The interview - Scholing & Visser - 2019 - Article

What is the role and purpose of the interview in the diagnostic cycle?

The main objective of an interview is the collection of information, and particularly the information that is needed to answer the client’s question. There is also a relational objective: developing a good and professional working relationship. During an interview, observations may also yield information.

What are the requirements for an interview?

There are a number of requirements for a diagnostic interview to run smoothly, which refer to the environment, the interviewer’s knowledge, and the interviewer’s skills.

The environment

The interview should be conducted in a quiet environment which does not distract from the goal of the interview. The client must feel comfortable, so that he is able to discuss personal and emotional topics. The interview room should be neutral, but pleasant. The interviewer must also assure that there are no interruptions. There is disagreement about whether notes should be taken on paper or on the computer.

The interviewer’s knowledge

An interviewer must have a lot of knowledge of psychological processes, functions and disorders. He or she must be up-to-date on the DSM-5 and the ICD-10. One should also have a general knowledge of epidemiology. He or she needs to know which mental disorders occur often and which mental disorders do not (this is called the base rate). The interviewer must also have knowledge of somatic disorders which may correspond to psychiatric symptoms, in order to be able to either consult a doctor or to refer the client.

The interviewer’s skills

The specific skills that an interviewer should have, are described by Carl Rogers (1961). For example, empathy of the interviewer is an important skill. Also, the interviewer should show unconditional positive acceptance: he must make it clear that he accepts and respects the client exactly as the client is. The third requirement according to Rogers is authenticity. This refers to that the interviewer is aware of his own thoughts, feelings, prejudices, values and norms. These skills will help to develop a positive relationship with the client, also called ‘rapport’. To achieve this rapport, the interviewer can also conform a bit to the client’s style of speech and communication. He should also consider the client’s intelligence level, so to choose the correct words.

What is the interview about?

 An intake interview has the goal to determine four things:

1. The client’s request for help
2. Whether the organization is capable of adequately meeting this request for help and if so,
3. What type of treatment is deemed appropriate; or if the organization is not capable of meeting this request for help,
4. The details of the organization to which the client should preferably turn.

During an intake interview, often the following topics are discussed: the reason for the client’s application, mood and anxiety, impulse control and suicidal tendencies, current social, academic and vocational functioning, the presence of social support in the client’s environment, environmental factors, developmental factors, medical history.

What is the effect of the client’s age on the content of the interview?

When the client is above 18, the age of the client has little effect on the interview techniques that should be used. However, it does have an effect on the topics that are discussed. There are four life stages of adulthood: early adulthood (18-40), middle adulthood (40-60), late adulthood (60-70) and old age (70+). According to Coyle, the topics that are discussed during interviews should be based on the life stage of the client. Important themes in early adulthood are for example being independent or dependent on one’s immediate family, the ability or inability to establish intimate relationships, having children, parenting, and educational and career goals. It is also during early adulthood when various mental disorders such as depression, anxiety and psychotic episodes clearly surface. For middle adulthood, important themes are (not) achieving work goals and family goals, taking responsibility for aging parents, the death of grandparents and parents, a diminishing responsibility for one’s children, and changes in physical appearance and characteristics. In the late adulthood phase, common themes are accepting one’s situation with respect to family and career, learning to cope with diminishing physical capabilities and changes in health, accepting the loss of one’s siblings, partner and friends and an increasing reliance on being cared for by one’s own children or others. In the last phase of adulthood, important themes are dealing with diminishing health, dependence on being cared for by other and preparing for death. Especially in the last two phases, the interviewer must take into account that there can be cognitive disorders present.

How is information collected during an interview?

During an interview, there is a lot of information. This information must be collected. A common method to do this is to use questionnaires, which are completed in advance by the client. Questionnaires can be useful, because it is often easier for clients to describe emotionally charged behaviour in a self-assessment questionnaire than it is to talk about them in direct conversation.

What are rating scaled and structured interviews?

Studies into the reliability and validity of clinical experts has shown that experienced clinicians often reach very different conclusions on the basis of an interview with the same client. To make sure that interviewers use the same information when forming their judgments, rating scales and structured interviews were developed. The main feature of rating scales is that the assessor provides a standardized judgment on a number of predefined topics. The process in which the assessor reaches these judgments is not determined: the assessor could conduct an interview, go through old files of the client or a combination of methods.

Structured interviews contain prescribed questions that can be used to reach a judgment. So, the process is standardized.

