Module 2: Clinical Interview

Unit 1: Goals, General skills and specific behaviours of interviewer, Components of interview –
Rapport and Techniques

Generally, there are four possible goals of a clinical interview. ese 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 informa tion,italsomovesbeyondproblemdenition
or diagnosis and involves the introduction of
atreatmentplantoapatient);(d)thegoalof
providing, as appropriate and as needed, a spe-
cic educational or therapeutic intervention,
or referral for a specic intervention; this
intervention is tailored to the patient’s particu-
lar problem or problem situation (as dened in
items b and c)
The clinical interview has been referred to as the foundation of all mental health treatment and as arguably
the most valuable skill among psychologists and other mental health practitioners. Clinical interviewing has
been defined in many ways by many authors. At its core, the clinical interview involves a professional
relationship between a mental health provider and a patient or client. Whether patients are voluntary or
mandated, usual and customary ethical practice requires that professional clinical interviewers provide both
written and oral informed consent. Informed consent is used not only to obtain consent for treatment, but
also to educate patients about what to expect during the clinical interview.

psychologists and psychiatrists aligned with

the medical model consider the clinical inter-
view as primarily a method for investigating
patient symptoms and establishing a psy-
chiatric diagnosis. In such cases, the clinical
interview may be referred to as a diagnostic
or psychiatric interview
Psychologists and psychiatrists aligned with the medical model consider the clinical inter-view as primarily
a method for investigating patient symptoms and establishing a psychiatric diagnosis. In such cases, the
clinical interview may be referred to as a diagnostic or psychiatric interview.

clinical interview, in part, as a “conversa-

tion characterized by respect and mutuality, by
immediacy and warm presence, and by empha-
sisonstrengthsandpotential
Clinical interview is described as a “conversation characterized by respect and mutuality, by immediacy and
warm presence, and by emphasis on strengths and potential. Traditionally, clinical interviews have a pre-
determined duration of 50 min, but many variations exist. In all cases the clinical interview is a rich and
complex interpersonal interaction between mental health professional and patient.

In
allcasestheclinicalinterviewisarichand
complex interpersonal interaction between
mental health professional and patient.
GOALS OF CLINICAL INTERVIEW

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
(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 of 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
(e) All clinical interviews implicitly address the

(f) rst two primary goals (i.e., relationship devel-

(g) opment and assessment or evaluation). Some

(h) clinical interviews also include, to some extent,

(i) case formulation or psychological intervention

(j) All clinical interviews implicitly address the

(k) rst two primary goals (i.e., relationship devel-

(l) opment and assessment or evaluation). Some

(m)clinical interviews also include, to some extent,

(n) case formulation or psychological intervention

(o) All clinical interviews implicitly address the

(p) rst two primary goals (i.e., relationship devel-

(q) opment and assessment or evaluation). Some

(r) clinical interviews also include, to some extent,

(s) case formulation or psychological intervention

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

The Interviewer

The most fundamental element of a clinical interview is the person who conducts it. A skilled interviewer
only is not a master of the technical and practical aspects of the interview but also demonstrates broad-based
wisdom about the human interaction it entails.

GENERAL SKILLS

General skills focus on the interviewer’s own frame of mind rather than any particular set of techniques.
Sommers-Flanagan and Sommers-Flanagan (2009) describe several such requirements: quieting yourself,
being self-aware, and developing positive working relationships.

1. Quieting yourself

The term quieting yourself does not simply mean that the interviewer shouldn’t talk much during the
interview (although rambling by the interviewer is usually not a good idea). Rather than the interviewer’s
speech, what should be quieted is the interviewer’s internal, self-directed thinking pattern. To the extent that
interviewers are preoccupied by their own thoughts, they will struggle in the fundamental task of listening to
their clients. Simply put, the voice in the interviewer’s own mind should not interrupt or drown out the voice
of the client.

2. Being self-aware

Being self-aware is another important skill for the clinical interviewer. This self-awareness should not be
confused with the excessive self-consciousness, which should be minimized. The type of self-awareness that
should be maximized is the interviewer’s ability to know how he or she tends to affect others interpersonally
and how others tend to relate to him or her. Every interviewer has a distinct combination of idiosyncratic
qualities—looks, voice, mannerisms, body language, accents, and so on—that may evoke certain responses
from clients. Skilled interviewers are cognizant of their unique traits, including their cultural assumptions as
well as more superficial characteristics, and consider their effect on the interview process.

3. Developing positive working relationships

There is no formula for developing positive working relationships during an interview; however, attentive
listening, appropriate empathy, genuine respect, and cultural sensitivity play significant roles. Positive
working relationships are always a function of the interviewer’s attitude as well as the interviewer’s actions

SPECIFIC BEHAVIORS

When interviewers succeed in quieting themselves, knowing themselves, and developing good working
relationships, they have laid the groundwork for conducting successful interviews. The next task is to master
the tools of the trade, the specific behaviors characteristic of effective interviewers.

