Copyright 1998 Elsevier Science Ltd. All rights reserved.

4.04
Clinical Interviewing
EDWARD L. COYLE
Oklahoma State Department of Health, Oklahoma City, OK, USA
and
DIANE J. WILLIS, WILLIAM R. LEBER, and JAN L. CULBERTSON
University of Oklahoma Health Sciences Center, Oklahoma City,
OK, USA
4.04.1 PURPOSE OF THE CLINICAL INTERVIEW

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4.04.1.1 Gathering Information for Assessment and Treatment

4.04.1.2 Establishing Rapport for Assessment and Treatment
4.04.1.3 Interpersonal Style/Skills of the Interviewer
4.04.1.4 Structuring the Interview
4.04.1.4.1 Setting variables
4.04.1.4.2 Preparing for the patient
4.04.1.5 Introductory Remarks
4.04.1.6 How to Open the Interview
4.04.1.7 The Central Portion of the Interview
4.04.1.8 Closing the Interview
4.04.1.9 The Collateral Interview
4.04.2 DEVELOPMENTAL CONSIDERATIONS IN INTERVIEWING
4.04.2.1 Interviewing Children (Preschool Age through Older Elementary)
4.04.2.2 Interviewing Parents
4.04.2.3 Social Context
4.04.2.4 Developmental Context
4.04.2.5 Direct Interview of Children
4.04.2.6 Adolescents
4.04.2.6.1 Separationindividuation
4.04.2.6.2 Resolving conflict with authority figures
4.04.2.6.3 Peer group identification
4.04.2.6.4 Realistic appraisal and evaluation of self-qualities
4.04.2.7 Interviewing Young Adults (1840 Years)
4.04.2.8 Interviewing Adults in Middle Adulthood (4060 Years)
4.04.2.9 Interviewing Older Adults (6070 Years)
4.04.2.10 Interviewing In Late Adulthood (70 YearsEnd of Life)
4.04.3 INTERVIEWING SPECIAL POPULATIONS OR SPECIFIC DISORDERS
4.04.3.1 Interviewing Depressed Patients
4.04.3.2 Interviewing Anxious Patients

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4.04.4 SUMMARY

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4.04.5 REFERENCES

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Clinical Interviewing

4.04.1 PURPOSE OF THE CLINICAL

INTERVIEW
The clinical interview is extremely important
as a diagnostic tool in the assessment and treatment of patients. Clinicians who do thorough
and competent interviews have a much better
understanding of the developmental course of
symptoms presented by the patient. Indeed,
before there were any personality inventories,
before the Rorschach and one-way mirror behavioral observation, there was the clinical interview. The purpose of the clinical interview is to
gain sufficient information from the informant
or informants to formulate a diagnosis, assess
the individual's strengths and liabilities, assess
the developmental and contextual factors that
influence the presenting concerns, and to allow
planning for any interventions to follow. The
interview is in many instances the ultimate clinical tool, and effective interviewing must be an
integral part of any clinician's professional
abilities. Although the clinical interview is used
primarily to gather information for clinical
evaluation or psychotherapeutic treatment, it
can also serve the purpose of preparing the
patient for therapy, and less frequently the interview process itself provides some relief from
psychological distress. The interview may be
performed in many different settings: outpatient
private practice, community mental health
center, psychiatric hospital, prison, emergency
or medical hospital room, school, and others.
While the amount of time devoted to the
interview, the setting, and the purposes may
vary, the features of an effective clinical interview remain the same. When completed, the
interviewer has created a relatively comprehensive portrait of the patient that can be communicated readily to others and will provide the
basis for making important judgments about the
subject of the interview. The relative importance
of various symptoms or concerns should be
established, along with an estimate of the
individual's overall functioning. The relative
importance of various symptoms or concerns
should be established, and some estimate of the
individual's responses in a variety of settings can
be made with an acceptable degree of validity.
These features can be said to be a part of any
clinical interview. Some specific purposes of the
interview are described next, along with suggestions about different approaches and emphases
the clinician may be required to take.
4.04.1.1 Gathering Information for Assessment
and Treatment
The most common purposes of the clinical
interview are to gather information to establish a

diagnosis, evaluate mental status and historical

data that impact upon the individual, and
provide a full understanding of the important
personality, biological, and environmental variables that have brought the patient to this point.
All treatment planning begins with some type of
formal or informal evaluation. The clinical
interview is the most effective way to gain an
understanding of the current functioning and the
difficulties faced by the patient, and is a necessary adjunct to the data gathered from other
assessment approaches. In the clinical interview,
the clinician inquires directly and in a focused
manner about the patient's development, adaptation, and current difficulties. When the interview is part of a comprehensive evaluation, some
features may be emphasized as a result of the
specific referral reason that would not be as
prominent in the interview conducted for psychotherapy treatment planning. As an example,
the interview conducted for an initial psychoeducational evaluation of an elementary grade
school child to determine reasons for school
failure is likely to entail considerable emphasis
upon academic and learning history and the
involvement of one or more of the child's
teachers as collateral informants. If the same
child were to present later for psychotherapeutic
interventions to address the depression and
oppositional behaviour problems identified by
previous evaluation to be the cause of his
academic failure, the interviewer would likely
spend more time and effort in determining
family interactions, parenting skills, and social
supports.
4.04.1.2 Establishing Rapport for Assessment
and Treatment
One function of the clinical interview is to
prepare the patient for the clinical interventions
that follow, including additional formal assessment procedures. In order to obtain valid
psychometric data, the patient must be adequately cooperative and invested in the testing
process. The interview can help the clinician
achieve this end by providing a sense of
professional intimacy and a feeling of compassion and interest in the patient's well-being.
Thus prepared, the respondent is more willing to
give themself over to the process, and to perceive
it as being something that will provide them with
some beneficial outcome.
4.04.1.3 Interpersonal Style/Skills of the
Interviewer
While the basic purpose of gathering relatively concrete information may be accomplished by individuals with a minimum of

Purpose of the Clinical Interview

training and sensitivity, there are a number of
personal qualities that tend to improve the
quality of information gained and to result in a
more helpful and pleasant experience on the
part of the informant. Chief among these is the
quality of empathy, which must be readily
recognized by the informant through subtle and
overt communications from the interviewer.
Empathy means identifying with and understanding someone else's feelings, motives, or
word view. It means entering the private
perceptual world of another person and being
at home in itto be sensitive to what they feel
(Egan, 1994; Luborsky, 1996). An intellectual
understanding of empathy, however, does not
provide one with the interpersonal skills and
experience that result in the ability to truly
resonate to the informant's experience and to
respond in ways that will ease the flow of
information of a personal and often sensitive
nature. The skill and art of attuning oneself not
only to the overt communications of the patient,
but also to the underlying feelings and meanings, must become a continuing focus of
attention for the interviewing clinician. While
much of this process is not fully accessible to
conscious awareness, there are some components that lend themselves readily to examination and modification. For example, the
interviewer's responses that communicate to
the informant negative value judgments are
perhaps more easily modified.
Although the mental health fields and their
practitioners have often been vilified for their
purported moral relativism, no reasonable
clinician would believe himself or herself to be
free of individual prejudices and deeply-held
convictions regarding right and wrong. These
values are a part of each person, and to truly
expunge them would result in an insipid and
ineffective shell of a human being. The relevance
to a discussion of clinical interviewing is this: the
effective interviewer takes care to be aware of
his or her own expectations and biases regarding
human behaviour and strives to avoid making
explicit negative judgments of the informant in
order to provide a comfortable and supportive
environment during the interview. This skill can
be and is developed and improved through
careful attention to the process, internal
changes within the interviewer during the
interaction, and by effective supervision and
review of actual interviews with other clinicians.
Often such judgments can be communicated
to the respondent with no more than a change in
facial expression or in a shift in questioning.
Specific wording and follow-up questions
sometimes can have the effect of casting a chill
upon the interview process. For example, the
interviewer who learns the informant is homo-

