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).
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
- Behavior/psychomotor activity
- Attitude toward examiner (interviewer)
- Affect and mood
- Speech and thought
- Perceptual disturbances
- Orientation and consciousness
- Memory and intelligence
- 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).