assessing personality and psychopathology with interviews · 02-03-2015 · interview, assessment...

CHAPTER 21

Assessing Personality and PsychopathologyWith Interviews

ROBERT J. CRAIG

487

HISTORY OF INTERVIEWING 488PURPOSE OF ASSESSMENT INTERVIEWS 488TYPES OF INTERVIEWS 488

Case History Interviews 489Diagnostic Interviews 489Follow-Up Interviews 489Forensic Interviews 489Intake Interviews 490Interviewing for Etiology 490Mental Status Exams 490Orientation Interviews 490Pre- and Posttesting Interviews 490Screening Interviews 491Specialized Interviews 491Termination Interviews 491

THE CLIENT’S APPROACH TO THE INTERVIEW 491THE PSYCHOLOGIST’S APPROACH

TO THE INTERVIEW 492DIAGNOSTIC INTERVIEWING 492STRUCTURE OF THE CLINICAL INTERVIEW 493INTERVIEWING TECHNIQUES 493

Questioning 494Clarification 494Confrontation 494Exploration 494Humor 494Interpretation 494

Reflection 494Reframing 494Restatement 494Silence 494

INTERVIEWING MODELS 495The Medical Model 495Behavioral Assessment 495Interview Biases 495

ASSESSING PSYCHOPATHOLOGY WITHCLINICAL INTERVIEWS 496Structured Versus Unstructured Interviews 496

ASSESSING PERSONALITY WITHCLINICAL INTERVIEWS 498Personality Assessment Versus Assessing

Personality Disorders 498Problems in Assessing Personality and Personality

Disorders With Clinical Interviews 498Role of Culture 499

RELIABILITY OF CLINICAL INTERVIEWSAND PSYCHIATRIC DIAGNOSES 499

INCREMENTAL VALIDITY 501COMPUTER-ASSISTED DIAGNOSIS AND

COMPUTER INTERVIEWS 501MISUSE OF THE INTERVIEW 502WHAT NEEDS TO BE DONE? 502REFERENCES 504

Interviews are the most basic and most frequently usedmethod of psychological assessment and the most impor-tant means of data collection during a psychological eval-uation (Watkins, Campbell, Nieberding, & Hallmark, 1995).They are endemic to the task performance of almost allpsychologists—especially clinical and counseling psycholo-gists. A computer search, using the key search words clinicalinterview, assessment interview, and initial interview, for thepast 20 years yielded 1,260 citations, or 63 per year. Clearlyinterviewing continues to be an important process and onethat continues to occupy clinicians and researchers alike.

This chapter discusses contemporary issues in assessingpsychopathology and personality with interviews. We discusstypes of interviews, how clients and clinicians approach an in-terview, and structured versus unstructured interviews. Thestructure of the interview is presented along with continu-ing concerns with official diagnostic systems. Issues that com-plicate the assessment process for personality disorders arediscussed, including the base rate problem, the role of affec-tive disorders, state versus trait assessment, the role of culture,reliability of psychiatric diagnosis, diagnostic overlap, and co-morbidities. Current findings on the reliability of structured

488 Assessing Personality and Psychopathology With Interviews

clinical interviews are presented. The chapter concludes witha discussion on computer-assisted diagnosis and suggestionsfor the future.

HISTORY OF INTERVIEWING

Diagnosing has a long history. In fact, conditions that we nowlabel as depression and hysteria appear in both Sumerian andEgyptian literature as far back as 2400 B.C. (Wiens &Matarazzo, 1983). Initial attempts at formal psychiatricclassification began in 1840 and grouped all disorders intotwo categories—idiotic and insane. In 1880, there wereonly seven psychiatric diagnoses in existence: dementia, dip-somania (alcoholism), epilepsy, mania, melancholia, mono-mania (depression), and paresis. There are now hundreds ofdiagnoses in Diagnostic and Statistical Manual of MentalDisorders–Fourth Edition (DSM-IV; American PsychiatricAssociation, 1994). Readers interested in the history of psy-chiatric diagnosis are referred to several excellent reviews ofthis elsewhere (Menninger, Mayman, & Pruyser, 1963, a70-page history of psychiatric diagnosis from 2600 B.C. to1963; Zilboorg, 1941) and to the several revisions of DSM.

The word interview was initially included in standarddictionaries in 1514 and designated a meeting of personsface-to-face for the purpose of formal conference onsome point (Matarazzo, 1965). Initially assessment inter-views were modeled on question-and-answer formats. Theintroduction of psychoanalysis allowed for a more open-ended, free-flowing format. During the 1940s and 1950s,researchers began to study interviews in terms of their con-tent versus process, problem-solving versus expressiveelements, degree of directedness within an interview, theamount of structure, and the activity of both the respondentand interviewer. Carl Rogers stimulated much research in the1960s by emphasizing personal qualities of the clinician(e.g., warmth, accurate empathy, unconditional positive re-gard, genuineness). The 1970s introduced the idea of usingstructured diagnostic interviews, and advances in behavioralassessment resulted in more specificity and objectivity in in-terviews. Seminal behavioral assessment models includesuch approaches as the BASIC-ID model (behaviors, affect,sensation, imagery, cognition, interpersonal relations, andpossible need for psychotherapeutic drugs). In the 1980s, theDSM revision provided improved reliability of diagnostic en-tities, and the 1990s afforded increasing appreciation of therole of culture, race, and ethnicity in the development of psy-chopathology. Managed health care also emphasized cost-setting measures and essentially required psychologists torely on assessment interviews to the near exclusion of other

assessment methods (e.g., psychodiagnostic testing; Groth-Marnatt, 1999).

Although assessment interviews have much in commonwith more social interactions such as group dynamics, dyadicconsiderations, and rules of etiquette and communication,they are fundamentally different. In assessment interviews,communication is generally both privileged (i.e., materialdiscussed in the context of a professional relationship is notdiscoverable in legal evidentiary proceedings unless other-wise permitted in writing by the client) and confidential (ma-terial discussed in the context of a professional relationshipcannot be disclosed and is protected from discovery by bothprofessional ethics and laws). The demeanor of the cliniciantends to be more professional, and the nature of the inquiry isoften unidirectional and organized for the task at hand. Thereare limits on the nature of the interaction imposed by bothlaw and ethics. The clinician’s statements serve a larger pur-pose than mere mutual dialogue (Craig, 1989).

PURPOSE OF ASSESSMENT INTERVIEWS

Assessment interviews can be thought of as having four majorfunctions: administration, treatment, research, and prevention(Wiens & Matarazzo, 1983). Sometimes, psychologists’ inter-views are for purposes of fulfilling certain agency require-ments, such as determining eligibility for services. Thetreatment function of an interview might involve assigningdifferential diagnoses. For example, I was once asked to de-termine whether the patient had a delusional disorder or a bor-derline personality disorder. If the patient had a delusionaldisorder, the physician was going to treat the patient with med-ication, whereas if the patient had a borderline condition, thetreatment would have been psychotherapy and no medicationwould be given. Assessment interviews are also conducted forresearch purposes. A salient example is the use of interviewsfor psychiatric epidemiological research or the use of struc-tured psychiatric interviews to assess reliability and validity ofclinical interviews. Finally, the prevention function followsthe treatment and research function. If we have ways to reli-ably classify disorders, then we can include homogeneousgroups of patients into research protocols. Findings from thesestudies then could serve a prevention function.

TYPES OF INTERVIEWS

We need to make a distinction between therapeutic versusassessment interviews. The former includes generic activitieswithin a session designed to advance some treatment goal.The latter includes an array of activities in order to gain

Types of Interviews 489

information that leads to the development of treatment goalsand intervention plans or other decisions, such as personnelselection. An example of a therapeutic interview is Miller’s(1991) motivational interviewing. Although this approachwas developed for the purpose of changing addictive behav-ior, the principles are generic enough so that the techniquecould be applied to a number of assessment situations requir-ing behavior change.

This approach considers motivation a dynamic conceptrather than inherently a personality trait. The behavior ofthe clinician is a salient determinant as to whether changewill occur. Miller recommends that clinicians give feedback,emphasize that clients take responsibility for change, giveclients advice and a menu of treatment choices and strate-gies, be emphatic, and promote self-efficacy. The acronymFRAMES is used here as a mnemonic device. The techniquealso requires that the clinician point out discrepancies in be-havior, avoid arguments, roll with resistance, use reflectivelistening, emphasize personal choice, reframe, and continu-ally support self-efficacy. Thus, motivational interviewingcan be used as an assessment tool and as an interventiontool.

Several types of interviews have been delineated. Theydiffer in purpose, focus, and duration. Listed in the followingsections are several types of interviews that have been dis-cussed in the literature. They are not necessarily mutually ex-clusive, and several of the formats listed in the followingsections can be utilized within a single interview. For exam-ple, a clinician can begin with an orientation interview, tran-sition into a screening interview, continue with an interviewfor etiology, and then conclude with an ending interview. Onthe other hand, there are settings and circumstances in whicheach of these types of interviews is conducted separately orperhaps to the exclusion of the others. There is no agreed-upon list of interview types and the list presented in thischapter is somewhat arbitrary, but it provides the reader witha reasonable array of the various kinds of interviews avail-able for clinical use.

