Intake Interviewing and Report Writing (Chapter 7) - Sommer-Flanagan - 2003 - Article

An intake interview is an assessment interview. Before initiating counselling, psychotherapy, or psychiatric treatment, it is necessary and wise to conduct an intake interview.

In an intake interview, there are a number of questions that will be addressed.

What is an intake interview?

An intake interview is an assessment interview. Before initiating counselling, psychotherapy, or psychiatric treatment, it is necessary and wise to conduct an intake interview.

In an intake interview, there are a number of questions that will be addressed, which often include:

• Is the client suffering from a mental, emotional, or behavioural problem?
• If so, are his or her mental, emotional, or behavioural problems sufficient to require treatment?
• What form of treatment should be provided to the client?
• Who should provide the treatment and in what setting?

The intake interview procedures have been affected by managed care mental health programs. Today, practitioners need to be faster and more efficient in identifying client problems, establishing treatment goals, and outlining an expected treatment course. However, increasing speed does not always reflect efficiency. For example, when individuals need to work faster, it does not matter whether they are baking cakes, building cabinets, or something else: quality can always be compromised.

What about settings and professional groups?

An intake interview before treatment is necessary, no matter whether the setting is a social service agency, hospital, mental health center, college counselling center, or a private office. It also does not matter whether the interviewer is a social worker, psychiatrist, psychologist, or counsellor: all practitioners must have the ability to conduct an adequate intake interview. However, the nature and the focus of intake interviews varies depending on the type of practitioner, the setting, and the purpose of the interview, but even then there is more consistency than variation.

Often an intake interview is called ‘an intake’. For example, the intake interview is the entry point for clients who seek professional mental health assistance. Intakes however are not designed to help clients to resolve their problems, the only goal is assessment.

What are the objectives of intake interviewing?

There are three objectives of intake interviews:

1. Identifying, evaluating, and exploring the client’s chief complaint and associated therapy goals
2. Obtaining a sense of the client’s interpersonal style, interpersonal skills, and personal history.
3. Evaluating the client’s current life situation and functioning

To achieve these objectives (goals), one needs adequate skills and attentiveness to interpersonal processes and informational content. An additional goal of intake interviews is to communicate the results of the intake, often to other professionals or other interested parties. Often, in mental health settings, one also writes a report of the intake interview.

Identifying, evaluating, and exploring the client’s complaints and therapy goals

It is important to first understand what the client’s problem is. This can be achieved by asking: “Why are you here? How can I help you?”. After the opening statement, the interviewer should spend 5 to 15 minutes observing the client and try to understand their answers. Sometimes clients are clear, and sometimes it is unclear. It is also the task of the interviewer to help clients orient toward solutions early in the counselling process. Behind every client problem, there is a client goal. Common problems are anxiety, depression, and relationship conflicts. Problems can be very broad, and there is a wide range of symptoms, and therefore interviewers need to have general knowledge of psychopathology and DSM-IV-TR. Early in the intake, the interviewers can help clients to re-frame their problem statements into goal statements. For example, when a client is talking about anxiety, interviewers can translate language into something positive:

“I hear you talking about nervousness and anxiety. If I did understand you correctly, what you are saying is that you want to feel more relaxed and calm. I guess that therefore one of your general goals for therapy might be to feel calm and relaxed more often, is that right?”.

By re-framing, interviewers help clients to feel more hopeful and this also leads to a positive, therapeutic goal-setting process.

Prioritizing and selecting client problems and goals

Most clients come to an intake interview with a more than one problem. Then, after asking and observing the client for 5 to 15 minutes, the interviewer has to create a list of primary problems and goals. This is called a transitioning from client free expression to more structured interactions. This has two purposes: it allows the interviewer to check for any additional problems, and the transition begins the process of problem prioritization, selection, and goal setting.

Analyzing symptoms

After the interviewer has identified a primary problem together with the client, then there should be a thorough analysis of the problem, including emotional, cognitive, and behavioural aspects. This includes answering the following questions:

1. When did the problem or symptoms first occur? (In some cases, the symptom is one that the client has experienced before. If so, you should explore its origin and more recent development and maintenance).
2. Where were you and what exactly was happening when you first noticed the problem? (What was the setting, who was there, etc.?)
3. How have you tried to cope with or eliminate this problem?
4. Which efforts have been most effective?
5. Can you identify any situations, people, or events that usually precede your experience of this problem?
6. What exactly happens when the problem or symptoms begin?
7. What thoughts or images go through your mind when it is occurring?
8. Do you have any physical sensations before, during, or afterwards?
9. Where and what do you feel in your body? Describe it as precisely as possible
10. How frequently do you experience this problem?
11. How long does it usually last?
12. Does the problem affect or interfere with your usual ability to function at work, at home, or at play?
13. In what ways does it interfere with your work, relationships, school, or recreational pursuits?
14. Describe the worst experience you have had with this particular symptom. When the symptom is at its worst, what are your thoughts, images, and feelings then?
15. Have you ever expected the symptom to occur and it did not occur, or it occurred only for a few moments and then disappeared?
16.  If you were to rate the severity of your problem, with 1 indicating no distress and 100 indicating so much distress that it’s going to cause you to kill yourself or die, how would you rate it today?
17. What rating would you have given your symptom on its worst day ever?
18. What’s the lowest rating you would ever have given your symptom? In other words, has it ever been complete absent?
19. As we have discussed your symptom during this interview, have you noticed any changes? (Has it gotten any worse or better as we have focused on it?)
20. If you were to give this symptom and its effects on you a title, like the title of a book or play, what title would you give?

The order of these questions is good, but it is not standard. Before conducting an interview, one can review a list of questions similar to these and re-word them to fit your own style. You can also add new questions and delete others.

How can we use problem conceptualization systems?

To analyse client problems, some researchers suggest to use organized problem conceptualization systems. These systems are theory-based, but some are more eclectic. These systems guide interviewers by analysing and conceptualizing problems with strict attention to predetermined, specified domains of functioning.

Lazarus developed a ‘multimodal’ behavioural-eclectic approach. He developed the BASIC ID to represent a seven-modality system:

• Behavior. This means that specific, concrete behavioural responses are analysed. This is especially about behavior that clients engage in too often or too infrequently. For example, positive or negative habits or reactions. A question could be: “Are there some things you would like to stop doing?”
• Affect. Affect includes feelings, moods, and other emotions. A question could be: “What makes you happy?”
• Sensation. This is about sensory processing of information. Some clients report physical symptoms associated with high levels of anxiety. A question could be: “What happens to cause you those unpleasant situations?”
• Imagery. Imagery refers to internal, visual cognitive processes. Clients often experience pictures/images of themselves or of past/future events that affect them. A question could be: “When you are feeling anxious, what images come to your mind?”
• Cognition. According to Lazarus, it is important to closely evaluate client thinking patterns and beliefs. This usually includes an evaluation of distorted or irrational thinking patterns that occur almost automatically. A question could be: “When you meet someone new, what thoughts go through your mind?”
• Interpersonal Relationships. This is about communication skills, relationship patterns, and assertive capabilities. A question could be: “What words would you sue to describe the positive or health relationships that you have?”
• Drugs: This is about biochemical and neurological factors that can affect behavior, emotions, and thinking patterns. A question could be: “Are you participating in any regular physical exercise?”

This model emphasizes cognitive processes, and neglects spiritual, cultural, and recreational domains. There is another model, the ABC model: behavioural Antecedents, the Behavior or problem itself, and the behavioural Consequences. Interviewers can apply the following ABCs with their clients:

1. What events, thoughts and experiences precede the identified problem?
2. What is the precise operational definition of the problem?
3. What events, thoughts, and experiences follow the identified problem?

What are syndromes?

A syndrome is a set of responses that usually occur together. When you identify a symptom, it is important to explore it and to identify accompanying symptoms. One can use the DSM-IV-TR and the ICD-10 for this.

What about background and historical information?

In an intake interview, there are three sources of information used to assess the client’s personality and mental condition:

1. The client’s personal history
2. The client’s manner of interacting with others
3. Formal evaluation of client mental status.

How can we identify the client’s personal history?

After spending 15 to 25 minutes exploring the present problem, it is important to understand the reasons for why the client is seeking counselling. It is also important to explore the personal or psychosocial history, this can be done with ‘the question’:

“I think I understand why you are coming here for counselling. However, I wonder why you are coming now.”

This question aims to identify why the client is seeking help at this particular time in their life. It helps to determine whether a specific event lead to the referral. After the client answers the question, you can shift the interview’s focus from the problem to the person. For example, you can say:

“We discussed the concerns that caused you to come for counselling. Now I would like to try to get a more complete sense of how you have become the person you are today. One of the best ways for me to do that is to ask you some questions about your past.”

It is important to be nondirective: clients reveal significant information simply by what they choose to focus on and by what they choose to avoid to talk about. After a nondirective period of for example 2 to 5 minutes, there can be more structure provided and one can ask specific questions about their past. For example, many clients do not like to talk freely about their childhood: they like some structure and guidance. You can provide some structure by asking: “What is your earliest memory?”.

How to assess current functioning?

After exploring historical and interpersonal issues, interviewers should make one more shift and focus on current functioning. It is also important not to end an interview with a focus on the past. In the end of the interview, it is important to encourage clients to focus on personal strengths and environmental resources, and not on past problems.