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Structured versus Semistructured versus Unstructured Interviews

Chapter · January 2015

DOI: 10.1002/9781118625392.wbecp069

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Structured versus by the clinician’s theoretical model (e.g.,
psychodynamic, cognitive-behavioral, existen-
Semistructured versus tial/humanistic, etc.), view of psychopathology,
Unstructured Interviews training, knowledge base, intuitions, and inter-
personal style, as well as by the nature of
Anne E. Mueller and Daniel L. Segal the client’s responses. With the unstructured
University of Colorado at Colorado Springs, U.S.A.
approach, clinicians are entirely responsible
for determining the specific questions that are
Among mental health professionals, the clinical critical to successfully completing the diag-
interview is the most commonly used method nostic process. However, a clear advantage
for evaluating, or assessing, clients (Segal & of this relatively unstructured approach is
Hersen, 2010). The purpose of the clinical that it provides extensive opportunities for
interview is to develop rapport with the client empathizing with the client and developing
while obtaining a comprehensive understand- a strong therapeutic relationship. Another
ing of the client’s symptoms, including relevant advantage associated with the unstructured
biographical and historical information. This clinical interview is its inherent flexibility with
information is used to make an accurate psy- respect to topics of discussion, with no a priori
chiatric diagnosis, which typically guides the guidelines limiting the boundaries of explo-
treatment process. Clinical interviews vary ration. The lack of structure in this approach
tremendously in terms of their degree of struc- can be a serious disadvantage, however, as the
ture, ranging from completely unstructured to clinician may not gather all the information
entirely structured. This entry reviews three needed for an accurate diagnosis and useful
types of clinical diagnostic interview (unstruc- case conceptualization.
tured, semistructured, and fully structured
interviews) and discusses the advantages and The Structured Interview
limitations of each.
On the other end of the spectrum, structured
interviews conform to a standardized list of
The Unstructured Interview
questions (including follow-up questions), a
The unstructured clinical interview is a ubiqui- uniform sequence of questioning, and sys-
tous, time-honored, and significant contributor tematized ratings of the client’s responses.
to the diagnostic and treatment processes in The most common types of structured inter-
clinical psychology. In a sense, it is like a view are those that focus on the psychiatric
free-flowing conversation between the clini- diagnostic process. In structured diagnostic
cian and respondent, and there are no a priori interviews, the standardized questions are
parameters for the specific topics and rela- designed to measure the specific criteria for
tive depth of conversation. This unstructured mental disorders as defined in the DSM. These
approach provides ample opportunities for essential elements of structured diagnostic
gathering general client information and a interviews serve several important purposes.
relatively rich description of the client’s expe- Most notably, their use increases the cover-
rience (rather than an exclusively stringent age of many mental disorders that otherwise
focus on the client’s problems or symp- might be overlooked in a less standardized
toms). The flow, sequence, and content of approach, enhances the diagnostician’s ability
this type of interview are largely determined to accurately determine whether particular

The Encyclopedia of Clinical Psychology, First Edition. Edited by Robin L. Cautin and Scott O. Lilienfeld.
© 2015 John Wiley & Sons, Inc. Published 2015 by John Wiley & Sons, Inc.
DOI: 10.1002/9781118625392.wbecp069
2 STRUCTURED VERSUS SEMISTRUCTURED VERSUS UNSTRUCTURED INTERVIEWS