83

sexual and then avoids asking questions about

sexual functioning and current relationships
readily communicates their discomfort with an
important aspect of the informant's personality.
The effective interviewer does not perfect an
unexpressive mask, but does develop the ability
to decrease the immediate translation of visceral
responses into explicit behaviours during the
interview. Introspection about areas that increase the clinician's anxiety and honest confrontation about discriminatory beliefs are
necessary if one is to perform clinical tasks
competently and ethically.
4.04.1.4 Structuring the Interview
As with any therapeutic or evaluative intervention, the setting and structure of the interview have a significant effect on the outcome of
the interaction. Because the actual face-to-face
time spent with patients must be as productive
and positive as possible, the clinician should
take care to prepare for the clinical interview
prior to contact. While the goals of the interview
may vary somewhat as discussed previously,
many factors common to all clinical interviews
should at least be in one's mind prior to and
during the interview.
4.04.1.4.1 Setting variables
Some basic attention should be given to
simple environmental factors when preparing
for the interview. Although many fruitful interviews have been conducted with patients,
families, and other sources under conditions
that might be charitably described as less-thanoptimal, doing so in a comfortable and soothing
environment will often add to an informant's
ease in discussing delicate and/or emotionally
charged matters. Seating accommodations
should be given consideration, as hard, uncomfortable, or rickety, precarious seats can add
a tinge of anxiety or discomfort to the gestalt of
the interview process and thus to the evaluation
and/or treatment that follows the interview. It
should go without saying that the space being
used for the clinical interview should be held
relatively inviolate from intrusions, including
external noises and conversation to the degree
possible. While most people are able to tolerate
minor interruptions such as a ringing telephone,
having another clinician open the door while
your patient is tearfully recounting a past
trauma is likely to be somewhat harmful to
the tentative alliance you are developing. Therefore, if you work in a setting with multiple users
you will do well to take precautions to avoid such
disruptions. A white-sound generator can help

84

Clinical Interviewing

decrease the penetration of external sounds and

add somewhat to the intimacy of the interaction.
Throughout the interview the clinician will be
carefully observing the behaviours of the
subject, noting congruencies and incongruencies, attending to shifts in voice and posture. One
sometimes overlooked source of information
that may add to the interview process is that of
behavioral observations made while the patient
and collaterals are in the waiting area of the clinic
or office. Often it is possible to observe
interactions and general demeanor while you
organize paperwork or make other preparations
before formally introducing yourself. It may
then be helpful to comment during interview on
some salient interaction or response. Of course,
as has been particularly noted by various
custody and forensic evaluators (Bricklin,
1990), the behavior in the waiting room must
not be taken as necessarily representative of the
person's usual response outside of the clinic.
However, one often can observe telling interactional patterns, particularly between parents
and children, and this may provide opportunity
for addressing problematic areas during the
subsequent interview.
4.04.1.4.2 Preparing for the patient
It is common practice now to present the
patient with relatively extensive questionnaires
or personal history forms prior to the first clinic
visit. With this information in hand, the
clinician may be able to focus in quickly on
the salient symptomatology and current concerns. When available, this information should
be used to tailor the interview, allotting time
during the face-to-face interview in the most
effective manner. If the clinician does choose to
utilize such instruments, he or she would be well
served to take the time necessary to review the
data prior to entering the room with the
informant. Watching the professional read
and murmur over the forms for minutes while
the informant is ignored or asked disconnected
questions can be expected to result in a sense of
devaluation for the informant. It also gives the
impression of disorganization and lack of
preparation on the part of the clinician. Neither
of these will be helpful in the ensuing interview
process.
4.04.1.5 Introductory Remarks
It is helpful to develop a standard approach
to the clinical interview, including the introduction and beginning of the interview. One
should introduce oneself, and give the informant information about the purpose of the

interview and the expected duration. The

interviewer's role and title should be clarified,
and any supervisory or other training relationship must be disclosed prior to beginning the
interview. It is essential that issues of confidentiality be fully addressed, and the informant be given opportunity and encouragement
to ask questions about disclosure of information. If any of the data obtained will be shared
with other individuals, this must be explained
clearly. This is of particular importance in
forensic or custody evaluations. When interviewing children and parents, keep in mind the
fact that in many jurisdictions the noncustodial
parent may retain full rights to examine medical
records, including data from the clinical interview. Even if the informant has signed a general
disclosure or consent for treatment, it is the
clinician's ethical responsibility to review duties
to warn and the possible limits on confidentiality. The legal definition of informed consent
in many jurisdictions is not necessarily satisfied
by the presence of a signature on a form, but
rather is established by questioning the informant about their understanding at the time
the information was given. The best practice is
for the clinician to do their best to make certain
that the person with whom they are communicating for professional purposes is fully
informed of such issues. In illustration, imagine
for a moment being 30 minutes into an
interview with a man who informs you very
clearly that he intends to use the pistol in his car
to shoot his wife when he returns home. If you
have fully informed him of the limits of
confidentiality, you are in a very distressing
situation. If you have not done so, your position
is much worse. The growth of managed care and
its attendant prospective treatment review
process may complicate the ethical duties
involved in the clinical interview. As Corcoran
and Vandiver (1996) point out, There can be no
doubt that managed care has restricted clients
autonomy and interferes with the confidential
relationship (p. 198). During the initial interview and prospective utilization review of a
patient whose care is managed by a third (or
possibly fourth) party, the clinician may find
him or herself in the uncomfortable position of
being more the agent of the managed-care
organization than the advocate of the patient. In
such relationships, it is imperative that the
patient be made fully aware at the outset of the
interview of the additional limits of confidentiality imposed by the managed-care entity. This
may include multiple reviews of the data gained
during interview and any subsequent treatment
sessions. An additional ethical concern arises in
the clinical interview with regard to the
establishment of a professional relationship

