Clinical Interviewing Dos and Don’ts

By: Daniel L. Segal, Andrea June, and Meghan A. Marty

Although there is great flexibility in the ways clinicians conduct the clinical or diagnostic interview, we gently offer the following guidance regarding some positive strategies clinicians may endorse and some tactics they may wish to avoid.

Beginning with the “dos” of the interview,

Do focus as much on developing rapport as on gathering data. Whereas the two primary goals of the clinical interview are to develop a working alliance with the client and to gather relevant data about the personal background of the client and the types of problems he or she is experiencing, the first goal of establishing rapport is arguably the most important of the two. Indeed, without the development and ongoing nurturance of a positive therapeutic relationship, the act of gathering information about the client is pointless if he or she does not return for ongoing treatment (Hook et al., 2010).

Do provide structure and direction in the interview as needed (Segal, Maxfield, & Coolidge, 2008). Whereas advantages of a non-structured clinical interview include its flexibility, which allows for discussion and exploration of topics that may not necessarily be covered by a structured interview, and its provision of extensive opportunities for empathizing with the client and developing a strong therapeutic alliance, a potential hazard is that the interview may stray excessively.

A general rule of thumb is that if clients provide appropriate structure to the interview (moving appropriately from topic to topic), then no active structuring is required by the clinician. However, if clients struggle with providing their own structure (e.g., spending too much time on topics of little or questionable relevance to the problems at hand), then the clinician must provide more guidance. Along these lines, do have a solid knowledge of the symptoms and requirements for diagnosing a wide range of disorders from the DSM-IV-TR to be able to assess for the full range of cardinal and associated symptoms as part of the diagnostic process. This knowledge will also be of help when crafting case conceptualizations and treatment plans.

Do pay special attention to the final moments of the initial interview (Segal et al., 2008). There is a lot to accomplish during the first interview, and this includes the last 5–10 min as well. Rather than end abruptly, the clinician should attend to the sensitive information that has been shared and may want to thank the client for sharing personal, potentially upsetting experiences. The ending of the interview is also an opportunity to review important themes addressed and, as a means for offering a sense of hope, clinicians can suggest some of the ways that psychotherapy could be helpful in addressing the presenting complaints.

Conversely, there are a number of things to avoid during the interviewing process.

Don’t become overly committed to an initial diagnostic hypothesis, instead maintain  multiple hypotheses (Segal et al., 2008). Although knowledge of a previous diagnosis and initial impressions of the client are useful, it is important to keep an open mind. If clinicians are not flexible in diagnosing, they may be closed off or dismissing of information that does not align with that first hypothesis. Maintaining multiple hypotheses is essential in making accurate diagnoses and subsequently providing an effective treatment.

Don’t make assumptions (Segal et al., 2008). It is tempting to believe that we understand the client’s symptoms when they use labels. For example, when someone says that they have been experiencing “panic attacks,” it is easy to imagine increased heart rate, sweating, and the intense fear that he or she is going to die or have a heart attack. As another example, when someone says that they are “codependent” it likely conjures an image of a person who exhibits overdependence on people, behaviors, or things, such as a spouse who supports addiction by excusing, denying, or concealing evidence of the partner’s alcohol abuse. At first blush, these labels seem reasonable. However, without specific inquiry and the gathering of specific examples of behaviors, it is unclear that the clinician and client define the problem or symptoms in the exact same way. It is possible in fact that the clinician and client are thinking of quite different experiences, making appropriate and effective treatment unlikely.

Finally, it is important that clinicians do not let their opinions or values unduly factor into the interview (Segal et al., 2008). There will be instances in which the clinician feels at odds with the client’s decisions and behaviors; however, with the exception of illegal and harmful actions, it is important to provide an environment for the client that is free of the clinician’s biases and values. This is especially challenging if the client has done things the clinician feels are reprehensible or disgusting. In these cases, it can be helpful to try to understand and empathize with a person who has done awful things rather then with an awful client, so try to conceptualize the person as not equivalent to their behavior.

In order to feel comfortable sharing such personal information with a stranger, the client must feel safe, rather than conscious of the topics that make the clinician uncomfortable or are of particular interest to the clinician. Unfortunately, one’s biases and judgments are not always conscious, so special attention must be paid to one’s reactions to the content of interviews and psychotherapy sessions. In the event that a clinician’s opposition to the client’s behaviors, values, or decisions is intense, the clinician should discuss the issue with a colleague or supervisor, and if the feelings continue to intrude into the treatment, the clinician should refer the client elsewhere if ongoing psychotherapy is needed.

References

Daniel L. Segal and Michel Hersen, Diagnostic Interviewing, Fourth Edition, 2010, Springer

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