symptoms are present or absent, and reduces eating disorders, substance abuse, borderline
variability among interviewers. Taken together, personality disorder features, gambling, autism
these elements serve to increase reliability, or spectrum disorder). In addition to the purpose
replicability, of diagnosis. This is highly valued of DSM differential diagnosis, structured
because diagnostic reliability is a prerequisite of interviews have been developed to assess one’s
diagnostic validity (discussed further below). competency to stand trial or one’s personality
There are two types of structured inter- traits according to the five-factor model of
view: fully structured and semistructured. In personality.
a fully structured interview, questions are Structured and semistructured interviews
asked verbatim to the respondent in a spe- have many different uses or applications,
cific predetermined order, the wording of including research, clinical practice, and clin-
probes used to follow up on initial ques- ical training. The research domain is the most
tions is specified, and interviewers are not common application in which structured and
to deviate from this format. In contrast, in semistructured interviews are used. Such inter-
a semistructured interview, although initial views may be used to formally select research
questions for each symptom are specified and participants based on particular diagnostic
are typically asked verbatim to the respondent, criteria so that etiology, comorbidity, and
the interviewer has considerable latitude to treatment approaches can be explored for a
follow up on responses. The interviewer can particular diagnosis or group of diagnoses.
modify or augment the standard inquiries Sound empirical research on mental disorders
with individualized and contextualized probes requires that individuals assigned a diagnosis
to more accurately rate specific psychiatric truly meet full criteria for that diagnosis, and
symptoms. The amount of structure provided thus structured and semistructured interviews
in an interview clearly impacts the extent help researchers achieve this need. Structured
of clinical experience and judgment needed interviews also provide a standardized method
to administer the interview appropriately: for assessing change in psychopathology or
Semistructured interviews require clinically diagnosis over time, which may be especially
experienced examiners to administer the inter- relevant in longitudinal studies.
view and to make diagnoses, whereas fully The next most common application for
structured interviews can often be adminis- structured and semistructured interviews is in
tered by nonclinicians who receive training on clinical settings, where administration of an
the specific instrument. This latter difference interview is used as part of a comprehensive
makes fully structured interviews popular and and standardized intake evaluation. Routine
economical, especially in large-scale research administration of a structured or semistruc-
studies in which an accurate diagnosis is essen- tured interview is increasingly common in
tial (e.g., population-based epidemiological psychology training clinics, but doing so
studies to determine the prevalence and inci- requires considerable training for clinicians
dence of various mental disorders in specific and time for full administration. A variation
populations). on this theme is that sections of a structured or
Structured and semistructured interviews semistructured interview may be administered
have been created to assist with the differential subsequent to a traditional unstructured clin-
diagnosis of all major clinical and person- ical interview to confirm specific diagnoses.
ality disorders in the DSM system, as they Finally, use of structured or semistructured
are specifically designed to assess the formal interviews for training mental health profes-
diagnostic criteria specified in the manual. sionals is an increasingly popular and ideal
Other structured interviews are narrower in application because interviewers have the
focus, designed to assess a specific problem or opportunity to learn (through repeated admin-
form of psychopathology in great depth (e.g., istrations) specific questions and follow-up
 STRUCTURED VERSUS SEMISTRUCTURED VERSUS UNSTRUCTURED INTERVIEWS 3

probes used to elicit information and eval- differences, rather than consequences of
uate specific diagnostic criteria provided by different interviewing techniques.
the DSM. Modeling the questions, sequence, Validity of psychiatric diagnosis refers to the
and flow from a structured or semistructured meaningfulness or accuracy of the diagnosis.
interview can be an invaluable source of Because reliability is a required prerequisite for
training for beginning clinicians. validity, by virtue of the fact that structured
In the mental health field, all diagnos- and semistructured interviews greatly increase
tic assessments have relative strengths and reliability of diagnosis, they also increase the
weaknesses, and structured and semistruc- likelihood that the diagnosis is valid. Struc-
tured diagnostic interviews are no exception. tured interviews also improve the validity
Perhaps the most important advantage of of diagnoses in other ways. The systematic
structured and semistructured interviews construction of structured and semistructured
centers on their ability to increase diagnos- interviews lends more methodological validity
tic reliability (which refers to consistency or to these types of assessment as compared to
agreement about diagnoses assigned by differ- unstructured approaches. Because structured
ent raters). By systemizing and standardizing and semistructured interviews are designed to
the questions interviewers ask and the way thoroughly and accurately assess well-defined
answers to those questions are recorded and diagnostic criteria, they are often better assess-
interpreted, structured and semistructured ments of those criteria than unstructured
interviews decrease the amount of information interviews. Clinicians who use unstructured
variance in diagnostic evaluations. That is, interviews may diagnose too quickly, narrow
these interviews decrease the chances that their diagnostic options prematurely, and miss
two different interviewers will elicit different comorbid diagnoses. Indeed, it is not uncom-
information from the same client, which may mon for trainee clinicians or MA/PhD level
result in different diagnoses and subsequent students in practicum performing an unstruc-
treatment. Thus, interrater reliability, or the tured clinical interview to gather information
likelihood that two different interviewers about the presence or absence of only a few
examining the same individual will arrive at common mental disorders about which they
the same diagnosis, is greatly increased. are most conversant. Because structured and
In addition, structured and semistructured semistructured interviews require clinicians to
interviews increase the likelihood that the assess all of the specified criteria for a broad
diagnosis is reliable across time and across range of mental disorders, they offer a more
different sources of information. In many thorough and valid assessment of many dis-
clinical and research settings, individuals are orders compared to unstructured interviews.
in fact assessed on different occasions. Using Coverage of other disorders may be neglected
a structured or semistructured interview for during an unstructured interview if the inter-
multiple assessments helps ensure that changes viewer is unfamiliar with the specific criteria
in a client’s presentation are due to changes of some disorders. Because they incorporate
in symptoms rather than variance in inter- systematic ratings, structured and semistruc-
view questions. Likewise, in many settings, tured interviews easily provide information
clinicians conduct collateral interviews with that allows for the determination of the level of
significant people in the client’s life to glean severity and the level of impairment associated
a broader picture of the client’s symptoms, with a particular diagnosis.
problems, and experiences. Using a struc- A final advantage of structured and semi-
tured or semistructured interview for both a structured interviews is their utility as
client and a collateral source greatly increases training tools for trainee mental health pro-
the chances that discrepancies between the fessionals and experienced clinicians who
client and collateral informant reflect veridical desire to enhance their diagnostic skills.
4 STRUCTURED VERSUS SEMISTRUCTURED VERSUS UNSTRUCTURED INTERVIEWS

