Clinical Interview Notes

Learning Objectives

Summarize key skills and behaviors for a psychologist conducting a clinical interview.
Define rapport as it relates to a clinical interview.
Explain major techniques that a clinician may use during a clinical interview.
Evaluate the potential impact of note taking during the clinical interview.
Describe characteristics of a clinician’s office that may contribute to successful clinical interviews.
Differentiate among the types of clinical interviews.
Propose ways a psychologist could acknowledge cultural differences while interviewing clients from differing backgrounds.

Psychological Assessment

Psychological assessment should benefit both the clinician and the client.
Feedback is a common element in all kinds of psychological assessment.
Clinical psychologists provide clients with the results of tests or interviews.
Feedback can be face-to-face, written, or other forms.
Psychologists learn to provide feedback during training and experience.
Most psychologists believe clients find feedback helpful, even before intervention.
Clinical psychologists use various methods, including:
- Intelligence tests
- Achievement tests
- Neuropsychological tests
- Personality tests
- Specialized measures
Psychological testing is considered a valuable aspect of clinical psychology.
Clinical psychologists most frequently rely on the clinical interview.

The Interviewer

The interviewer is the most pivotal element of a clinical interview.
A skilled interviewer is a master of technical aspects and demonstrates wisdom about human interaction.

General Skills

Interviewers should acquire general skills as a foundation for interviewing.
These skills focus on the interviewer’s frame of mind.
Sommers-Flanagan and Sommers-Flanagan (2009) describe several requirements:
- Quieting yourself
- Being self-aware
- Developing positive working relationships

Quieting Yourself

Quieting yourself means quieting the interviewer’s internal, self-directed thinking pattern.
Interviewers should listen to their clients rather than being preoccupied by their own thoughts.
The voice in the interviewer’s mind should not drown out the voice of the client.
Example: A novice interviewer may have self-directed questions running through his mind, which distract him from the client.
As the interviewer gains experience and confidence, their listening capacity may increase.

Being Self-Aware

Self-awareness is an important skill for the clinical interviewer.
Self-awareness 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 that may evoke certain responses from clients.
Skilled interviewers are cognizant of their unique traits, including their cultural assumptions, and consider their effect on the interview process.

Developing Positive Working Relationships

Good interviewers appreciate the importance of developing positive working relationships with clients.
A good start to the working relationship benefits both parties.
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

The next task is to master the tools of the trade, the specific behaviors characteristic of effective interviewers.
A primary task of the interviewer is to listen, which can be broken down into even more fundamental building blocks of attending behaviors.

Eye Contact

Interviewers must realize the connection between attentive listening and eye contact.
Eye contact not only facilitates listening, but it also communicates listening.
When the client notices the interviewer’s continuous, appropriate eye contact, the client feels heard.
Culture plays a significant role in the meaning of eye contact.
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

Culture can shape the connotations of body language.
Guidelines for the interviewer include facing the client, appearing attentive, minimizing restlessness, and displaying appropriate facial expressions.
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.
They use pitch, tone, volume, and fluctuation in their own voices to let clients know that their words and feelings are deeply appreciated.
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 weave the clients’ language into their own.
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 than abruptly.

Referring to the Client by the Proper Name

Using the client’s name correctly is essential.
Inappropriately using nicknames or shortening names, omitting a “middle” name that is in fact an essential part of the first name, or addressing a client by first name rather than a title followed by surname are presumptuous mistakes.
Especially with clients of certain ethnicities or ages, the misuse of names in this way may be disrespectful and may be received as a microaggression.
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.

Observing Client Behaviors

All of the previously described interviewer behaviors, and many other important decisions the interviewer makes, can be informed by behavioral observations of the client by the interviewer.
When psychologists write a report summarizing the results of an assessment (including the clinical interview), that report contains at least a brief section describing the behavior of the client during the process.
Observing client behaviors during the interview allows the psychologist to consider not only what the client said but how the client said it.
The interviewer should carry out all these attending behaviors naturally and authentically.

