Using observation as part of a clinical interview can help the interviewer to

The following is a preview from a chapter I wrote with my colleagues Roni Johnson and Maegan Rides At The Door. The full chapter will be in the Cambridge Handbook of Clinical Assessment and Diagnosis . . . which is coming out soon.

The clinical interview is a fundamental assessment and intervention procedure that mental and behavioral health professionals learn and apply throughout their careers. Psychotherapists across all theoretical orientations, professional disciplines, and treatment settings employ different interviewing skills, including, but not limited to, nondirective listening, questioning, confrontation, interpretation, immediacy, and psychoeducation. As a process, the clinical interview functions as an assessment (e.g., neuropsychological or forensic examinations) or signals the initiation of counseling or psychotherapy. Either way, clinical interviewing involves formal or informal assessment.

Clinical interviewing is dynamic and flexible; every interview is a unique interpersonal interaction, with interviewers integrating cultural awareness, knowledge, and skills, as needed. It is difficult to imagine how clinicians could begin treatment without an initial clinical interview. In fact, clinicians who do not have competence in using clinical interviewing as a means to initiate and inform treatment would likely be considered unethical (Welfel, 2016).

Clinical interviewing has been defined as

“a complex and multidimensional interpersonal process that occurs between a professional service provider and client [or patient]. The primary goals are (1) assessment and (2) helping. To achieve these goals, individual clinicians may emphasize structured diagnostic questioning, spontaneous and collaborative talking and listening, or both. Clinicians use information obtained in an initial clinical interview to develop a [therapeutic relationship], case formulation, and treatment plan” (Sommers-Flanagan & Sommers-Flanagan, 2017, p. 6)

A Generic Clinical Interviewing Model

All clinical interviews follow a common process or outline. Shea (1998) offered a generic or atheoretical model, including five stages: (1) introduction, (2) opening, (3) body, (4) closing, and (5) termination. Each stage includes specific relational and technical tasks.

Introduction

The introduction stage begins at first contact. An introduction can occur via telephone, online, or when prospective clients read information about their therapist (e.g., online descriptions, informed consents, etc.). Client expectations, role induction, first impressions, and initial rapport-building are central issues and activities.

First impressions, whether developed through informed consent paperwork or initial greetings, can exert powerful influences on interview process and clinical outcomes. Mental health professionals who engage clients in ways that are respectful and culturally sensitive are likely to facilitate trust and collaboration, consequently resulting in more reliable and valid assessment data (Ganzini et al., 2013). Technical strategies include authentic opening statements that invite collaboration. For example, the clinician might say something like, “I’m looking forward to getting to know you better” and “I hope you’ll feel comfortable asking me whatever questions you like as we talk together today.” Using friendliness and small talk can be especially important to connecting with diverse clients (Hays, 2016; Sue & Sue, 2016). The introduction stage also includes discussions of (1) confidentiality, (2) therapist theoretical orientation, and (3) role induction (e.g., “Today I’ll be doing a diagnostic interview with you. That means I’ll be asking lots of questions. My goal is to better understand what’s been troubling you.”). The introduction ends when clinicians shift from paperwork and small talk to a focused inquiry into the client’s problems or goals.

Opening

The opening provides an initial focus. Most mental health practitioners begin clinical assessments by asking something like, “What concerns bring you to counseling today?” This question guides clients toward describing their presenting problem (i.e., psychiatrists refer to this as the “chief complaint”). Clinicians should be aware that opening with questions that are more social (e.g., “How are you today?” or “How was your week?”) prompt clients in ways that can unintentionally facilitate a less focused and more rambling opening stage. Similarly, beginning with direct questioning before establishing rapport and trust can elicit defensiveness and dissembling (Shea, 1998).

Many contemporary therapists prefer opening statements or questions with positive wording. For example, rather than asking about problems, therapists might ask, “What are your goals for our meeting today?” For clients with a diverse or minority identity, cultural adaptations may be needed to increase client comfort and make certain that opening questions are culturally appropriate and relevant. When focusing on diagnostic assessment and using a structured or semi-structured interview protocol, the formal opening statement may be scripted or geared toward obtaining an overview of potential psychiatric symptoms (e.g., “Does anyone in your family have a history of mental health problems?”; Tolin et al., 2018, p. 3).

Body

The interview purpose governs what happens during the body stage. If the purpose is to collect information pertaining to psychiatric diagnosis, the body includes diagnostic-focused questions. In contrast, if the purpose is to initiate psychotherapy, the focus could quickly turn toward the history of the problem and what specific behaviors, people, and experiences (including previous therapy) clients have found more or less helpful.

When the interview purpose is assessment, the body stage focuses on information gathering. Clinicians actively question clients about distressing symptoms, including their frequency, duration, intensity, and quality. During structured interviews, specific question protocols are followed. These protocols are designed to help clinicians stay focused and systematically collect reliable and valid assessment data.

Closing

As the interview progresses, it is the clinician’s responsibility to organize and close the session in ways that assure there is adequate time to accomplish the primary interview goals. Tasks and activities linked to the closing include (1) providing support and reassurance for clients, (2) returning to role induction and client expectations, (3) summarizing crucial themes and issues, (4) providing an early case formulation or mental disorder diagnosis, (5) instilling hope, and, as needed, (6) focusing on future homework, future sessions, and scheduling (Sommers-Flanagan & Sommers-Flanagan, 2017).

