An Overview of the Interview Process

Structural Models

Just as many professional and social interactions have a normal, implicit sequence, ritual, or set of phases, so does the clinical interview. Shea (1998) identifies these phases as:

The introduction.
The opening.
The body.
The closing.
The termination.

Other models exist too. Depending on theoretical orientation and clinical setting, astute interviewers often initially allow clients to set the pace as much as possible because observing this process yields valuable information. Being allowed to set the pace also provides clients with a sense of control and safety; they do not feel rushed from stage to stage. Ideally, interviewers guide clients gently forward through the interview, allowing them to rush through or linger on a given point as needed. The interviewer is responsible for managing the essential elements of a good interview, seeing that it does not run overtime, and ensuring it covers what is necessary, given the setting and expectations. However, the less overtly and rigidly this responsibility is exercised, the better.

The Introduction

Shea (1998) defines the introduction phase: "The introduction begins when the clinician and the patient first see one another. It ends when the clinician feels comfortable enough to begin an inquiry into the reasons the patient has sought help" (p. 58). The introduction phase of an interview primarily involves initiating a helping relationship, which involves putting the client at ease in such a way that facilitates an open discussion of a wide range of personal information.

Telephone Contact

In some situations, the introduction phase begins _before _you see the client. You may set up an initial appointment by telephone. Whether you do this yourself or a receptionist makes the call, be aware that therapy relationships begin with initial contact. The phone call, the paperwork, and the clarity and warmth with which clients are greeted can put them at ease or confuse and intimidate. There are several important parts to doing this successfully.

First, scheduling the initial appointment should be a collaborative activity - hopefully the first of many - between interviewer and client. This activity begins the working alliance.
Second, the interviewer should clearly identify themself, their status (i.e. clinical psychologist), and their place of employment.
Third, the interviewer should check to make sure the client knows how to get to the interview location. Even though many clients will obtain a map to your location via the internet, you should still prepare clear directions before making the call.
Fourth and finally, the interviewer closes by repeating the appointment time and noting that she is looking forward to meeting the client. She also clarifies exactly what the client should do when arriving at the centre (i.e., check in with the receptionist)

Initial Face-to-Face Meeting

Privacy is important to consider when first meeting clients. It's more difficult to keep a client's identity anonymous in public settings than for single clinicians in private practice. Therefore, it is incumbent on interviewers who work in relatively public settings to consider how to best respect client privacy. One option is to have the receptionist point out or describe a new client so you can walk up and say the client's name in a quiet, friendly voice, not easily overheard by others in a room and introduce yourself. In such a scenario, you can quickly assess whether the client might welcome a handshake; if so, offer a hand and simply say, "Come back this way," and lead the client to the private consulting office.

Many issues are associated with first impressions. You need to be aware of how much hinges on first impressions and how much information you gain by being especially observant of your client's behaviour during the first few moments of your meeting. Some clients will be nervous, although others may be eager to meet you, angry, or nonchalant. Assuming your new client is nervous, you have an excellent opportunity to observe how he or she expresses nervousness. Is he or she quiet or loud, clinging to a coffee cup, chewing his or her nails or lip, excessively formal, informal, talkative, withdrawn, pale, or flushed? The first meeting may give you a sense of how your client deals with anxiety and stress.

As you observe your client's behaviour, your client is simultaneously sizing you up and the situation. To increase the consistency of client perceptions, some professionals always follow an introductory ritual that includes all or some of the following:

Shaking hands.
Offering something to drink.
Chatting about a neutral topic while walking to the private interviewing room.

A standard greeting ritual can be comforting and frees you to be more observant. Standardisation strengthens your ability to make inferences from your observations. You can design your greeting ritual to reflect a warm, welcoming, professional image. Not every interviewer uses a standardized ritual, however. Many interviewers never establish an exact routine; they like to size up clients individually and offer whatever seems called for. Lazarus (1996) has referred to this as being an authentic chameleon.

Some beginning interviewers are put off by the fact that standardisation and routine are part of the interviewing process. After all, we're dealing with unique individuals, and shouldn't we give each one a unique and human response? Well, yes and no. No, it is not necessary to give each client a unique or different response just for the sake of avoiding routine. And yes, we should give each client a human response. For example, we usually begin first sessions with clients with a description of confidentiality and a comment on how initial interviews are sometimes uncomfortable because they involve two strangers getting to know each other. Although this is part of a standardised introduction, we sincerely mean what we're saying every time; we genuinely want each client to understand the concept of confidentiality and its limits. Just because we say the same statement to hundreds of clients doesn't mean we're operating on auto-pilot.

