned, they can assist with learning about clients’ abilities, strength, and resources, and in searching for exceptions and differences. (p. 79)

Effective diagnostic interviewing isn’t exclusively a fact-finding process. Throughout the interview, skilled diagnosticians express compassion and support for a fellow human being in distress. The purpose of diagnostic interviewing goes beyond establishing a diagnosis or “pigeonhole” for clients. Instead, it’s an initial step in developing an individualized treatment plan.

 

 

 

What’s the Difference between the Clinical Interview and Full-On Counseling or Psychotherapy?

I know my obsession with all things clinical interviewing is abnormal. This means I already know that most humans on the planet will have no interest in my hashing out the details and differences between clinical interviewing and psychotherapy. So, why then do I persist on blogging about such things? Well, the answer is simple: Obsessions are thoughts and compulsions are behaviors. Therefore, obsessions and compulsions go together like beans and rice. And so, as George Bush senior might have said, “It wouldn’t be prudent to not follow my clinical interviewing obsessions with a clinical interviewing behavior or two.” Now that I think of it, I’m certain that’s exactly what GWB I would have said, had he been asked about this very important situation.

There is, of course, the other reason. I’m revising (along with Rita) our Clinical Interviewing text to put it into the 6th edition. While doing so I have intermittent inspirations to post some of the new material we’re adding here and there. I think to myself . . . “this is the 6th edition of one of the most profound and exciting textbooks of all time and so I’m sure there might be 6 people out there who are interested in reading about what we’re writing.” Then again, as most of us know from either psychological research or common sense, it’s super-easy for me to fool myself into thinking other people are interested in whatever I’m interested in.

Now, having sufficiently fooled or rationalized or intellectualized or inspired myself . . . I present you with our latest thinking on clinical interviewing vs. counseling and psychotherapy.

Clinical interviewing vs. Counseling and Psychotherapy

Students often ask: “What’s the difference between a clinical interview and counseling or psychotherapy?” This is an excellent question and although it’s tempting to answer flatly, “There’s no difference whatsoever” the question deserves a more nuanced response.

The clinical interview is a remarkably flexible and ubiquitous interpersonal process. It’s designed to simultaneously initiate a therapeutic relationship, gather assessment information, and begin therapy. As such, it’s the entry point for clients (or patients) seeking mental health treatment, case management, or any form of counseling. Depending on setting, clinician discipline, theoretical orientation, and other factors, the clinical interview is also commonly known as the intake interview, the initial interview, the psychiatric interview, the diagnostic interview, the first contact or meeting, or any one of a number of other idiosyncratic and theoretically-driven names (Sommers-Flanagan, 2016, in press).

Although it includes therapeutic dimensions, the clinical interview is viewed primarily as an assessment procedure. This is one reason why clinical interviewing is typically included within the assessment portion of course curricula in counseling, psychology, psychiatry, psychiatric nursing, and social work. However, beginning with Constance Fischer’s work on Individualized Psychological Assessment and continuing with Stephen Finn’s articulation and development of therapeutic assessment, it’s also clear that, when done well, clinical assessment is or can be simultaneously therapeutic.

To make matters more complex, every attitude, technique, and strategy described in this text are also the attitudes, techniques, and strategies used in counseling and psychotherapy. Examples (along with their theoretical orientations) range from projective questions (psychoanalytic), therapeutic questions (solution-focused therapy), unconditional positive regard (person-centered), to psychoeducation (cognitive behavior therapy). Even further, some theoretical orientations ignore or de-emphasize assessment to such an extent that the traditional initial clinical assessment interview is transformed completely into an intervention (think solution-focused or narrative). In other cases, the clinical setting or client problem require that single therapy sessions involve an entire course of counseling or psychotherapy. For example,

“. . . in a crisis situation, a mental health professional might conduct a clinical interview designed to quickly establish . . . an alliance, gather assessment data, formulate and discuss an initial treatment plan, and implement an intervention or make a referral.” (Sommers-Flanagan et al., 2015, p. 2)

From this perspective, not only is the clinical interview always the starting point for counseling, psychotherapy, and case management, it also may be the end-point. This is partly because many clients stop treatment after only one therapy session.