Eye Contact
Eye contact not only facilitates listening, but it also communicates listening. That is, when the client notices
the interviewer’s continuous, appropriate eye contact, the client feels heard. Of course, culture plays a
significant role in the meaning of eye contact. In some cultures, eye contact that lasts too long or is too
intense may communicate threat, seduction, or other messages that an interviewer would be wise to avoid.
On the other hand, scarce, inconsistent eye contact may be viewed by some clients as inattentive or
insulting. Like so many other aspects of the clinical interview, eye contact is a specific behavior that
requires cultural knowledge and sensitivity on the part of the interviewer, both as the sender and receiver of
eye contact.

Body Language
As with eye contact, culture can shape the connotations of body language. There are a few general rules for
the interviewer: face the client, appear attentive, minimize restlessness, display appropriate facial
expressions, and so on. But even these basic rules are subject to cultural interpretation, and a client may not
feel understood if an interviewer unknowingly communicates disinterest through body language.
Furthermore, the client’s body language can be misinterpreted by an interviewer whose knowledge of the
client’s cultural background is deficient.

Vocal Qualities
Skilled interviewers have mastered the subtleties of the vocal qualities of language—not just the words but
how those words sound to the client’s ears. They use pitch, tone, volume, and fluctuation in their own voices
to let clients know that their words and feelings are deeply appreciated. And these interviewers also attend
closely to the vocal qualities of their clients.

Verbal Tracking
Effective interviewers are able to repeat key words and phrases back to their clients to assure the clients that
they have been accurately heard. Interviewers don’t do this in a mechanical way; instead, they weave the
clients’ language into their own. In addition, interviewers skilled at verbal tracking monitor the train of
thought implied by clients’ patterns of statements and are thus able to shift topics smoothly rather that
abruptly.

Referring to the Client by the Proper Name

It sounds simple enough, but using the client’s name correctly is essential (Fontes, 2008). Inappropriately
using nicknames or shortening names (e.g., calling Benjamin “Benji”), omitting a “middle” name that is in
fact an essential part of the first name (e.g., calling John Paul “John”), or addressing a client by first name
rather than a title followed by surname (e.g., addressing Ms. Washington as “Latrice”) are presumptuous
mistakes that can jeopardize the client’s sense of comfort with the interviewer. Especially with clients of
certain ethnicities or ages, the misuse of names in this way may be disrespectful and may be received as a
micro aggression.

The initial interview is an ideal opportunity to ask clients how they would prefer to be addressed and to
confirm that it is being done correctly. This gesture in itself can be interpreted by clients as a sign of
consideration. The interviewer should carry out all these attending behaviors naturally and authentically.
Specific examples of the importance of cultural variables to listening during the clinical interview may help
illustrate the points above. Compared with traditional Western culture, Chinese culture tends to feature far
less eye contact, especially between members of the opposite sex. Eye contact that falls within the normal
range among Western individuals may communicate rudeness or sexual desire among Chinese people.
Norms for physical touch also differ from one culture to another, with Asian cultures typically incorporating
less than European Americans. Thus, a touch on the shoulder, intended and received as innocuous from one
European American to another, might be received as inappropriate by an Asian individual. People from
diverse cultures have also developed measurable differences in the physical distance or “personal space”
they maintain.

COMPONENTS OF THE INTERVIEW

Although interviews may vary drastically according to the setting, purpose, and other factors, several
components are universal to interviews: rapport, technique, and conclusions.
1. Rapport
Rapport refers to a positive, comfortable relationship between interviewer and client. When clients feel a
strong sense of rapport with interviewers, they feel that the interviewers have “connected” with them and
that the interviewers empathize with their issues. In this situation, clients tend to disclose more information
and invest themselves further in the interview process than they might have otherwise.
No foolproof technique exists, however, there are some specific efforts interviewers can make to enhance
the client’s experience of rapport.
a) First, interviewers should make an effort to put the client at ease, especially early in the interview
session. For some clients, the first visit to a clinical psychologist can be daunting. They may be fearful
about the interview or may be under a misperception of what the session will entail. Engaging in small
talk about innocuous topics (“Did you have any trouble finding the office?” or “I haven’t been outside in
a while—is it still cold out?”) for a minute or two at the beginning of the interview can make an initially
nervous client feel more comfortable. Of course, this small talk should not be excessive, nor should it
distract from the purposes of the interview.
b) Second, interviewers can acknowledge the unique, unusual situation of the clinical interview. From the
client’s perspective, the interview experience is unlike any other interaction: They are expected to
discuss private, difficult, often emotionally charged issues with a person they just met and know very
little about. Letting clients know that you recognize their position and appreciate their willingness to
participate communicates empathy and enhances rapport. Along the same lines, inviting clients to ask
questions about the interview process provides them with a sense of knowledge and control, which can
also improve their comfort level.
c) Third, interviewers can enhance rapport by noticing how the client uses language and then following the
client’s lead. Interviewers should pick up on the client’s vocabulary and, as much as possible, speak in
similar terms. If they use more tactile, “touch” words (“It feels like everything’s slipping through my
fingers,” “I’m losing my grip,” etc.), interviewers should respond accordingly. When a client uses a
metaphor, the interviewer can extend it.