Establishing Rapport

_Rapport _is a generic relationship variable. Interviewers of all theoretical orientations acknowledge the importance of having a positive rapport with clients. Positive rapport is defined as having an especially harmonious connection. Positive rapport is defined as having an especially harmonious connection. Effective interviewers take specific steps to establish rapport with clients. Many technical responses already discussed are associated with developing rapport (e.g., paraphrase, reflection of feeling, and feeling validation). When working interculturally or with young clients, rapport building may be especially dependent upon acceptance of diverse communication styles, language use, and personal values. The following factors contribute to positive rapport:

Having Sensitivity to Common Client Fears

Clients have many fears and doubts about going to therapy. Obviously, it's impossible to address every client fear and doubt during an initial session; establishing the rapport necessary to make clients comfortable is a complex and ongoing process. On the other hand, you need to get started with rapport building immediately and being aware of common client concerns and doubts will help with that process. Clients often enter therapy with some of the following concerns:

Is this therapist competent?
More importantly, can this person help me?
Will this therapist understand me, my culture, my values, my religion, and my problems?
Am I going crazy?
What will this therapist think of me?
Can I trust this person to be honest with me?
Will I be pressured to say things I don't want to say?
Will this interviewer think I'm a bad person?

Basically, all professional interviewers are perceived by clients as authority figures. Believe it or not, both power and authority reside in the mental health professional role. Clients may believe they should act in a manner similar to the way they act around other authority figures, such as physicians and teachers. In addition, they may expect you to behave as previous authority figures in their lives have behaved. This can range from warm, caring, wise, and helpful to harsh, cold, and rejecting. Because clients come into counselling with both conscious and unconscious assumptions about authority figures, you may need to help your client view you as a partner in the therapeutic process. Consequently, it may be helpful to say something very clear, straightforward, and informative about the developing collaborative partnership between you and your client early on during your initial meeting. E.g. "I'm looking forward to working together today", or "Since we're both strangers, sometimes counselling can feel awkward at first, but hopefully we'll be able to start getting comfortable together today."

In addition to statements implying partnership, it's also important to provide support and reassurance to clients. However, you should be careful regarding the type of reassurance you offer - not generic (e.g., "everything will be okay) but used in a way that facilitates the client's sense of universality. It's also important to refrain from reassurance unless or until you see or hear evidence that reassurance might be appropriate. Examples of appropriate reassurance include: "Lots of people who come for counselling feel uncomfortable at first, but it usually gets more comfortable as we get to know each other."

Putting the Client at Ease

After explaining confidentiality, you may wish to use a statement similar to the following:

"Counselling is a unique situation. We're strangers - I don't know you, and you don't know me. So this first meeting is a chance for us to get to know each other better. My goal is to understand whatever's concerning you. Sometimes I'll just listen, and other times I'll ask you some questions. This first session is also a chance for you to see how I work with people in counselling and whether that feels comfortable to you. If you have questions at any time, feel free to ask them."

This sort of introduction, stated in your own words, is crucial for helping put clients at ease.It acknowledges the fact that interviewers and clients are initially strangers and gives the client permission to evaluate you and ask questions about therapy.

Conversation and Small Talk

Conversation and initial informal chatting are common methods to help put clients at ease. These efforts may involve the following:

"You must be Steven Green" (initial greeting)
"Do you like to be called Steven, Steve, or Mr Green?" (clarifying how the client would like to be addressed, or how to correctly pronounce his name)
"Were you able to find the place okay?" (small talk and empathic concern)
(with children or adolescents) "I see you've got a Los Angeles Lakers hat on. You must be a Lakers fan." (small talk; an attempt to connect with the client's world)

Educating Clients and Evaluating Their Expectations

Another introductory phase involves client education and an evaluation of client expectations. The purpose of this task is to set the interview frame or boundaries. At this point, we sometimes say to clients something like:

"Before we officially get started, we've got some housekeeping [or whatever word works for you and your clients] to take care of."

