Clinical Interview
Clinical Interview
Subject PSYCHOLOGY
TABLE OF CONTENTS
1. Learning Outcomes
2. Introduction
3. The goals of the Clinical interview
4. Clinical Interview Situations
5. Common types of interviews
5.1 Intake Interview
5.2 Case history interview
5.3 Diagnostic Interview
5.4 Mental status exam
6. Structure of Interview
6.1 Non-directive interviews
6.2 Structured interviews
6.3 Semi-structured interviews
7. Stages of Interview
PSYCHOLOGY PAPER No. : 15. Clinical psychology
MODULE No. : 26 Clinical Interview
____________________________________________________________________________________________________
1. Learning Outcomes
After studying this module, you shall be able to
2. Introduction
An interview represents a verbal and nonverbal dialogue between two participants, whose
behaviors affect each other’s style of communication, resulting in specific patterns of interaction.
In the interview one participant who labels himself or herself as the “interviewer” attempts to
achieve specific goals, while the other participant generally assumes the role of “answering the
questions.” (Shea, 1998, pp. 6–7)
According to Flanagan & Flanagan (2003), an adequate definition of clinical interviewing should
include the following factors:
1. A professional relationship between interviewer and client is established.
2. The client is motivated, at least to some degree, to accomplish something by meeting with the
interviewer.
3. The interviewer and client work together, to some extent, to establish and achieve mutually
agreeable goals for the client.
4. In the context of the professional relationship, interviewer and client interact, both verbally and
nonverbally, as the interviewer applies a variety of active listening skills and psychological
techniques to evaluate, understand, and help the client achieve his or her goals.
5. The quality and quantity of interactions between interviewer and client are influenced by many
factors, including interviewer and client personality style, attitudes, and mutually agreed on goals.
4.1 Intake
The most common type of clinical interview is when a client comes to the clinician because of
some problem in living. The psychologist may have little information about the client, so intake
interviews are designed mainly to establish the nature of the problem. Information gathered in
this situation may be used by the interviewers to decide whether they are an appropriate source of
help for the client or they should refer the client to another professional or agency for alternative
services. The intake interview is often critically important to successful treatment because half the
client who attend intake interview fails to return for the treatment (Baekeland & Lundwall, 1982).
Intake interviews are also aimed at problem identification. In clinical situations where a decision
to work with the client has already been made, an interview may focus entirely on identification
or elaboration of the client’s problems.
Less psychiatrically oriented clinicians and those not required to classify people may use
problem- identification interviews to develop descriptions of clients and the environmental
context in which their behaviour occurs.
This type of interview is sometimes known as psychiatric interview. According to Siassi (1984)
the purposes of psychiatric interviews are “to arrive at a diagnosis formulation and a rational
treatment plan . . . an attempt is made to discover the origin and evolution of the patient’s mental
disorder(s) by obtaining a biographical-historical account that can provide a psychological
portrait of the patient” many psychiatric interviews contain a mental status examination.
4.3 Orientation
To make the experiences of receiving psychological assessment or treatment less mysterious and
more comfortable, many clinicians conduct special interviews to acquaint the client with the
assessment, treatment or research procedures to come.
Orientation interviews are beneficial in at least two ways. First, because the client is encouraged
to ask questions and make comments, misconceptions that might obstruct subsequent sessions can
be discussed and corrected. Second, orientation interviews also can communicate new
expectations designed to facilitate later interactions. Often this can be done by describing the
kinds of things that “good” clients are expected to do in assessment or treatment.
4.4 Termination
An interview (or at least a portion of it) designed to explain the procedures and protections
involved in transmission of privileged information and to provide a summary and interpretation
of assessment results, can help alleviate the distress that clients feel about the assessment.
In research settings, a termination interview is referred to as debriefing. Debriefing includes an
explanation of the project in which the subject has participated and discussion of the procedures
employed in it.
Completion of treatment also requires some form of termination interview. Many loose ends need
to be tied up: There is gratitude to be expressed and accepted, reminders to be given about the
PSYCHOLOGY PAPER No. : 15. Clinical psychology
MODULE No. : 26 Clinical Interview
____________________________________________________________________________________________________
In the cases when a person’s problems are of an immediate and pressing nature, the interviewer
doesn’t have the luxury of scheduling a series of assessment sessions followed by treatment.
