10 Clinical Interviewing
JOHN SOMMERS-FLANAGAN, VERONICA I. JOHNSON, AND MAEGAN RIDES AT THE DOOR
The clinical interview is a fundamental assessment and
intervention procedure that mental and behavioral health
professionals learn and apply throughout their careers.
Psychotherapists across all theoretical orientations, pro-
fessional disciplines, and treatment settings employ differ-
ent interviewing skills, including, but not limited to,
nondirective listening, questioning, confrontation, inter-
pretation, immediacy, and psychoeducation. As a process,
the clinical interview functions as an assessment (e.g.,
neuropsychological or forensic examinations) or signals
the initiation of counseling or psychotherapy. Either way,
clinical interviewing involves formal or informal
assessment.
Clinical interviewing is dynamic and flexible; every inter-
view is a unique interpersonal interaction, with interviewers
integrating cultural awareness, knowledge, and skills, as
needed. It is difficult to imagine how clinicians could begin
treatment without an initial clinical interview. In fact, clin-
icians who do not have competence in using clinical inter-
viewing as a means to initiate and inform treatment would
likely be considered unethical (Welfel, 2016).
Clinical interviewing has been defined as
a complex and multidimensional interpersonal process that
occurs between a professional service provider and client [or
patient]. The primary goals are (1) assessment and (2) help-
ing. To achieve these goals, individual clinicians may empha-
size structured diagnostic questioning, spontaneous and
collaborative talking and listening, or both. Clinicians use
information obtained in an initial clinical interview to develop
a [therapeutic relationship], case formulation, and treatment
plan. (Sommers-Flanagan & Sommers-Flanagan, 2017, p. 6)
Given their breadth and multidisciplinary nature, clin-
ical interviews have one or more of the following goals and
objectives:
1. initiate and develop a therapeutic relationship
2. provide a role induction or orientation to therapy
3. acquire assessment and diagnostic information
4. formulate a case conceptualization and treatment
plan
5. implement a psychological or educational intervention
(adapted from Sommers-Flanagan, 2016).
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Tackling and managing all or some of these goals and
objectives during a limited time frame is no small feat,
even for experienced clinicians. In cases when clinical
interviewing is used solely for assessment purposes, there
is still an art to balancing information gathering with
efforts to develop rapport and solicit client cooperation.
In this chapter, we describe and explore clinical inter-
viewing as foundational to mental health assessment and
intervention. To start, we review the origins and develop-
ment of clinical interviewing, including how interviews
can vary with respect to theoretical orientation, setting,
client problem, and purpose. Subsequently, we present
a generic, atheoretical interviewing model, along with sev-
eral variations for clinicians who are required or inspired
to use the clinical interview as a specific assessment
procedure. We close the chapter with a discussion of lim-
itations, cultural issues, technological advances, and the
future of clinical interviewing.
THE CLINICAL INTERVIEW: ORIGINS,
DIALECTICS, AND INFLUENTIAL FORCES
In the 1920s, Swiss psychologist Jean Piaget first used the
term “semi-clinical interview” to describe an assessment pro-
cess (Elkind, 1964). Piaget’s efforts to understand how chil-
dren acquire and understand concepts related to religion and
God led him to blend psychiatric interviewing with standar-
dized mental testing questions. Piaget’s approach was foun-
dational to how contemporary mental health professionals
later came to think about and practice clinical interviewing.
Although the ideas and applications of clinical interviewing
have moved beyond Piaget’s original strategies, many of the
core attitudes required to conduct successful clinical inter-
views remain the same (e.g., “a liking for [clients], a respect
for their individuality, and patience”; Elkind, 1964, p. 41).
Piaget’s purpose was primarily assessment (i.e., informa-
tion gathering). More recently, postmodern theorists and
psychotherapists have emphasized that initial interviews
are therapeutic. Specifically, during interviews, clinicians
are viewed as not just “taking [a] history” but also “making
history” (Hoyt, 2000, p. 3). Hoyt’s description speaks to the
therapeutic component of clinical interviewing.
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An Interviewing Dialectic
Clinical interviewing’s flexibility includes a dialectic in
purpose and process. On the one hand, many researchers
view clinical interviews primarily as a means for gathering
objective, quantifiable data. In contrast, practitioners
value clinical interviews as a relational process that facil-
itates client and clinician collaboration. Despite polariza-
tion regarding the true purpose and process of clinical
interviews, interviews can and should integrate both scien-
tific and relational components (Sommers-Flanagan &
Sommers-Flanagan, 2017). Overall, clinical interviewing
exists within a large tent; it encompasses the richness of
witnessing and empathically resonating with human
experiences; it also involves collecting reliable and valid
assessment data.