Case History Interviews

Sometimes additional or more elaborate and detailed se-quencing of case history material is required in order to makefinal decisions. In this case a special interview is completed inwhich the focus is only on ascertaining the nature of the per-son’s problems in historical sequence, with a possible focuson critical periods of development or events, antecedents andprecipitants of behavior, and other matters of clinical interest.Case history interviews can be conducted with the respondentdirectly, the respondent’s family, friends, or others.

Diagnostic Interviews

Here, the clinician attempts to categorize the behavior of theclient into some formal diagnostic system. For psychopathol-ogy, there are two official diagnostic classification systemspresently in widespread use. The first is the official classifica-tion system of the World Health Organization—InternationalClassification of Disease–Tenth Edition (World Health Orga-nization, 1992). The second is the DSM (American PsychiatricAssociation, 1980, 1987, 1994). For reimbursement purposes,insurance companies recognize both, but the DSM is morepopular in the United States and is the more commonly useddiagnostic system in psychiatric research, teaching, and clini-cal practice. The DSM is also becoming more popular interna-tionally than ICD-10 (Maser, Kaelber, & Weise, 1991).Although there have been calls for considering other classifi-cation systems (Dyce, 1994), DSM is the predominant diag-nostic system in use today. For assessing personality, the issueis a bit more complicated. Most clinicians still use the person-ality disorder diagnostic categories contained in these twoofficial diagnostic systems, but others prefer to assess peopleaccording to more theoretically derived personality classifica-tions, such as Millon’s (1991, 2000) bioevolutionary model,Cattell’s (1989) factors, interpersonal models (Benjamin,1996), the five-factor model (Costa & Widiger, 1997), or morebiologically based systems (Cloninger, 2000).

Follow-Up Interviews

These are specific-focused interviews, which usually have asingle purpose. Perhaps it is to review highlights of assess-ment results or to evaluate quality of services and patient sat-isfaction received from an HMO. Researchers may conduct adebriefing interview when the research involves deception.

Forensic Interviews

Psychologists may be called upon to contribute their exper-tise in legal matters that may be complicated by factors re-lated to mental health. These factors include evaluations fordangerousness, competency to stand trial, various insanitypleas, behaviors that may be induced by substance abuse, orcustody evaluations, to name a few. These interviews are typ-ically far more investigative than many other types of inter-views, often are of longer duration, and may occur overmultiple sessions. Often the person being interviewed is notthe client at all, but rather the court or perhaps private attor-neys who retain these services on behalf of their clients.Forensic evaluations do not carry with them the same protec-tion of privacy and confidentiality of material obtained in theevaluation as do most other mental health interviews.


Intake Interviews

These interviews are designed to obtain preliminary infor-mation about a prospective client and most typically occurwithin agencies; they may include a determination as to a per-son’s eligibility in terms of the agency’s mission. Intake inter-views may also be used to acquire information to be presentedat a case conference, to help clarify the kind of services avail-able at the agency, to communicate agency rules and policies,or to consider whether the case needs to be referred elsewhere.

Interviewing for Etiology

This type of interview is designed to determine such mattersas etiology and motivational attributions. The interviewerseeks to understand from a theoretical perspective why theperson is behaving in a certain way. This kind of interviewcan be conducted from many theoretical frameworks, such aspsychodynamic behavioral, cognitive-behavioral, family sys-tems, and existential-humanistic perspectives. Also, withineach of these defined frameworks are subcategories that alsodiffer from each other. For example, an interview from an an-alytic perspective can proceed along the line of classicalFreudian theory, object relations theory, or self psychology.An interview from a behavioral perspective can be conductedusing Pavlovian (classical conditioning), Skinnerian (instru-mental conditioning), or more cognitive-behavioral perspec-tives. The main point is that interviews for etiology are theoryderived and theory driven.

Mental Status Exams

A special type of interview is the mental status exam, which isconducted to determine the kind and degree of mental impair-ment associated with a given clinical disorder. Mental statusexams traditionally explore content areas such as reasoning,concentration, judgment, memory, speech, hearing, orienta-tion, and sensorium. They are particularly relevant whenevaluating for major psychiatric disorders, neurological in-volvement, or substance-induced disorders. These exams canbe formal, wherein each content area is specifically addressed,or informal, wherein information is ascertained about thesecontent areas while talking to the person about other issues.Table 21.1 presents content areas often addressed in a mentalstatus exam.

Orientation Interviews

These interviews are designed to orient a person to some pro-tocol. They may be used by clinical researchers, who are re-quired to tell each prospective participant the basic procedures

of the experiment, any risks associated with it, and the right towithdraw from the study at any point in time. The goal here isto obtain informed consent for the study. A clinician might usethis type of interview to inform a new client about treatmentoptions, program policies, rules, and expectations. A psychol-ogist in private practice may use this procedure to orient theclient to such matters as confidentiality, cancellation proce-dures, billing practices, insurance claims, and professionalcredentials. An industrial psychologist may begin executiveassessments with this type of interview in order to preparethe interviewee for what lies ahead. Orientation interviewsare particularly useful to help answer any questions the recip-ient may have and to help develop a client-interviewer con-tract for services, which may be either a formal document oran informal understanding between both parties.

Pre- and Posttesting Interviews

Modern methods of psychological assessment require inter-views that initially explore with the client particular problem

TABLE 21.1 Common Content Areas in a Mental Status Exam

Appearance Abnormal Physical Traits Appropriate AgeAttention to Grooming Eye ContactLevel of Consciousness Position of Body

Attitude Cooperative Dysphoric

Mood (affect) Alexithymic EuthymicAnxious FlatApathetic HostileAppropriate ManicDepressed

Perception Depersonalization HallucinationsDerealization IllusionsDéjà vu Superstitions

Orientation Time PlacePerson Space and location

Thought processesIntellectual Abstract thinking Attention span

Impairment in IQJudgment Intact ImpairedInsight Intact ImpairedAssociations Connected Directed

LooseMemory Immediate Recent

Remote

Thought content Blocking Overinclusive thinkingClanging PerseverationsCompulsions PhobiasConcrete PreoccupationsDelusions RuminationsNeologisms Suicidal ideationPhobias Violent thoughts

Speech and language Articulation Stream of speech

Movements Automatic, spontaneous VoluntaryCompulsions TicsInvoluntary

The Client’s Approach to the Interview 491

areas prior to more formal psychological assessment, andthen a posttesting interview, wherein the psychologist re-views or highlights major findings or recommendations de-rived from the assessment, which may include psychologicaltesting. These findings are also valuable in that hypothesesderived from the assessment can be later explored with theclient in the posttesting interview.

Screening Interviews

These interviews are usually brief and designed to elicit in-formation on a specific topic. They may include such areas asdetermining whether a client is eligible for services, whetherthe patient is acutely suicidal, whether the patient meets thecriteria for a particular diagnosis, or whether the patientneeds to be hospitalized as a danger to self or others. Screen-ing interviews are very common in psychology and may infact be the most frequent kind of clinical interview.

Specialized Interviews

Sometimes the clinician needs to conduct an interview for aspecial purpose, such as determining the ability to stand trial,determining legal insanity, assessing the need for psychiatrichospitalization, or making a specific diagnosis of a particulardisorder. Many specialized clinical interviews have beenpublished for these purposes.

Termination Interview

Very often, clinicians ending services to a client conclude withan interview designed to review treatment goals, progress,and future plans. Clinicians working in inpatient settings oftenhave an ending interview to reinforce the need for continuedoutpatient follow-up services. Addiction specialists usuallyhave a last session to review planned aftercare and to highlightpatient risk factors for relapse. Industrial psychologists meetwith a person to review highlights of assessment findings.

Table 21.2 presents topics frequently addressed in assess-ment interviews.

THE CLIENT’S APPROACH TO THE INTERVIEW

Interviews are influenced by a number of factors. First, is theclient’s visit voluntary or involuntary? Presumably a volun-tary client has noticed that there is a problem, has made failedattempts to resolve it—perhaps through discussions withfriends or clergy or through self-help methods—and then hassought professional assistance. The client may come with theexpectation that the distress (often a particular symptom orcluster of symptoms) will be ameliorated through profes-sional help. This fact tends to increase the truthfulness ofclient self-reports and promotes a therapeutic working al-liance and a more goal-oriented approach within counseling.

When a third party has referred the client, the situation isquite different. There are many cases in which the client is re-ceiving services at the insistence of someone else. Clients ar-rested for driving under the influence may be sent for anevaluation to a psychologist by a judge. A teenager showingoppositional and conduct-disordered behavior may be taken toa psychologist by his or her parents. A person who is addictedto drugs may come for help at the insistence of a spouse whothreatened to leave the relationship unless he or she gets help.In each of these scenarios, the client may not feel the need forhelp and may actually resist it.