2. Technique
If rapport is how an interviewer is with clients, technique is what an interviewer does with clients. These are
the tools in the interviewer’s toolbox, including questions, responses, and other specific actions.

i) Directive versus Nondirective Styles

Interviewers who use a directive style get exactly the information they need by asking clients specifically for
it. Directive questions tend to be targeted toward specific pieces of information, and client responses are
typically brief, sometimes as short as a single word (e.g., “yes” or “no”). On the other hand, interviewers
who use a nondirective style allow the client to determine the course of the interview. Without direction
from the interviewer, a client may choose to spend a lot of time on some topics and none on others.
Certainly, both directive and nondirective approaches play an important role in interviewing. Direct
questioning can provide crucial data that clients may not otherwise choose to discuss: important historical
information (“Is there a history of schizophrenia in your family?”).

Indirect questioning, conversely, can provide crucial information that interviewers may not otherwise know
to inquire about.
Both directive and nondirective approaches have shortcomings as well, especially when an interviewer relies
too heavily on either one. Sometimes, directive approaches can sacrifice rapport in favor of information. In
other words, interviewers who are overly directive may leave clients feeling as though they didn’t have a
chance to express themselves or explain what they thought was important. Although nondirective
interviewing can facilitate rapport, it can fall short in terms of gathering specific information. Interviewers
who are overly nondirective may finish an interview without specific data that are necessary for a valid
diagnosis, conceptualization, or recommendation.

ii) Specific Interviewer Responses

Ultimately, interviewing technique consists of what the interviewer chooses to say. The interviewer’s
questions and comments can span a wide range and serve many purposes. There are numerous common
categories of interviewer responses: open- and closed-ended questions, clarification, confrontation,
paraphrasing, reflection of feeling, and summarizing.

a) Open- and Closed-Ended Questions

Whether a question is open- or closed-ended can have great impact on the information a client provides
an interviewer. Open-ended questions allow for individualized and spontaneous responses from clients.
These responses tend to be relatively long, and although they may include a lot of information relevant
to the client, they may lack details that are important to the clinical psychologist.
Closed-ended questions allow for far less elaboration and self-expression by the client but yield quick
and precise answers. Indeed, open-ended questions are the building blocks of the nondirective
interviewing style described above, whereas the directive interviewing style typically consists of
closed-ended questions.
b) Clarification
The purpose of a clarification question is to make sure the interviewer has an accurate understanding of
the client’s comments. Clarification questions not only enhance the interviewer’s ability to “get it,”
they also communicate to the client that the interviewer is actively listening and processing what the
client says. [ For example, with Brianna (the client with bulimic symptoms described above), the
interviewer may at one point say, “I want to make sure I’m understanding this correctly—did you
mention that you’ve been struggling with eating-related issues for about 6 months?” ]
c) Confrontation
Interviewers use confrontation when they notice discrepancies or inconsistencies in a client’s
comments. Confrontations can be similar to clarifications, but they focus on apparently contradictory
information provided by clients. [For example, an interviewer might say to Brianna, “Earlier, you
mentioned that you had been happy with your body and weight as a teenager, but then a few minutes
ago you mentioned that during high school you felt fat in comparison with many of your friends. I’m a
bit confused.]
d) Paraphrasing
 Paraphrasing is used simply to assure clients that they are being accurately heard. When interviewers
paraphrase, they typically restate the content of clients’ comments, using similar language. A
paraphrase usually doesn’t break new ground; instead, it maintains the conversation by assuring the
client that the interviewer is paying attention and comprehending. ( So if Brianna mentions, “I only
binge when I’m alone,” the interviewer might immediately respond with a statement such as, “You
only binge when no one else is around.”)
e) Reflection of Feeling
Whereas a paraphrase echoes the client’s words, a reflection of feeling echoes the client’s emotions.
Reflections of feeling are intended to make clients feel that their emotions are recognized, even if their
comments did not explicitly include labels of their feelings. Unlike paraphrasing, reflecting a client’s
feelings often involves an inference by the interviewer about the emotions underlying the client’s
words. ( For example, if Brianna’s comment above (“I only binge when I’m alone”) was delivered
with a tone and body language that communicated shame—her hand covering her face, her voice
quivering, and her eyes looking downward—the interviewer might respond with a statement like, “You
don’t want anyone to see you binging—do you feel embarrassed about it?”)
d) Summarizing
At certain points during the interview—most often at the end—the interviewer may choose to summarize
the client’s comments. Summarizing usually involves tying together various topics that may have been
discussed, connecting statements that may have been made at different points, and identifying themes
that have recurred during the interview. Like many of the other responses described above, summarizing
lets clients know that they have been understood but in a more comprehensive, integrative way than, say,
paraphrasing single statements. An accurate summarization conveys to the client that the interviewer has
a good grasp on the “big picture.”
(for eg: After a full interview with Brianna, an interviewer may summarize by offering statements along
the lines of, “It seems as though you are acknowledging that your binging and purging have become
significant problems in recent months, and while you’ve kept it to yourself and you may feel ashamed
about it, you’re willing to discuss it here with me and you want to work toward improving it.”)