Factors That Influence and Drive Clinical Interviews
Clinical interviews look and feel quite different depending
on many factors.
Interview setting and purpose. Interview purpose and
clinical setting are intimately intertwined. For example,
a clinician working at an adoption agency might interview
prospective parents with the singular goal of assessing their
suitability as adoptive parents. In other settings, clinicians
focus on mental status examinations (MSEs), violence
potential, collecting forensic assessment data, or psy-
chotherapy preparation. Interviews conducted in private
practice settings look very different from interviews in inpa-
tient settings or those conducted in outpatient mental health
agency settings. Some settings (e.g., employee assistance
programs) emphasize interventions from first contact.
Client factors. Clinicians should be sensitive to unique cli-
ent characteristics (Sue & Sue, 2016). Clients who present in
crisis will likely benefit from brief and structured clinical
interviews, whereas clients struggling with divorce might
appreciate less structure and more opportunity to talk freely.
Common client factors that influence clinical interviewing
process and content include, but are not limited to, (1) pre-
senting problems or goals, (2) preferences about therapy, (3)
religious or spiritual identity, (4) coping style, (5) expecta-
tions, (6) culture, and (7) client resources (Norcross &
Lambert, 2011). Identifying and addressing these character-
istics can determine whether or not clients return to psy-
chotherapy following an initial session (Sue & Sue, 2016).
Clinician factors. Several clinician factors drive the inter-
view. At minimum, these include professional discipline,
theoretical orientation, and clinician skills.
Clinicians from psychiatry, psychology, social work, and
professional counseling use interviews for overlapping pur-
poses. However, each discipline also has a primary empha-
sis. Specifically, psychiatrists and psychologists tend to use
interviews for assessment, including psychiatric diagnosis,
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MSE, psychological or psychiatric evaluations, and treat-
ment planning. Social workers typically focus more on
psychosocial history, family history, and systemic or cul-
tural issues. In contrast, professional counselors orient
toward relationship development, collaborative engage-
ment, and client wellness or strengths.
Clinician theoretical orientation and skills also influ-
ence how professionals conduct interviews. An Adlerian
therapist is likely to conduct a family constellation inter-
view during a first session. Family systems therapists
might engage clients in a similar process but call it
a genogram assessment. Clinicians with a behavioral
orientation conduct in-session or in vivo functional beha-
vioral assessments; their focus would be on defining spe-
cific problem behaviors and identifying behavioral
antecedents and consequences. These theory-based inter-
view approaches contribute to case formulation and treat-
ment planning.
Structured, semi-structured, and unstructured interviews.
Clinical interviews also vary based on time and structure.
The most prescriptive clinical interview is the structured
interview. Structured interviews follow a predetermined
question list. Nearly all structured interviews are psycho-
diagnostic interviews; clinicians gather symptom-related
information with diagnostic formulation or behavioral
prediction as their ultimate goal. In contrast, unstructured
interviews allow clients to talk freely while clinicians
respond with reflections, summaries, and open questions.
Semi-structured interviews, a middle ground of sorts, pro-
vide clinicians with structure and focus while retaining
flexibility to explore content areas that emerge organically.
A GENERIC CLINICAL INTERVIEWING MODEL
All clinical interviews follow a common process or outline.
Shea (1998) offered a generic or atheoretical model, includ-
ing five stages: (1) introduction, (2) opening, (3) body,
(4) closing, and (5) termination. Each stage includes speci-
fic relational and technical tasks.
Introduction
The introduction stage begins at first contact. An introduc-
tion can occur via telephone, online, or when prospective
clients read information about their therapist (e.g., online
descriptions, informed consents). Client expectations, role
induction, first impressions, and initial rapport-building
are central issues and activities.
First impressions, whether developed through informed
consent paperwork or initial greetings, can exert powerful
influences on interview process and clinical outcomes.
Mental health professionals who engage clients in ways
that are respectful and culturally sensitive are likely to
facilitate trust and collaboration, consequently resulting
in more reliable and valid assessment data (Ganzini et al.,
2013). Technical strategies include authentic opening

statements that invite collaboration. For example, the clin-
ician might say something like, “I’m looking forward to
getting to know you better” and “I hope you’ll feel comfor-
table asking me whatever questions you like as we talk
together today.” Using friendliness and small talk can be
especially important to connecting with diverse clients
(Hays, 2016; Sue & Sue, 2016). The introduction stage
also includes discussions of (1) confidentiality, (2) thera-
pist theoretical orientation, and (3) role induction (e.g.,
“Today I’ll be doing a diagnostic interview with you. That
means I’ll be asking lots of questions. My goal is to better
understand what’s been troubling you.”). The introduction
ends when clinicians shift from paperwork and small talk
to a focused inquiry into the client’s problems or goals.