Second, the client’s purpose or motive for the interview alsoaffects its course and direction. Even if the patient seems to beself-referred, there may be hidden agendas that may compro-mise the purity of the interview. For example, a person mayseek help for a problem with incestuous behavior, but the realmotive may be to present a façade to the judge in order to es-cape more severe criminal sanctions and punishment. Anotherperson may present asking for assistance with anxiety ordepression, whereas the true motivation is to establish a recordof psychological treatment pursuant to a worker’s compensa-tion claim for disability. A person with a drug addiction mayseek inpatient treatment for detoxification but actually may be

TABLE 21.2 Content Areas of Assessment Interviews

History of Problem Description of the ProblemOnset (Intensity, Duration)Antecedents and ConsequencesPrior Treatment Episodes

Family background Nuclear family constellationCultural backgroundSocioeconomic levelParents’ occupationsMedical historyFamily relationshipsFamily atmosphere

Personal history Developmental milestonesSchool and work historyRelationship with parentsHistory of childhood abuse (physical,

sexual)Current relationshipsVocational problemsMarital-partner historyEmotional stabilityHistory of psychological treatmentLegal problemsUse of illicit substancesMedical problems


hiding out from the police. A psychiatric patient may allegedelusions, hallucinations, and threats of suicide so that he orshe is determined to be in need of inpatient care, whereas thetrue motivation may be to receive basic food and shelter duringthe severe cold weather. It is incumbent on the clinician, if pos-sible, to ascertain the person’s real motivation for assessmentand treatment.

Third, client expectations can affect the quality of theassessment results. All clients come to the interview with ex-pectations about the nature of the process, how the psycholo-gist may approach the task, and what results the process willhave. It is a good idea for psychologists, who will be in a sub-sequent professional relationship with the client, to clarify anymisperceptions or misunderstandings about the interviewingprocess. In order to explore possible misconceptions, ask theperson, “What do you think we are going to do here?” or “Whatdo you expect to happen as a result of our meeting?”

Fourth, the client also has perceptions of the psychologist,which can affect the course and outcome of the interviewingprocess; analysts have referred to this as object relations. Here,the interviewer embodies all that is contained in a particularrole, and all of the client’s prior experiences and beliefs of peo-ple in this role are then projected onto the psychologist. Thepatient may view the relationship as parent-child, teacher-student, judged-accused, or lover-love object. These projec-tions are transferences and tend to develop quickly in anongoing relationship. Sometimes they are outside the aware-ness of the client.At other times they are at the surface and cancontaminate the relationship with unreasonable expectations.In fact, a large body of research in social psychology hasshown that humans tend to evaluate someone on the basis oftheir first impression, and all subsequent encounters with thatperson are evaluated in the light of those first impressions.

THE PSYCHOLOGIST’S APPROACHTO THE INTERVIEW

Psychologists approach an interview with certain preexistingvalues. The first of these values is philosophical or theoreticalorientation. As clinical psychologists, we do not come to aninterview with a blank slate; rather, we bring with us attitudesthat may influence the areas of inquiry, the methods and tech-niques used in that inquiry, the words we use to subsequentlydescribe the person, and the goals we set for clients. For ex-ample, a psychologist with an existential-humanistic theoret-ical orientation will conduct a very different interview fromthat of a psychologist who has a family systems orientation.Treatment goals developed from an assessment interview

with a behaviorist will look quite different from treatmentgoals from an analyst.

Just as the client has certain expectations and beliefs aboutthe nature of the interview, the psychologist also comes to theinterview with certain preexisting beliefs and values that mayaffect the course of the interview. First, some psychologistsvalue a directed approach, whereas others value a nondirectedapproach. Some value humor, whereas others refrain from itsuse. One psychologist may value discussions about a client’smanifest behavior, whereas another may value a focus on aperson’s inner mental life. Second, psychologists value cer-tain kinds of material more than they do others, and they se-lectively respond to client material that is considered moreimportant (e.g., more highly valued). Third, psychologistsmay have a set of assumptions about behavior change andmay view the person in the light of those assumptions. Thereare certainly other areas that could be explicated, but the es-sential point here is that we all come to the interview with pre-conceived notions and then act according to these preexistingbeliefs and assumptions.

Psychologists eventually try to understand the client andproblems in the light of their theoretical orientation. Mostarrive at a diagnosis or some formulation of the problem, butthe nature of this description differs. Some may think of theclient in terms of oedipal and preoedipal functioning. Othersmay think of the person in terms of a homeostatic emotionalsystem designed to maintain a dominant-submissive dyadicrelationship against a triangulated third party. Others maycouch the problem as lack of assertiveness because of a his-tory of punishments during attempts at assertiveness. Stillothers may see the person as primarily dependent with bor-derline features. All of these characterizations are a diagnosisof a sort, but by the end of the interview, the psychologist islikely to have a hypothesis upon which an intervention ap-proach will be fashioned.

DIAGNOSTIC INTERVIEWING

Good interviewing consists of putting the client at ease,eliciting information, maintaining control, maintaining rap-port, and bringing closure. Putting the client at ease consistsof attending to privacy and confidentiality issues, reducinganxiety, avoiding interruptions, showing respect by using theclient’s preferred name, and arranging seating configurationsthat promote observation and interaction. Eliciting informationis accomplished by asking open-ended questions, avoidingunnecessary interruptions, intervening at critical junctionsof client elaborations, and clarifying any inconsistencies.

Interviewing Techniques 493

Controlling the interview does not mean assuming a com-pletely directive interviewing stance; rather, it means that thepsychologist has a purpose in mind for the interview itself andengages in behaviors that accomplish this purpose. The psy-chologist does not dominate the interview but rather guides italong a desired path. Skillfully disrupting client ramblings thatare counterproductive, discouraging unnecessary material, andmaking smooth transitions from one stage of the interview toanother can accomplish this goal. Rapport is maintainedthroughout by being nonjudgmental, displaying empathy,using language appropriate to the client, addressing salientclient issues, and communicating a sense that the client’s prob-lems are understood and can be helped. Finally, the psycholo-gist brings closure to the interview by informing the personabout the next steps in the process.

STRUCTURE OF THE CLINICAL INTERVIEW

The interpersonal psychiatrist, Harry Stack Sullivan (1954),suggested a format for the clinical interview, conceiving it as aphase-sequenced process consisting of (a) the formal in-ception, (b) reconnaissance, (c) detailed inquiry, and (d) termi-nation. This model remains viable even today (Craig, 1989).

In the formal inception (e.g., introduction) phase, the clin-ician learns what brought the client to the interview and ex-plains to the patient what will transpire within the interview.Sometimes all that is necessary in this introductory phase isto tell the client we’re going to put our heads together andsee if we can find ways to help you. Next, tell the client whatinformation you already know. If little or no information isavailable, it is acceptable to communicate that as well.

The reconnaissance (e.g., exploration) is the phase inwhich the clinician learns some basic information about theinterviewee. The client will present what has come to becalled the presenting complaint. Aside from demographics,the clinician also assesses for clinical syndromes and person-ality disorders during this part of the process. Sullivan (1954)believed this phase should not take longer than 20 min.

By assessing the syndrome, the clinicians convey that theyunderstand the problem. Consider a patient who is new intown, is looking for a primary care provider to manage Type2 diabetes and has narrowed down the search to two physi-cians. Doctor A takes a history, records the patient’s presentsymptoms, reviews the most recent glucose levels, and givesthe patient a prescription. Dr. B does the same thing but alsoinquires about the person’s kidney function, examines theheart, eyes, and feet, and asks whether there is any numbnessin the feet. In other words, Doctor B is telling the patient by

his or her actions that he or she knows about diabetes andits complications and assesses for them. Other things beingequal, the patient will probably select Doctor B as theprovider, feeling that he or she is more competent. Doctor Amay be just as competent in managing diabetes but failed tocommunicate that to the patient through a systematic reviewof the disease. This same process is recommended in mentalhealth interviews. Show the client that you understand theproblem or syndrome by assessing its major symptoms, asso-ciated disorders, and comorbidities.

The third phase is called the detailed inquiry (e.g., hypoth-esis testing). Here the initial impression gained during thefirst two phases is further assessed, and the clinician inter-views for an understanding of why the client is in the presentsituation and why the patient exhibits particular behaviorsand coping styles. I term this phase “interviewing for etiol-ogy.” Again, the clinician can frame the etiology within apreferred theoretical framework, citing such concepts as neg-ative reinforcements, unbalanced family systems, or oral fix-ation. The crucial point is to develop a working hypothesisthat will account for the behavior. At the end of this phase, theclinician should have a working hypothesis as to the source ofthe problem.

The final phase Sullivan called termination, but I preferto call it planning and intervention. Here the clinician makesa summary statement (e.g., feedback) as to what has beenlearned in the session; this is not a mere repetition of what theinterviewee has said but rather a clinical assessment from theinterviewer’s perspective. It can be framed in psychody-namic, behavioral, existential-humanistic, or family systemsperspectives, but in any case, it tells the client that you under-stand the problem. It lays the groundwork for how the prob-lem will be addressed. An important point in this phase is tocommunicate that you can help the client. You understand theproblem and can address it so that you can give the client hopeand an expectation of improvement. At this phase, basic pro-cedural issues are also discussed. These issues include thingssuch as frequency of visits, issues of confidentiality, fees, oremergency calls. I believe that if the clinician follows this for-mat and satisfactorily addresses the items to be assessed in it,the probability that the client will return for therapeutic workis maximized.

