THE CLINICAL INTERVIEW:The intake / admission interview, Structured interview

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Clinical Psychology (PSY401)

LESSON 16

THE CLINICAL INTERVIEW

DEFINITION OF INTERVIEW

A situation of primarily vocal communication, more or less voluntarily integrated, on a progressively

unfolding expert-client basis for the purpose of elucidating characteristic patterns of living of the

patients, client, or subject, which pattern he/she experiences as particularly troublesome or especially

valuable, and in the revealing of which he expects to derive benefit..

According to "Bingham" and "Moore" The clinical interview is a conversation with a purpose but as the

purpose differ the area of the interview also differs.

INTRODUCTION OF INTERVIEW

Almost all professions count interviewing as chief technique for gathering data and making decisions.

For politicians, consumers, psychiatrists, employers, or people in general, interviewing has always been

a major tool. As with any activity that is engaged in frequently, people sometime take interview for

granted or believe that it involve no special skills; they can easily overestimate their understanding of

the interview process. Although many people seem awed by the mystique of projective tests or

impressed by the psychometric intricacies of objective tests.

The assessment interview is at once the most basic and the most serviceable technique used by the

clinical psychologists. In the hands of a skilled clinician, its wide range of applications and adoptability

make it a major instrument for clinical decision making, understanding, and predictions. But for all this,

we must not lose sight of the fact that the clinical interview is not greater than the skill and sensitivity of

clinicians who use it.

IMPORTANT THINGS TO KNOW ABOUT CLINICAL INTERVIEWS

1. It is not a cross-examination but rather a process during which the interviewer must be aware of the

client's voice intonation, rate of speech, as well as non-verbal messages such as facial expression,

posture, and gestures.

2. Although it is sometimes used as the sole method if assessment, it is more often used along with

several of the other methods.

3. It serves as the basic context for almost all other psychological assessments.

4. It is t he most widely used clinical assessment method.

ADVANTAGES OF THE CLINICAL INTERVIEW

Inexpensive

Taps both verbal and non verbal behavior

Portable

Flexible

5. Facilitates the building of a therapeutic relationship

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TYPES OF INTERVIEW

There are many different forms of interviews conducted by psychologists. Some interviews are

conducted prior to admission to a clinic or hospital, some are conducted to determine if a patient is in

danger of injuring themselves or someone else, some are conducted to determine a diagnosis. Whereas

some Interviews are highly structured with specific questions asked for all patients, others are

unstructured and spontaneous. In this section the common forms of clinical interviews will be briefly

discussed. Some important forms of interview are:

The intake / admission interview

The case history interview

Mental status examination interview

The crisis interview

Diagnostic interview

Structured interview

THE INTAKE/ADMISSION INTERVIEW

According to Watson;

"This type of interview is usually concerned with clarification of the patient's percentage complaints,

the steps he has taken previously to resolve his difficulties and his expectances in regard to what may be

done for him".

The purpose of the initial intake interview or admission interview is to develop a better understanding of

the patient's symptoms or concerns in order to recommend the most appropriate treatment or

intervention plan. Whether the interview is conducted for admission to a hospital, an outpatient clinic, a

private practice, or some other setting the initial interview attempts to evaluate the patient's situation as

efficiently as possible.

Ordinarily a psychiatric social worker conducts this interview; however, upon occasion, the

psychologist, one of the physician, or a psychiatric nurse may serve as intake interviewer. The basic

question to be dealt with is "Why is the patient here? i.e., what doe she says is the matter with him?

Important but secondary questions involve information about previous hospitalization, the name of his

doctors, what the patient expect from treatment, his availability for treatment, and the like.

Although typically brief, the intake or admission interview is extremely important in conserving the

time of other professional staff members and in sparing the clinic or hospital for occasional

embarrassing or awkward situations. The patient may in some instances desire treatment which a

particular clinic may not be prepared to give. Certain hospitals, for example, do not handle alcoholic or

narcotic addiction cases; thus the patient can be at once referred to an appropriate institution, saving

time for the examining psychiatrist, psychologist, the various attendants, and for the patient himself.

Similarly, the awkward consequences of an overly casual admission procedure can be avoided by a well

planned interview. Hospital staff members can relate many anecdotes of relative's who were mistaken

for the patient himself, of surgical patient who were given diagnostic psychiatric interview, or of

salesman who were escorted to a room and confronted with a personality test.

