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:
- 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).
- 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).
- 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.
- 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).
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.
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.
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.