INTERVIEWING TECHNIQUES

Regardless of one’s theoretical position (for the most part),clinicians rely on a finite set of interviewing techniques thatcut across interviewing systems.


Questioning

This interviewing technique is certainly the most often uti-lized. Clients rarely spontaneously reveal the kind of infor-mation necessary, and the interviewer must, perforce, askquestions to get more precise information. Questions may beeither closed-ended or open-ended. In closed-ended ques-tions, the interviewee is asked a specific question that has tobe answered in a yes-no format. There is little opportunity forelaboration. An example of the closed-ended question isHave you lost any weight within the past 30 days? In contrast,an open-ended question allows for a full range of responseand for client elaboration. An example would be How doesyour spouse feel when you keep losing your job? Both open-ended and closed-ended questions are necessary, but clini-cians should try to avoid too many close-ended questionsbecause they inhibit free-flowing communication.

Clarification

This technique is often necessary because the nature of a per-son’s responses may remain obscure; this is usually done byusing one of the other interviewing techniques (e.g., ques-tioning, paraphrasing, restating) and is often appreciated byclients because it gives them a continued opportunity to telltheir story.

Confrontation

This is a technique whereby the clinician points out the dis-crepancy between what is stated and what is observed. It hasfrequently been employed with substance abusers, who con-tinue to deny or minimize their drinking and drug abuse. It isalso used with persons with character disorder diagnoses tobreak down their defenses. When done in a nonhostile andfactual manner, it can be helpful, but too often it is done in adestructive manner that increases client resistance. Neophyteinterviewers often have a problem with this technique becausethey may not be prepared to deal with the client’s response ifthis technique is mishandled. This technique probably shouldbe minimized and rarely used because more recent evidencehas called into question its utility (Miller, 1991).

Exploration

Some areas may require a review that is more in-depth thanwhat is initially presented by the client. In this technique theclinician structures a more thorough inquiry into a given area.Most clients expect to be questioned about certain issues andmay wonder why this was not done. Clinicians also should

not be reluctant to explore areas that may be consideredsensitive.

Humor

There is increasing recognition that humor does play a role inclinical interviews. It should not be overdone and should al-ways be done to benefit the client. It can reduce anxiety, fa-cilitate therapeutic movement, and enhance the flow of thesession.

Interpretation

This technique has a long history in clinical psychology andemanates from the Freudian tradition, which considers muchof human motivation outside of conscious awareness. It isprobably the most difficult technique to use successfully be-cause it requires a good knowledge of the client, personality,motivation, and dynamics. Interviewers in training should notemploy this technique without first processing this techniquewith their supervisor. It is important to recognize that manyclients will acquiesce to the authority of the clinician andagree with the interpretation when in fact it may be erroneous.

Reflection

Here the clinician skillfully and accurately restates what theclient has just said to show that the feelings and statementshave been understood.

Reframing

This technique is sometimes called cognitive restructuring.Attitudes, opinions, beliefs, or feelings are rephrased so thatthey correspond more to reality. Reframing can provide aclient with a new perspective and may undercut negative self-statements that are often irrational and maladaptive. Refram-ing also suggests new ways of thinking and behaving.

Restatement

This technique is sometimes called paraphrasing. It differsfrom reflection primarily in purpose. Restatement is mostoften used to promote understanding and clarification,whereas reflection is used primarily as a therapeutic tool.

Silence

Sometimes no response is the best response. Silence can pro-vide the client with an opportunity to process and understand

Interviewing Models 495

what has just been said. It should be done to promote intro-spection or to allow clients to recompose themselves afteran emotional episode. It needs to be done in such a way thatthe client understands that the clinician is using silence for areason.

The basic techniques of interviewing and examples illus-trating these techniques are presented in Table 21.3.

INTERVIEWING MODELS

The Medical Model

Many psychologists have argued that interviewing fromthe medical model is inappropriate. The medical model as-sumes that symptoms are developed due to externalpathogens; heritable vulnerabilities that are biologically de-termined; or structural, anatomical, or physiological dys-functions and abnormalities. These problems can only becorrected or ameliorated through surgery, medicine, or re-habilitation techniques. One can think of the medical modelas having two broad functions. The first is to guide classifi-cation, diagnosis, and ultimately, treatment and prevention.The second major function is to control both socially andlegally the health practices of society. Some psychologistswould prefer that we adopt a biopsychosocial model, whichadmits the role of biological processes in the develop-ment of disorders but which also includes the role of psy-chological and social factors in their etiology, course, andtreatment.

Behavioral Assessment

Many psychologists prefer a behavioral to a medical modelof interviewing. Behavioral psychologists do not espouse theidea that health-related problems are rooted in biology.Rather, they believe that contingencies of reinforcement oc-curring in the context of certain environments are primarilyresponsible for problematic behaviors. They thus decry med-ical terminology and nosology in favor of such concepts asresponse patterns, positive and negative reinforcements, andantecedents and consequences. A behaviorally based inter-view might analyze the problem by taking a reinforcementhistory, looking for patterns of rewards and punishments fol-lowing critical behaviors, and carefully defining and quanti-fying each targeted behavior for intervention. The chapter byO’Brien, McGrath, and Haynes in this volume discusses be-havioral interviewing at greater length.

Interview Biases

Interviews are not without problems, and many sources of in-terviewer biases have been researched. These biases includefactors such as positive and negative halo; reliance on firstimpressions; client attractiveness; theoretical biases (e.g., in-sisting that one theory can explain all forms of behavior); em-phasizing trait, state, or situational determinants of behaviorto the exclusion of the others; and conceptualizing behavioras a static rather than a dynamic process.

One problem with an assessment interview is the extent towhich bias exists throughout the diagnostic process. One bias

TABLE 21.3 Basic Interviewing Techniques

Technique Patient Statement Interview Response

Clarification Sometimes my husband doesn’t What do you think he’s doing whencome home for days. this happens?

Confrontation I no longer abuse my wife. You hit her yesterday!

Exploration In service I saw a guy get killed. What were the conditions?Did you have any bad dreams about it?

Humor Sometimes, doc, I act so crazy In that case, that will be $50.00 each.I think I got a split personality.

Interpretation I took my father’s Valium and If he were able to stand up to yourflushed them down the toilet. mother, then you would not have

to behave aggressively towards her.

Reflection I’m not getting anywhere. Your lack of progress frustrates you.

Reframing My boyfriend left me for Although it is upsetting now, it givessomeone else. you the chance to meet someone else.

Restatement I hear voices and get confused. These strange things are disturbing you.

Self-disclosure I just can’t learn like the others. I am dyslexic too. It need not holdI get so upset with myself. you up. You just have special needs.

Silence Someday I’m going to tell her (no response)exactly how I feel.

Questioning As a youth I was in detention home. What did you do to get in there?


that has been particularly addressed is gender bias. There areother sources of bias as well, including biased constructs, bi-ased criteria for making diagnoses, biased sampling popula-tions to study the issue, biased application of the diagnosticcriteria, and biased assessment instruments and gender biasesin the methods used to assess diagnostic entities (see alsoLindsay, Sankis, & Widiger, 2000). Hartung and Widiger(1998) have provided the most recent summary of prevalencerates of various diagnoses by gender, but these rates are notimmune to systematic distortions, as mentioned previously.Biased representation within clinical settings, empirical stud-ies, and biased diagnostic criteria sets can also skew the re-ported findings. However, these data presented by Hartungand Widiger (1998) are reasonable estimates of prevalencerates of psychiatric disorders by gender based on currentresearch.

Brown (1990) proposed a model for integrating gender is-sues into the clinical interview. It includes preassessment ac-tivities, such as familiarizing oneself in the scholarship andresearch on gender and its relationship to clinical judgments;it also includes suggestions to attend to one’s activities withinthe assessment process itself. These activities include in-quiries that will help the clinician determine the meaning ofgender membership for the client and the client’s social andcultural environment, determine gender-role compliance orvariation, notice how the client attends to the evaluator’s gen-der, and guard against inappropriate gender stereotyping.

ASSESSING PSYCHOPATHOLOGYWITH CLINICAL INTERVIEWS

Structured Versus Unstructured Interviews

Interviews to assess for psychopathology vary considerably inhow they are conducted. A basic dimension of interviews istheir degree of structure. Structured interviews follow rigidrules. The clinician asks specific questions that follow an exactsequence and that include well-defined rules for recording andjudging responses. This practice minimizes interview biasesand unreliable judgments, hence providing more objective in-formation.Although structured interviews generally have bet-ter psychometric properties than do unstructured ones,structured interviews may overlook idiosyncrasies that add tothe richness of personality, artificially restraining the topicscovered within the interview. They also may not create muchrapport between client and clinician. Semistructured inter-views are more flexible and provide guidelines rather thanrules. There are neither prepared questions nor introductoryprobes. These types of interviews may elicit more informationthan would emerge from a structured interview because the

clinician is allowed more judgment in determining what spe-cific questions to ask. The interviewer also may ascertain moredetailed information about specific topics. In completely un-structured interviews, the clinician assesses and explores con-ditions believed to be present within the interviewee. Thesehypotheses are generated from the person’s elaborations dur-ing the interview. In clinical practice, diagnoses are moreoften established using unstructured interviews, whereas in aresearch context diagnoses are more often established byusing a structured or semistructured interview.