A careful intake interview will guard against such mistakes. It should be noted that every patient will

not be able to state coherently what the nature of his trouble may be. But even the unclear replies can be

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highly revealing, and the astute intake interviewer can report significant observation of the patient's

behavior which he may not reveal again for some time or which may be missed by later examiners.

Ordinarily, the diagnostic and treatment session which come at some time after the intake interview are

carried out by another, different staff person. This does not mean however, that therapy begins later. The

formal label of "psychotherapy" it is true, is given to the later procedures, but real therapy, in the sense

of patient's attitude and his motivation to get well, begins at the time of the patient's admittance. It is no

exaggeration to assert that a bungled intake interview prolong treatment while an effective one can

shorten it.

CASE HISTORY INTERVIEW

In many hospitals and clinics the intake or admission interview is followed immediately by the personal

and social history interview. The same person usually a psychiatric social worker, commonly conduct

both interviews, often in one sitting. Sources of information other then the patient himself are, of course,

utilized when completing a personal and social history report. Frequently, the patient does not remember

or can not for other reasons communicate material which may have a bearing upon his problem. Thus,

information from friends, relatives, hospital, military, and other records are also used for the history. But

whatever the source of information, the purposes of the social and personal history report is to gather

information which will be helpful in diagnosing and treating the patient's disorder.

Frequent job changes, for example, may be evidence of general instability. The adult schizophrenic who

showed marked apathy and withdrawal symptoms as a preschool child is probably more severely

afflicted than patients whom symptoms appeared more recently. Neurotic symptoms which appear after

the divorce of parents may have different etiology than similar symptoms which appear after the head

injury.

In most instances a standardized form or social history guide of some sort is used. There are advantages

in using a standardized printed form, as Louttite has noted in that pertinent information will not be

skipped; however as he also notes, a rigid dependency upon the form may ensue. Certain obvious

information may not be recorded because the form does not call for it or details which are unimportant

for a particular case may be set down in time wasting abundance. Obviously the common sense of the

interviewer is the answer to such problems.

The typical information obtained in a personal and social history includes material on the patient's early

life, with particular attention paid to family relationship and general environment. Also included are

data on the patient's educational and vocational history, neuropathic traits, his habits and recreations, as

well as other material. Obviously much of this information can be obtained only by direct questioning.

Some patients are threatened by situations which require specific answers, and they may show panic

reactions of varying degree. Others will lie, perhaps because they cannot remember and do not wish to

say so, but more often because painful memories are awakened of jail sentences, of divorce, of previous

hospitalization, or the like. Most patients, of course, are truthful, but only in their cultural fashion.

It is this area that the skill of the interviewer is brought out. While much of the information requested is

factual, the manner in which the patient communicates his facts may be quite misleading.

The fact that an occasional patient will lie about his personal social history, even about trivial matters, is

sometimes irritating or disheartening to the newcomer to the interviewing situation. Such falsification is

not a reflection upon the interviewer's skill or comportment but rather upon the reason why the patient

is being interviewed. He is a patient. He may be confused, a psychopath, or something else; but he is

sick. This may seem like unnecessary emphasis; yet every clinician should be prepared to ward off

feelings of indignation or humiliation which may arise when he learns that virtually every fact he so

laboriously recorded, from age and address to family history and vocation, is false. This happens with

extreme rarity, of course; but it happen to almost every clinician sooner or later. When it does, and if

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one is taken in, a little self directed humor helps restore a sense of proportion. Then a firm resolution to

check other information sources can turn the experiences to one's advantage.

MENTAL STATUS EXAMINATION INTERVIEW

Often a mental status examination interview is conducted to screen the patient's level of psychological

functioning and the presence or absence of abnormal mental phenomena such as delusions, delirium, or

dementia. Mental status exams include a brief evaluation and observation of the patient's appearance

and manner, speech characteristics, mood, thought processes, insight, judgment, attention,

concentration, memory, and orientation.

Results from the mental status examination provide preliminary information about the likely psychiatric

diagnosis experienced by the patient as well as offering some direction for further assessment and

intervention (e.g. referred to a specialist, admission to psychiatric unit, and evaluation for medical

problems that impact psychological functioning). For instance, mental status interviews typically

include questions and tasks to determine orientation to time (e.g., "what day is it? What month is it?),

place (e.g., Where are you now? Which hospital are you in?"), and person ("who am I who is the

president of United States?"). Also, the mental status interview asses short term memory (e.g. "I am

going to name three objects I'd like you to try and remember: dog, pencil, and vase") and attention-

concentration (e.g., "count down by 7s starting at 100. For example 100, 93, and so forth").