Use of such interviews in the training con- classification system itself. Because structured
text helps clinicians to develop or enhance interviews used for diagnosis are inherently
their understanding of the flow, format, and tied to specific diagnostic systems (e.g., the
questions inherent in a comprehensive diag- DSM), they are only as valid as the systems
nostic interview. Structured interviews can also upon which they are based. One should recog-
be a useful means of training those who make nize that DSM diagnostic criteria were devel-
preliminary mental health assessments—for oped to operationalize diagnostic constructs
example, intake staff at psychiatric hospitals (e.g., panic disorder, depression, schizophre-
or mental health clinics—so that clients are nia) but there is no absolute basis on which cri-
thoroughly and accurately evaluated in prepa- teria were created and no definitive gold stan-
ration for treatment planning. In the case of dard for diagnosis (Segal & Coolidge, 2001).
nonclinician interviewers, fully structured Mental disorders are social constructions that
interviews are advisable because they mini- have evolved over time. Furthermore, the cri-
mize the amount of clinical judgment needed teria for many mental disorders in the DSM are
for accurate administration. Use of these impacted by cultural and subcultural variations
trained paraprofessionals can make large-scale in the respondent, as well as by the age of the
research studies cost effective. respondent. Thus, the accuracy of certain crite-
The most common criticism of structured ria may fluctuate across various editions of the
and semistructured interviews is that their DSM, thus requiring structured and semistruc-
use may damage the rapport or bond between tured interviews to be continually updated with
clinician and client. There is a danger that inter- newer versions of the DSM. With many signifi-
viewers may get so concerned with the protocol cant changes in diagnostic criteria coming with
of their interview that they fail to demonstrate the publication of DSM-5, all of the current
the warmth, empathy, and genuine regard nec- structured and semistructured interviews will
essary to form a therapeutic alliance. However, have to be revised in the coming years.
proponents of structured interviews note that A final criticism of structured and semistruc-
the problem of rapport-building during a struc- tured interviews centers on the fact that no
tured interview can be overcome with training, one structured interview can be all things in
experience, and flexibility. Interviewers must all situations, covering all disorders and even-
be aware of the potential negative effects of tualities. For example, if a structured interview
structured interviews on rapport building and has been designed to cover an entire diagnostic
make the nurturance of the therapeutic alliance system (like the DSM that identifies over sev-
a prominent goal during an interview, even eral hundred specific disorders), then inquiries
when they are also focused on following the about each disorder must be limited to a few
protocol. It behooves those who use structured inclusion criteria. In this case, the fidelity of
and semistructured interviews to engage their the official diagnostic criteria has been com-
respondents in a meaningful way during the promised for the sake of a comprehensive
interview and to avoid a rote-like interviewing interview. If the fidelity of the criteria is not
style that may serve to alienate. On the other compromised, then the structured interview
hand, not all clients have a negative perception becomes unwieldy in terms of time and effort
of a structured interview that must be inten- required for its full administration. Most struc-
tionally overcome. Some clients may prefer the tured and semistructured interviews attempt
structured approach to assessment because it some kind of compromise between these two
is perceived as thorough and detailed, and in points of tension.
these cases rapport is easily attained. As can be seen, there are meaningful advan-
Another disadvantage of structured and tages and disadvantages of all forms of clinical
semistructured diagnostic interviews is interview. Users of such instruments must
that they are limited by the validity of the make a choice about which is most useful in
 STRUCTURED VERSUS SEMISTRUCTURED VERSUS UNSTRUCTURED INTERVIEWS 5