The introduction of criteria sets in DSM-III (American Psy-chiatric Association, 1980) ushered in renewed interest in thereliability of psychiatric diagnoses. Clinicians devoted a sub-stantial amount of effort to improving diagnostic categoriesand to establishing psychiatric diagnoses. To respond to thischallenge, clinical psychologists relied on their history ofmeasuring individual differences in personality via structuredinventories. Psychiatrists relied on their rich history of observa-tion and interviews to establish a diagnosis, and they developeda spate of structured psychiatric interviews for an array of prob-lems and disorders. This move was an attempt to reduce subjec-tive clinical judgments. Table 21.4 presents a selected review ofavailable structured psychiatric interviews for a variety of con-ditions. I provide a brief summary of the most frequently usedstructured diagnostic interviews. Although each of the struc-tured instruments was designed for somewhat different pur-poses and was to be used with its companion diagnostic system,all have been revised and can now be used with DSM-IV.

The structured psychiatric interviews that have receivedthe most attention are the Schedule of Affective Disor-ders and Schizophrenia (SADS; Endicott & Spitzer, 1978),the Diagnostic Interview Schedule (DIS; Robins, Helzer,Croughan, & Ratcliff, 1981), and the Structured ClinicalInterview for DSM Disorders (SCID; Spitzer, Williams,Gibbon, & First, 1992).

The SADS is a standardized, semistructured diagnostic in-terview that was initially developed to make a differentialdiagnoses among 25 diagnostic categories in the ResearchDiagnostic Criteria, a precursor to DSM-III. The clinicianuses a set of introductory probes and further questions todetermine whether the responses meet the diagnostic criteria.The SADS has two main sections. In the first section, the in-terviewer ascertains a general overview of the client’s con-dition by using detailed questions about current symptomsand their severity. Level of impairment is determined throughthe use of standard descriptions and is not left to clinicaljudgment. The second section covers the patient’s history ofmental disorders; questions are clustered within each diag-nosis. It assesses psychopathology and functioning in thecurrent episode, assessing mood, symptoms and impairment.

Assessing Psychopathology With Clinical Interviews 497

Current functioning is defined as level of function 1 weekprior to the interview. The final results yield both current andlifetime diagnoses, and the interview requires 1–2 hours toadminister. There are three versions of the SADS, including alifetime version (SADS-L), a change version (SADS-C) thatcan be used to evaluate treatment effectiveness, and a chil-dren’s version (K-SADS-P).

The DIS is a completely structured diagnostic interviewdesigned to be used by lay interviewers. It was developed

by National Institute of Mental Health to assess current andlifetime diagnoses in large-scale epidemiological surveys ofpsychopathology and psychiatric disorders, although it alsohas been used in clinical research studies. To administer theDIS, the interviewer reads the questions exactly as they areprovided in the interview booklet. In general, there is noprobing, although a separate probe flowchart can be used fororganic diagnoses with psychiatric symptoms. Separate sec-tions are provided for 32 specific diagnoses containing about263 items. Current symptoms are assessed for four time peri-ods: the past 2 weeks, the past month, the past 6 months, andthe past year. Administration time is about 45–90 minutes.Much of the research with the DIS has compared DIS to psy-chiatric-clinician diagnosis established by traditional means.There are child and adolescent versions of the DIS, and bothare available in a computerized DIS (C-DIS) program.

The SCID is a semistructured diagnostic interview de-signed to be used by clinical interviewers and was intended tohave an administration time shorter than that of the SADS. Ittakes 60–90 minutes to administer and assesses problemswithin the past month (current) and lifetime. The interview be-gins with a patient’s description of his or her problems. Afterthe clinician has an overview of the client’s difficulties, themore structured section begins, organized in a modular formatdepending on suspected diagnoses. The questions are open-ended. After each section, the interviewer scores the disorderfor severity (mild, moderate, severe) within the past month,according to symptoms and functional impairment. The inter-view follows the hierarchical structure that appears in DSM.There are several versions of the SCID. One is designedfor use with inpatients (SCID-P), one with outpatients (SCID-OP), and one with nonpatients (SCID-N). Subsequently, theSCID-II was developed to diagnose personality disorders. TheSCID has been translated into several foreign languages. It iscurrently in use in Japan, Puerto Rico, and China and has be-come the most researched structured psychiatric interview.

Should you use a structured psychiatric interview? Theycan be useful to teach diagnostic interviewing for clinicians intraining. They may be more valuable than are unstructured in-terviews in certain forensic applications. They can provide anautomatic second opinion, and some may save valuable timefor the professional because they can be administered by men-tal health paraprofessionals. However, for routine clinicalpractice, structured clinical interviews are cumbersome andtime-consuming and seem more appropriate when method-ological rigor is required for research diagnoses.

Psychometric properties, so often discussed in the contextof assessing psychological tests, may also be applied to clin-ical interviews that assess psychopathology (Blashfield &Livesley, 1991). The purpose of these interview schedules

TABLE 21.4 A Selected Presentation of Structured PsychiatricInterviews

General interview schedulesSchedule of Affective Disorders Endicott & Spitzer, 1978.and Schizophrenia

Diagnostic Interview Schedule Robins et al., 1981.

Structured Interview Pfohl, Blum, & Zimmerman, 1983;for DSM Disorders Pfohl, Stangl, & Zimmerman, 1995.

Structured Clinical Interview Spitzer, Williams, Gibbon, & for DSM-III-R First, 1992.

Axis I disordersAcute stress disorder Bryant et al., 1998.

Anxiety Spitzer & Williams, 1988.

Affective disorders and Endicott & Spitzer, 1978.schizophrenia

Borderline personality disorder Zanarini, Gunderson, et al., 1989.

Depression Jamison & Scogin, 1992.

Depressive personality Gunderson, Phillips, Triebwasser, &disorder Hirschfield, 1994.

Dissociative disorders Steinberg, Cicchetti, Buchanan, &Hall, 1993.

Eating disorders Cooper & Fairbairn, 1987.

Hypocondriasis Narcissism Barsky et al., 1992. Gunderson,Ronningstam, & Bodkin, 1990.

Panic disorder Williams, Spitzer, & Gibbon, 1992.

Personality disorders Stangl Pfohl, Zimmerman, Bowers, &Corenthal, 1985.

Selzer, Kernberg, Fibel, Cherbuliez, &Mortati, 1987.

Zanarini, Frankenburg, Chauncey, &

Gunderson, 1987; Zanarini, Frankenburg, Sickel, & Yong, 1995.

Loranger et al., 1987, 1994.

Widiger, Mangine, Corbitt, Ellis, &Thomas, 1995.

Posttraumatic stress disorder Watson, Juba, Manifold, Kucala, &Anderson, 1991.

Psychopathy Hare, 1991.

MiscellaneousChild abuse Shapiro, 1991.

Suicide Reynolds, 1990.

Sommers-Flanagan &Sommers-Flanagan, 1995.

Symptoms Andreasen, Flaum, & Arndt, 1992.


was to improve the reliability of psychiatric diagnosis. Evenso, serious problems in assessment reliability continue toexist; even when using structured interviews and responsesets, both in the interviewer and patient can affect the out-come of the evaluation (Alterman et al., 1996).

One outcome of the development of structured clinical in-terviewing has been the inquiry of comorbidities of Axis Idisorders associated with an Axis II disorders (and viceversa). For example, disorders that have been studied includeeating disorders (Braun, Sunday, & Halmi, 1994; Brewertonet al., 1995), psychotic disorders (Cassano, Pini, Saettoni,Rucci, & Del’Osso, 1998), and substance abuse (Abbott,Weller, & Walker, 1994; Oldham et al., 1992). These findingsare presented later in this chapter. It is incumbent on the in-terviewer to assess those disorders that may be associatedwith an Axis I or Axis II diagnosis.

Many factors interact and complicate the process of usinginterviews to assess psychopathology. These factors include(but are not limited to) definitional ambiguities, criterion unre-liability, overlapping symptoms, contextual moderators, multi-dimensional attributes, population heterogeneity, and deficitsin the instruments and processes (e.g. interviews) that we asclinicians use to assess psychopathology (Millon, 1991).Addi-tionally, the diagnostic system we use (DSM-IV) is imperfect.Complaints about this system include conceptual obscurity,confusion, a questionable broadening of the range and scope ofcategories classified as mental disorder, use of a categoricalrather than dimensional model, poor applicability to disordersin children, and issues the medicalization of psychiatric diag-nosis (American Psychiatric Association, 1980).

