The Unstructured Clinical Interview

Article excerpt

The initial interview is the most fundamental area of counselor training; it is the beginning of every counseling relationship and the cornerstone of assessment. In mental health and community counseling settings, the initial interview, using an unstructured, open-ended approach, remains the primary assessment tool for diagnosing mental disorders based on the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association [APA], 2000; Craig, 2003; Miller, 2003; Sommers-Flanagan & Sommers-Flanagan, 2003). When used for purposes of diagnosis, the initial interview is known as the clinical interview or diagnostic interview.

Traditionally only a psychiatrist's task, the responsibility of diagnosing now falls to almost all master's-level counselors (marriage and family, mental health, and community; Bogels, 1994; Mead, Hohenshil, & Singh, 1997). Diagnostic training in counselor education program curricula has existed for the last 15 to 20 years, and the Council for Accreditation of Counseling and Related Educational Programs (CACREP, 2009) mandates that community and mental health counselors receive training on the use of the DSM-IV-TR (APA, 2000). Despite the emphasis in CACREP requirements for diagnostic training, the majority of counselors are trained in traditional interviewing techniques, not in clinical interviewing (Morrison, 1995; Turner, Hersen, & Heiser, 2003). Traditional interviewing techniques focus on gathering background history about the client but do not emphasize the identification of diagnostic signs and symptoms that aid in determining a diagnosis. The importance of clinical interviewing cannot be overemphasized because a client's DSM-IV-TR diagnosis is the primary basis for treatment planning. Being an effective clinical interviewer requires a broad knowledge of psychopathology and the current diagnostic system as means to properly evaluate the information obtained during the initial interview.

Information about clinical interviewing is scarce in the counseling literature or in counseling assessment textbooks. The literature that does exist on clinical interviewing is published mostly in psychiatry journals and textbooks, and much of that literature espouses the use of structured and semistructured interviews for accurate diagnosis (Basco, 2003). Despite the current emphasis on the use of structured and semistructured interviews, the unstructured clinical interview remains the most commonly used clinical assessment among psychiatrists and psychologists, as well as counselors (Craig, 2003; Miller, 2003; Sommers-Flanagan & Sommers-Flanagan, 2003).

The ability to interview for diagnosis is an important skill for counselors to develop. Counselors should know what information they need to obtain during the clinical interview and how that information is relevant to making a DSM-IV-TR (APA, 2000) diagnosis. This article provides (a) information about clinical interviewing for the purpose of making a DSM-IV-TR diagnosis, (b) the format of the unstructured clinical interview, and (c) examples of diagnostic clues and questions. This article focuses on interviewing adult clients with DSM-IV-TR Axis I and Axis II disorders. The term clinical interview is used throughout this article to describe interviewing for the purpose of developing a DSM-IV-TR diagnosis.

* Clinical Interviewing

Clinical interviews may be unstructured, semistructured, or structured. Each approach has benefits and drawbacks, but the primary purpose of all three types is to obtain accurate information relevant in making a DSM-IV-TR (APA, 2000) diagnosis. Unstructured interviews consist of questions posed by the counselor with the client responses and counselor observations recorded by the counselor. This type of interview is considered unstructured because there is no standardization of questioning or recording of client responses; it is the counselor who is "entirely responsible for deciding what questions to ask and how the resulting information is used in arriving at a diagnosis" (Summerfeldt & Antony, 2002, p. …