3. Conclusions

Typically, clinical interviews involve a conclusion of some kind made by the interviewer. The conclusion
can take a number of different forms, depending on the type of interview, the client’s problem, the setting, or
other factors. In some cases, the conclusion can be essentially similar to a summarization, as described
above. Or the interviewer might be able to go a step further by providing an initial conceptualization of the
client’s problem that incorporates a greater degree of detail than a brief summarization statement. In some
situations, the conclusion of the interview may consist of a specific diagnosis made by the interviewer on the
basis of the client’s response to questions about specific criteria. Or the conclusion may involve
recommendations. These recommendations might include outpatient or inpatient treatment, further
evaluation (by another psychologist, psychiatrist, or health professional), or any number of other options.

UNIT 2 : PRAGMATICS OF INTERVIEW

Note taking

Written notes are certainly more reliable than the interviewer’s memory. Many clients will expect the
interviewer to take notes and may feel as though their words will soon be forgotten if the interviewer is not
taking notes. On the other hand, there are also drawbacks to taking notes. The process of note taking can be
a distraction, both for the interviewer, who may fail to notice important client behaviors while looking down
to write, and for the client, who may feel that the interviewer’s notebook is an obstacle to rapport. Some
interviewers aim for a middle ground between no notes and excessive notes, such that they jot down the
most essential highlights of an interview but prevent the note-taking process from disrupting the
conversation or their attention toward the client.

In some clinical situations, interviewers may be wise to explain their note-taking behavior to clients. In
particular, a client-centered rationale for the note-taking behavior— “I’m taking notes because I want to
make sure I have a good record of what you have told me” Or “I don’t take notes during interviews because
I don’t want anything to distract either of us from our conversation”—may enhance rapport between
interviewer and client (Fontes, 2008; Sommers-Flanagan & Sommers-Flanagan, 2009).

Some research has looked at how note-taking impacts interviews, but the results are mixed. One study found
that using different note-taking tools like pen and paper, iPad, or computer didn't affect the relationship
between the interviewer and the interviewee. However, another study discovered that when interviewers
used computers to take notes, the quality of the relationship with the client was lower compared to not
taking notes at all.

It is likely that the effect of note taking is highly dependent on the particular situation, including exactly how
a client interprets the use of any particular mode of note taking and exactly how an interviewer uses that
mode.

Audio and Video recording

Clinical psychologists may prefer to audio or video-record the session. Unlike note taking, recording a
client’s interview requires that the interviewer obtain written permission from the client. While obviously
providing a full record of the entire session, recordings can, with some clients, hinder openness and
willingness to disclose information. As with note taking, an explanation of the rationale for the recording, as
well as its intended use (e.g., review by the interviewer or a supervisor) and a date by which it will be erased
or destroyed, is typically appreciated by the client.

Interview Room

As a general rule, “when choosing a room [for interviews], it is useful to strike a balance between
professional formality and casual comfort” (Sommers-Flanagan & Sommers-Flanagan, 2009). That is, the
interview room should subtly convey the message to the client that the clinical interview is a professional
activity but one in which warmth and comfort are high priorities.

Seating arrangements in interview rooms can be different and have various options. For example, the
traditional setup where the client lies on a couch while the interviewer sits in a chair, or they may sit face-to-
face or at an angle. There could be a table or small side tables between them, or no furniture at all. The
chairs themselves can be of different styles.

The most important thing is that the interview room should help achieve the main goals of the interview, like
gathering information and creating a good connection in a private space without interruptions. As long as the
room serves these purposes, the specific seating arrangement can be chosen based on what works best for
the interviewer and client (Sommers-Flanagan & Sommers-Flanagan, 2009).

Devlin and Nasar (2012) conducted a study where they asked therapists and non-professionals to look at
pictures of different therapists' offices and rate them. They found that people preferred offices that were neat
and organized, with comfortable furniture, soft lighting, art, and plants. They liked spacious and uncluttered
offices more than cramped ones with messy piles of papers and tangled cords. The study shows that the
choices therapists make about their office setup can be important in creating a positive impression on clients.

Clinical psychologists avoid putting personal items like family photos, souvenirs, and memorabilia in their
office decor. These items might not create a professional atmosphere that the interview room should have,
and they could also impact the content of the interview in some cases.

Confidentiality

When clients come for an interview with a psychologist, they may have wrong ideas about confidentiality.
Some think everything is completely confidential, but there are situations where the psychologist may have
to break confidentiality. These situations are usually defined by the law and involve cases where the client
might harm themselves or others, or if there's ongoing child abuse.