ASSESSING PERSONALITY WITHCLINICAL INTERVIEWS

Personality Assessment Versus AssessingPersonality Disorders

It is one thing to assess personality and quite another to as-sess personality characteristics. The latter is substantiallyeasier because there are diagnostic criteria codified in offi-cial diagnostic classification systems (e.g., DSM, ICD-10),and to make the diagnosis one merely has to determinewhether the client meets the criteria. Furthermore, there areboth structured clinical interviews and psychometric testsavailable to supplement the clinical interview (Widiger &Frances, 1985b, 1987). Because there is no agreed-uponclassification system for personality, the clinician typicallylooks for certain traits that are related to the referral or treat-ment issue.

Problems in Assessing Personality and PersonalityDisorders With Clinical Interviews

Many assessment difficulties complicate the diagnosis of per-sonality disorders. Many issues have occupied the field ofpersonality assessment (Zimmerman, 1994) and need to beconsidered by an individual clinician when interviewing forpersonality characteristics and personality disorders. First, thelines of demarcation between normal and pathological traitsare porous and not well differentiated (Goldsmith, Jacobsberg,& Bell, 1989; Strack & Lorr, 1997). The normality-pathologycontinuum can be viewed from different theoretical positions,making it difficult for the clinician to determine whetherthe behavior observed in the interview is normative or aber-rant. Second, official diagnostic classification systemshave adopted a categorical system for personality disorders(Widiger, 1992). One criticism of this approach is that it artifi-cially dichotomizes diagnostic decisions into present-absentcategories when they are inherently continuous variables.From this perspective, personality disorders have no discretedemarcations that would provide a qualitative distinctionbetween normal and abnormal levels (Widiger, 2000). In con-trast, a dimensional approach assumes that traits and behav-iors are continuously distributed in the population and that aparticular individual may have various degrees of each trait orbehavior being assessed. Dimensional systems are seen asmore flexible, specific, and reliable and are able to providemore comprehensive information, whereas categorical sys-tems lose too much information and can result in classificationdilemmas when a client meets the criteria for multiple disor-ders (Widiger & Kelso, 1983). However, dimensional systemsare too complex for practical purposes and may provide toomuch information. Determining the optimal point of demarca-tion between normal and abnormal would be difficult from adimensional perspective.

Third, many have lamented that the DSM personality dis-order section lacks a theoretical approach to the understand-ing and classification of personality disorders. Fourth, fixeddecision rules—as contained in official diagnostic systems—decrease diagnostic efficiency when the cutoff points for di-agnosis are not adjusted for local base rates (Widiger &Kelso, 1983). Fifth, affective disorders can influence the ex-pression of traits and confound diagnostic impressions. Forexample, many patients with clinical depression appear toalso have a dependent personality. However, when theirdepression abates, they no longer appear to be dependent.Patients with bipolar manic disorder may appear histrionicduring the acute phase of the manic-depression but not whenthe affective disorder has stabilized. Affective disorders com-plicate the diagnosis of personality disorders. Sixth, is the

Reliability of Clinical Interviews and Psychiatric Diagnoses 499

behavioral manifestation or expression seen in diagnostic in-terviews due to endemic personality traits, or is the manifes-tation situationally induced? Specific life circumstances canchange behavior and confuse the diagnosis of personality dis-orders. Seventh, patients often meet the diagnostic criteria formore than one personality disorder, and the optimal numberof diagnostic criteria needed for an individual diagnosis re-mains unclear.

One trend in the assessment literature has been to studythe role of prevalence of personality disorders in Axis I syn-dromes. There is now recognition that personality disorderscan influence the expression, course, and duration of Axis Idisorders, as well as be a focus of treatment in their ownright. Table 21.5 presents the personality disorders mostoften diagnosed for selected Axis I disorders. Clinicianswho assess for specific Axis I disorders should evaluate forthe presence of personality disorders commonly associatedwith those syndromes (Livesley, 2001; Millon & Davis,1996).

One continuing concern is that although the reliability ofpersonality disorder diagnoses has improved, their discrimi-nant validity continues to be a problem. This means that therewill continue to be high levels of comorbid personality disor-der diagnosis within an individual patient (Blais & Norman,1997).

Role of Culture

We are only beginning to appreciate the role of culture andhow it affects behavior. DSM-IV has recognized many cul-tural manifestations that are viewed as common within thedesignated culture. However, while DSM-IV includes Axis Iconsiderations in the Appendix, it has been slow to take intoaccount the role of cultural considerations and applying themto the diagnostic criteria for Axis II disorders.

RELIABILITY OF CLINICAL INTERVIEWSAND PSYCHIATRIC DIAGNOSES

Most clinicians make a personality disorder diagnosis by lis-tening to the person describe interpersonal interactions andby observing behavior in the interview itself (Westen, 1997).However, even with the introduction of criteria sets, person-ality disorder diagnoses generally obtain lower levels of reli-ability compared to Axis I disorders (Widiger & Frances,1985a); this is because the clinician has to address the issuesof boundary overlap, the possible influences of state, role,and situational factors on behavioral expression, the client’sinability or unwillingness to report symptoms, and the diffi-culty of determining whether a trait is pervasive and mal-adaptive within the confines of a brief psychiatric interview(Gorton & Akhtar, 1990).

Prior to DSM-III, the mean interrater reliability (kappa) forthe diagnosis of personality disorders was 0.32. DSM-III in-troduced criteria sets for the establishment of a diagnosis.DSM-III also included field trials of the reliability of the pro-posed diagnoses using over 450 clinicians involving over800 patients, including adults, adolescents, and children. Forpersonality disorders in adults, results indicated that the over-all kappa coefficient of agreement on diagnosis was .66 afterseparate interviews. For Axis II personality disorders, thekappas were .61 for joint assessments and .54 for using a test-retest format (Spitzer, Williams, & Skodal, 1980). High kap-pas (.70 and above) reflect generally good agreement. With theintroduction of criteria sets, the mean kappa for DSM-III per-sonality disorders was 0.61 when the decision was any per-sonality disorder but only a median 0.23 for individualdisorders (Perry, 1992). Even so, Wiens and Matarazzo (1983)concluded that “. . . DSM-III is a remarkably reliable systemfor classifying disorders in Axis I and Axis II” (p. 320).

However, method variance contributes significantly to theobserved results. Reliability estimates change depending onwhether the reliability is based on unstructured interviews,semistructured interviews, or joint-interview raters comparedto single-interview raters (Zimmerman, 1994), as well aslong versus short test-retest intervals. Perry (1992) reportedthat the diagnostic agreement between a clinical interviewand a self-report measure of personality disorders was notsignificantly comparable across methods. In fact, certain do-mains that are part of the clinical diagnostic picture of a per-sonality disorder may not be reliably assessed by eitherstructured clinical interviews or self-report measures becausethese domains pertain to implicit processes that may be out-side the awareness of the client.

There has not been a comparable presentation on thereliability and validity of psychiatric interviewing and

TABLE 21.5 Personality Disorders with Higher Prevalence Rates forSelected Axis I Syndromes

Clinical Syndrome Personality Disorder

Anxiety disorders: General BorderlinePanic disorders Avoidant, dependent, obsessive-compulsiveSocial phobia AvoidantAgoraphobia AvoidantSomatoform Avoidant, paranoid

Depression: Dysthymia Avoidant, borderline, histrionicMajor depression Borderline

(episodic)Bipolar Histrionic, obsessive-compulsive,

borderline, paranoidEating disorders: Anorexia Avoidant

Bulimia Dependent, histrionic, borderlineSubstance abuse (alcohol Antisocial, narcissistic

and drugs)


diagnosis since Matarazzo’s work on these topics some timeago (Matarazzo, 1965, 1978; Wiens & Matarazzo, 1983); thefocus of clinical interviewing research has changed fromgeneric interviews, which were the focus of Mattarazo, tostructured and focused interviews. It is not scientificallyaccurate to discuss the reliability of psychiatric diagnosis orto discuss the reliability of clinical interview because the re-liability will change based on (a) diagnosis, (b) instrumentused to assess reliability, and (c) the method used to deter-mine reliability. Psychiatric research now addresses the relia-bility and validity (usually concurrent diagnoses) amongthese various structured and semistructured techniques.

There are three strategies to evaluate the reliability of struc-tured psychiatric interviews. In the first strategy (test-retestmethodology), two or more clinicians interview the samepatient on two separate occasions and independently estab-lish a diagnosis. In the second method, two raters interviewthe same patient simultaneously and the raters make indepen-dent judgments as to diagnosis. Often researchers using thismethod provide the raters with an audio or videotape of the in-terview. In the third method, two or more structured psychi-atric interviews, self-report tests, or both are given to the samepatient. In all methods, the extent of agreement between inter-viewers as to the presence or absence of a particular disorderis determined by using the kappa statistic. By consensus,kappa values greater than .70 are considered to reflect goodagreement, values .50 to .70 reflect fair to good agreement,and values less than .50 reflect poor agreement. Values lessthan 0.00 reflect less than chance agreement between raters.

The Structured Clinical Interview for DSM diagnoses(SCID; First, Spitzer, Gibbon, & Williams, 1995a; Spitzer &Williams, 1984; Spitzer, Williams, Gibbon, & First, 1992) hasbeen the diagnostic instrument most often used in psychiatricresearch, and researchers have considerable reliability data onthis instrument. Our discussion on reliability of psychiatricdiagnoses concentrates on research using this instrument.