Opening
The opening provides an initial focus. Most mental health
practitioners begin clinical assessments by asking some-
thing like, “What concerns bring you to counseling today?”
This question guides clients toward describing their pre-
senting problem (i.e., psychiatrists refer to this as the
“chief complaint”). Clinicians should be aware that open-
ing with questions that are more social (e.g., “How are you
today?” or “How was your week?”) prompt clients in ways
that can unintentionally facilitate a less focused and more
rambling opening stage. Similarly, beginning with direct
questioning before establishing rapport and trust can eli-
cit defensiveness and dissembling (Shea, 1998).
Many contemporary therapists prefer opening state-
ments or questions with positive wording. For example,
rather than asking about problems, therapists might ask,
“What are your goals for our meeting today?” For clients
with a diverse or minority identity, cultural adaptations
may be needed to increase client comfort and make certain
that opening questions are culturally appropriate and rele-
vant. When focusing on diagnostic assessment and using
a structured or semi-structured interview protocol, the for-
mal opening statement may be scripted or geared toward
obtaining an overview of potential psychiatric symptoms
(e.g., “Does anyone in your family have a history of mental
health problems?”; Tolin et al., 2018, p. 3).
Body
The interview purpose governs what happens during the
body stage. If the purpose is to collect information pertain-
ing to psychiatric diagnosis, the body includes diagnostic-
focused questions. In contrast, if the purpose is to initiate
psychotherapy, the focus could quickly turn toward the
history of the problem and what specific behaviors, peo-
ple, and experiences (including previous therapy) clients
have found more or less helpful.
When the interview purpose is assessment, the body
stage focuses on information gathering. Clinicians actively
question clients about distressing symptoms, including
their frequency, duration, intensity, and quality. During
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CLINICAL INTERVIEWING 115
structured interviews, specific question protocols are fol-
lowed. These protocols are designed to help clinicians stay
focused and systematically collect reliable and valid
assessment data.
Closing
As the interview progresses, it is the clinician’s responsi-
bility to organize and close the session in ways that assure
there is adequate time to accomplish the primary inter-
view goals. Tasks and activities linked to the closing
include (1) providing support and reassurance for clients,
(2) returning to role induction and client expectations, (3)
summarizing crucial themes and issues, (4) providing an
early case formulation or mental disorder diagnosis, (5)
instilling hope, and, as needed, (6) focusing on future
homework, future sessions, and scheduling (Sommers-
Flanagan & Sommers-Flanagan, 2017).
Termination
Termination involves ending the session and parting ways.
The termination stage requires excellent time management
skills; it also requires intentional sensitivity and responsive-
ness to how clients might react to endings in general or
leaving the therapy office in particular. Dealing with termi-
nation can be challenging. Often, at the end of an initial
session, clinicians will not have enough information to
establish a diagnosis. When diagnostic uncertainty exists,
clinicians may need to continue gathering information
about client symptoms during a second or third session.
Including collateral informants to triangulate diagnostic
information may be useful or necessary. See Chapter 11 of
this volume for more details on collateral reports.
CLINICAL INTERVIEWING AS ASSESSMENT
The clinical interview often involves more assessment and
less intervention. Interviewing assessment protocols or
procedures may not be limited to initial interviews; they
can be woven into longer term assessment or therapy
encounters. Allen Frances (2013), chair of the DSM-IV
task force, recommended that clinicians “be patient,”
because accurate psychiatric diagnosis may take “five min-
utes,” “five hours,” “five months, or even five years” (p. 10).
Four common assessment interviewing procedures are
discussed next: (1) the intake interview, (2) the psycho-
diagnostic interview, (4) MSEs, and (4) suicide assessment
interviewing.
The Intake Interview
The intake interview is perhaps the most ubiquitous clin-
ical interview; it may be referred to as the initial interview,
the first interview, or the psychiatric interview. What fol-
lows is an atheoretical intake interview model, along with
examples of how theoretical models emphasize or ignore
specific interview content.