On the other hand, some clients might worry that their personal information will be shared with family,
bosses, or others. To clear up these misunderstandings, psychologists should explain their confidentiality
policies early on in the process. This explanation should be consistent with the law and ethics, and it's a
good idea to provide it in writing and discuss it orally as well. By doing this, psychologists demonstrate that
they are competent and ethical in their practice (American Psychological Association, 2002).
UNIT 3

Types of Interviews

Clinical interviews take on different forms according to the demands of the situation, which may depend on

the setting, the client’s presenting problem, and the issues the interview is intended to address. In actual

practice, there are countless unique, idiosyncratic varieties of interviews, but most fall into a few broad

categories:

1. Intake interviews,
2. Diagnostic interviews,
3. Mental status exams,
4. Crisis interviews.

1. Intake Interviews
The purpose of the intake interview is essentially to determine whether to “intake” the client to the setting

where the interview is taking place. In other words, the intake interview determines whether the client needs

treatment; if so, what form of treatment is needed (inpatient, outpatient, specialized provider, etc.); and

whether the current facility can provide that treatment or the client should be referred to a more suitable

facility. Intake interviews typically involve detailed questioning about the presenting complaint.

Intake interviews typically involve detailed questioning about the presenting complaint. Questions about the

frequency, intensity, and duration of Julia’s psychotic symptoms, as well as symptoms of other conditions,

are asked here. Clinical psychologists would also closely observe patient during the interview and note any

relevant behaviors. Questions about the patient’s personal history, especially the previous existence of this

or other psychological or psychiatric problems, would also be an important part of the intake interview. At

the conclusion of the interview, Psychologists would use all information solicited to decide whether the

patient’s problems would be best treated at this community mental health center and, if so, recommend a

particular mode or frequency of treatment. If not, provide a referrals to other treatment providers, including

inpatient or outpatient settings as appropriate.

2. Diagnostic Interviews
As the name indicates, the purpose of the diagnostic interview is to diagnose. At the end of a well-conducted

diagnostic interview, the interviewer is able to confidently and accurately assign Diagnostic and Statistical

Manual of Mental Disorders (DSM) diagnoses to the client’s problems. When an interview yields a valid,

specific diagnosis, the effectiveness of the recommendations and subsequent treatment may be increased. If

the purpose of the diagnostic interview is to produce a diagnosis, it would make sense for the diagnostic

interview to include questions that relate to the criteria of DSM disorders.

How directly should the questions reflect the diagnostic criteria? Some clinical psychologists believe that the

questions should essentially replicate the DSM criteria; after all, if our profession follows a diagnostic

manual with disorders defined by meticulous lists of symptoms, what better way to reach a diagnosis than to

ask directly about each symptom? Other clinical psychologists believe that every question in a diagnostic

interview need not be coupled with a specific DSM diagnostic criterion. These clinical psychologists prefer

a more flexible interview style in which they choose or create questions as they move through the interview,

and they use inference rather than absolute fact to make diagnostic decisions. In other words, some clinical

psychologists prefer structured interviews, while others prefer unstructured interviews.

3. Mental Status Exam

Case History

It is the detailed account of facts affecting the development or condition of the person or group under

treatment or study especially in medicine, psychiatry, or psychological setting.

Gathering information, both objective and subjective for the purpose of generating diagnosis, evaluating

progress, following a specific treatment, and evaluating change in the patient’s condition or impact of a

specific disease.
Demographic Detail: age, gender, religion, education

Presenting Complaints: This section focuses on the main issues that led the individual to seek help. It is

expressed in simple, non-technical language, often in the patient's own words, and should be listed in

chronological order along with the duration of each symptom.

History of Presenting Illness: Here, detailed information is gathered about when the patient's problematic

behavior or symptoms initially appeared. It provides a chronological account of the central problem, how

symptoms have evolved, and the sequence of each presenting complaint.

Biological Functions/Associated Disturbances: This section notes any disturbances in biological

functions, such as sleep, appetite, or excretory patterns, as these can be relevant to the individual's

psychological well-being.

Negative History: By ruling out certain factors, like head injury or seizures, this section helps narrow down

possible diagnoses. It emphasizes elements that can aid in diagnosis and confirms a lack of history of

psychological illness.

Past History: This includes the individual's medical history, psychiatric history, and substance use history.

It provides insights into their physical health, mental health background, and any substance-related issues.
Family History: The patient's and relatives' health information across three generations is recorded. It may

involve creating a genogram to map family patterns and relationships and assess psychiatric morbidity

within the family.

Current Social Situation: Information about the individual's home circumstances, income, emotional

range, cultural and religious values, and social support system is gathered. The type of family structure

(nuclear or joint) and birth order are specified.

Personal History: This section collects data about the person's life experiences:

Birth History: Covers the period before and after birth, including any complications.

Childhood History: Provides insights into upbringing, primary caregivers, childhood experiences, and any

potential abuse or bullying.

Educational History: Includes details about formal education, school type, academic performance,

relationships with peers and teachers, and any learning difficulties.