a given situation. It is especially important interviews are semistructured. By definition, a

to carefully contemplate what is needed in a fully structured interview clearly specifies all
particular clinical or research situation before questions and probes and does not permit devi-
choosing a structured or semistructured inter- ations. Due to complex scoring algorithms, the
view. These interviews can be invaluable tools DIS-IV is typically computer-scored. Adminis-
in both clinical and research work; however, tration usually takes between 90 and 150 min.
it is essential that one does not make use of Schedule for Affective Disorders and Schizo-
such tools without accounting for some of phrenia. The Schedule for Affective Disorders
the problems inherent in their use. In certain and Schizophrenia (SADS; Endicott & Spitzer,
situations, unstructured interviews may meet 1978) is a semistructured diagnostic inter-
the objectives of a particular clinical inquiry view designed to evaluate a range of Axis I
more efficiently than a structured interview. In clinical disorders, with a focus on mood and
other cases, greater assurances that diagnoses psychotic disorders. Ancillary coverage is pro-
assigned are valid and meaningful would take vided for anxiety symptoms, substance abuse,
priority, such as in clinical research or in the psychosocial treatment history, and antiso-
delivery of clearly defined psychotherapeutic cial personality features. The SADS provides
intervention protocols. in-depth but focused coverage of the mood
and psychotic disorders and also supplies
Specific Diagnostic Instruments meaningful distinctions of impairment in the
Fully structured and semistructured diagnostic clinical range for these disorders. The SADS
interviews can be divided into those that focus can be used to make many DSM-IV diagnoses
on either clinical disorders or personality dis- but it is not completely aligned with the DSM
orders. system, which represents a significant point of
concern. It usually takes between 90 and 150
Diagnostic Instruments Focused min to administer the SADS.
on Clinical Disorders Structured Clinical Interview for DSM-IV
Anxiety Disorders Interview Schedule Axis I Disorders. The Structured Clini-
for DSM-IV. The Anxiety Disorders Inter- cal Interview for DSM-IV Axis I Disorders
view Schedule for DSM-IV (ADIS-IV; Brown, (SCID-I; First, Spitzer, Gibbon, & Williams,
DiNardo, & Barlow, 1994) is a semistructured 1997) is a flexible, semistructured diagnostic
clinician-administered interview designed to interview designed for use by trained clinicians
measure current episodes of anxiety disorders to diagnose many adult DSM-IV Axis I clinical
as defined by the DSM-IV. It provides differ- disorders. The SCID-I has widespread popular-
ential diagnosis among anxiety disorders and ity as an instrument to obtain reliable and valid
includes sections on mood, somatoform, and psychiatric diagnoses for clinical, research,
substance-use disorders, as anxiety disorders and training purposes, and it has been used in
are frequently comorbid with such conditions. more than 1,000 studies. Full administration
Administration typically takes between 45 and typically takes between 45 and 90 min.
60 min.
Diagnostic Interview Schedule for DSM-IV. Diagnostic Instruments Focused
The Diagnostic Interview Schedule for DSM-IV on Personality Disorders
(DIS-IV; Robins et al., 2000) is designed to Diagnostic Interview for DSM-IV Person-
ascertain the presence or absence of the most ality Disorders. The Diagnostic Interview
common mental disorders in the DSM. It is for DSM-IV Personality Disorders (DIPD-IV;
unique among the multidisorder diagnos- Zanarini, Frankenburg, Sickel, & Yong, 1996)
tic interviews in that it is a fully structured is a semistructured interview designed to
interview specifically designed for use by non- assess the presence or absence of the 10
clinician interviewers, whereas all of the other standard DSM-IV personality disorders as
6 STRUCTURED VERSUS SEMISTRUCTURED VERSUS UNSTRUCTURED INTERVIEWS