When interviewing a client in crisis, the clinician tries to provide reassurance, assess the problem,
and explore potential resources, all the while projecting a calm and confident manner. The goal of
the crisis interview is to resolve the problem immediately at hand so that a catastrophic outcome
(e.g., suicide) is avoided. For some individuals one or two interviews with a skilled clinician will
resolve the crisis and they are able to resume to their lives without further need of mental health
service. For others, the crisis interview is the first step towards developing permanent solutions to
long standing problems.
4.6 Observation
The first meeting between a psychologist and client is usually an intake interview. The primary
purpose of the interview is to determine the nature of the client’s problem. Why is the individual
looking for help? The second purpose of the interview, which follows from the first, is to
determine whether the psychologist has the resources and competencies to help the individual.
For the client seeking help for personal problems, the intake interview is particularly important.
In the initial interview the psychologist must balance the need to gather information with the need
to help the client feel at ease and build rapport.
When a client seeks psychotherapy, the main goals of the first interview are to define the
problems to be worked on therapy and establish the goals of treatment. The kinds of questions the
therapists might ask include “What is the main problem for which the client is seeking help?”
“What are the client’s expectations?”
The way in which therapists help clients articulate their problems can have a significant impact
upon the success of the therapy. From cognitive-behavioural perspective, Kanfer and Scheft
(1988) suggested six “think rules” to guide clinicians helping clients to define their problems:
5.1.1 Think behaviour: To set the stage for change, the clinician and the client define the
problem, and possible solutions in terms of actions.
The case history, sometimes called the psychosocial history, is a detailed description of a client’s
background. The history provides information that may be necessary to formulate a complete
diagnosis. Knowing a person’s history also helps the clinician to understand how the presenting
problems fit in the broader context of a person’s life.
Typical information gathered in a case history interview might include:
5.2.1 Birth and Development: Were there any complications in pregnancy or during birth?
Did the client achieve developmental milestones (e.g. walking, talking, toileting) at the
normal age?
5.2.2 Family of origin: Who raised the client? Did the family remain intact? How were the
client’s relationships with parents, siblings, extended family? Did any family members
experience mental health, substance abuse, significant medical or legal problems?
5.2.3 Education: Till which standard did the client go in school? Did he or she repeat any
grade or receive special education services? Were there any significant behavioural
problems in school (e.g., suspension or expulsions)?
5.2.4 Employment: What type of job is the client doing? Has the client ever been fired? If so,
why? Has the client changed jobs often? Why?
5.2.5 Recreation/Leisure: How does the client spend his or her free time? What are his or
her hobbies or interests?
5.2.6 Sexual History: How did the client learn about sex? What were the circumstances of
client’s first sexual experiences (e.g., coercive, in context of romantic relationship, one-
night stand)? What is the nature of client’s current sexual functioning?
5.2.7 Dating and Marital: When did the client start dating? Significant romantic
relationships? How many times has the client been married?
5.2.8 Alcohol and Drugs: What is the nature and pattern of client’s alcohol and drug use?
Has the client experienced legal, employment or social problems secondary to alcohol or
drug use?
5.2.9 Physical health: Has the client had significant medical problems (e.g., head injuries,
chronic illnesses)?
The goal of a diagnostic interview is classification of the client and his or her problems. The
assumption underlying diagnostic interviewing is that psychiatric disorders make themselves
apparent through set of signs or symptoms. The client’s complaints or dysfunctions are classified
according to a diagnostic system like DSM-V or ICD-10.
In the diagnostic interview, the clinician observes the client’s behaviour, inquires about his or her
symptoms in detail, and gathers relevant personal and family history. In addition to inquiring
about the criteria for specific mental disorders, the interviewer also gathers information about
stable personality characteristics, general medical conditions, life stressors and general ability to
function.
Unstructured clinical interviews are probably the most popular method of arriving at a diagnosis.
In an unstructured clinical interview, the clinician develops hypotheses about the client and his or
her symptoms over the course of assessment.
Othmer and Othmer (1994) proposed the following five steps in diagnostic interviewing:
5.3.1 Diagnostic clues: The clinician looks for diagnostic clues in the client’s chief
complaint, behaviour, history and presentation. Based on these clues, the clinician will
create lists of possible psychiatric disorders, excluded disorders and unexplored
disorders. In this step of the interview the clinician tends to ask open-ended questions,
such as “What brought you here?” or tell me “What is troubling you”.