The SCID and SCID-II were designed for use with expe-rienced diagnosticians. It has different modules, including allAxis I and Axis II groups of disorders. SCID-I assesses 33 ofthe more commonly diagnosed DSM-III-R disorders. Thestructured format requires the interviewer to read the ques-tions exactly as they are printed (in the first of three columns)and to determine the presence or absence of criteria, whichappear in the second column. The third column contains threelevels of certainty—yes, no, or indeterminate—as to whetherthe patient met the criteria. The structured clinical interviewallows the clinician to probe and restate questions, challengethe response, and ask for clarification in order to determinewhether a particular symptom is present. The use of opera-

tional criteria for a diagnosis has improved the selection ofresearch participants, thereby improving participant homo-geneity and reducing interviewer bias. But potential sourcesof bias, such as cultural bias, are present, which can influencethe expression of psychiatric symptoms and psychopathol-ogy as well as the interpersonal nature of the diagnosticprocess between patient and interviewer (Lesser, 1997).However, these issues are extant in all structured clinical in-terviews as well. Prevalence rates of disorders may also varybased on which version of DSM (e.g., DSM-II-R, DSM-IV) isused as the criterion (Poling et al., 1999).

Segal, Hersen, and Van Hasselt (1994) have published themost recent literature review on the reliability of the SCID-I(Axis I) and SCID-II (Axis II) disorders. Their review foundkappa values for the SCID-I ranging from – .03 to 1.00. It isinteresting to note that both of these values were for the so-matoform diagnosis in separate studies. The median kappavalues for 33 different diagnoses reported in the literaturewas .78. Median kappa values for SCID-II reliability studiesfor Axis II disorders ranged from .43 (histrionic personalitydisorder) to 1.00 (dependent, self-defeating, and narcissisticpersonality disorders), with a median of .74.

Several additional reliability studies on SCID diagnosishave appeared since that review. Using test-retest methodol-ogy, 12-month reliability data for SCID-II diagnosis in31 cocaine patients was .46 (Weiss, Najavits, Muenz, &Hufford, 1995). Kappa values ranged from .24 (obsessive-compulsive disorder) to .74 (histrionic personality disorder)with an overall kappa at .53 among 284 patients at multiplesites (First, Spitzer, Gibbon, & Williams, 1995b). Using aDutch sample of 43 outpatients, six raters evaluated the samepatient within 1–4 weeks of the initial interview. Kappa forone or more personality disorders was .53, suggesting onlyfair agreement (Dreessen & Arntz, 1998).

Research has found little agreement between SCID-II andthe Minnesota Multiphasic Personality Inventory (MMPI) andMillon Clinical Multiaxial Inventory (MCMI-II) diagnoses(Butler, Gaulier, & Haller, 1991; Marlowe, Husband,Bonieskie, & Kirby, 1997). Although there were no apparentgender biases in assessing personality diagnoses betweenSCID-II and the Personality Diagnostic Questionnaire-Revised (Golomb, Fava,Abraham, & Rosenbaum, 1995; Hyler& Rieder, 1987), there is often low agreement between person-ality disorder diagnoses between these two assessment meth-ods, with many false positives (Fossati et al., 1998). This samepattern of results appears between the SCID and the Personal-ity Disorder Examination (Loranger, Susman, Oldham, &Russakoff, 1987)—low diagnostic agreement and many falsepositives (Lenzenweger, Loranger, Korfine, & Neff, 1997;

Computer-Assisted Diagnosis and Computer Interviews 501

Modestin, Enri, & Oberson, 1998; O’Boyle & Self, 1990).Using two separate structured psychiatric interviews revealsdifferent patterns of comorbidity of personality disorders(Oldham et al., 1992). Because the false negative rates betweenthese instruments tends to be low, one possibility is to have aclinician question only those diagnostic elements endorsedin the self-report instrument (Jacobsberg, Perry, & Frances,1995), but this has not been done to date.

In summary, the present available data suggest that al-though structured psychiatric interviews are reliable, theyshow low to modest agreement with each other in terms ofindividual diagnoses; this is true not only for the SCID butalso for other major structured clinical interviews.

INCREMENTAL VALIDITY

Using a computer search that included the terms incrementalvalidity and clinical interviews as well as interviews, wecould find no references pertaining to research that ad-dressed the question of whether adding an interview addsany other information than was attainable through othermeans (e.g., psychological tests, collateral information). In-cremental validity studies are readily available for such enti-ties as the addition of a particular test to a test battery(Weiner, 1999), the prediction of a specific behavior such asviolence, (Douglas, Ogcuff, Nicholls, & Grant, 1999), orvarious constructs such as anxiety sensitivity (McWilliams& Asmund, 1999) or depression (Davis & Hays, 1997), butthe criteria in these studies were all established using otherself-report inventories rather than a clinical interview.

I did find studies that documented the fact that structuredclinical interviews yield higher rates of various disorders thando unstructured interviews. For example, body dysmorphicdisorder, which is relatively rare, was three times more likelyto be diagnosed using a structured clinical interview (SCID)than with a routine clinical interview (Zimmerman & Mattia,1998). Comparing comorbidities among 500 adult psychi-atric patients assessed at intake with routine clinical interviewand 500 patients assessed with the SCID, results showed thatone third of the patients assessed with the structured diagnos-tic interview had three or more Axis I diagnoses, compared toonly 10% of patients assessed with an unstructured clinicalinterview. In fact, 15 disorders were more frequently diag-nosed with the SCID than with routine clinical assessment;they occurred across mood, anxiety, eating, somatoform, andimpulse-control disorders (Zimmerman & Mattia, 1999a).Similarly, posttraumatic stress disorder (PTSD) is often over-looked in clinical practice when PTSD symptoms are not the

presenting complaint. However, PTSD was more frequentlydiagnosed using a structured clinical interview such as theSCID (Zimmerman & Mattia, 1999b). Also, these researchersfound that without the benefit of the detailed informationprovided by structured interviews, clinicians rarely diagnoseborderline personality disorder during routine intake evalua-tions (Zimmerman & Mattia, 1999c).

These studies attest to the fact that structured clinical in-terviews diagnose more clinical disorders than do routineclinical interviews. The need for incremental validity studieswith clinical interviews is readily apparent. We especiallyneed studies that compare clinical interviews to other assess-ment methods. Several studies have reported rates of diagnos-tic agreement between clinician-derived or structured clinicalinterviews compared to self-report measures, such as theMCMI, but they are reliability studies and not studies ofincremental validity.

COMPUTER-ASSISTED DIAGNOSISAND COMPUTER INTERVIEWS

In recent years the use of computers to interview patients hasbeen attempted, mostly in research contexts. Its potential ad-vantages include increased reliability of the information andan increased ability to obtain specific data about a patient.Critics complain that computer interviews are too impersonaland miss subtle aspects of a patient’s problem. Perhaps themost promising use of computer interviewing is in highly fo-cused evaluations of a particular problem, such as depres-sion, substance abuse, or sexual disorders.

We can safely predict that computers and technologicaladvances will eventually permeate future diagnostic studies.Indeed, researchers have already established that it is feasibleto do diagnostic work via the computer (Keenan, 1994;Kobak et al., 1997; Neal, Fox, Carroll, Holden, & Barnes,1997). Some research has shown that automated screeningcan record basic client information—particularly as it per-tains to demographics and symptoms—even before clientssee a clinician for the initial assessment and that clients viewit as helpful to their treatment (Sloan, Eldridge, & Evenson,1992).

Computerization of standardized clinician-administeredstructured diagnostic interviews has also been shown to havevalidity comparable to that obtained in face-to-face contexts(Levitan, Blouin, Navarro, & Hill, 1991; Lewis, 1994) andcan also be reliably done via the telephone using structuredformats (Ruskin et al., 1998). One study reported that outpa-tients in an acute psychiatric setting, who had been diagnosed


by computer, generally liked answering questions on the com-puter (94%), understood the questions without difficulty(83%), and even felt more comfortable with the computerizedinterview than with a physician (60%). However, psychiatristsagreed with only 50% of the computer-generated diagnoses,and only 22% of psychiatrists believed that the computergenerated any useful new diagnoses (Rosenman, Levings, &Korten, 1997).

Computer-based systems usually provide a list of probablediagnoses and do not include personality descriptions, in con-trast to computer-derived psychological test interpretations(Butcher, Perry, & Atlis, 2000). Logic-tree systems aredesigned to establish the presence of traits or symptoms thatare specified in the diagnostic criteria and thereby lead to aparticular diagnosis. Examples of computerized systematizeddiagnostic interviews include the DTREE for DSM-III-Rdiagnoses (First, 1994), and the computerized version of theInternational Diagnostic Interview (CIDI-Auto; Peters &Andrews, 1995). However, research in this area has morecommonly evaluated the computerized version of the Diag-nostic Interview Schedule. This research has found thatkappa coefficients for a variety of DSM-III diagnoses rangedfrom .49 to .68, suggesting fairly comparable agreement be-tween clinician determined and computer-based psychiatricdiagnoses (Butcher et al., 2000).