There may be other situations where an ordinary therapy session (if there is such a thing) can suddenly transform into a clinical assessment interview. The most common example of this involves suicide assessment interviewing (see Chapter 10). If and when clients begin talking about suicide ideation or exhibiting other suicide risk factors, the usual and customary standard of practice for all mental health and healthcare professionals is to smoothly shift the clinical focus from whatever was happening to a state-of-the-art suicide assessment.

All this leads us to the stunning conclusion: Everything that happens in a full course of counseling or psychotherapy may also occur within the context of a single clinical interview—and vice versa. Although it’s usually the starting point of counseling and psychotherapy, parts of a traditional clinical interview also occur during counseling and psychotherapy, regardless of theoretical orientation. The entire range of attitudes, techniques, and strategies you learn from this text constitute the foundation of skills you’ll need for conducting more advanced and theoretically specific counseling or psychotherapy.

R and J in Field

The Art and Science of Clinical Interviewing (in Chicago)

In about 10 days I’ll be on my way to Chicago to video-record five short lectures on Clinical Interviewing. Alexander Street Press is producing this video project and Dr. Sharon Dermer of Governor’s State University is hosting. The project is titled “Great Teachers, Great Courses.” [This is pretty cool and my thanks to JC for getting me included.]

I’ll be recording the morning of Tuesday, May 19, which happens to be just before Debbie Joffe Ellis, who just happens to be the wife of the late Albert Ellis. She asked to switch times with me and so I obliged, noting in an email to Dr. Dermer:

Sure. I can do morning. Besides, if I said no I would end up with the Ghost of Albert Ellis’s scratchy voice in the back of my head saying things like, “What the Holy Hell is wrong with you?”

I’d just as soon avoid that.

All this is my slightly braggy way of explaining why I’ll be writing about five upcoming blogs on Clinical Interviewing. Here we go.

What is a Clinical Interview?

Definitions can be slippery. This is especially true when our intention is to define something related to human interaction.

One of my favorite descriptions of clinical interviewing is scheduled for inclusion in the forthcoming “Handbook of Clinical Psychology.” Mostly I suppose I like this description because I wrote it (smiley face). Here it is:

In one form or another, the clinical interview is unarguably the headwaters from which all mental health interventions flow. This remarkable statement has two primary implications. First, although clinical psychologists often disagree about many important matters, the status of clinical interviewing as a fundamental procedure is more or less universal. Second, as a universal procedure, the clinical interview is naturally flexible. This is essential because otherwise achieving agreement regarding its significance amongst any group of psychologists would not be possible. (page numbers tbd)

When it comes to formal definitions, it’s clear that clinical interviewing has been defined in many ways by many authors. Some authors appear to prefer a narrow definition:

An interview is a controlled situation in which one person, the interviewer, asks a series of questions of another person, the respondent. (Keats, 2000, p. 1)

Others are more ambiguous:

An interview is an interaction between at least two persons. Each participant contributes to the process, and each influences the responses of the other. However, this characterization falls short of defining the process. Ordinary conversation is interactional, but surely interviewing goes beyond that. (Trull & Prinstein, 2013, p. 165)

Others emphasize the development of a positive and respectful relationship:

. . . we mean a conversation characterized by respect and mutuality, by immediacy and warm presence, and by emphasis on strengths and potential. Because clinical interviewing is essentially relational, it requires ongoing attention to how things are said and done, as well as to what is said and done. The emphasis on the relationship is at the heart of the “different kind of talking” that is the clinical interview. (Murphy & Dillon, 2011, p. 3)

From my perspective, the BIG goals of this “different kind of talking” can be broken into two main parts: (1) ASSESSMENT and (2) HELPING That said, I’m likely to further break these two main parts into four interrelated and overlapping parts that may or may not be formally including in a single clinical interview:

1. Establishing a therapeutic relationship
2. Collecting assessment information
3. Developing a case formulation or treatment plan
4. Providing a specific educational or psychotherapeutic intervention

What are the Goals of a Clinical Interview?