Occupational History: Records work-related information, such as job history, changes, relationships with

authorities, and income.

Menstrual History: For female patients, this includes menarche age, menstrual regularity, and associated

mood disturbances. Information about the last menstrual period and menopause age is also collected.

Marital History: Details about marital status, the duration of marriage, the type of marriage (arranged or

love), and information about separation or divorce, if applicable.

Sexual History: Covers sexual orientation, sexual functioning, abnormal sexual behaviors, and any history

of pre-marital or extra-marital relationships.

Premorbid Personality: Describes personality traits before the onset of illness or injury, such as

interpersonal tendencies and mood.

Use of Leisure Time: Notes how the individual spends their free time and hobbies.
Habits and Fantasy Life: Explores habits, religious beliefs, moral attitudes, and the patient's attitude

towards work and responsibility.

Mental Status Examination

The mental status exam should include the general awareness and responsiveness of the patient.

Additionally, one may also include the orientation, intelligence, memory, judgment, and thought process of

the patient. At the same time, the patient's behavior and mood should undergo assessment.

Initial Formulation: Grounded in the biopsychosocial model, this stage summarizes the insights gained

from the case history and Mental Status Examination (MSE).

It involves identifying defense mechanisms, understanding relationships, recognizing strengths, and

evaluating various factors contributing to the individual's psychological well-being.

Points in Favor: This aspect relies on diagnostic criteria found in the DSM (Diagnostic and Statistical

Manual of Mental Disorders) or ICD (International Classification of Diseases).

It specifies the symptoms present that align with the established diagnostic criteria.

Provisional Diagnosis: The clinician arrives at a preliminary diagnosis based on the points in favor

identified during the assessment.

Differential Diagnosis: In situations where an individual meets diagnostic criteria for more than one

disorder, a differential diagnosis is considered. This helps in distinguishing between potential diagnoses.

Prognostic Factors: An analysis of the individual's abilities and potential is conducted, providing insights

into their future development.

This assessment identifies both positive (good prognostic factors) and negative (bad prognostic factors)

indicators.

Psychological Assessment: Psychological tests are administered as part of the assessment process, aiding in

the formulation of a diagnosis and treatment plan.

Final Formulation: A comprehensive summary is created, integrating the findings from the psychological

assessment, Mental Status Examination, and case history.

Intervention: Based on the gathered information, a treatment plan is developed to address the individual's

psychological well-being.

Mental status examination

The mental status exam is employed most often in medical settings. Its primary purpose is to quickly assess

how the client is functioning at the time of the evaluation. The mental status exam does not delve into the

client’s personal history, nor is it designed to determine a DSM diagnosis definitively. Instead, its yield is

usually a brief paragraph that captures the psychological and cognitive processes of an individual “right

now”—like a psychological snapshot.

The format of the mental status exam is not completely standardized, so it may be administered differently

by various health professionals. (Psychiatrists, in addition to clinical psychologists and other mental health

professionals, often use the mental status exam.) Although specific questions and techniques may vary, the

following main categories are typically covered:

● Appearance Behavior/psychomotor activity

● Attitude toward examiner
● Affect and mood
● Speech and thought
● Perceptual disturbances
● Orientation to person, place, and time
● Memory and intelligence
● Reliability, judgment, and insight

Appearance and Behavior:

Appearance: Note the individual's age, gender, grooming, clothing, hygiene, and any unusual physical

characteristics.
Behavior: Observe their motor activity, posture, facial expressions, eye contact, and overall demeanor.

Motor Activity and Psychomotor Skills:

Note any abnormalities in motor behavior, such as agitation, psychomotor retardation, or catatonia.

Attitude and Relationship:

Attitude: Assess their cooperative, hostile, anxious, or indifferent demeanor.

Relationship: Describe how they interact with the examiner, such as being cooperative, distant, or avoidant.

Mood and Affect:

Mood: Ask the individual how they're feeling, and note if they report being happy, sad, anxious, or any

other mood.

Affect: Observe their emotional expression during the interview. Note if their affect matches their reported

mood (e.g., congruent or incongruent affect).

Thought Process:

Thought Form: Evaluate the coherence and organization of their thoughts. Note if there are logical or

tangential thought patterns, thought blocking, or flight of ideas.

Thought Content: Assess the content of their thoughts for any delusions, obsessions, phobias, or

suicidal/homicidal ideation.

Perception:
Hallucinations: Ask if the individual is experiencing hallucinations (e.g., auditory, visual, tactile) and note

their content and frequency.

Illusions: Inquire about any misperceptions of reality.

Cognition:

Orientation: Assess their awareness of time (date, day, year), place (current location), and person (self and

others).

Memory: Evaluate both immediate (recalling recent events) and remote (recalling past events) memory.

Attention and Concentration: Test their ability to focus and sustain attention, often using tasks like serial

sevens or spelling words backward.

Language and Speech: Observe their fluency, coherence, and any abnormalities in speech (e.g., pressured

speech, poverty of speech).