Termination

Termination involves ending the session and parting ways. The termination stage requires excellent time management skills; it also requires intentional sensitivity and responsiveness to how clients might react to endings in general or leaving the therapy office in particular. Dealing with termination can be challenging. Often, at the end of an initial session, clinicians will not have enough information to establish a diagnosis. When diagnostic uncertainty exists, clinicians may need to continue gathering information about client symptoms during a second or third session. Including collateral informants to triangulate diagnostic information may be useful or necessary.

See the 6th edition of Clinical Interviewing for MUCH more on this topic: https://www.amazon.com/Clinical-Interviewing-John-Sommers-Flanagan/dp/1119215587/ref=sr_1_1?crid=1J46F6YFDV7XG&keywords=clinical+interviewing+6th+edition+sommers-flanagan&qid=1561646075&s=books&sprefix=clinical+inter%2Cstripbooks%2C242&sr=1-1

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A clinical interview is a tool that helps physicians, psychologists, and researchers make an accurate diagnosis of a variety of mental illnesses, such as obsessive-compulsive disorder (OCD). There are two common types: structured clinical interviews and clinical diagnostic interviews.

The gold standard for structured clinical interviews is the Structured Clinical Interview for DSM-5, also known as SCID. It is a semi-structured interview guide that is administered by a psychologist or other mental health professional who is familiar with the diagnostic criteria of mental health conditions.

Structured clinical interviews have a variety of uses, including:

• Assessing patients in order to make a diagnosis based on the Diagnostic and Statistical Manual of Mental Health Disorders, 5th Edition (DSM-5)
• Practice for students going into the mental health field to become better interviewers
• Research to study certain groups of people who all have the same symptoms or clinical trials

SCIDs can also help determine if you have more than one illness. They contain standardized questions to ensure that each patient is interviewed in the same way.

Since many of the questions concerning diagnostic criteria are subjective (in comparison, for example, to the number on a blood test which may be used to diagnose a physical disorder), a standardized guide such as the SCID helps to make sure studies are looking at people with the same general symptoms.

A structured clinical interview helps to make a largely subjective diagnosis a little more objective.

The questions on the SCID range from asking about your family and medical history to your illnesses and current complaints, as well as the nature, severity, and duration of the symptoms you have experienced. The questions get very detailed and specific, but not all questions will need answers since the SCID covers a broad range of illnesses, most of which you probably do not have. 

Questions that you may be asked during a structured clinical interview that are specifically about OCD include:

• Did your symptoms start after a new illness or taking a new drug?
• What are the specific details of your obsessions and compulsions?
• How long have you had these obsessions and compulsions?
• How have these obsessions and compulsions affected your life?
• Were you physically sick before you started having obsessions and/or compulsions?
• Were you using drugs before you started having obsessions and/or compulsions?
• How old were you when these symptoms started?

A SCID can take anywhere from 15 minutes to several hours to complete, depending on the severity and types of your symptoms.

Another valid way to assess and/or diagnose mental illness is by using a clinical diagnostic interview (CDI). CDIs are different in that they involve a conversation, or narrative, between the mental health professional and the patient instead of a list of standardized questions like the SCID entails.

A clinical diagnostic interview takes about two and a half hours, and the mental health professional doing the interview will likely take notes as you talk. A symptom checklist might also be used along with the CDI to help the interviewer make a diagnosis.

The questions during a CDI are much broader and leave you room to give details. Examples of questions are:

• What was your childhood like?
• What is your relationship with your mother/father/siblings like?
• What was school like for you?
• What sort of friendships did you have as a child?
• What have your romantic relationships been like?
• What is your job and how long have you done it?

You may be wondering if one interview method is better than the other. The short answer is no. In fact, a 2015 study showed that both interview methods are equally valid and useful. Which method a clinician uses will likely depend on the standard of their organization and/or personal preference.

It is extremely important that a thorough method of diagnosis is used, regardless of which interview method your therapist recommends to determine if you are coping with obsessive compulsive disorder or another mental health condition,

Too often, a mental health diagnosis is made without the help of these tools. With the information available on the Internet, people are increasingly self-diagnosing mental health conditions. And with a shortage of mental health providers (plus constraints on time and charges placed by third-party payers), this step is sometimes inappropriately streamlined.

Considering the great effect that OCD and other mental health disorders can have on a person's life, it is imperative that these initial diagnostic interviews are not skipped. Making a precise diagnosis is helpful in determining the type of treatments and therapies which have found to be most effective in clinical studies for that particular diagnosis.

It is also very important to conduct these interviews to get a baseline as to how much the condition is interfering with your life. Progress in mental health can sometimes be slow and often follows the proverbial three steps forward and two steps back trajectory. Understanding exactly what you were coping with at the time you were diagnosed can help your therapist determine if your current therapy plan is working, or if a different approach is needed.

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1. Drill R, Nakash O, DeFife J, Westen D. Assessment of clinical information: Comparison of the validity of a structured clinical interview (the SCID) and the clinical diagnostic interview. J Nerv Ment Dis. 2015 Jun;203(6):459-62. doi:10.1097/NMD.0000000000000300

2. Rapp A, Bergman L, Piacentini J, McGuire J. Evidence-based assessment of obsessive-compulsive disorder. J Cent Nerv Syst Dis. 2016;8:13-29. doi:10.4137/JCNSD.S38359

• Drill, R., Nakash, O., DeFife, J., and D. Westen. Assessment of Clinical Information: Comparison of the Validity of a Structured Clinical Interview (the SCID) and the Clinical Diagnostic Interview. Journal of Nervous and Mental Disorders. 2015. 203(6):459-62.
• Rapp, A., Bergman, L., Piacentini, J., and J. McGuire. Evidence-Based Assessment of Obsessive-Compulsive Disorder. Journal of Central Nervous System Disease. 2016. 8:13-29.