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LESSON 16
THE CLINICAL INTERVIEW
DEFINITION OF INTERVIEW
A situation of primarily vocal communication, more or less voluntarily integrated, on a progressively unfolding expert-client basis for the purpose of elucidating characteristic patterns of living of the patients, client, or subject, which pattern he/she experiences as particularly troublesome or especially valuable, and in the revealing of which he expects to derive benefit..
According to “Bingham” and “Moore” The clinical interview is a conversation with a purpose but as the purpose differ the area of the interview also differs.
INTRODUCTION OF INTERVIEW
Almost all professions count interviewing as chief technique for gathering data and making decisions. For politicians, consumers, psychiatrists, employers, or people in general, interviewing has always been a major tool. As with any activity that is engaged in frequently, people sometime take interview for granted or believe that it involve no special skills; they can easily overestimate their understanding of the interview process. Although many people seem awed by the mystique of projective tests or impressed by the psychometric intricacies of objective tests.
The assessment interview is at once the most basic and the most serviceable technique used by the clinical psychologists. In the hands of a skilled clinician, its wide range of applications and adoptability make it a major instrument for clinical decision making, understanding, and predictions. But for all this, we must not lose sight of the fact that the clinical interview is not greater than the skill and sensitivity of clinicians who use it.
IMPORTANT THINGS TO KNOW ABOUT CLINICAL INTERVIEWS
- It is not a cross-examination but rather a process during which the interviewer must be aware of the client’s voice intonation, rate of speech, as well as non-verbal messages such as facial expression, posture, and gestures.
- Although it is sometimes used as the sole method if assessment, it is more often used along with several of the other methods.
- It serves as the basic context for almost all other psychological assessments.
- It is t he most widely used clinical assessment method.
ADVANTAGES OF THE CLINICAL INTERVIEW
- Inexpensive
- Taps both verbal and non verbal behavior
- Portable
- Flexible
- Facilitates the building of a therapeutic relationship
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TYPES OF INTERVIEW
There are many different forms of interviews conducted by psychologists. Some interviews are conducted prior to admission to a clinic or hospital, some are conducted to determine if a patient is in danger of injuring themselves or someone else, some are conducted to determine a diagnosis. Whereas some Interviews are highly structured with specific questions asked for all patients, others are unstructured and spontaneous. In this section the common forms of clinical interviews will be briefly discussed. Some important forms of interview are:
- The intake / admission interview
- The case history interview
- Mental status examination interview
- The crisis interview
- Diagnostic interview
- Structured interview
THE INTAKE/ADMISSION INTERVIEW
According to Watson; “This type of interview is usually concerned with clarification of the patient’s percentage complaints, the steps he has taken previously to resolve his difficulties and his expectances in regard to what may be done for him”.
The purpose of the initial intake interview or admission interview is to develop a better understanding of the patient’s symptoms or concerns in order to recommend the most appropriate treatment or intervention plan. Whether the interview is conducted for admission to a hospital, an outpatient clinic, a private practice, or some other setting the initial interview attempts to evaluate the patient’s situation as efficiently as possible.
Ordinarily a psychiatric social worker conducts this interview; however, upon occasion, the psychologist, one of the physician, or a psychiatric nurse may serve as intake interviewer. The basic question to be dealt with is “Why is the patient here? i.e., what doe she says is the matter with him? Important but secondary questions involve information about previous hospitalization, the name of his doctors, what the patient expect from treatment, his availability for treatment, and the like.
Although typically brief, the intake or admission interview is extremely important in conserving the time of other professional staff members and in sparing the clinic or hospital for occasional embarrassing or awkward situations. The patient may in some instances desire treatment which a particular clinic may not be prepared to give. Certain hospitals, for example, do not handle alcoholic or narcotic addiction cases; thus the patient can be at once referred to an appropriate institution, saving time for the examining psychiatrist, psychologist, the various attendants, and for the patient himself.
Similarly, the awkward consequences of an overly casual admission procedure can be avoided by a well planned interview. Hospital staff members can relate many anecdotes of relative’s who were mistaken for the patient himself, of surgical patient who were given diagnostic psychiatric interview, or of salesman who were escorted to a room and confronted with a personality test.
A careful intake interview will guard against such mistakes. It should be noted that every patient will not be able to state coherently what the nature of his trouble may be. But even the unclear replies can be
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one is taken in, a little self directed humor helps restore a sense of proportion. Then a firm resolution to check other information sources can turn the experiences to one’s advantage. MENTAL STATUS EXAMINATION INTERVIEW
Often a mental status examination interview is conducted to screen the patient’s level of psychological functioning and the presence or absence of abnormal mental phenomena such as delusions, delirium, or dementia. Mental status exams include a brief evaluation and observation of the patient’s appearance and manner, speech characteristics, mood, thought processes, insight, judgment, attention, concentration, memory, and orientation.