Abstract Thinking: Assess their ability to think abstractly through questions or proverbs.

Insight and Judgment:

Insight: Ask if they recognize their mental health condition, its implications, and the need for treatment.

Insight:

Grade I: Complete denial - The patient will not accept that he/she has an illness

Grade II: Slight awareness - The patient would say that something is wrong with him/her but does not

realize the cause.

Grade III: Awareness attributing to external factors - the patient would say he/she is unwell because of

other people or other external events.

Grade IV: Awareness attributing to unknown factors – Awareness of being sick due to something unknown

in the self

Grade V: Intellectual insight - knows about the nature of the illness, and its consequences but might find it

difficult to use this knowledge to help oneself

Grade VI: Emotional Insight or True Insight - Awareness which leads to significant changes in behavior.

Judgment: Evaluate their capacity to make sound decisions and solve problems, including assessing

hypothetical scenarios.

Additional Observations:

Any unusual or noteworthy behaviors, responses, or information that may be relevant to the assessment.

The MSE provides valuable information to clinicians in diagnosing mental health conditions, developing

treatment plans, and monitoring progress. It is a comprehensive tool that aids in understanding the

individual's mental state and any potential areas of concern.

Because of its lack of standardization, two interviewers who use the mental status exam may ask different

questions within the same category. For example, in the “memory and intelligence” category, the

interviewer may assess memory by asking the client about schools attended or age differences with siblings

and assess intelligence by asking the client to count backward by 7 from 100, to recall a brief series of

numbers or words, or to indicate the direction traveled between two cities. The mental status exam is not

intended as a meticulous, comprehensive diagnostic tool. Instead, it is intended for brief, flexible

administration, primarily in hospitals and medical centers, requiring no manual or other accompanying

materials.
 4. Crisis Interviews
The crisis interview is a special type of clinical interview and can be uniquely challenging for the

interviewer. Crisis interviews have purposes that extend beyond mere assessment. They are designed not

only to assess a problem demanding urgent attention (most often, clients actively considering suicide or

another act of harm toward self or others) but also to provide immediate and effective intervention for that

problem. Crisis interviews can be conducted in person but also take place often on the telephone via suicide

hotlines, crisis lines, and similar services.

Quickly establishing rapport and expressing empathy for a client in crisis, especially a suicidal client, are

key components of the interview. Providing an immediate, legitimate alternative to suicide can enable the

client to endure this period of very high distress and reach a later point in time when problems may feel less

severe or solutions may be more viable. Sometimes, interviewers in these situations ask clients to sign or

verbally agree to suicide prevention contracts. These contracts essentially require the client to contact the

interviewer before committing any act of self-harm.

When interviewing an actively suicidal person, five specific issues should be assessed (adapted from

SommersFlanagan & Sommers-Flanagan, 2009):

1. How depressed is the client? Unrelenting, long-term depression and a lack of hope for the future
indicate high risk.
2. Does the client have suicidal thoughts? If such thoughts have occurred, it is important to inquire
about their frequency and intensity.
3. Does the client have a suicide plan? Some clients may have suicidal thoughts but no specific plan.
If the client does have a plan, its feasibility (the client’s access to the means of self-harm, such as a
gun, pills, etc.), its lethality, and the presence of others (family, friends) who might prevent it are
crucial factors.
4. How much self-control does the client currently appear to have? Questions about similarly
stressful periods in the client’s past, or about moments when self-harm was previously contemplated,
can provide indirect information about the client’s self-control in moments of crisis.
5. Does the client have definite suicidal intentions? Direct questions may be informative, but other
indications such as giving away one’s possessions, putting one’s affairs in order, and notifying
friends and family about suicide plans can also imply the client’s intentions.

UNIT5

Structured versus unstructured interview

A structured interview is a predetermined, planned sequence of questions that an interviewer asks a client.

Structured interviews are constructed for particular purposes, usually diagnostic. A structured interview is a

quantitative research method where the interviewer a set of prepared closed-ended questions in the form of

an interview schedule, which he/she reads out exactly as worded. The interviewer will not deviate from the

interview schedule (except to clarify the meaning of the question) or probe beyond the answers received.

Replies are recorded on a questionnaire, and the order and wording of questions, and sometimes the range of

alternative answers, is preset by the researcher.

An unstructured interview, in contrast, involves no predetermined or planned questions. Instead, the

interviewer asks open-ended questions based on a specific research topic and will try to let the interview

flow like a natural conversation. The interviewer modifies his or her questions to suit the candidate’s

specific experiences. They determine their questions on the spot, seeking information that they decide is

relevant during the course of the interview’. Unstructured interviews are sometimes referred to as ‘discovery

interviews’ and are more like a ‘guided conservation’ than a strictly structured interview.

Structured interviews possess a number of advantages over unstructured interviews, particularly from a

scientific or empirical perspective:

• Structured interviews produce a diagnosis based explicitly on DSM criteria, reducing reliance on

subjective factors such as the interviewer’s clinical judgment and inference, which can be biased or

otherwise flawed.