Rating scales and interviews differ, for example in ‘width’ and ‘depth’. A broad instrument addresses a variety of topics, but only in a superficial way. An example of this is the MINI, which is an interview for identifying current mental disorders according to the DSM. A more specific instrument only looks at a particular disorder or category of disorders. An example of this is the Psychopathy Checklist-Revised (PCL-R). During an intake interview, often broad-based instruments are used.

According to Rogers, the main advantage of structured interviews are that they have better and higher reliability, a better estimation of the seriousness of the complaints, a reduction in both information variance and criterion variance, and greater comprehensiveness.

Structured Clinical Interview for DSM Disorders (SCID-S and SCID-P)

The SCID is a semi-structured interview that is used for the classification of mental disorders according to the DSM. The SCID-I shows satisfactory interrater reliability, when the interviewers are all trained. The SCID-5-P is also a semi-structured interview, but then for personality disorders according to the DSM-5.

Mini International Neuropsychiatric Interview (MINI)

The MINI and the MINI plus are structured diagnostic interviews that can help clinicians to establish DSM and ICD-10 classifications.

What are other structured and semi-structured interviews?

Other structured interviews for assessing mental disorders in adults are the Diagnostic Interview for ADHD in Adults, the Autism Diagnostic Interview, the Clinical Interview for PTSS, the Social Competence Interview, the Positive and Negative Syndrome Scale, and the interview from the Psychopathy Checklist-Revised.

There are also two interviews that are used often in epidemiological research: the Diagnostic Interview Schedule and the Composite International Diagnostic Interview. The advantage of these interviews is that they assume that the interviewer has limited knowledge of psychopathology. Therefore, these tests can also be administered by nurses and health care assistants.

The SCAN/Present State Examination (PSE)

The SCAN or PSE is an example of a rating scale which is used to standardize the diagnosis of psychiatric symptoms that occur in different mental disorders.

The Health of the Nation Outcome Scales (HoNOS)

The HoNOS is a simple rating scale for examining a client’s psychological and social functioning. It can also be used for routine outcome measurements (ROM). It consists of four subscales: behavioral problems, limitations, symptomatology, and social problems. It contains a total of 12 items which are rated on a five-point Likert scale.

What are other rating scales?

Measurements in the Addictions for Triage and Evaluation (MATE) was developed within the context of addiction treatment. It is designed for determining valid and reliable client traits for the purpose of the indication for care and treatment in the addiction care sector and for the purpose of evaluating the care and treatment that the client receives. It can be used to determine the client’s use of psychoactive substances, the client’s history of addiction treatment, the diagnoses dependence and abuse according to the DSM and the extent to which the client craves psychoactive substances. The Yale-Brown Obsessive Compulsive Scale (Y-BOCS) is a structured interview used for obsessive-compulsive symptoms. The interview can be scored by a therapist or by an independent assessor. It consists of ten items, which measure the severity of the compulsive symptoms. It has two subscales: obsessions and compulsions.

How does the interview take place?

First, the interviewer must decide on whether the information that was acquired before the interview is reliable and usable. Lange suggests that the only information that the interviewer should examine before the interview is objective information (tests, medical examinations). Only after the interviewer has formed his own impression of the client, he or she should read the more ‘subjective’ information.

What happens during the interview?

The intake interview is divided into three phases. During the first and last phases, the interviewer provides the client with information about the procedure. In the middle phase, the client mainly provides information. In the beginning, the interviewer introduces himself and explains the purpose of the interview. He also states how long the interview is expected to take. He also informs the client about the confidentiality of the information. Then, to enter the middle phase, the interviewer uses an open question, for example: “Would you like to tell me what your main reasons are for coming here?”. In the last phase of the interview, the interviewer briefly summarizes the topics that have been discussed. The client can comment on this, to make sure that there are no false conclusions. Lastly, the interviewer informs the client about the course of the subsequent procedures.

What are potential obstacles during the interview?

During the interview, there can be obstacles that lie with the interviewer, the client, or within the interaction between them.

Interviewer obstacles

Sometimes, the interviewer avoids topics such as sexuality, domestic violence, incest and other traumatic experiences. However, during an intake interview, these topics are often not discussed. So, especially in later interviews, the interviewer should make sure that he is able to talk about these topics.