This housekeeping includes the following:

Confidentiality
Informing the client of the purpose of the interview. A general statement regarding the interview's purpose helps put clients at ease by clarifying their expectations about what will happen during the session. It can also help clarify the roles that client and interviewer are expected to take during the interview. An example (when working with youths who might not want to be sitting there talking to a mental health professional) might be:

"Before we start, let me tell you what I've been told about you and why you're here. Mr Pepion asked me to meet with you because he said you have a history of depression and he wanted me to check in with you on how you're doing in your adjustment here. So, I'm going to spend some time getting to know you a bit and then I'll ask you some questions about depression and other stuff. Also, just so you know, I see my job as helping you be successful here. You're not in any trouble. I meet with lots of students. And my job is always to help students adjust to life here at the Job Corps and to help you be successful here and in your life. Even though I'll be asking you some questions today, I hope you'll also feel free to ask me whatever you want to ask."

The third issue concerning client education is time. Early in the interview clients should be informed or reminded of the session's length.

Checklist for Introduction Phase:

Schedule a mutually agreed upon meeting time.
Introduce yourself.
Identify how the client likes to be addressed.
Engage in conversation or small talk.
Direct client to an appropriate seat (or let the client choose).
Present your credential or status (as appropriate).
Explain confidentiality.
Explain the purpose of the interview.
Check client expectations of interview for similarity to and compatibility with your purpose.
Clarify time limits as needed.

The Opening

The opening begins with an interviewer's first questions about the client's current concerns and ends when the interviewer begins determining the interview's focus by asking specific questions about specific topics. In Shea's (1998) model, the opening is a nondirective interview phase lasting about five to eight minutes. During this phase, the interviewer uses basic attending skills and nondirective listening responses to encourage client disclosure. The main interviewer task is to stay out of the way so clients can tell their story. It is useful to apply an attitude of scientific mindedness during this phase: forming tentative hypotheses about the client, and then, throughout initial and subsequent contacts, maintaining an open mind about the client and his/her culture, personality style, problems, and so on. Being willing to modify old hypotheses and, if necessary, disregard them.

The Interviewer's Opening Statement

The opening statement signals to the client that small talk, introductions, and explanations of confidentiality are over and it's time for the interview to begin. An opening statement consists of the interviewer's first direct inquiry into what brought the client to seek professional assistance. The statement can usually be delivered in a calm, easy manner, so it doesn't feel like an interruption in the flow. However, occasionally, you will need to assertively cut in to officially start the interview. Most counsellors and psychotherapists develop a comfortable opening statement. A common prototype is: "Tell me what brings you to counselling (or therapy) at this time." Other popular opening statements include the following:

"What brings you here?"
"How can I be of help?"
"Maybe you could begin by telling me things about yourself, or your situation, that you believe are important."
"So, how's it been going?"
"What are some of the stresses you have been coping with recently?"

The Client's Opening Response

After your opening statement, the spotlight is on the client. Will he or she take your opening statement and run with it, or hesitate, struggle for the right words, and perhaps ask for more direction or structure? As noted, some clients come to a professional interviewer expecting authoritative guidance; therefore, they may be surprised by an open question. Usually, their first response gives you clues about how they respond to less structured situations. Some clinicians consider this initial behaviour crucial in understanding the client's personality dynamics.

Rehearsed Client Responses

Clients may begin in a way suggesting they've rehearsed for this part of the interview. For example, we've heard clients begin with: "Well, let me begin with my childhood", "currently, my symptoms include", "There are three things going on in my life right now that I'm having difficulty with", "I'm depressed about..."

There are advantages and disadvantages to working with clients in a straightforward and organised manner. The primary advantages are that these clients have thought about their personal problems and are trying to get to the point as quickly as possible. If they are relatively insightful and have a good grasp of why they want professional assistance, then you are at an advantage; the interview should proceed smoothly. On the other hand, sometimes client openings characterised by too much directness and organisation may indicate the beginning of what Shea (1998) refers to as a "rehearsed interview" (p. 76). In such cases, clients may be providing stock interview responses out of defensiveness. They may give factual and informative, but emotionally distant accounts of their problems. Emotional distance may, in fact, be a major part of the problem (e.g., the client could have trouble being emotionally connected in close relationships). A very organised and direct opening response sometimes reflects general discomfort with unstructured situations; clients may be reacting to an unstructured opening statement by providing excessive structure and organisation.