Research in the area has shown that computer-assisteddiagnostic interviews yielded more disorder diagnoses thandid routine clinical assessment procedures (Alhberg, Tuck, &Allgulander, 1996). Compared to computer-administered clin-ical interviews, clinician-administered interviews resulted inless self-disclosure—particularly of socially undesirable in-formation (Locke & Gilbert, 1995). In fact, respondents seemmore willing to reveal personal information to a computer thanto a human being (Hofer, 1985) and tend to prefer a computer-administered interview to a clinician-conducted interview(Sweeny, McGrath, Leigh, & Costa, 2001). This is probablybecause they felt more judged when interviewed in personthan when identical questions were administered from a com-puter. However, some evidence exists suggesting that com-puter diagnostic assessment, although it is reliable, shows poorconcordance with SCID diagnoses, except for the diagnoses ofantisocial and substance abuse (Ross, Swinson, Doumani, &Larkin, 1995; Ross, Swinson, Larkin, & Doumani, 1994).

Advances in technology are likely to find applicationsin the diagnostic process as well (Banyan & Stein, 1990).The future will certainly see more utilization of these typesof sophisticated technologies. Technology, however, willnot obviate the essential difficulties in the diagnostic processas described throughout this chapter—computer-assisteddiagnostic formats are programmed to contain the same

problems and deficiencies inherent in a face-to-face diagnos-tic interview.

MISUSE OF THE INTERVIEW

Many clinicians have such faith in the clinical interview (andin their own skills) that interviews can be misused. One suchcurrent venue is that occasioned by managed care constraintsthat often preclude the use of other methods (e.g., psycholog-ical tests, collateral interviews) that would either add incre-mental validity in clinical practice or possibly confirmhypotheses gleaned from the interview itself. Psychologistsneed to guard against such practices and to advocate for thebest possible psychological practice for a given problem.

WHAT NEEDS TO BE DONE?

Most problems in any classification system of personalitydisorders are endemically and systematically related to theissue of construct validity. One continuing problem in assess-ment is that it has been extremely difficult to find independentoperationalizations of personality traits and personality dis-order constructs that are consistent across assessment de-vices. Convergent validity between self-report measuresand interview-based assessments range from poor to modest.Median correlations between structured psychiatric interviewsrange from .30 to .50; median correlations between self-reportmeasures range from .39 to .68; and median correlationsbetween questionnaires and structured interviews range from.08 to .42. Consistently moderate correlations between ques-tionnaires have been reported for the diagnoses of borderline,dependent, passive-aggressive, and schizotypal personalitydisorders. Better convergent validity between questionnairesand clinical interviews has been found with diagnoses ofborderline and avoidant personality disorders. For clinical in-terviews, consistently good convergence has been found foronly avoidant personality disorder (Clark, Livesley, & Morey,1997).

Although method variance and general measurement errormay account for some of the findings, the real problem is alack of clear and explicit definitions of the diagnostic con-structs and behavioral anchors that explicate examples ofspecific items that define the disorder and aid the diagnosti-cian (and researcher) to diagnose the disorder. For example,with a criteria set of eight items, of which five are need tomake a diagnosis of borderline personality disorder, there are95 different possible sets of symptoms that would qualify forthis diagnosis (Widiger, Frances, Spitzer, & Williams, 1988).

What Needs to Be Done? 503

Are there really 95 different types of borderline personalitydisorders? Obviously not! The criteria merely reflect our con-fusion on the diagnosis itself. This situation is clearly absurdand serves to illustrate the problems that accrue when theconstruct and defining criteria are obfuscating. Similarly, theproblem of a patient’s meeting two or more of the personalitydisorder diagnoses will continue to exist, due largely to defi-nitional problems. A clinician can reduce this bias somewhatby carefully assessing all criterion symptoms and traits, butthe problem in the criteria themselves remains.

Associated with the need for more conceptual clarity is theneed to reduce terminological confusion inherent in the crite-ria set. For example, when does spontaneity become impul-sivity? There is also a need for improved accuracy inclinician diagnosis. Evidence exists that trained interviewersare able to maintain high levels of interrater reliability, diag-nostic accuracy, and interviewing skills, such that qualityassurance procedures should be systematically presentedin both research and clinical settings (Ventura, Liberman,Green, Shaner, & Mintz, 1998). For example, 18 clinical vi-gnettes were sent to 15 therapists, along with DSM personal-ity disorder criteria sets. Fourteen of the vignettes were basedon DSM criteria and 14 were made up and suggested diag-noses of no personality disorder. Results showed and 82%rate of agreement in diagnosis. This type of procedure can becost-effective to establish and to assess continuing compe-tency in diagnosing personality disorders (Gude, Dammen, &Frilis, 1997).

Some have called for the explicit recognition of dimen-sional structures in official classification systems becausesuch structures recognize the continuous nature of personal-ity functioning (Widiger, 2000). Millon (2000) called foradoption of a coherent classification-guiding theory. How-ever, it is unlikely that theorists would ever agree as to theparsimonious system to be adopted. Others suggested the useof prototype criteria sets to define pure cases (Oldham &Skodol, 2000; Westen & Shedler, 2000), but such prototypesmight only rarely be observed in clinical practice, and hencesuch a system would live little practical utility, althoughMillon (2000) has persuasively argued otherwise. He has alsocalled for the inclusion of personality disorder subtypes hier-archically subsumed under the major prototypes. Still otherscall for the inclusion of level of functioning (e.g., mild, mod-erate, severe), within the personality diagnostic system.Hunter (1998) suggested that personality disorder criteria berewritten from the patient’s perspective. This would have theeffect of removing negative language and provide a simpli-fied and more straightforward and objective means of assess-ment. Cloninger (2000) suggested that personality disordersbe diagnosed in terms of four core features: (a) low affective

stability, (b) low self-directedness, (c) low cooperativeness,and (d) low self-transcendence. Perhaps a blend of both thecategorical and dimensional systems is preferable. The clini-cian could diagnose a personality disorder in a categoricalsystem, reference personality (disorder) traits that are spe-cific to the individual, and include a specifier that depictslevel of functioning.

The aforementioned suggestions apply more to assessingpersonality disorders with interview. Karg and Wiens (1998)have recommended the following activities to improve clini-cal interviewing in general:

• Prepare for the initial interview. Get as much informa-tion beforehand as possible; be well-informed about thepatient’s problem area. This preparation will allow you toask more meaningful questions. There may be importantinformation learned from records or from other sourcesthat warrant more detailed inquiry within the assessmentinterview. If this information is not available to you at thetime of the interview, the opportunity for further inquirymay be lost.

• Determine the purpose of the interview. Have a clearunderstanding of what you want to accomplish. Have aninterview structure in mind and follow it.

• Clarify the purpose and parameters of the interview to theclient. If the client has a good understanding of what istrying to be accomplished, his or her willingness to pro-vide you with meaningful information should increase.

• Conceptualize the interview as a collaborative process.Explain how the information will be used to help the clientwith his or her situation.

• Truly hear what the interviewee has to say. This may beaccomplished by using active listening and by clarifyingthe major points of understanding with the intervieweeduring the interview.

• Use structured interviews. These interviews promote asystematic review of content areas and are more reliable.

• Encourage the client to describe complaints in concretebehavioral terms. This will help the psychologist to un-derstand the client better and will provide examples of thepotential problematic behavior in relevant context.

• Complement the interview with other assessment methods,particularly psychological testing. This may provide bothconvergent and incremental validity.

• Identify the antecedents and consequences of problembehaviors. This will provide more targeted interventions.

• Differentiate between skill and motivation. Some patientsmay have the desire to accomplish goals that are beyondtheir capacities, and vice versa.


• Obtain base rates of behaviors. This will provide a bench-mark for later assessment of progress.

• Avoid expectations and biases. Self-monitor your ownfeelings, attitudes, beliefs, and countertransference to de-termine whether you are remaining objective.

• Use a disconfirmation strategy. Look for information thatmight disprove your hypothesis.

• Counter the fundamental attribution error. This occurswhen the clinician attributes the cause of a problem to oneset of factors, when it may be due to other sets of factors.

• Combine testing with interviewing mechanistically. This isbecause combining data from interview with data fromother sources will be more accurate and valid than datafrom one source alone.

• Delay reaching decisions while the interview is being con-ducted. Don’t rush to judgments or to conclusions.

• Consider the alternatives. Offering a menu of choices andpossibilities should engender greater client acceptance ofgoals and interventions.

• Provide a proper termination. Suggest a course of action,a plan of intervention, recommended behavioral changes,and so on, that the person can take with them from the in-terview. It is pointless for the psychologist to conductthorough assessments and evaluations without providingsome feedback to the client.

The future will no doubt actively address, research, re-fine, and even eliminate some of these problems discussed inthis chapter. We can look forward to improvements in diag-nostic criteria, improved clarity in criteria sets, increasedtraining so that clinicians can self-monitor and reduce anypotential biases in diagnostic decision-making, and take therole of culture more into account in the evaluation of clients.I hope that these advances will lead to improvements in ther-apeutic interventions designed to ameliorate pathologicalconditions.

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