Client obstacles        

Clients often have experience psychopathology, which may hinder the interview. For example, depressive clients are often difficult to work with: he does not have much to say and only gives short answers. The interviewer could work choose to take more time during interviews or to schedule extra interviews. He also needs to be more supportive than usual and needs to explore the client’s strengths in more detail. Clients who suffer from anxiety,  must be made to feel at ease. The interviewer could for example give minor encouraging interjections, ask short open-ended and use summaries more frequently. Suggestive questions can also help (“I often hear from clients with your type of complaints that they can be deeply upset by events that are relatively minor, does that sound familiar to you?”). Sometimes, a client is ashamed of his or her own behavior. The interviewer should be alert to this and should identify the shame, while he probes for more information. Clients with addiction-related issues may deny or trivialize their problems and therefore give vague or incorrect answers. Therefore, the interviewer should pay extra attention to the client’s problem definition and explanatory statement. When there are somatizing and hypochondriac clients, they often rather see a doctor than a psychologist. Therefore, the interviewer should make clear what the goal of the interview is and what the client should not expect (a referral to the hospital, for example). Another difficult group are psychotic clients. Sometimes it is impossible to conduct an interview because they have lost contact with reality. The interviewer should pay attention to different elements: he should distinguish between the client’s psychotic and non-psychotic expressions. It is advised to ignore the client’s psychotic utterances. Sometimes, clients have a preference for a specific gender of the interviewer (for example, in the case of a woman who has been sexually abused). Then, it is advised to take this into account and provide the woman with a female interviewer.

Interaction obstacles

In an intake interview, the interviewer wants to know a lot of about the interviewee, while the interviewee knows almost nothing about the interviewer. Sometimes, clients find this concept difficult to deal with. Sometimes the client starts asking questions about the interviewer. Then, the interviewer should respond in a friendly, understanding, and decisive manner and point out that the interaction is meant to be one-sided. Clients could also experience difficulty in accepting the authority of the interviewer. Then, the interviewer should decide whether he triggered this behavior. In the field of addiction, Motivational Interviewing (MI) was developed. The goal of it is to deal with ambivalent clients. The authors suggest that every caregiver should be trained in this.

Another technique that helps to avoid conflict is positive labeling. This means that the client’s conduct is placed in a positive context. This helps to improve the therapeutic relationship, it reinforces the client’s self-image and it prevents conflict between the client and the interviewer.

What are the other interviews during the intake phase?

During the intake phase, there are other types of interviews that may be conducted.

The crisis intervention

Crisis intervention interviews are another type of ‘first interviews’. These interviews happen during a crisis, in which the person is often suffering from severe psychopathology (psychosis, addiction or severe depression). The main goal of it is to make sure that the crisis is diminished or overcome. After this, a decision can be made with regards to whether the client is still able to take part in the more common intake procedure.

The consultation

The consultation is the end of the intake phase. In a consultation, the interviewer gives his own perspective on the problems and the client’s request for help. The interviewer makes a recommendation about the future (treatment). In a consultation, the interviewer mainly talks and the client listens.

The bad news interview

Sometimes, a consultation feels like a bad news interview. In this type of interview, the interviewer discloses information that the client would preferably not hear. Interviewers often dread these types of interview, because of four reasons

1. Delivering bad news elicits strong emotions in the client, in which the interviewer is confronted with his powerlessness
2. It is often emphasized in the medical sector that the well-being of seriously ill clients is dependent on the manner in which bad news is delivered to them
3. The messengers of bad news sometimes have to deliver a message with which they do not agree
4. The interviewer may be confronted with complaints from clients who are unhappy about the way in which they were treated during the bad news interview

Voorendonck suggested to follow five steps with regard to bad news interviews:

1. Preparation: The interviewer needs to make sure that he has all of the information that is relevant to the interview and that the interview can be held at a suitable time and with the appropriate people.
2. Conveying the bad news: It should be checked what the client already knows and then, gradually, bad news should be conveyed in very clear terms.
3. Blowing off steam and allowing space for emotions: It is important that the interviewer’s words and attitude convey to the client that his emotions are acknowledged and that there is time for the necessary discussion.
4. Impact of the message and explanation: Only when the client has processed the shock of the news, he or she can be given more information about the background of the distressing message.
5. View of the future and the search for solutions: The content of this step depends on the nature of the news.

How does reporting take place during an interview?

After every interview, a report of the proceedings must be available in the dossier as soon as possible. This is important for the psychologist himself, but also for the colleagues. In the report, it should be clear what are objective facts and what information was given by the patient. The report that is written during the intake phase is more extensive than the report that is written during discussions about the treatment plan.