While there are some mental status examination that are structured resulting in scores that can be

compared to national norms, most are unstructured and do not offer a scoring or norming option. During

the examination the interviewer notes any unusual behavior or answers to questions that might be

indicative or psychiatric disturbance. For example, being unaware of the month, year, or the name of the

current president of the United States usually indicate mental problems. This can result in bias based on

the interviewer's clinical judgment during and evaluation.

THE CRISIS INTERVIEW

A crisis interview occur when the patient is in the middle of a significant and often traumatic or life

threatening crisis. The psychologists or the mental health professionals (e.g., a trained volunteer) might

encounter such a situation while working at a suicide or poison control hotline, an emergency room, a

community mental health clinic, a student health service on campus, or in many other settings. The

nature of the emergency dictates a rapid, "get to the point" style of interview as well as quick decision

making in the context of a calming style. For example, it may be critical to determine whether the

person is at significant risk of hurting him- or herself or others. Or it may be important to determine

whether the alcohol, drugs, or any other substances are used, so as to make sure that the clinician

interviews the person in a calming and clear headed manner while asking critical questions in order to

deal with the situation effectively.

The interviewer may need to be more directive (e.g., encouraging the person to phone the police, unload

a gun, provide instructions to induce vomiting, or step away from a tall building or bridge); break

confidentiality if the person (or someone else, such as a child) is in serious and immediate danger; or

enlist the help of others (e.g., police department, ambulance).

THE DIAGNOSTIC INTERVIEW

The purpose of the screening or diagnostic interview is to assist the clinician in his attempt to

understand the patient.

If the level of diagnostic understanding required is merely a separation of the fit from the unfit, as in

military neuro-psychiatric examinations, the interview task is one of screening. That is, after a brief

interview the interviewee be adjusted fit for specific duties, such as a regular military assignment, or he

may be referred for prolonged observation and extended psychological testing. Occasionally, limit or

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trial duty may be recommended as an alternative to regular duty of psychological observation. Upon

other occasions the diagnostic task is highly specific, and a detailed level of understanding is required.

This may involve a diagnostic label as categorized as "paranoid schizophrenia" and a description of

personality dynamics. In the later case primary dependence is not placed upon the interview alone, for

psychological tests play a most important role in such detailed diagnostic procedures.

In the diagnostic interview, while the examination progresses; the interviewer observes the

interviewee's behavior as well as noticing the content of his answers. Thus thighs pressed together, a

mincing walk, and fluttery feminine gestures in a male should lead the interviewer to suspect and

investigate the possibility of homosexuality. The bubbling, enthusiastic replies and exaggerated gestures

in another interview should lead the interviewer to hypothesize tentatively a manic condition and seek

further evidence. Similarly, as Wittson, et al. noted, the psychopath often gives evidence of his deviation

by his utter impersonality or even belligerence towards the interviewer.

Ordinarily, brief neuro psychiatric interviews are not oriented towards future psychotherapeutic activity

because most of the interviews have no need of therapy. However, it is not difficult to adopt the

procedure of the brief interviews so that those who seem in need of treatment are rendered more

receptive to the idea. Thus this kind of interview is used to describe that whether an individual needs

help or not.

STRUCTURED INTERVIEW

In an effort to increase the reliability and validity of clinical interviews, a number of structured

interviews have been developed. These interviews include very specific questions asked in a detailed

flow chart format. The goal is to obtain necessary information, to make an appropriate diagnosis, to

determine whether a patient is appropriate for a specific treatment or research program, and to secure

critical data that are needed for patient care. The questions are generally organized and developed in a

decision tree format. If a patient answers yes to particular questions (for example, about panic), the list

of additional questions might be asked to obtain details and clarification.

RELIABILTY AND VALIDITY OF INTERVIEWS

As with any form of psychological assessment, it is important to evaluate the reliability and validity of

interviews.

RELIABILITY

The reliability of an interview is typically evaluated in terms of the levels of agreement between at least

two raters who evaluated the same patients or client, by agreement we mean consensus on diagnosis

assigned, on ratings of levels of personality traits, or any other type of summary information derived

from an interview. This is often referred as inter-rater reliability.