Cultural Variables

Compared with traditional Western culture, Chinese culture tends to feature far less eye contact, especially between members of the opposite sex.
Norms for physical touch also differ from one culture to another, with Asian cultures typically incorporating less than European Americans.
People from diverse cultures have also developed measurable differences in the physical distance or “personal space” they maintain.
Individuals of Middle East and Latino/Latina cultures tend to stand or sit closer together, whereas North American and British people tend to maintain more space between themselves.
Tendencies such as these represent essential knowledge for the culturally competent interviewer.

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.
In this situation, clients tend to disclose more information and invest themselves further in the interview process than they might have otherwise.
There is no substitute for genuinely connecting and sympathizing with the client.

Enhancing Rapport

Interviewers should make an effort to put the client at ease, especially early in the interview session.
- Engaging in small talk about innocuous topics for a minute or two at the beginning of the interview can make an initially nervous client feel more comfortable.
Interviewers can acknowledge the unique, unusual situation of the clinical interview.
- Letting clients know that you recognize their position and appreciate their willingness to participate communicates empathy and enhances rapport.
- 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.
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.

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.

Communication Across Cultures

Members of some cultures tend to exhibit identifiably distinct communication behaviors.
Interviewers should accept this concept generally, but they should also be aware of as many of these distinct communication tendencies as possible.
D. W. Sue and Sue (2008) identify some of these variables in communication style and describe how they differ across ethnicities.
Ethnicity is not the only characteristic on which communication differences may center.
Mio, Barker-Hackett, and Tumambing (2009) and J. Wood (1994, 1999) highlight the observable and common differences in speaking style between men and women.

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”).
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.
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.
- 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.
- Although nondirective interviewing can facilitate rapport, it can fall short in terms of gathering specific information.
Perhaps the best strategy regarding directive and nondirective interviewing is one that involves balance and versatility.

Specific Interviewer Responses

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.

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.
- Open-ended questions are the building blocks of the nondirective interviewing style, whereas the directive interviewing style typically consists of closed-ended questions.

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.
It’s better to wait than to immediately demand clarification.

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.

Paraphrasing

Unlike clarifying or confronting, paraphrasing is not prompted by the interviewer’s need to resolve or clarify what a client has said.
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.

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.
Reflecting a client’s feelings often involves an inference by the interviewer about the emotions underlying the client’s words.

Summarizing

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 in this section, 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.”

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.
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.
The conclusion may involve recommendations for treatment or further evaluation.

Pragmatics of the Interview

The interviewer encounters quite a few decisions long before the client arrives for the interview.
Many of these decisions involve the setting in which the interview will take place and the professional behaviors the interviewer plans to use during the interview itself.

Note Taking

Should an interviewer take notes during an interview?
There is little consensus about note taking among clinical psychologists.
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.
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 some clinical situations, interviewers may be wise to explain their note-taking behavior to clients.
A client-centered rationale for the note-taking behavior may enhance rapport between interviewer and client.

Audio and Video Recordings

Clinical psychologists may prefer to audio- or video-record the session.
Recording a client’s interview requires that the interviewer obtain written permission from the client.
Recordings can, with some clients, hinder openness and willingness to disclose information.
An explanation of the rationale for the recording, as well as its intended use and a date by which it will be erased or destroyed, is typically appreciated by the client.

The Interview Room

What should the interview room look like?
It is useful to strike a balance between professional formality and casual comfort.
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.
There are quite a few options for seating arrangements.
As long as the interview room facilitates the fundamental goals of the interview, such as gathering information and building rapport in a private setting free of interruptions, its purpose is well served.
The interviewers should steer clear of overtly personal items such as family photos, souvenirs, and memorabilia, because:
- Such items might be inconsistent with the professional ambience that the interview room should exude
- They can influence the content of the interview in some cases

Confidentiality

When clients enter the interview room, they may have inaccurate assumptions about the confidentiality of the ensuing discussion.
To inform their clients about confidentiality, and especially to correct any misconceptions, interviewers should routinely explain policies regarding confidentiality as early as possible.
Such explanations should be consistent with state law and professional ethics and provided in writing, with ample opportunity for oral discussion offered as well.
Psychologists who discuss confidentiality and its limits with interview clients demonstrate competent and ethical practice.

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.
Most fall into a few broad categories: intake interviews, diagnostic interviews, mental status exams, and crisis interviews.

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.
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.