Purpose of the Clinical Interview

and responsibility for the clinical care of the
patient. Does performing the clinical interview
and prospective review obligate the clinician to
provide service even if the managed-care entity
denies authorization? Again, the only way to
avoid difficulties, misunderstandings, and possible litigation or board complaints is to be
absolutely clear with interviewees and any
involved third-party payer about these issues
prior to the professional contact. If it is possible
that the interviewing clinician will not receive
reimbursement from the managed-care company for services, any alternative financial
arrangements should also be discussed with
the prospective patient before any formal
clinical contact. If there are inherent limitations
to the number of sessions or type of interventions that are covered by the third-party payer,
the potential client should also be made aware
of these before ending the interview. Of course,
it is possible that no treatment will be necessary;
thus it seems sensible to leave discussing the
mechanics of paying for it until it is determined
to be needed.
4.04.1.6 How to Open the Interview
The best way to open the interview is with a
very general, open-ended question about the
circumstances that have brought the patient to
the interview. Morrison (1995) recommends
taking approximately eight to 10 minutes in the
typical one-hour interview to allow the respondent to explain in their own words their needs
and history. Morrison points out that, among
other things, this provides the clinician an
opportunity to obtain a true flavor for the
respondent's personality and communication
style, and to make general observations of
behavior, affect, and thought process relatively
free from the clinician's direction. An example
of an opening question might be Please tell me
about the things that are concerning you most
right now or I would like for you to tell me
what you need some assistance with now or
even Please give me an idea of how you came to
be here today. The amount of information
gathered during this portion of the interview
will be to some degree dependent upon the
respondent's intellectual ability and verbal
facility. Many people are characterologically
unwilling to self-disclose, even within the
confines of the clinical interview, and may
require additional urging. The clinician should
generally respond to hesitations with supportive
restatement of the opening question, or with
gentle encouragement and reflection of any
apprehension that is detected. If hesitation or
lack of content appear to be due to cognitive

85

limitations, disorientation, or distractibility, it

may be helpful to ask more direct and closeended questions based upon previously
obtained information or the patient's brief
verbalizations. It is generally not desirable to
lead the patient any more than necessary, as the
more you query the less likely you will be able to
distinguish between accurate responses and
those that are colored by the demands experienced by the patient. However, in some cases the
clinician must take a more directive approach to
complete the interview successfully.
The topics to be included in every interview
are:
(i) Introduction, purpose of interview, credentials/role of interviewer;
(ii) Confidentiality and exceptions;
(iii) Presenting problems (preferably phrased
in general, open-ended manner);
(iv) Mood/Anxiety symptoms;
(v) Impulse control and direct inquiry of
suicidal ideation/history;
(vi) Current social, academic, and vocational
functioning;
(vii) System of social support;
(viii) Environmental factors, including current basic needs/shelter;
(ix) Developmental factors (especially for
children) that may influence symptom presentation;
(x) Medical history, including family health
history and previous treatment/hospitalization;
(xi) Substance use;
(xii) Legal involvement and history; and
(xiii) Vegetative symptoms.
4.04.1.7 The Central Portion of the Interview
After the initial introduction, housekeeping,
and rapport-building, it is time to focus upon
the most salient features of the person being
evaluated, and the circumstances that maintain
the current dysfunction. Once the presenting
problems have been identified and an adequate
alliance with the respondent established, the
clinician must utilize their knowledge of
psychopathology and diagnostic criteria to fully
understand and classify the presenting problems, as well as to identify the primary
strengths and resources that will be drawn
upon by the patient and the professionals
involved in subsequent interventions. The
central portion of the interview is dedicated
to adding to the framework established by
queries about the presenting problem. One mistake made by novice (as well as by some more
seasoned but overly concrete) interviewers is to
rigidly adhere to an interviewing framework,
disregarding the natural flow of conversation.

86

Clinical Interviewing

If one is unable to recognize the more subtle

verbal and nonverbal messages that should be
probed and instead forces one's way forward,
the clinician will end up with less information
than they should. Thus, it is essential to
attend carefully to shifts in mood during the
interview, both within the patient and the
interviewer.
Luborsky (1996) details the utilization of
momentary shifts in mood during a therapy
session to focus upon vital underlying thoughts
that are salient to the therapeutic issues. The
interviewing clinician can also benefit by
noticing changes in voice tone, volume, and
content of speech. During the central portion of
the interview the clinician continues to focus on
the problems and possible explanations for
present distress. When possible, avoid becoming
involved in digressive topics, as some respondents may prefer to spend most of the available
time presenting problems that are not central to
the services being sought. By the same token, it
is the clinician's responsibility to follow any
significant leads in the interview, and to be
aware of any tendencies on their own part to
avoid distressing topics. Experience shows that
clinicians tend to be vulnerable to this type of
error in particular with regard to sexual
functioning, substance use, and racial/ethnic
discrimination issues. It may be helpful to keep
in mind that while the interview shares many
commonalties with social conversation, it is by
definition not a run-of-the-mill social interaction. Thus, inhibitions that prevent the interviewer from querying these admittedly
uncomfortable topics must be dealt with.
Because many clinicians may find themselves
having completed much of their formal training
without ever overcoming the discomfort experienced when such topics are broached, it may be
necessary to practice on colleagues in role-play
activity designed to help the clinician become
adept at obtaining the necessary information
despite initial resistance from within as well as
from the respondent. As one of the primary
purposes of the clinical interview is accurate
diagnosis according to current syndromal
criteria from the Diagnostic and statistical
manual of mental disorders (4th ed., DSM-IV),
the clinician must have a solid working knowledge of the criteria for major disorders. Many of
the diagnostic categories require precise time
qualifiers, so any reports of significant symptoms should be followed by the clinician's
efforts to establish their time of onset, duration,
and severity. The respondent should be encouraged by the clinician to employ descriptive
terms, and to indicate in some way the intensity
of the symptoms with a numerical scaling or
comparative descriptors.

4.04.1.8 Closing the Interview

As the time for the interview draws to a close,
the clinician should consolidate the information
gained. It is helpful to review one's notes so that
any lingering questions may be answered, and to
clarify any dates, names, or other details that
may have become confused during the course of
the interview. An additional responsibility of the
clinician conducting the interview is to assist
the informant in achieving closure. Many times
the clinical interview results in emotional
dilation and some level of cognitive disorganization as distressing events are recalled and
exposed to another person. The skilled clinician
will continue to structure the interview with
reminders about the amount of time remaining,
summarizing the information provided, and
giving appropriate feedback to the informant
regarding what to expect next. Avoid rushing
the informant out of the room, but be prepared
to set limits about the closing of the interview.
When possible, it is beneficial to give the
informant a good idea of your diagnostic
formulation, and to outline possible intervention strategies. If this is not possible or
appropriate at the close of interview, convey
to the informant what steps will be taken to
complete the evaluation, or provide the informant with an idea of how the information
provided will be utilized. If possible the
informant should leave the interview with the
feeling that they have been heard, understood,
and will be benefiting in some way from having
participated.