Standardized (structured) interviews with clear scoring instructions will be more reliable than

unstructured interviews. The reason is that structured interviews reduce both information variance and

criterion variance. Information variance refers to the variation in the question that clinicians ask, the

observations that are made during the interview, and the method of integrating the information that is

obtained. Criterion variance refers to variations in scoring thresholds among clinicians.

Another type of reliability is the test-retest interviews-the consistency of scores or diagnoses across

time. We expect the test re test reliability of an interview quite high when the intervening time period

between the initial testing and the retest testing is short. However when the intervening time period is

long test retest reliability suffers.

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VALIDITY

The validity of an interview concerns how well the interview measures what it is intended to measure.

The validity of any type of psychological measures can take many forms.

CONTENT VALIDITY:-refers to the measure's comprehensiveness in assessing the variable of

interest. In other words, does it do a good job of adequately measuring all important aspects of the

construct of interest?

CRITERION RELATED VALIDITY:-refers to the ability of a measure to predict (correlate with)

scores on other relevant measures. These measures may be administered concurrently with the interview

(concurrent validity) or at some point in the future (predictive) validity

DISCRIMINANT VALIDITY:-refers to the interview's ability to not correlate with measures that are

not theoretically related to the construct being measured.

CONSTRUCT VALIDITY:-is used to refer to all these aspects of validity. Thus many researchers

describe the process of developing and validating a measure as a process of construct validity.

In case of structured diagnostic interviews, content validity is usually assumed, because these interviews

were developed to measure the DSM criteria for specific mental disorders. That leaves us in need for

validation efforts aimed at establishing an interview's criterion-related, discriminant, and construct

validity.

SUGGESTIONS TO IMPROVE RELIABILTY AND VALIDITY

1. Whenever possible use a structured interview.

2. If a structured interview does not exist for your purpose, consider developing one.

3. Whether you are using a structured or unstructured interview, certain interviewing skills are essential.

4. Be aware of the patient's motives and expectancies with regard to the interview.

5. Be aware of your expectations, biases, and cultural values.

FACTORS THAT INFLUENCE INTERVIEWS

Many factors influence on the productivity and utility of data obtained from interview. Some involve the

physical setting. Others are related to the nature of the patient. A mature communicative patient may not

cooperate regardless of the level of the interviewer's skill. Few interviewers are effective with every

patient. Several factors or skills, however, can increase the likelihood that interviews will be productive.

Training and supervised experiences in interviewing are very important. Techniques that work well for

one interview can be notably less effective for another; there is crucial interaction between techniques

and interviewer. This is why gaining experience in a supervised setting is so important; it enables the

interviewer to achieve some awareness of the nature of this interaction. Training, then, involves not just

a simple memorization of rules, but rather, a growing knowledge of the relationships among rules, the

concrete situation being confronted, and one's own impact in interview situation.

1.THE PHYSICAL SETTING

An interview can be conducted any where that the two people can meet and interact. The best

interviewing conditions are characterized by privacy, freedom from interruption, and some control of

both inside and out side sounds. Nothing is more damaging to the continuity of an interview then a

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phone that rings relentlessly, a secretary's query, or an imperative knock on the door. Such interruptions

are extremely disruptive.

The general appearance of the room should suggest comfort and yet have a professional flavor about it.

2. NOTE-TAKING AND RECORDING

All contacts with the client ultimately need to be documented. However, there is some debate over

whether notes should be taken during an interview. Although there are few absolutes, in general, it

would seem desirable to take occasional notes during an interview. A few key phrases jotted down will

help the clinicians to recall. Most clinicians have had the experience of feeling that the material in an

interview is so important that there is no need to take notes. The material will easily be remembered.

However, after having a few additional patients the clinicians cannot be able to recall much for their

earlier interview. Therefore, a moderate amount of note - taking seems worthwhile. Most patients will

not be troubled by it, and if one should be, the topic can be discussed.

However, any attempt at taking verbatim note should be avoided. One danger in taking verbatim is that

this practice may prevent the clinicians from attending fully to the essence of the patient's

verbalizations. An overriding compulsion to get it all down can detract from a genuine understanding of

the nuances and significance of the patient's remarks. In addition, excessive note taking tends to prevent

the clinicians from observing the patient and from noting subtle changes of expression or slight changes

in body position.

With today's technology, it is easy to audio tape or videotape interviews. Under no circumstances

should be this done with out the patient' fully informed consent.