[In the following two paragraphs I’m including a more wordy and erudite way of saying the preceding . . . which is one of the things that we academics are wont to do. I should note these paragraphs are excerpted from my entry in the Encyclopedia of Clinical Psychology (2015). This piece, very recently published, is cleverly titled, “The Clinical Interview” and coauthored with Drs. Waganesh Abeje Zeleke, and Meredith H. E. Hood.]

Perhaps the clearest way to define a clinical interview is to describe its purpose or goals. Generally, there are four possible goals of a clinical interview. These include: (a) the goal of establishing (and maintaining) a working relationship or therapeutic alliance between clinical interviewer and patient; research has suggested the relationship between interviewer and patient is multidimensional, including agreement on mutual goals, engagement in mutual tasks, and development of a relational bond (Bordin, 1979; Norcross & Lambert, 2011); (b) the goal of obtaining assessment information or data about patients; in situations where the goal of the clinical interview is to formulate a psychiatric diagnosis, the process is typically referred to as a diagnostic interview; (c) the goal of developing a case formulation and treatment plan (although this goal includes gathering assessment information, it also moves beyond problem definition or diagnosis and involves the introduction of a treatment plan to a patient); (d) the goal of providing, as appropriate and as needed, a specific educational or therapeutic intervention, or referral for a specific intervention; this intervention is tailored to the patient’s particular problem or problem situation (as defined in items b and c).

All clinical interviews implicitly address the first two primary goals (i.e., relationship development and assessment or evaluation). Some clinical interviews also include, to some extent, case formulation or psychological intervention. A single clinical interview can simultaneously address all of the aforementioned goals. For example, in a crisis situation, a mental health professional might conduct a clinical interview designed to quickly establish rapport or an alliance, gather assessment data, formulate and discuss an initial treatment plan, and implement an intervention or make a referral.

What Happens During a Clinical Interview?

The range of interactions that can happen during a clinical interview is staggering. This could partly explain why we (foolishly) wrote a textbook on this topic that’s 598 pages long and includes an instructional DVD.

My son-in-law says one good way to get a flavor for any book is to put together the first and last words. In this case, our Clinical Interviewing text reads (not including the front or back matter), “This . . . culture.” To give you a further taste of “This . . . Clinical Interviewing . . . culture,” here’s a modified excerpt from the text:

Imagine sitting face-to-face with your first client. You carefully chose your clothing. You intentionally arranged the seating, set up the video camera, and completed the introductory paperwork. You’re doing your best to communicate warmth and helpfulness through your body posture and facial expressions. Now, imagine that your client:

  • Refuses to talk.
  • Talks so much you can’t get a word in.
  • Asks to leave early.
  • Starts crying.
  • Tells you that you’ll never understand because of your racial or ethnic differences.
  • Suddenly gets angry (or scared) and storms out.

Any and all of these responses are possible in an initial clinical interview. If one of these scenarios plays out, how will you respond? What will you say? What will you do?

From the first client forward, every client you meet will be different. Your challenge or mission (if you choose to accept it) is to make human contact with each client, to establish rapport, to build a working alliance, to gather information, to instill hope, and, if appropriate, to provide clear and helpful professional interventions. To top it off, you must gracefully end the interview on time and sometimes you’ll need to do all this with clients who don’t trust you or don’t want to work with you. (pp. 3-4)

In my opening Great Teachers, Great Courses lecture I’ll be focusing on the definition of the clinical interview and then limit myself to describing and demonstrating about 18 different interviewing “behaviors” or responses that clinicians who conduct clinical interviewing have at their disposal. These behaviors are named and organized into three categories. And so to help myself stop writing this blog and get back to work, I’ll wait and write about them later.

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Powerpoint Slides from the ACES Clinical Interviewing Presentation in Denver

This post includes a link to the powerpoiint slides for our presentation at the Association for Counselor Education and Supervision in Denver, CO. For this we offer a BIG THANKS to Sidney Shaw, Ed.D. who presented on our behalf so we could be in Erie, PA for the birth of our new granddaughter, Nora Flanagan Bodnar. Thanks Sidney!!

ACES clinical interview