5.3.2 Diagnostic criteria: The clinician inquires about specific diagnostic criteria. Specific
questions relating to specific criteria are asked. Questions might include “Have you ever
heard voices or seen things which others cannot see or hear?”
5.3.3 Psychiatric history: The third step of the interview is to get a psychiatric history. In
this step a history of the disorder is gathered. Has the client received mental health
services in the past? For what problems? What were the outcomes? In addition the
clinician gathers information about premorbid functioning and family history.
5.3.4 Diagnosis: The fourth step is to arrive at a diagnosis. This is where the clinician
condenses the various data into a handful of diagnostic labels and ratings.
5.3.5 Prognosis: The last step is to arrive at a prognosis for the patient. Based upon the five
diagnostic axes, as well as ancillary information gathered during the interview, the
clinician estimates the likely future course of the disorder and the client.
6. Structure of Interview
6.1 Non-directive interviews: At one end of the structure continuum are non-directive
interviews, in which the clinician does as little as possible to interfere with the natural flow of
the client’s speech and choice of topics.
6.2 Structured interviews: At the other end are structured interviews, which involve a specific
set of questions presented in a particular order. In addition, there is usually a carefully
specified set of rules for probing, so that as in a structured test, all interviewees are handled in
the same manner. Structured interviews lend themselves to scoring procedures from which
norms can be developed and applied. Mental status exam is a good example of structured
clinical interviews.
6.3 Semi-structured interviews: In between are many blends, referred to as guided or semi-
structured interviews. These interviews combine organization with flexibility and require the
interviewer to exercise well tuned listening skills and discretion in guiding the interview.
Semi-structured interviews follow a specific outline of topics, provide explicit rules for the
interviewer to follow and also require the interviewer to make independent decisions about
the wording of questions and interpretation of answers.
Majority of the clinicians adjust structure to accommodate the goals of the interview. For
example, by nature crises demand more structure than might be needed during a routine
intake interview. Structure may change during an interview; many problem identification
interviews begin in a non-directive way and become more structured as the interview
continues.
Structure also depends on the theoretical orientation and personal preferences of the
interviewer. In general, phenomenological clinicians provide the least structure.
PSYCHOLOGY PAPER No. : 15. Clinical psychology
MODULE No. : 26 Clinical Interview
____________________________________________________________________________________________________
7. Stages of Interview
The body of the interview is concerned with gathering information necessary for at least a
tentative formulation of the patient’s problems and character. In general, the clinician seeks to
learn:
1. What are the patient’s current complaints and symptoms (“presenting problems”)? Why
has he sought help at this time? What is the nature of his present crisis? What are his
present life circumstances?
2. Were there recent stressful events that might have dislocated adaptive mechanisms and
led to the present crisis?
3. What kind of a person is he? What are his talents, strengths and competencies as well as
personality defects? What are his most important character traits, affects, defenses,
conflicts, particularly those which seem relevant to his present problems? Have there
been any important changes in this behaviour in the recent past? Are there early
experiences which might take his present character or problems more applicable?
4. Are there any relevant organic factors? Might medical consultation or treatment be
necessary?
7.2.1 Look for past events: As patients discuss about their problems and respond to questions,
interviewer watch for points of change, conflict, or confusion. In general, the clinician works out
from discussion of the patient’s present concerns to consideration of surrounding and past events.
After the patient has told about his immediate predicament and distress it seems reasonable to
inquire “How long has this been going on?” “What was your life like before that?” “Did anything
else change at about that time?” Exploring possible precipitating events often yields critical
information about the person’s present problems.
7.2.2 Eliciting affect: When there are verbal or nonverbal signs of affect, patient should be
helped to clarify what he or she feels with statements such as “That must have been pretty sad” or
“It sounds like you feel angry about that”. The way in which the patient responds to the
interviewer’s probe will illuminate the patient’s degree of insight.
7.2.3 Pursuing themes: There is no set scenario, sequence of topics or questions to be covered
in the interview. The clinician takes his cues from the patient and pursues those themes which
seem most important. He is attentive to repetitive inferences, the order in which the patient
present issues, the emotional emphasis he gives different topics, and indeed the areas he avoid or
passes over too lightly. It is not only what the patient says, and how he says it, but what he does
not say gives information about him. Some material is avoided because of repression; those areas
must also be inquired later.