4.04.1.9 The Collateral Interview

Collateral interviewing refers to any direct
interviewing done with persons other than the
identified patient. Common collateral individuals who are interviewed in the clinical setting
include parents, spouses, siblings, and other
close relatives. In the case of children and
adolescents, school teachers, administrators,
and counselors are also often interviewed
directly about the behavior and adaptive
functioning of the patient. The same skills used
in interviewing the identified patient will be
employed in these interviews. Empathy, a lack of
criticism, and an appropriate use of humor are
just as indispensable in talking with a spouse or
school principal as they are with the individual
presenting for assessment and/or treatment. In
many cases, the collateral interview is conducted
because the patient is unable to provide the
needed information on their own because of
disorganizing pathology or other limiting factors, making a collateral information source

Developmental Considerations in Interviewing

even more important. In conducting the collateral interview, one must also determine, to the
extent possible, the degree of reliability or
weight to place upon the information thus
gathered.
The clinician should consider the amount of
time the informant has known the patient, and
the circumstances under which the patient has
been observed by the informant. In the case of
the school teacher, beginning with questions
regarding the amount of time spent with the
patient and the subjects taught provides an
opportunity to gather useful information about
the school setting. In addition, this allows the
clinician to evaluate to some extent the affective
responses of the informant toward the patient,
for example, excessive anger or frustration on
the part of the teacher may point to possible
distortions in reporting. It is helpful to probe
gently for the teacher's experience level, to avoid
being unduly influenced by the observations of
one who has relatively little comparative
knowledge of normative classroom behavior.
Begin by asking how long they have been in this
particular school, or teaching this particular
grade. If the teacher is special education
certified, ask how long they have been certified
and in what areas. Usually these queries will be
sufficient to obtain a good estimate of the
experience base of the teacher, and most will
actually respond to the general probes with
more than enough information to make appropriate judgments.
In the case of the parent interview, take care
to establish current custody arrangements and
responsibilities as clearly as possible. Depending upon the jurisdiction in which the clinician
works, noncustodial parents may not have the
right to seek mental health services for the child.
It is the clinician's responsibility to be aware of
all the legal constraints on service, as well as the
ethical duties peculiar to working with children
or others who are unable to consent to
treatment legally. Be cautious about taking
the word of one parent involved in a visitation
or custody dispute who reports that the other
parent has no interest in the child, or that the
other parent would be completely uninterested
in assisting in assessment or treatment for the
child. Experience indicates that while this may
be true in some cases, this attempt to shut the
other parent out of clinical work may result in
significant distortion of the presenting facts,
and can hamper effective work with the child.
Thus, if the parent bringing the child for services
indicates that their (ex)spouse will not participate in the interview, go ahead and obtain
consent from the present parent to contact the
reportedly uninvolved parent. This action
would only be contraindicated if the clinician

87

has convincing evidence that contacting the

other parent would present a significant danger
to the patient.
4.04.2 DEVELOPMENTAL
CONSIDERATIONS IN
INTERVIEWING
4.04.2.1 Interviewing Children (Preschool Age
through Older Elementary)
Because children are usually brought into the
clinic setting by their parents, clinicians typically schedule an interview with the parents to
obtain information about current concerns and
past history. Parents are in a unique position to
provide a chronology of significant events in the
child's life, leading up to the present concerns
and reasons for referral. Often collateral interviews will be scheduled with others who play a
significant role in the child's life, such as
grandparents, teachers, day care providers,
etc. Indeed, some diagnoses (such as attention
deficit hyperactivity disorder [ADHD]) require
that symptoms be documented across at least
two settings, and it is helpful to have informants
from settings such as school to add to the
history provided by parents. One should not
limit interviewing to only the adults who are
significant in the child's life, however. To do so
would create a risk of overlooking important
information that could be obtained from the
child directly about the child's perceived fears,
anxieties, mood, and critical events in the child's
world. The child's perspective is often overlooked in situations where the child is not
articulate about feelings or is immature in
language development. It is necessary for the
clinician to develop skill in obtaining interview
information from children even in these circumstances. An excellent resource for interviewing or observing children, including infants,
can be found in Sattler (1998, pp. 96132).
4.04.2.2 Interviewing Parents
The purpose of the interview with parents is
similar to that discussed earlier in the chapter, in
that the clinician attempts to clarify the reasons
for concern, identify strengths and weaknesses
that moderate the presenting problems in the
child, and obtain information that could assist
with treatment planning. However, there are
important ecological variables that are salient
for children and should be addressed in the
interview. These include placing the child's
current and past problems into a social and
developmental context, assessing possible risk
and resilience factors that may relate to the

88

Clinical Interviewing

child's problems, and assessing the consequences or developmental impact of the child's
problems on their future development.
4.04.2.3 Social Context
Schroeder and Gordon (1993) outlined
several steps in assessing the problems of young
children, including clarifying the referral questions and determining the social context of the
problem. Parents often present to clinicians
feeling anxiety and/or frustration about their
child's problems. This may lead to emotionallyladen, imprecise descriptions of behavior (e.g.,
He never minds! or She is always disrespectful to her parents!). The first task in the
interview is to help parents define the specific
behaviors that cause concern, and to obtain
information about the frequency, intensity, and
nature of the problem. For instance, a threeyear-old child who displays temper tantrums
once per week may be of mild concern, but, one
who has tantrums three to five times per day
would be of much greater concern. The intensity
of the child's problems might be gauged by the
degree of distress caused to the child or the
disruption to typical family activities. For
instance, tantrums that occur occasionally at
home may cause less distress than if they occur
with regularity at church, school, or in other
public places. Finally, the nature of the child's
problems will be an indicator of severity.
Children who engage in cruelty to animals or
other people, who are destructive, or who
engage in a pattern of fire-setting behavior with
the intent to destroy property are of more
concern than those who have less serious
oppositional and defiant symptoms. As clinicians interview parents about the specific
behaviors of concern, important information
about the frequency, nature, and severity of the
problems can be assessed.
The social context is best assessed by asking
simple questions such as, Who is concerned
about the child?, Why is this person concerned?, and Why is this person concerned
now vs. some other time? (Schroeder &
Gordon, 1993). Although parents or teachers
may refer children for assessment or treatment,
this does not mean that the child necessarily has
a problem that needs treatment. A teacher who
refers several active children from a first grade
class may be feeling overwhelmed by the sheer
number of active children in the class at one
time, although a given child's behavior may not
be severe enough to warrant a diagnosis of
ADHD. Rutter and Schroeder (1981) provided
a case of example of a mother who presented
with concerns about her daughter occasionally
masturbating while watching television. In an