well as depressive personality disorder and about 20 min for the self-administered screen
passive-aggressive personality disorder in the followed by 60 min for the interview portion.
DSM-IV appendix. It typically takes about 90 Structured Interview for DSM-IV Personal-
min to administer the DIPD-IV. ity. The Structured Interview for DSM-IV
International Personality Disorder Examina- Personality (SIDP-IV; Pfohl, Blum, & Zimmer-
tion. The International Personality Disorder man, 1997) is a comprehensive semistructured
Examination (IPDE; Loranger, 1999) is an diagnostic interview for DSM-IV personality
extensive, semistructured diagnostic interview disorders. It covers 14 DSM-IV personality
administered by experienced clinicians to eval- diagnoses, including the 10 standard per-
uate personality disorders for both the DSM-IV sonality disorders, self-defeating personality
and ICD-10 classification systems. The IPDE disorder, depressive personality disorder,
was designed as a standardized assessment negativistic personality disorder, and mixed
instrument to measure personality disorders personality disorder. Full administration
on a worldwide basis. As such, the IPDE is the typically takes between 60 and 90 min.
only personality disorder interview based on It is apparent that structured and semistruc-
worldwide field trials. The IPDE manual con- tured diagnostic interviews have greatly
tains the interview questions to assess either facilitated both the objective measurement
the 11 DSM-IV or the 10 ICD-10 personality of psychiatric symptoms and the accurate
disorders. The two IPDE modules (DSM-IV diagnosis of mental disorders in a diverse
and ICD-10) contain both a self-administered range of clinical and research settings. The
screening questionnaire and a semistructured unstructured clinical interview is an acceptable
interview booklet with scoring materials. and common alternative to a more structured
Because of the instrument’s ties to the DSM-IV interview, especially in situations in which
and ICD-10 classification systems and adop- depth and flexibility are needed. The field’s
tion by the World Health Organization, the recent emphasis on empirically supported psy-
IPDE is widely used for international and chotherapeutic interventions and processes has
cross-cultural investigations of personality dis- necessitated refinement and use of clinically
orders. Administration typically takes about 15 relevant, standardized, objective, and validated
min for the self-administered screen followed assessment procedures. Indeed, structured and
by 90 min for the full interview. semistructured diagnostic interviews play an
Structured Clinical Interview for DSM-IV important role in the advancement of the sci-
Axis II Personality Disorders. To comple- ence of clinical psychology, and it is expected
ment the Axis I version of the SCID, a version that they will continue to evolve as the field of
focusing on Axis II personality disorders clinical psychology similarly matures.
according to DSM-IV has been developed, and
it is called the Structured Clinical Interview SEE ALSO: Clinical Interview; DSM-IV; Evidence-
for DSM-IV Axis II Personality Disorders Based Assessment; Personality Disorders; Struc-
(SCID-II; First, Gibbon, Spitzer, Williams, & tured Clinical Interview for the DSM (SCID)
Benjamin, 1997). The SCID-II has a similar
semistructured format as the SCID Axis I ver- References
sion but it covers the 10 standard DSM-IV Axis
Brown, T. A., DiNardo, P. A., & Barlow, D. H.
II personality disorders, as well as depressive
(1994). Anxiety Disorders Interview Schedule for
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assessment, the SCID-II may be easily used in Endicott, J., & Spitzer, R. L. (1978). A diagnostic
conjunction with the Axis I SCID that would interview: “The Schedule for Affective Disorders
be administered prior to personality disorder and Schizophrenia.” Archives of General
assessment. Administration typically takes Psychiatry, 35, 837–844.
 STRUCTURED VERSUS SEMISTRUCTURED VERSUS UNSTRUCTURED INTERVIEWS 7

First, M. B., Gibbon, M., Spitzer, R. L., Williams, J. (DIS-IV). St. Louis, MO: Washington University
B. W., & Benjamin, L. S. (1997). Structured School of Medicine.
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Psychiatric Press. Yong, L. (1996). The Diagnostic Interview for
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Pfohl, B., Blum, N., & Zimmerman, M. Further Reading
(1997). Structured Interview for DSM-IV Hunsley, J., & Mash, E. J. (Eds.). (2008). A guide to
Personality. Washington, DC: American assessments that work. New York: Oxford
Psychiatric Press. University Press.
Robins, L. N., Cottler, L. B., Bucholz, K. K., Rogers, R. (2001). Handbook of diagnostic and
Compton, W. M., North, C. S., & Rourke, K. structured interviewing. New York: Guilford
(2000). Diagnostic Interview Schedule for DSM-IV Press.

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