7.2.4 Sources of Clinical Judgment: Making Inferences: Depending on the interview’s
purpose, the inferences and provisional formulation will relate to some of the following:
Knowledge of the patient’s current problem, physical state, and social environment,
precipitating stressors and habitual coping mechanisms and their current efficacy.
The patient’s self-concept, identity, characteristic affects and defenses, his ego-strength
and capacities for self-determined as well as pathological functioning.
Statements about client personality style and functioning.
Estimates of client intellectual or cognitive functioning.
Statements pertaining to parenting ability, attitudes, and adequacy.
Before the interview is ended, there is need to restore the patient’s calm, give him information
and plan with him the next steps.
7.3.1 Restoring the client’s composure: Before terminating it is necessary, to restore the
patient’s composure and if possible have him leaving with some sense of accomplishment and
hope. As in the earlier session, the clinician communicates an empathic understanding of the
difficult task of talking in the interview, appreciation of the profundity of the patient’s problems
and hope for the future.
7.3.2 Summarizing Crucial Themes and Issues: Shea (1998) points out, perhaps the most
important task of the closing is “solidifying the patient’s desire to return for a second appointment
or to follow the clinician’s referral”. Also, the interviewer must keep in mind that patients
rightfully expect him/her to share impressions and recommendations with them.
73.3 Providing information: The ultimate choice is of course the patient’s and he should have
as much information as possible on which to make it. He may have misconceptions or simply
lack information about the nature, availability, cost and procedures of psychotherapy. The
clinician should give as much information as possible, in all of these areas without overselling his
clinic or procedure.
7.3.4 Clinician’s thinking back: After the patient leaves, time should be allowed for thinking
back over the events of the session. . Notes are scanned and a more detailed account written or
dictated. In the process, we reconceptualize and focus major themes and bring them into the
framework of our theoretical thinking. Moving away somewhat from the primary data of the
interview to a higher level of abstraction increases our understanding, though one has to guard
against losing the distinctive detail of the individual life in the process.
8. Communication strategies
The clinician may use different types of questions to elicit information from the client. They
might use open-ended questions or at other times closed questions. Open-ended questions tend to
start with words such as what, how, when, where and who (Cormier & Cormier, 1991). Open-
ended questions are used frequently in an initial interview. As the interview progresses, however
the clinician is interested in gathering more specific information. Three examples of appropriate
closed questions might be “Of all questions we discussed, which bothers you the most?” “Is there
a history of depression in your family?” “Are you planning to look for a job in next few months?”
Much of what gets communicated in an interview occurs non-verbally. It has been estimated, for
example, that 65% meaning of a message is gleaned from non-verbal behaviour (Birdswhistell,
1970). Skilled clinician reads a client’s non-verbal behaviour for clues about client’s emotions,
attitudes and behaviour. The client who never makes eye-contact with clinician may be anxious
or depressed. Fidgeting might suggest anxiety or agitation. Slouching in the chair with arms
folded can boredom, or the client may be communicating resentment toward the interview
process. Clinician need to take into consideration the client’s cultural background when
developing hypotheses based upon client’s non-verbal behaviour. In some cultures, for example,
averting one’s eyes is a signal of respect.
9. Skills of Interviewing
9.2 Transitional phase: Interviewer should use minimum effort to maintain the flow, such as
using a transitional phrase such as “Yes,” “And,” or “I see.” weaknesses
9.3 Verbatim playback: In verbatim playback, the interviewer simply repeats the
interviewee’s last response.
9.5 Summarizing and Clarification statements: The summarizing communicates that the
interviewer has a good idea of what the interviewee is trying to communicate. And clarification
shows yet further comprehension.
9.6 Empathy and understanding: This is a more powerful response. This response
communicates that the interviewer understands how the interviewee feels. Understanding
responses that stay close to the content and underlying feeling provided by the interviewees
permit them to explore their situations more and more fully.
12. Summary
The interview remains the most basic most commonly used and most powerful technique in
clinical assessment. Through training and practice, the interviewers can function more effectively.
For some purposes, greater standardization can make the interview a sharper and more
dependable tool. In the interview, the clinician is at one time stimulus to, observer of and
interpreter of the patient’s state.