3.RAPPORT

Report is the word often used to characterize the relationship between patient and clinician. Rapport

involves a comfortable atmosphere and a mutual understanding of the purpose of the interview. Good

rapport can be primary instrument by which the clinicians achieve the purpose of the interview. A cold,

hostile or adversarial relationship is not likely to be constructive. Although a positive atmosphere is

certainly not the sole ingredient for a productive interview, it is usually a necessary one. Whatever skills

the interviewer possess will surely be rendered more effective in proportion to the interview's capacity

to establish a positive relationship.

4. SETTING THE RIGHT TONE

Experienced interviewers have learned and repeatedly confirmed that the atmosphere most conducive to

the successful elicitation of information is one of mutual respect.

5. GETTING THE INTERVIEW OFF TO A GOD START

One of the first tasks, in fact, obligations, of the clinician is to make sure that the client understands the

purpose of the interview as clearly as he is capable of understanding.

COMPONENTS OF GOOD LISTENING

-elimination of distraction

-alertness

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-concentration

-patience

-Open-mindedness

6. ADJUSTMENT

Adjust the sequence of topics to be discussed to the anxiety level of the informant.

7. MOVING RAPIDLY THROUGH THE INTERVIEW

In personal interviewing and, even more important, in case history interviewing a rapid fire technique

may result in grater reliability.

8. ASKING QUESTIONS STRAIGHTFORWARDLY

Johnson, et al., remarked, having laid a solid foundation of rapport, mutual understanding and respect, it

is best to ask questions in a direct manner.

9. CONSIDERABLE TACT AND SKILL MUST BE USED IN HANDLING PAUSES

We should not be too eager to make and answer for a client and should give him time to think through

his answer carefully. On the other hand, we must not allow pauses to become so long as to become

painful or awkward and this make the client uncomfortable.

10.ATTEPMT TO GET BENEATH SUPERFICAL ANSWER

We should attempt to rephrase or ask additional questions when client's answers are obviously

superficial.

11. NOTE DISCRIPANCIES IN THE ACCOUNT AND CHECK THEM

When inconsistencies are noted, they should not be ignored, but should be checked as unobtrusively as

possible without challenging the client's veracity.

12. HANDLING EMOTIONAL SCENES TACTFULLY

A moderate amount of crying, weeping, anger, or hostility is to be expected and is frequently of sign a

good rapport. However it is responsibility of the clinician to maintain control of the situation and not to

allow it to get out of hand, or the client to become too depressed.

13. PREPAREDNESS

Be prepared for the questions directed to you by the informant. Clinician's answer will depend upon his

role in clinic routine i.e., what his answers will mean in terms of helping or hindering the progress of the

interview.

POTENTIAL THREATS OF EFFECTIVE INTERVIEWING

BIASNESS

Interviewers may be biased. Their personality, theoretical orientation, interests, values, previous

experiences, cultural background, and other factors may influence how they conduct an interview, what

they attend to, and what they conclude. Interviewers may consciously or unconsciously distort

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information collected during an interview based on their own slant on the patient or the patient's

problems.

For example, a psychologist is an expert on child sexual abuse. She treats children who have been

sexually abused as children and publishes professional articles and books on the topic. She is often

asked to give lectures around the country on the subject. When a patient describes symptoms often

associated with child sexual abuse such as depression, anxiety, low self esteem, relationship conflicts,

and sexually concerns, the psychologists assume that the symptoms are associated with sexual abuse.

When a patient denies any experience of sexual abuse, the psychologist assumes that the patient has

repressed or forgotten the traumatic memory. She then works to help the patient uncover the repressed

memory in order to realize that they have been abused. Clearly, this example illustrates how bias can

lead to distorted or even destructive approaches.

RELIABILITY AND VALIDITY

Reliability and validity may also be threatened. For example, if two or more interviewers conduct

independent interviews with a patient, they may or may not end up with the same diagnosis, hypothesis,

and treatment plans. Further more; patients may not report the same information when questioned may

be several different interviews. Interviewer gender, race, age, and skill level are some of the factors that

may affect patient response during an interview (Grantham, 1973).

Emotional level may also have an impact on reporting of information. For example, personal questions

regarding sexual behavior, alcohol use, child abuse, or other sensitive issues may elicit varying

responses from patients under different circumstances. Reliability and validity may be enhanced by

using structured interviews, asking similar questions in different ways, using multiple interviewers, and

supplementing interview information from other sources (e.g., medical records, observers,

questionnaires).

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