THE CLINICAL INTERVIEW

THE INTERVIEWER
The most pivotal element of a clinical interview is the person who conducts it. A
skilled interviewer is not only 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
Sommers Flanagan and Sommers-Flanagan (2009) describe several such
requirements: quieting yourself, being self-aware, and developing positive working
relationships.
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.
Being self-aware is another important skill for the clinical interviewer. This
self- awareness should not be confused with the excessive self-consciousness.
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.
Developing positive working relationships with clients. 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 (Sommers-Flanagan & Sommers-Flanagan, 2009)
Specific Behaviors
A primary task of the interviewer is to listen. Listening may seem like a simple enough
task, but it can be broken down into even more fundamental building blocks of
attending behaviors (many described in Ivey, Ivey, & Zalaquett, 2010)
Eye contact.
Eye contact not only facilitates listening, it also communicates listening. That is,
when the client notices the interviewer’s continuous, appropriate eye contact, the client
feels heard.
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.
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 being deeply appreciated.
Verbal tracking.
Effective interviewers are able to repeat key words and phrases back to their
clients to ensure the clients that they have been accurately heard.
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.
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.
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.
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.
How can an interviewer establish good rapport with clients?
No foolproof technique exists, especially across the culturally, demographically,
and diagnostically wide range of clients with whom a clinical psychologist might work.
And if the goal is to make the client feel connected and sympathized with, there is
no substitute for genuinely connecting and sympathizing with the client. However, there
are some specific efforts interviewers can make to enhance the client’s experience of
rapport.
 First, interviewers should make an effort to put the client at ease,
especially early in the interview session.
Second, interviewers can acknowledge the unique, unusual situation
of the clinical interview.
Third, interviewers can enhance rapport by noticing how the client
uses language and then following the client’s lead.
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
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.
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 behaviors
“How often have you had panic attacks?”,
and duration of a problem
“How long has your son had problems with hyperactivity?”
Perhaps the best strategy regarding directive and nondirective
interviewing is one that involves balance and versatility (Morrison, 2008).
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 (Othmer & Othmer, 1994;
Sommers-Flanagan & SommersFlanagan, 2009)
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.
An open-ended question, such as:
“Can you please tell me more about the eating problems you mentioned on the
phone?”
may take the interview in a different direction than a closed-ended question, such as
“How many times per week do you binge and purge?”
“Which purging methods do you use—vomiting, exercise, nausea?” and
“Have you been diagnosed with an eating disorder in the past?”
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 question
Clarification
The purpose of a clarification question is to make sure the interviewer has an
accurate understanding of the client’s comments.
The interviewer may at one point say:
“You mentioned that a few months ago you started exercising excessively after
eating large amounts of food but that you’ve never made yourself vomit—do I have that
right?” or
“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?”
Either of these questions would allow Brianna to confirm or correct the
interviewer so that ultimately the client is correctly understood
Confrontation
Interviewers use confrontation when they notice discrepancies or inconsistencies
in a client’s comments.
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 to many of your friends. I’m a bit confused.
Paraphrasing
Unlike clarifying or confronting, paraphrasing is not prompted by the
interviewer’s need to resolve or clarify what a client has said. Instead, paraphrasing is
used simply to ensure clients that they are being accurately heard.
When interviewers paraphrase, they typically restate the content of clients’
comments, using similar language.
Example
Client: “I only binge when I’m alone,”
Therapist: “You only binge when no one else is around.”
Reflection of Feeling
Whereas a paraphrase echoes the client’s words, a reflection of feeling echoes the
client’s emotions.
Example:, if the client says (“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,
Therapist: “You don’t want anyone to see you binging—do you feel embarrassed
about it?”
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.
The interviewer may summarize by offering statements along the lines of:
Therapist: “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.”
Conclusions
In some cases, the conclusion can be essentially similar to a summarization, 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.
PRAGMATICS OF THE INTERVIEW
Note Taking
There are good reasons for taking notes. Written notes are certainly more reliable
than the interviewer’s memory.
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.
In particular, a client-centered rationale for the note-taking behavior:
Therapist: “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”
Audio and Video Recordings
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.
The Interview Room
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.
 When making decisions related to the decor of an office, clinical psychologists
usually steer clear of overtly personal items such as family photos, souvenirs, and
memorabilia.
Confidentiality
Many people incorrectly assume that any session with a psychologist is absolutely
confidential (Miller & Thelen, 1986), when in fact there are some situations that require
the psychologist to break confidentiality. These situations are typically defined by state
law and often involve the psychologist discovering during a session that the client
intends to seriously harm someone (self or others) or that ongoing child abuse is
occurring.
Structured Interviews Versus Unstructured Interviews
A structured interview is a predetermined, planned sequence of questions that an
interviewer asks a client.
An unstructured interview, in contrast, involves no predetermined or planned
questions.
Structured interviews possess a number of advantages over unstructured interviews,
particularly from a scientific or empirical perspective (Sommers-Flanagan &
SommersFlanagan, 2009):
 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.
Mental Status Exam
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.
Instead, its yield is usually a brief paragraph that captures the psychological and
cognitive processes of an individual “right now”—like a psychological snapshot (Lukas,
1993; Morrison, 2008; Sommers-Flanagan & Sommers-Flanagan, 2009; Strub & Black,
1977).
The format of the mental status exam is not completely standardized, so it may be
administered differently by various mental health professionals
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
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.
Quickly establishing rapport and expressing empathy for a client in crisis,
especially a suicidal client, are key components of the interview.
When interviewing an actively suicidal person, five specific issues should be
assessed (adapted from Sommers-Flanagan & Sommers-Flanagan, 2009):
 How depressed is the client? Unrelenting, long-term depression and a lack of
hope for the future indicate high risk.
 Does the client have suicidal thoughts? If such thoughts have occurred, it is
important to inquire about their frequency and intensity.
 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.
 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
 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