• Structured interviews tend to be highly reliable, in that two interviewers using the same structured

interview will come to the same diagnostic conclusions far more often than two interviewers using

unstructured interviews. Overall, they are more empirically sound than unstructured interviews.

• Structured interviews are standardized and typically uncomplicated in terms of administration.

On the other hand, structured interviews have numerous disadvantages as well:

• The format of structured interviews is usually rigid, which can inhibit rapport and the client's

opportunity to elaborate or explain as he or she wishes.

• Structured interviews typically don’t allow for inquiries into important topics that may not be

directly related to DSM criteria, such as relationship issues, personal history, and problems that fall below or

between DSM diagnostic categories.

• Structured interviews often require a more comprehensive list of questions than is clinically

necessary, which lengthens the interview.

Advantages of unstructured interview

• Unstructured interviews are more flexible as questions can be adapted and changed depending on the

respondents’ answers. The interview can deviate from the interview schedule.

• Unstructured interviews generate qualitative data through the use of open questions. This allows the

respondent to talk in some depth, choosing their own words. This helps the researcher develop a real sense

of a person’s understanding of a situation.

• They also have increased validity because it gives the interviewer the opportunity to probe for a

deeper understanding, ask for clarification & allow the interviewee to steer the direction of the interview,

etc.

Limitations of unstructured Interview

• It can be time-consuming to conduct an unstructured interview and analyze the qualitative data

(using methods such as thematic analysis).

• Employing and training interviewers is expensive and not as cheap as collecting data via

questionnaires. For example, certain skills may be needed by the interviewer. These include the ability to

establish rapport and knowing when to probe.

• Biased questions so to elicit ‘fabricated’ answers. Interviewers may bias the respondents’ answers,

but interviewees may develop demand characteristics and social desirability issues.

Directive versus Nondirective Styles

Interviewers who use a directive style get exactly the information they need by asking clients specifically for

it. Directive questions tend to be targeted toward specific pieces of information, and client responses are

typically brief, sometimes as short as a single word (e.g., “yes” or “no”). On the other hand, interviewers

who use a nondirective style allow the client to determine the course of the interview. Without direction

from the interviewer, a client may choose to spend a lot of time on some topics and none on others.

Direct questioning can provide crucial data that clients may not otherwise choose to discuss: important

historical information (“How often have you attempted suicide in the past?” “Is there a history of

schizophrenia in your family?”), the presence or absence of a particular symptom of a disorder (“How many

hours per day do you typically sleep?”), frequency of behaviours (“How often have you had panic

attacks?”), and duration of a problem (“How long has your son had problems with hyperactivity?”), among

other information. For example, imagine Dr. Molina interviewing Raymond, a client whose presenting

problem is depressive in nature. If Dr. Molina directly inquires about symptoms and duration—“When did

you first notice these feelings of sadness? Has your weight changed during that time? Do you feel fatigued?

Do you have trouble concentrating?”—Dr. Molina will be sure to gather information essential for diagnosis.

Indirect questioning, conversely, can provide crucial information that interviewers may not otherwise know

to inquire about. If, instead of the direct questions listed above, Dr. Molina asks Raymond, “Can you tell me

more about your feelings of sadness?” Raymond’s response may not specifically mention how long the

symptoms have been present or refer to each individual criterion for major depression, dysthymia, or other

related disorders. However, Dr. Molina’s indirect question does allow Raymond to expand on anything he

believes is essential, including symptoms, duration, background data, or other elements that may prove to be

extremely relevant.

Both directive and nondirective approaches have shortcomings as well

• Sometimes, directive approaches can sacrifice rapport in favor of information. In other words,

interviewers who are overly directive may leave clients feeling as though they didn’t have a chance to

express themselves or explain what they thought was important.

• Although nondirective interviewing can facilitate rapport, it can fall short in terms of gathering

specific information. Interviewers who are overly nondirective may finish an interview without specific data

that are necessary for a valid diagnosis, conceptualization, or recommendation.

Issues related to reliability and validity

• Subjectivity of the researcher: The researcher's own biases and interpretations can affect the

reliability and validity of the research. For example, a researcher who is biased in favor of a particular

outcome may be more likely to interpret the data in a way that supports that outcome.

• Measurement error: Measurement error can occur when the instrument used to measure the

variable of interest is not accurate or precise. For example, a test that is poorly written or that is not

standardized can lead to measurement error.

• Participant characteristics: The characteristics of the participants in a study can also affect the

reliability and validity of the research. For example, if the participants are not representative of the

population of interest, the study's results may not be generalizable.

• Context effects: The context in which the research is conducted can also affect the reliability and

validity of the research. For example, if the research is conducted in a laboratory setting, the results may not

be generalizable to real-world settings.

• Threats to internal validity: Threats to internal validity are factors that can cause changes in the

dependent variable that are not due to the independent variable. Some common threats to internal validity

include history, maturation, instrumentation, testing, selection bias, regression to the mean, social

interaction, and attrition.