Results from the mental status examination provide preliminary information about the likely psychiatric diagnosis experienced by the patient as well as offering some direction for further assessment and intervention (e.g. referred to a specialist, admission to psychiatric unit, and evaluation for medical problems that impact psychological functioning). For instance, mental status interviews typically include questions and tasks to determine orientation to time (e.g., “what day is it? What month is it?), place (e.g., Where are you now? Which hospital are you in?”), and person (“who am I who is the president of United States?”). Also, the mental status interview asses short term memory (e.g. “I am going to name three objects I’d like you to try and remember: dog, pencil, and vase”) and attention- concentration (e.g., “count down by 7s starting at 100. For example 100, 93, and so forth”).
While there are some mental status examination that are structured resulting in scores that can be compared to national norms, most are unstructured and do not offer a scoring or norming option. During the examination the interviewer notes any unusual behavior or answers to questions that might be indicative or psychiatric disturbance. For example, being unaware of the month, year, or the name of the current president of the United States usually indicate mental problems. This can result in bias based on the interviewer’s clinical judgment during and evaluation.
THE CRISIS INTERVIEW
A crisis interview occur when the patient is in the middle of a significant and often traumatic or life threatening crisis. The psychologists or the mental health professionals (e.g., a trained volunteer) might encounter such a situation while working at a suicide or poison control hotline, an emergency room, a community mental health clinic, a student health service on campus, or in many other settings. The nature of the emergency dictates a rapid, “get to the point” style of interview as well as quick decision making in the context of a calming style. For example, it may be critical to determine whether the person is at significant risk of hurting him- or herself or others. Or it may be important to determine whether the alcohol, drugs, or any other substances are used, so as to make sure that the clinician interviews the person in a calming and clear headed manner while asking critical questions in order to deal with the situation effectively.
The interviewer may need to be more directive (e.g., encouraging the person to phone the police, unload a gun, provide instructions to induce vomiting, or step away from a tall building or bridge); break confidentiality if the person (or someone else, such as a child) is in serious and immediate danger; or enlist the help of others (e.g., police department, ambulance).
THE DIAGNOSTIC INTERVIEW
The purpose of the screening or diagnostic interview is to assist the clinician in his attempt to understand the patient.
If the level of diagnostic understanding required is merely a separation of the fit from the unfit, as in military neuro-psychiatric examinations, the interview task is one of screening. That is, after a brief interview the interviewee be adjusted fit for specific duties, such as a regular military assignment, or he
may be referred for prolonged observation and extended psychological testing. Occasionally, limit ordocsity.com
trial duty may be recommended as an alternative to regular duty of psychological observation. Upon other occasions the diagnostic task is highly specific, and a detailed level of understanding is required. This may involve a diagnostic label as categorized as “paranoid schizophrenia” and a description of personality dynamics. In the later case primary dependence is not placed upon the interview alone, for psychological tests play a most important role in such detailed diagnostic procedures.
In the diagnostic interview, while the examination progresses; the interviewer observes the interviewee’s behavior as well as noticing the content of his answers. Thus thighs pressed together, a mincing walk, and fluttery feminine gestures in a male should lead the interviewer to suspect and investigate the possibility of homosexuality. The bubbling, enthusiastic replies and exaggerated gestures in another interview should lead the interviewer to hypothesize tentatively a manic condition and seek further evidence. Similarly, as Wittson, et al. noted, the psychopath often gives evidence of his deviation by his utter impersonality or even belligerence towards the interviewer.
Ordinarily, brief neuro psychiatric interviews are not oriented towards future psychotherapeutic activity because most of the interviews have no need of therapy. However, it is not difficult to adopt the procedure of the brief interviews so that those who seem in need of treatment are rendered more receptive to the idea. Thus this kind of interview is used to describe that whether an individual needs help or not.
STRUCTURED INTERVIEW
In an effort to increase the reliability and validity of clinical interviews, a number of structured interviews have been developed. These interviews include very specific questions asked in a detailed flow chart format. The goal is to obtain necessary information, to make an appropriate diagnosis, to determine whether a patient is appropriate for a specific treatment or research program, and to secure critical data that are needed for patient care. The questions are generally organized and developed in a decision tree format. If a patient answers yes to particular questions (for example, about panic), the list of additional questions might be asked to obtain details and clarification.
RELIABILTY AND VALIDITY OF INTERVIEWS
As with any form of psychological assessment, it is important to evaluate the reliability and validity of interviews.
RELIABILITY
The reliability of an interview is typically evaluated in terms of the levels of agreement between at least two raters who evaluated the same patients or client, by agreement we mean consensus on diagnosis assigned, on ratings of levels of personality traits, or any other type of summary information derived from an interview. This is often referred as inter-rater reliability.