Diagnostic Interviews

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.
It would make sense for the diagnostic interview to include questions that relate to the criteria of DSM disorders.
Structured interviews: Some clinical psychologists believe that the questions should essentially replicate the DSM criteria
Unstructured interviews: Other clinical psychologists believe that every question in a diagnostic interview need not be coupled with a specific DSM diagnostic criterion.
Some clinical psychologists prefer structured interviews, while others prefer unstructured interviews.

Structured Interviews Versus Unstructured Interviews

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.
An unstructured interview, in contrast, involves no predetermined or planned questions.
- In unstructured interviews, interviewers improvise: They determine their questions on the spot, seeking information that they decide is relevant during the course of the 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.
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.
Semistructured interviews strike a balance between structured and unstructured approaches.

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.
The mental status exam does not delve into the client’s personal history, nor is it designed to determine a DSM diagnosis definitively.
The format of the mental status exam is not completely standardized, so it may be administered differently by various health professionals.
Although specific questions and techniques may vary, the following main categories are typically covered:
- Appearance
- Behavior/psychomotor activity
- Attitude toward interviewer
- Affect and mood
- Speech and thought
- Perceptual disturbances
- Orientation to person, place, and time
- Memory and intelligence
- Reliability, judgment, and insight
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.

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 this type of interview.
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.
Research on the use of contracts of this type (often called “no-suicide contracts”) suggests that they are questionable in their effectiveness.
As an alternative, some psychologists have suggested “commitment to treatment” statements, which essentially involve a promise to keep working toward improvement rather than a promise not to engage in suicidal behaviors.
When interviewing an actively suicidal person, five specific issues should be assessed:
- How depressed is the client?
- Does the client have suicidal thoughts?
- Does the client have a suicide plan?
- How much self-control does the client currently appear to have?
- Does the client have definite suicidal intentions?

Cultural Components

All human behaviors, including the words and actions of a client during a clinical interview, take place in a cultural context.
It is imperative that the interviewer retain this perspective when observing and listening to the client.
Interviewers should possess sufficient knowledge about culture—their own as well as their clients’—to understand the meaning of interview material within the appropriate cultural context.
Behaviors, thoughts, or emotions that might be viewed as abnormal or pathological by some cultural standards may in fact be normal according to others, and interviewers should be careful not to overpathologize by imposing their own cultural values.
Clinical psychologists should make efforts, in interviews and other interactions with clients, to appreciate clients from a perspective that takes into account the clients’ own cultures.
Clinical psychologists also make adaptations to cultural expectations or norms when conducting the interview, such as perhaps including a bit more small talk with a member of a culture where its absence is likely to hinder rapport, or consulting with professionals who know the culture well.
The culturally competent interviewer should not assume that every person from a culture holds identical values.

Acknowledging Cultural Differences

When cultural differences exist between interviewer and client—which happens quite frequently, especially if we define culture by ethnicity, gender, religion, age, or a number of other variables—it is often wise for the interviewer to acknowledge these differences openly.
Open, respectful discussion of cultural variables can enhance rapport, increase the client’s willingness to share information, and help the interviewer gain a more accurate understanding of the client’s issues.
Without it, the interview process—and the assessment process more broadly—can prove invalid and can lead to culturally insensitive treatment.
In many cases, it is appropriate for the interviewer to inquire directly about cultural background to become more informed about the client’s perspective.
The interviewer should not lean on them too strongly; interviewers should continually seek other sources of information about specific cultures—written, experiential, or otherwise—to increase their cultural awareness.

Key Terms and Names

assessment $179$
attending behaviors $183$
being self-aware $182$
body language $183$
clarification $188$
clinical interview $179$
clinical utility $179$
closed-ended question $188$
conclusion $191$
confrontation $190$
crisis interview $199$
developing positive working relationships $182$
diagnostic interview $196$
directive $187$
intake interview $195$
listening $183$
mental status exam $198$
nondirective $187$
open-ended question $188$
paraphrasing $190$
quieting yourself $181$
rapport $185$
reflection of feeling $190$
reliability $179$
semistructured interview $198$
Structured Clinical Interview for DSM-5 Disorders (SCID) $197$
structured interview $196$
summarizing $191$
technique $186$
unstructured interview $196$
validity $179$
verbal tracking $184$
vocal qualities $183$