attempt to determine why this mother was

concerned and the best approach to intervention, the clinician asked about the mother's
perception of what this behavior means. The
mother responded by saying that she knew her
daughter was at a developmental age when
exploring her body was normal, and she knew
that nothing bad would happen (e.g., such as
growing hair on the palms of her hands) as a
result of masturbation. The additional question
(`Why is the mother concerned now vs. any
other time?) yielded the most salient information about the mother's concerns. The mother
revealed that her mother-in-law was coming for
a visit the next week, and she was concerned that
this relative would have a negative reaction to
seeing her granddaughter masturbate. The
intervention was simplified by understanding
the true reason for the mother's concern. The
clinician recommended that the mother provide
rules about when and where it was acceptable to
masturbate (e.g., when her daughter was alone,
in her bedroom, or in the bathroom) and
institute a behavioral reward system for remembering not to masturbate while watching
television.
Other social contextual information can be
obtained about family status (who is living in
the home), recent transitions (moves, job
changes, births, recent deaths, or illnesses of
significant family members), and other family
stresses (marital problems, financial stresses,
etc.). The presence of persons who are supportive to the child, or who may provide a buffer in
the face of other stresses, is important. The
literature on resilience is replete with examples
of children who have lived with adversity but
have developed and functioned normally due to
protective factors in their social history (Routh,
1985). The interview with parents also provides
an opportunity for assessing possible psychopathology in the parents, such as significant
depressive or anxiety symptoms; problems with
anger management and self-control, as is often
seen in abusive parents; substance abuse
problems that may lead to parental instability
or neglect; or problems with reality testing, as in
schizophrenia. One mother, for example, described her 14-year-old son as being afraid of the
dark and reporting seeing ghosts at night. This
was viewed by the clinician as an example of a
fear that was developmentally inappropriate for
a 14-year-old; it also raised questions about
possible hallucinations. The context became
more clear when the mother revealed that she
saw nothing inappropriate about this behavior.
The mother reported that she, too, needed to
sleep with a light on due to her fear of the dark,
and that she also imagined seeing ghosts in her
bedroom. This mother reported that she and her

Developmental Considerations in Interviewing

son had many discussions about their mutual
fears. The context of the son's fears was changed
by the mother's revelation, and the clinician
decided to include a more thorough interview
regarding the mother's mental status in this
case. Even when no concerns about parental
psychopathology exist, parental stress levels
and affect must be considered when interpreting
their reports about child behavior. A parent
who is calm and rational in providing a history
of their child's behavior may be viewed as more
objective than a parent who is extremely upset,
tearful, or angry and uses exaggerated descriptors of the child's behavior.
4.04.2.4 Developmental Context
Developmental context provides an essential
lens from which to view children's behavior,
allowing the clinician to evaluate the child's
behavior relative to that of other children of the
same chronological and/or mental age. For
instance, enuresis may not be unusual in a fouryear-old, but would be of concern in a 14-yearold. Likewise, enuresis may not be unusual in a
six-year-old youngster with a moderate degree
of mental retardation. Some behavioral problems of young children are transient, reflecting
their responses to normative developmental
challenges (e.g., a five-year-old girl who displays
a regression to thumb-sucking and infantile
speech patterns following birth of a new
sibling). Other problems are more serious and
persistent, and suggest risk for later maladjustment. Familiarity with developmental theory
and the rich empirical literature in clinical child
psychology and developmental psychopathology can provide the clinician with guidance in
making these discriminations.
Knowledge of the sequence and transitions in
social/emotional development are helpful to the
clinician in judging the appropriateness of
children's behavior at various ages. For instance, a toddler who has never displayed a
strong attachment to a primary caregiver
(usually a parent or parents) and who seems
to form attachments indiscriminately with
others would raise concerns about possible
attachment relational problems. A seven-yearold child who cannot delay gratification or
consider the feelings of others would be of
concern for not having learned appropriate selfcontrol and capacity for emotional empathy
that would be expected at that age. Critical
developmental tasks for the preschool age child
include establishing effective peer relations (e.g.,
learning to share material resources and adult
attention with peers, establishing reciprocal
play relationships) and developing flexible selfregulatory skills (e.g., adjusting to the authority

89

of preschool or daycare teachers and classroom

routines). In contrast, children in middle to late
elementary years (seven to 12 years of age)
encounter developmental tasks related to mastery of knowledge and intellectual skills, leading
to feelings of productivity and competence.
Children with learning disorders or other
developmental problems that interfere with
academic progress may be at risk for secondary
behavioral or emotional problems related to
their primary problems with learning during
this developmental period. The clinician must
tailor the interview to exploration of the child's
strengths and weaknesses in the context of
appropriate developmental expectations for
particular ages.
The newly emerging field of developmental
psychopathology has provided a theoretical and
empirical base for better understanding the
developmental precursors of psychopathology
in children, and the impact of this psychopathology on subsequent functioning (cf,
Cicchetti & Cohen, 1995a, 1995b). There is a
growing body of research addressing risk
factors for the onset and continuity of various
childhood disorders. For example, Loeber and
colleagues have made important contributions
to understanding the developmental pathways
to childhood disruptive behavior disorders, in
which different constellations of risk factors
lead to different outcomes. In their longitudinal
study of inner city boys at ages seven, 10 and 13,
they found that initiation into antisocial
behavior was predicted by some factors (e.g.,
poor parentchild relations, symptoms of
physical aggression) that were present across
all three ages, while others (e.g., shyness at age
seven, depression at age 10) were age specific
(Loeber, Stouthamer-Loeber, Van Kammen, &
Farrington, 1991). Further, the environments of
children who remained antisocial differed from
those whose antisocial behavior dropped out;
good supervision was more important in helping older children (age 13 at intake) while
attitude toward school was more important for
the younger children. Studies such as these
illustrate the importance of understanding the
contextual variables related to parenting style
and parentchild relational issues, as well as
specific child behaviors, in determining the
significance of presenting problems and their
possible trajectory over time.
4.04.2.5 Direct Interview of Children
Perhaps the best and most comprehensive
resource guide for interviewing children and
adolescents who present with a variety of
problems is Sattler's (1998) book on clinical
and forensic interviewing of children. Basically,

90

Clinical Interviewing

the goals of the initial interview of the child

depends upon the referral questions as well as
the age and verbal ability of the child (Sattler,
1998). When interviewing children and their
families the information sought often includes
the following:
(i) to obtain informed consent to conduct the
interview (for older children) or agreement to be
at the interview (for younger children);
(ii) to evaluate the children's understanding
of why they are at the interview and how they
feel about being at the interview;
(iii) to gather information about the children's perception of the situation;
(iv) to identify antecedent and consequent
events related to the children's problems;
(v) to estimate the frequency, magnitude,
duration, intensity, and pervasiveness of the
children's problems;
(vi) to identify the circumstances in which the
problems are most or least likely to occur;
(vii) to identify potentially reinforcing events
related to the problems;
(viii) to identify factors associated with the
parents, school, and environment that may
contribute to the problems;
(ix) to gather information about the children's perceptions of their parents, teachers,
peers, and other significant individuals in their
lives;
(x) to assess the children's strengths, motivations, and resources for change;
(xi) to evaluate the children's ability and
willingness to participate in formal testing;
(xii) to estimate what the children's level of
functioning was before an injury; and
(xiii) to discuss the assessment procedures
and possible follow-up procedures. (Sattler,
p. 98).
A part of the interview process with children
includes observation of parent and child and
obtaining collateral information from the
schools or others if the presenting problem
relates to learning or behavior problems outside
the home. Recognizing the developmental tasks
that children must master at varying ages helps
the clinician understand the child's behavior.
Thus, a comprehensive, detailed developmental
history of the child and family milieu is an
integral part in establishing an appropriate
treatment.
Clinicians must also consider interviewing the
child at some stage during the evaluation
process. Very young children may be observed
using a free-play setting and using observational
guides during the play. The clinician can learn a
great deal about the child's energy level,
physical appearance, spontaneity, organization,
behavior, affect, and attitude through their play
and through a diagnostic play interview.