Helping Clients Who Struggle To Express Themselves

Some clients struggle because an opening statement did not provide clear enough directions and they don't know how to proceed. For example, imagine your client falls silent, looks at you with a pained expression, and asks, "So what am I supposed to talk about?" or "I don't know what you want me to say." If you're faced with clients who appear uncomfortable with an unstructured opening, try the following sequence:

Assume a kind and attentive posture, but allow them to struggle for a few moments (while you evaluate their coping methods).
Provide emotional support regarding the difficulty of the task.
Provide additional structure.

Letting clients struggle with an unstructured opening provides an opportunity to assess general expressive abilities. If a client responds to your opening by asking, "What should I talk about?" respond warmly with "Whatever you'd like." This places the responsibility for identifying the appropriate place to start back on the client and provides an excellent test of the client's expressive skills. In essence, you're learning how much help the client needs to express himself or herself.

Another reason it's important to let clients struggle with an unstructured opening is that it allows them an opportunity to overcome their faltering start and recover by adequately identifying a place to begin their communications with you. If you assist too soon, you do not allow them to demonstrate their ability to recover and express themselves. Perhaps the client prefers to reply on others to ask questions, but is perfectly capable of choosing what is important to talk about.

If your client falters a second time or seems to really need your help to get started, go ahead and offer support and more structure: "Sometimes it's difficult to know what to say first. How about if you start by talking a bit about how things have been going at home (or work or school)?" This interviewer statement provides structure and simplifies the demand placed on the client.

Other Client Responses to the Interviewer's Opening Statement

Some clients begin interviews in odd ways that give you concerns about their current functioning. For example, imagine the following client statements:

"I have come because the others told me to come. You will be my witness."
""You're the doc, you tell me what's wrong with me."
"It's by the grace of God (or Allah) that I'm sitting before you right now. May I pray before we begin?"
"I have this deep ache inside of me. It comes over me sometimes like a wave. It's not like I have been a wellspring of virtue and propriety, but then really ... I ask myself constantly, do I deserve this?"

Evaluating or judging client functioning is a difficult and demanding task requiring good clinical judgment. We discuss evaluation procedures in more detail later in this chapter.

Ideal client responses to your opening statement usually reflect thoughtfulness and the initiation of a working alliance. For example: "I'm not totally sure of all the reasons I'm here or why I chose to come right now. I've been pretty overwhelmed with stress at work lately, and it's affecting my family life. I guess I'll start by telling you about work and family and as I go along maybe you can tell me if I'm talking about the things you need to know about me."

Evaluating Client Verbal Behaviour During the Opening

As clients proceed during the opening phase of the interview, you should evaluate their approach and begin modifying your responses accordingly. For instance, with clients who are very verbal and tend to ramble, you need to be ready to interject yourself into the interview whenever you get the chance. You might consider using more closed questions in an effort to direct an overly verbal client. Similarly, you will get information about the client's frame of reference, whether they tend to think their problems are the result of internal or external factors - i.e., whether they have an _internalising _or an _externalising _style. Realistically, client problems usually stem from a combination of personal (internal) and situational (external) factors. It's useful, especially during the opening phase, to listen for whether your clients are taking too much or too little responsibility for their problems.

It takes more than one piece of evidence to conclude - even tentatively - something about a client from a brief opening statement. Recall again the concept of scientific mindedness. Opening responses provide you with an initial glimpse of how clients perceive themselves and their problems. As you consider your clients' openings, ask yourself the following questions:

Does the client express himself or herself in a direct and coherent manner?
Is the opening response overly structured, organised, and perhaps rehearsed?
Does the client struggle excessively with lack of structure?
If the client does struggle with lack of structure, what is the nature of the struggle (e.g., Does he or she ask you directly for more structure, become angry or scared in the face of low structure, digress into a disordered or confusing communication style)?
Is the client's speech characterised by oddities?
Does the client's response focus on external factors (other people or situations causing distress) or internal factors (ways the client may have contributed to his or her own distress)?
Does the client seem especially oriented toward a particular cultural group or to have very specific and strong religious beliefs?