Standardized (structured) interviews with clear scoring instructions will be more reliable than unstructured interviews. The reason is that structured interviews reduce both information variance and criterion variance. Information variance refers to the variation in the question that clinicians ask, the observations that are made during the interview, and the method of integrating the information that is obtained. Criterion variance refers to variations in scoring thresholds among clinicians.
Another type of reliability is the test-retest interviews-the consistency of scores or diagnoses across time. We expect the test re test reliability of an interview quite high when the intervening time period between the initial testing and the retest testing is short. However when the intervening time period is long test retest reliability suffers.
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phone that rings relentlessly, a secretary’s query, or an imperative knock on the door. Such interruptions are extremely disruptive.
The general appearance of the room should suggest comfort and yet have a professional flavor about it.
2. NOTE-TAKING AND RECORDING
All contacts with the client ultimately need to be documented. However, there is some debate over whether notes should be taken during an interview. Although there are few absolutes, in general, it would seem desirable to take occasional notes during an interview. A few key phrases jotted down will help the clinicians to recall. Most clinicians have had the experience of feeling that the material in an interview is so important that there is no need to take notes. The material will easily be remembered. However, after having a few additional patients the clinicians cannot be able to recall much for their earlier interview. Therefore, a moderate amount of note - taking seems worthwhile. Most patients will not be troubled by it, and if one should be, the topic can be discussed.
However, any attempt at taking verbatim note should be avoided. One danger in taking verbatim is that this practice may prevent the clinicians from attending fully to the essence of the patient’s verbalizations. An overriding compulsion to get it all down can detract from a genuine understanding of the nuances and significance of the patient’s remarks. In addition, excessive note taking tends to prevent the clinicians from observing the patient and from noting subtle changes of expression or slight changes in body position.
With today’s technology, it is easy to audio tape or videotape interviews. Under no circumstances should be this done with out the patient’ fully informed consent.
3.RAPPORT
Report is the word often used to characterize the relationship between patient and clinician. Rapport involves a comfortable atmosphere and a mutual understanding of the purpose of the interview. Good rapport can be primary instrument by which the clinicians achieve the purpose of the interview. A cold, hostile or adversarial relationship is not likely to be constructive. Although a positive atmosphere is certainly not the sole ingredient for a productive interview, it is usually a necessary one. Whatever skills the interviewer possess will surely be rendered more effective in proportion to the interview’s capacity to establish a positive relationship.
4. SETTING THE RIGHT TONE
Experienced interviewers have learned and repeatedly confirmed that the atmosphere most conducive to the successful elicitation of information is one of mutual respect.
5. GETTING THE INTERVIEW OFF TO A GOD START
One of the first tasks, in fact, obligations, of the clinician is to make sure that the client understands the purpose of the interview as clearly as he is capable of understanding.
COMPONENTS OF GOOD LISTENING
-elimination of distraction
-alertness
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-concentration
-patience
-Open-mindedness
6. ADJUSTMENT
Adjust the sequence of topics to be discussed to the anxiety level of the informant.
7. MOVING RAPIDLY THROUGH THE INTERVIEW
In personal interviewing and, even more important, in case history interviewing a rapid fire technique may result in grater reliability.
8. ASKING QUESTIONS STRAIGHTFORWARDLY
Johnson, et al., remarked, having laid a solid foundation of rapport, mutual understanding and respect, it is best to ask questions in a direct manner.
9. CONSIDERABLE TACT AND SKILL MUST BE USED IN HANDLING PAUSES
We should not be too eager to make and answer for a client and should give him time to think through his answer carefully. On the other hand, we must not allow pauses to become so long as to become painful or awkward and this make the client uncomfortable.
10.ATTEPMT TO GET BENEATH SUPERFICAL ANSWER
We should attempt to rephrase or ask additional questions when client’s answers are obviously superficial.
11. NOTE DISCRIPANCIES IN THE ACCOUNT AND CHECK THEM
When inconsistencies are noted, they should not be ignored, but should be checked as unobtrusively as possible without challenging the client’s veracity.
12. HANDLING EMOTIONAL SCENES TACTFULLY
A moderate amount of crying, weeping, anger, or hostility is to be expected and is frequently of sign a good rapport. However it is responsibility of the clinician to maintain control of the situation and not to allow it to get out of hand, or the client to become too depressed.
13. PREPAREDNESS
Be prepared for the questions directed to you by the informant. Clinician’s answer will depend upon his role in clinic routine i.e., what his answers will mean in terms of helping or hindering the progress of the interview. POTENTIAL THREATS OF EFFECTIVE INTERVIEWING
BIASNESS
Interviewers may be biased. Their personality, theoretical orientation, interests, values, previous experiences, cultural background, and other factors may influence how they conduct an interview, what
they attend to, and what they conclude. Interviewers may consciously or unconsciously distortdocsity.com