School-aged children are able to share thoughts

and feelings with the clinician unless they are
unusually shy or oppositional (Sattler, 1998).
Obviously establishing rapport and maintaining
the child's cooperation during the interview is
crucial. Kanfer, Eyberg, and Krahn (1992)
identified five basic communication techniques
that can aid the clinician in attaining rapport
and cooperation. First, the clinician can use
descriptive statements to describe the clients
ongoing behavior, for example, You're stacking the toys so nice. Second, using reflective
statements to mirror the childs statements can
be nonthreatening. For example, if the child
says she wants to play with blocks the clinician
merely reflects you want to play with the
blocks. Third, labeled praise helps the child feel
good and feel that the clinician approves of
them. Fourth, the clinician must avoid critical
statements that suggest disapproval or make the
child feel as though they are bad. Finally, openended questions avoid yes or no answers and
provide opportunities for children to elaborate
on their responses (Kanfer et al., 1995).
4.04.2.6 Adolescents
Interpersonal style may play a greater role in
good interviewing with this age group than with
any other. Adolescents tend to be intensely
attuned to any communications that concern
their personal appearance, skills, or competence, and the interviewer must avoid at all costs
even the hint of condescension. As numerous
authors have pointed out, older clinicians tend
to identify readily with the parents of adolescents, while younger ones may easily align
themselves with the youth. The clinician who
remains unaware of their tendencies in this
regard runs the risk of making insensitive or
intrusive statements that will inhibit rapport
rather than increase it. In the first case, the
clinician who approaches the adolescent with a
parental attitude may unconsciously interact in
a way that increases the informant's anxiety,
guilt, and hostility. Questions that presuppose
information the adolescent has not provided
may mirror intrusive interactions with other
adults, resulting in defensive efforts and
guardedness. Similarly, clinicians who identify
easily with the adolescent may also appear
hokey and insincere when they misuse
popular language, or try too hard to relate
their own somewhat misty adolescent experiences to those of the youth they are interviewing.
These errors result from incautious use of the
same techniques that will be necessary for
successful adolescent interviewing. That is, to
obtain good information and develop adequate
rapport, the adolescent must perceive that the

Developmental Considerations in Interviewing

clinician is clearly on their side within the
boundaries of the relationship. Judicious use of
self-disclosure can help the adolescent believe
that the interviewer is not attempting to take
away from the interaction without reciprocating. Earnest discussion of the limits of confidentiality and the purposes of the interview
will help allay some of the suspicions the
informant may have about the clinician's role,
and will serve to make a distinction between the
clinicianinformant relationship and those the
adolescent has with parents, teachers, parole
officers, and other adults.
The adolescent patient presents a number of
challenges to the interviewer that are often less
present or significant in interactions with both
older and younger people. Because of the
unique developmental pressures and challenges
of adolescence, special care must be taken in the
interview to ensure adequate cooperation as
well as to make the interview process a helpful
one to the patient. It is essential that the
interviewing clinician possess a basic knowledge
of the common demands and urges present in
the adolescent and their family to effectively
assess the patient's functioning. Listed next are
those tasks commonly believed to be operating
in the adolescent period of life according to
various developmental theorists (Erikson, 1963;
Rae, 1983).
4.04.2.6.1 Separationindividuation
Separationindividuation refers to the need
of the adolescent to identify those qualities in
themselves that set them apart from their
family. Many of the issues bringing adolescents
to treatment involve conflicts that are direct
results of this process. The adolescent during
this time begins testing family boundaries and
experimenting with beliefs and behaviors that
differ from those held by their caretakers. This
process often produces considerable anxiety for
all family members, and the adolescent's
interpersonal relations may become quite variable. Often, the adolescent moves between the
poles of autonomy from, and dependence upon,
the family. An important portion of the
adolescent interview is that of identifying the
severity of the stressors resulting from this
natural process.
4.04.2.6.2 Resolving conflict with authority
figures
Related to the individuation task is the
frequent occurrence of conflict with authority
figures outside of the family as well as within.
For younger adolescents this involves primarily
their teachers and other school personnel, and

91

for later adolescents this includes work supervisors as well. Conflicts with authority figures
outside the home often have their roots in
greater-than-average difficulties in resolving the
family relationship struggles. Thus, when
interviewing the adolescent, it is helpful to
identify both positive and negative relationships
with other adults in their life.
Often classroom performance for the adolescent presenting for services is related strongly to
the quality of the relationship with the teacher,
so discussion of academic performance (usually
a relatively nonthreatening issue in the context
of the clinical interview) can elicit useful
information about this area of functioning as
well. Adolescents, as well as younger children,
may readily express relational difficulties in
response to the question Is he/she a good
teacher? This often elicits the adolescent's
opinion regarding the desirable qualities in an
important adult, and allows the interviewer to
follow up with questions regarding the adolescent's ability to recognize their own role in any
positive or negative interactions.
4.04.2.6.3 Peer group identification
As adolescence is inarguably a time of shifting
focus from family relations to peer relations, it is
vital to gather information regarding the
patient's friendships and any identification with
a social subgroup. Some effective ways of
eliciting this information include discussion of
music topics, such as taste and dress, that will
provide clues to the adolescent's social presentation and degree of inclusion or exclusion
from social groups.
To effectively interview adolescents regarding
social issues, it is necessary for the clinician to
maintain a moderate degree of understanding of
popular culture. Thus, one would be well served
by making an effort to watch television
programming, read magazines, and spend time
taking in the various electronic media that are
aimed at people in this age group. The
interviewer should not attempt to present as
an authority on the adolescent's culture, but will
benefit from being able to recognize specific
music groups, current movies, video games and
Internet activities, and other elements that are
part of the adolescent's milieu. It is often helpful
to enlist adolescents' aid in delineating the social
groups present in their school, then ask them to
identify the group to which they feel they most
belong. This question can usually be asked
rather directly, and many teens are pleased by
the opportunity to display their understanding
of the social complexities in their school.
Follow-up inquiry should establish with
whom the adolescent spends most time and