Checklist for Opening Phase:

Continue working on rapport (nondirective listening).
Focus on client's view of life and problems (open-ended questioning, gentle prompting).
Provide structure and support if necessary (feeling reflections, clarify purpose of opening phase, narrow the focus of opening question).
Help client adopt an internal, rather than external frame of reference if culturally appropriate (nondirective listening, therapeutic questioning).
Evaluate how the interview is proceeding and think about what approaches might be most effective during the body phase. (Paraphrasing, summarisation, role induction, therapeutic questioning)

The Body

The body of an initial or assessment interview primarily involves information gathering. The quality and quantity of information gathered depends almost entirely on the interview's purpose. Most typically, the purpose of a clinical interview is, at least in part, to determine a client's clinical diagnosis and formulate a treatment plan. The body is the heart of the interview. As an interview, you must obtain certain information to formulate the case and make recommendations. Your ears are tuned to pick up information, and you use nondirective and directive responses discussed in earlier chapters to encourage your client to elaborate more fully in some areas than others.

Sources of Clinical Judgment: Making Inferences

During the body phase, the interviewer gathers information to make professional inferences about the client. Depending on the interviewer's purpose, the inferences will relate to some of the following:

The client's personality style, acculturation, or stress level.
Recommendations on whether therapy is needed.
Recommendations regarding the most appropriate therapy approach.
The client's mental status and/or psychiatric diagnosis.
Estimates of client intellectual or cognitive functioning.
Parenting ability, attitudes, and adequacy.
Suicide or violence potential.
Addictions, past criminal behaviour, past employment, and relationship and educational experiences.

Making statements, recommendations, estimates, or predictions based on a single clinical interview is risky. Describing, explaining, and especially predicting human behaviour is a challenging task, often fraught with error. Nonetheless, after conducting an assessment-oriented interview, you may be expected to make some tentative statements or definitive decisions about your client. The next section will help you become more capable of making accurate clinical inferences about client functioning.

Defining Psychological and Emotional Disorders

All interviewers must distinguish normal and healthy emotional or psychological functioning from disturbed or disordered functioning. What follows are general standards for determining whether a client might be experiencing a psychological disorder. These are not diagnostic criteria. Instead, they are guidelines to aid your clinical judgment and thinking about normal and abnormal behaviour.

Statistical Infrequency

One way of defining abnormality or psychopathology is through statistical infrequency. Obviously, all statistically infrequent behaviour does not indicate a mental disorder. Statistically infrequent behaviour should be further examined for the following conditions.

Disturbing to Self or Others

It is difficult for evaluators to predict what behaviours will produce personal distress in particular individuals. Therefore, interviewers should ask clients directly whether they are bothered by their own behaviours. Mental disorders may also be characterised by the fact that they consist of behaviours that disturb or bother others. Therefore, when evaluating clients, it can be helpful to ask if anyone in their immediate environment is especially bothered by their behaviour.

Maladaptive Behaviours

A key characteristic of mental or behavioural disorder is the tendency for an individual to repeatedly engage in self-defeating behaviour, hold self-defeating beliefs, or experience negative emotions. Although these repeating thoughts, feelings, or actions may serve some function in the person's life, for the most part, the patterns are dysfunctional or maladaptive. By definition, a behaviour is maladaptive when it interferes with effective occupational, social, physical, or recreational functioning.

Rationally or Culturally Unjustifiable

If a client's behaviour, thought, or feelings appears unusual or maladaptive, you should ascertain whether there is any reasonable excuse or justification for it. Take the case of a client who claimed that because his wife was unable to determine when she was hungry or sleepy, he saw it as his responsibility to force her to eat or sleep when he judged it necessary to do so. In this scenario, are there any rational justifications that a man might have for forcing his spouse to eat or sleep? In such a case, it is appropriate to focus on whether the spouse is capable of caring for herself. We asked several questions: How old is she? Is she able to work or perform other functions effectively? Does she have Alzheimer's or another brain disease or dysfunction? The client could be asked to describe why he thought his wife was unable to determine appropriate times to eat and sleep. In this case, it was obvious after conducting a thorough interview that the client was behaving in an unusual and disturbing manner. His behaviour was rationally unjustifiable, statistically infrequent, disturbing (to his wife), and maladaptive (the repeating pattern had contributed to a marital crisis).

Now we are left with a final question regarding the justifiability of the man's behaviour. Namely, is his behaviour culturally justified or sanctioned? Think about this standard. Can you think of any cultural situations that might adequately justify this man's rather controlling behaviours?

Clinical Interviewing