92

Clinical Interviewing

how they see themself as fitting into the groups

at school. Many youth social strata include a
group delineated primarily by drug/alcohol use
as well as different groups for aggressive or
delinquent behavior that may be gang-affiliated
or gang-emulating. Thus, the social categories
to which the adolescent assigns themself may
also point the interviewer toward necessary
inquiries into these possible problem areas as
well as providing information about the degree
of social integration in the adolescent's life.
4.04.2.6.4 Realistic appraisal and evaluation of
self-qualities
As the focus of evaluation or treatment is
likely to include assessing and modifying selfimage, it is necessary to include questions
regarding the ways in which the adolescent
views themself. Adolescents generally display
both overly optimistic and excessively pessimistic appraisals of personal qualities. One purpose
of the interview is to assist in determining when
these perceptions area faculty and result in
impaired functioning. It is often helpful to
present questions about self-image in terms of
strengths and liabilities, and to follow up on
both. Questions about the adolescent's physical
capacities as well as social and emotional
abilities are necessary components of the interview. This portion of the interview can be
directed toward uncovering problems with
perception of body image and behaviors related
to physical health. The interviewer should
attend carefully to clues that might indicate
the need for more focused exploration of
possible eating disorders, and to somatic
complaints indicative of anxiety or depression.
4.04.2.7 Interviewing Young Adults (1840
Years)
The psychological distinction between adolescence and young adulthood is frequently
blurred, and many of the same traits and
problems may be observed in individuals both
over and under the chronological age of
majority. However, since the age of majority
is generally 18 years, a higher proportion of
patients over age 18 will be self-referred and
hence will present in a more open and
cooperative manner than some adolescents.
Additionally, young adults are more likely to
present with some subjective description of their
distress and their situation. Therefore, the client
may be more likely to identify a problem area
spontaneously. Despite the fact that more
patients in this age group may independently
seek services, many of the adolescent issues

related to establishing an autonomous roleidentity may surface in the interactions with the
interviewer, especially with the youngest
adults. Therefore the interviewer may frequently call upon the skills used in interviewing
adolescents.
Erikson (1963) identified the primary developmental conflict for the various stages of
adulthood, and these stages suggest important
interview topics (see Table 1). The primary
conflict of young adulthood is intimacy vs.
isolation. Consequently, many of the psychological problem areas frequently encountered
will revolve around commitment to interpersonal relationships and establishing trust. Establishment of a working relationship with the
patient is also affected by these issues.
A relatively greater amount of the interview
might be devoted to exploration of existing
relationships or those the patient wishes existed.
One type of relationship to consider is that with
parents and family of origin. Establishing the
degree of desired independence continues to be
an issue with some young adults. Issues relevant
to these ties might be financial (e.g., parents may
be paying college expenses), or they may be
more interpersonal in nature (e.g., parents
controlling social relationships or defining goals
for the patient).
Intimate relationships with individuals of the
same or opposite sex may also be a source of
psychological discomfort and play a part in the
development of anxiety disorders or depression.
Inquiry about social functioning should include
peer relationships, such as partners in love
relationships, friends, and acquaintances.
Individuals in the young adult age group
generally will have established some degree of
independence, and the relative importance of
work and employment will be much greater than
at younger ages. The interview should therefore
include specific inquiry into current job status,
job satisfaction, goals, and relationships with
co-workers. The further one progresses into this
stage, the greater is the importance of establishment of a stable intimate relationship and
mutual trust, and the higher the probability that
the issue of procreation will arise. Therefore
inquiry should include questions about intentions and concerns associated with having
children and child rearing and any differences
with one's partner about children.
Finally, the initial episodes of many severe
psychiatric disorders are most likely to occur
within the young adult period. Initial episodes
of depression, and post-partum depression, are
likely to occur in those affected before they pass
through this period (Kaelber, Moul, & Farmer,
1995). Therefore screening for affective disorders should be included in the interview. A

Developmental Considerations in Interviewing

Table 1
Young adult
Middle adult

Older adult

Late adult

93

Interview topics for each developmental stage.

Independence from family, relationships with peers, stable intimate relationships,

trust in relationships, establishment of a family, issues related to having and
rearing children, education, and career goals.
Achievement of work and family goals, career or family role changes, responsibility
for aging parents, death of grandparents and parents, reducing responsibility for
children, changes in physical appearance and characteristics, and anticipating
retirement.
Accepting status of family and career, developing identity as grandparent or elder
advisor, coping with reduced physical capability and/or health changes, specific
plans for retirement, loss of siblings, spouse, and friends. Increased reliance on
children or caretakers.
Coping with deteriorating health, decreased mobility, dependence on caretakers, and
anticipation of death.

later section of this chapter deals with interviewing depressed and anxious patients. Additionally, first episodes of schizophrenia or
bipolar disorder generally take place in adolescence or young adulthood and the interviewer
should be sensitive to symptoms of these
disorders.
4.04.2.8 Interviewing Adults in Middle
Adulthood (4060 Years)
Interview techniques need not differ with this
age group, but the relevant topics from a
developmental perspective are somewhat different (see Table 1). This period encompasses
much of the creative and productive portion of
the life span in western culture. The emphasis is
not on starting, but on completing tasks begun
in young adulthood. The focus of individuals at
this stage of life is much less on goal setting than
on goal attainment. The growth and nurturing
of an established family, the attainment of
successive career goals, and nurturing of one's
parents and grandparents occur in this time
span. One's children come into adulthood and
begin to establish their identities and families.
Inquiry into the relationships with the former
and succeeding generations should be made.
Towards the middle of this period, individuals
are able to anticipate the likelihood of reaching
family and career goals, and become aware of
the fact that certain goals for themselves and
their children may not be met. Biological
changes associated with mid-life, which are
well-defined for women, but also may be present
for men, should be queried since they may be
associated with depression or anxiety. Possible
mid-life existential crises related to loss should
also be assessed. The losses may result from
death of parents or grandparents, or changes in
roles as parent, spouse, or worker.

4.04.2.9 Interviewing Older Adults (6070

Years)
For many adults in this age range, the
predominant life circumstance deals with additional impending changes in the area of life
roles. Retirement usually occurs within this time
frame, and inquiries might reveal difficulties in
psychological adjustment to one's own retirement or the retirement of a significant other.
The frequency of death in the patient's social
circle gradually increases, and may include a
spouse, close friends, or even an adult child.
Due to the possibility of some early decline in
cognitive capacity in this age group, the
response to inquiry may be defensiveness and
denial. The patient with some early impairment
may deny the need for the evaluation, object to
questions, and become resentful if the interview
serves to demonstrate difficulties with memory.
Therefore, it becomes more important to interview a collateral person or include a collateral
person in the patient interview. In addition to a
spouse or family member, a collateral person to
be considered with older adults is an adult
caretaker, who may or may not be related to the
patient. This may give rise to some special issues
of confidentiality.
Attention to the collateral person's nonverbal
behavior may sometimes suggest that they are
uncomfortable reporting the patient's difficulties, especially in the patient's presence. In such
circumstances a separate collateral interview is
desirable.
4.04.2.10 Interviewing In Late Adulthood (70
YearsEnd of Life)
Adults in the latest stages of life have their
own unique set of circumstances of which the
interviewer must be aware. The losses that may
have begun earlier may become more frequent.

94

Clinical Interviewing

Physical changes, often represented by medical

problems, may interfere with some life activities,
and there may be a need to accept reduced
independence. At some point anticipation of the
end of life is common. The combination of these
forces often lead the elderly to have a
perspective on life and the situation giving rise
to the interview that differs considerably from
younger adults, in that they may be unconcerned and see no need for the evaluation. Often
the reasons for the interview are more important
to someone else than to the patient. As with
children and adolescents, it is more likely that
someone other than the client identified the need
for and arranged for the mental health contact.
It is also common for the oldest adults to
answer questions more slowly, either because of
difficulty accessing information or because a
more tangential and elaborate route is taken to
reach a point in conversation. Patience on the
part of the examiner in these situations is
important, both for maintaining rapport and to
show the proper respect due the patient.
It has been estimated that the incidence of
cognitive decline in people over age 65 is
1020% (Brody, 1982). Estimates are as high
as 25% of those 80 years and older (Hooper,
1992). Thus, the likelihood of cognitive impairment is even greater in this age group than those
discussed previously. For those with cognitive
dysfunction, cooperation may be minimal and
denial, and even belligerence, may be present.
Again, the availability of a collateral person for
interview may be very important, as the patient
may not cooperate or may be impaired in their
ability to provide information.

4.04.3 INTERVIEWING SPECIAL

POPULATIONS OR SPECIFIC
DISORDERS
4.04.3.1 Interviewing Depressed Patients
Interviewing depressed adults may require
some adjustment in the tempo and the goals of
the interview. Due to low energy and psychomotor retardation, it may not be possible to
gather all the desired information within the
time available. Hence, some prioritization of
information is necessary, so that issues such as
suicidality, need for hospitalization, and need
for referral for medication may be addressed.
Beck (1967) and later, Katz, Shaw, Vallis, and
Kaiser (1995) pointed out that the interpersonal
interaction with the depressed patient may be
frustrating for the interviewer, not only due to
the slowness mentioned above, but also because
of the negative affect and negative tone of
information provided.

It is also particularly important with depressed patients, who are prone to hopelessness,
to provide encouragement and attempt to
impart hope to the patient during the interview.
This may be done by recognizing areas of
strength, either in terms of personal qualities or
successful areas of functioning.
Specific inquiry is necessary to diagnose
depression appropriately, and a variety of
sources are available to guide this inquiry.
Diagnostic criteria for depression are clearly
delineated in the DSM-IV (American Psychiatric Association [APA], 1994). A number of
structured interviews have been developed that
may serve as guides for inquiry or provide
sample questions. Formal training is required
for the reliable use of these interviews for
diagnostic purposes. The Schedule for Affective
Disorders and Schizophrenia (SADS; Endicott
& Spitzer, 1978) is a relatively early forerunner
of current interviews that slightly preceded the
DSM-III (APA, 1980), and includes probe
questions for depressive symptoms as well as
other disorders.
The Structured Clinical Interview for DSMIII-R (SCID; Spitzer, Williams, Gibbon, &
First, 1992) is a more current instrument with a
modular format so that sections for each
disorder may be used independently. Table 2
also lists sample questions that might be used to
probe for the presence of various depressive
symptoms.
4.04.3.2 Interviewing Anxious Patients
The anxious patient may also present some
special difficulties during the interview. If the
patient is acutely distressed at the time of the
interview, as might be true of someone with a
generalized anxiety disorder, they may provide a
rush of disorganized information so that it may
be difficult to obtain a coherent history. Anxiety
interferes with attention and concentration, so
that repetition may be necessary. Experience has
shown that in such a situation, some initial
intervention using brief relaxation techniques, is
helpful before proceeding with the interview.
Anxious patients also frequently seek reassurance that treatment will be effective in reducing
their anxiety. It is appropriate to indicate that
treatment techniques have been helpful to other
anxious patients, and that these techniques will
be available to them.
The diagnostic symptoms of various anxiety
disorders are identified in DSM-IV, and the
structured interviews mentioned earlier also
provide some guidance for the inquiry for
specific anxiety symptoms. In addition to the
diagnostic information, it is important to

Summary
Table 2
Mood (depressed)
Mood (irritable)
Interest and pleasure

Energy/fatigue

Weight loss/gain

Insomnia/hypersomnia

Psychomotor agitation/retardation

Worthlessness/guilt

Concentration/decisiveness

Thoughts of death/suicide

95

Sample questions for depressive symptoms.

How would you describe your mood?
Have you been feeling down or sad much of the time?
How much of the time do you feel down or sad?
Have you been more short-tempered than usual for you?
Do others say you are more irritable or lose your temper more easily
than usual?
Are you as interested as ever in things like your work, hobbies, or sex?
Do you continue to enjoy the things you usually like to do, like
hobbies, doing things with friends, or your work?
Has your interest declined in things which used to be really
interesting for you?
Do you have enough energy to do the things you want to do or need
to do?
Do you have the energy to do the things you find interesting?
Do you tire out more easily than usual for you?
Have you gained or lost weight since . . . (specify a time period)?
If the patient does not know, you may inquire about whether clothes
fit properly, or what others may have said about weight. Insomnia/
hypersomnia
How well are you sleeping?
Do you have difficulty getting to sleep? (initial insomnia).
Do you awaken frequently during the night and have trouble getting
back to sleep? (middle insomnia)
Do you awaken too early in the morning? (terminal insomnia)
Have other people commented on your being too active or being very
slowed down?
Are there times when you just can't sit still, when you have to be
active, like pacing the floor or something similar?
Are there times when you are very slowed down, and can't move as
quickly as usual?
How do you feel about yourself?
Do you think of yourself as worthwhile?
Do you often feel guilty or have thoughts of being guilty for
something?
Is guilt a problem for you?
Is it difficult for you to keep your attention on things you are doing?
Do you lose track of things, like conversations or things you are
working on?
Is there a problem with making decisions?
Does it seem that your thoughts are slowed down, so it takes a long
time to make a decision?
Do you frequently have thoughts of death?
Do you think a lot about friends or loved ones who have died?
(Inquire if someone close to the patient has recently died or is near
death.)
Do you sometimes think it would be better if you were dead?
Have you thought abut hurting yourself or killing yourself?
Have you planned a particular way in which you would kill yourself?
What would keep you from killing yourself?

inquire about ways the patient has attempted to

cope with the anxiety, and to provide some
reinforcement for such efforts.
4.04.4 SUMMARY
The clinical interview provides rich diagnostic
information that can aid in the assessment and
treatment of patients. Interpersonal style of the

clinician interview, structuring the interview,

the setting in which the interview takes place,
preparing the patient, and the beginning,
middle, and ending phases of the interview
are discussed. Developmental considerations
and suggestions are offered in interviewing
children, adolescents, and adults. Sample questions are primarily for interviewing depressed
patients.

96

Clinical Interviewing

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