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Broadly speaking, intake interviews focus on three The Mental Status Examination
assessment areas: (1) presenting problem, (2) psychoso-
The MSE is a semi-structured interview protocol. MSEs
cial history, and (3) current situation and functioning. The
are used to organize, assess, and communicate informa-
manner in which clinicians pursue these goals varies
tion about clients’ current mental state (Sommers-
greatly. Exploring the client’s presenting problem could
Flanagan, 2016; Strub & Black, 1977). To achieve this
involve a structured diagnostic interview, generation and
goal, some clinicians administer a highly structured Mini-
analysis of a problem list, or clients free associating to
Mental State Evaluation (MMSE; Folstein, Folstein, &
their presenting problem. Similarly, the psychosocial his-
McHugh, 1975), while others conduct a relatively unstruc-
tory can be a cursory glimpse at past relationships and
tured assessment interview but then organize their obser-
medical history or a rich and extended examination of
vations into a short mental status report. There are also
the client’s childhood. Gathering information about the
clinicians who, perhaps in the spirit of Piaget’s semi-
client’s current situation and functioning can range from
clinical interviews, combine the best of both worlds by
an informal query about the client’s typical day to a formal
integrating a few structured MSE questions into a less
MSE (Yalom, 2002).
structured interview process (Sommers-Flanagan &
Sommers-Flanagan, 2017).
Psychodiagnostic Interviewing Although the MSE involves collecting data on diagnostic
symptoms, it is not a psychodiagnostic interview. Instead,
The psychodiagnostic interview is a variant of the intake
clinicians collect symptom-related data to communicate
interview. For mental health professionals who embrace
information to colleagues about client mental status.
the medical model, initial interviews are often diagnostic
Sometimes MSEs are conducted daily or hourly. MSEs
interviews. The purpose of a psychodiagnostic interview is
are commonly used within medical settings. Knowledge
to establish a psychiatric diagnosis. In turn, the purpose of
of diagnostic terminology and symptoms is a prerequisite
psychiatric diagnosis is to describe the client’s current
to conducting and reporting on mental status.
condition, prognosis, and guide treatment.
Psychodiagnostic interviewing is controversial. Some
Introducing the MSE. When administering an MSE, an
clinicians view it as essential to treatment planning and
explanation or role induction is needed. A clinician might
positive treatment outcomes (Frances, 2013). Others
state, “In a few minutes, I’ll start a more formal method
view it in ways similar to Carl Rogers (1957), who
of getting . . . to know you. This process involves me asking
famously wrote, “I am forced to the conclusion that . . .
you a variety of interesting questions so that I can understand
diagnostic knowledge is not essential to psychotherapy. It
a little more about how your brain works” (Sommers-
may even be . . . a colossal waste of time” (pp. 102–103). As
Flanagan & Sommers-Flanagan, 2017, pp. 580–581).
with many polarized issues, it can be useful to take
a moderate position, recognizing the potential benefits
Common MSE domains. Depending on setting and clini-
and liabilities of diagnostic interviewing. Benefits include
cian factors, the MSE may focus on neurological responses
standardization, a clear diagnostic focus, and identifica-
or psychiatric symptoms. Nine common domains included
tion of psychiatric conditions to facilitate clinical
in a psychiatric-symptom oriented MSE are
research and treatment (Lilienfeld, Smith, & Watts,
2013). Liabilities include extensive training required,
1. Appearance
substantial time for administration, excess structure
2. Behavior/psychomotor activity
and rigidity that restrain experienced clinicians, and
3. Attitude toward examiner (interviewer)
questionable reliability and validity, especially in real-
4. Affect and mood
world clinical settings (Sommers-Flanagan & Sommers-
5. Speech and thought
Flanagan, 2017).
6. Perceptual disturbances
Clinicians who are pursuing diagnostic information
7. Orientation and consciousness
may integrate structured or semi-structured diagnostic
8. Memory and intelligence
interviews into an intake process. The research literature
9. Reliability, judgment, and insight.
is replete with structured and semi-structured diagnostic
interviews. Clinicians can choose from broad and compre- Given that all assessment processes include error and bias,
hensive protocols (e.g., the Structured Clinical Interview mental status examiners should base their reports on direct
for DSM-5 Disorders – Clinician Version; First et al., 2016) observations and minimize interpretive statements. Special
to questionnaires focusing on a single diagnosis (e.g., care to cross-check conclusive statements is necessary, espe-
Autism Diagnostic Interview – Revised; Zander et al., cially when writing about clients who are members of tradi-
2017). Additionally, some diagnostic interviewing proto- tionally oppressed minority groups (Sommers-Flanagan &
cols are designed for research purposes, while others help Sommers-Flanagan, 2017). Additionally, using multiple
clinicians attain greater diagnostic reliability and validity. assessment data sources (aka triangulation; see “Using mul-
Later in this chapter we focus on psychodiagnostic inter- tiple (collateral) data sources”) is essential in situations
viewing reliability and validity. where patients may have memory problems (e.g.,

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confabulation) or be motivated to over- or underreport
symptoms (Suhr, 2015).
MSE reports. MSE reports are typically limited to one para-
graph or one page. The content of an MSE report focuses
specifically on the previously listed nine domains. Each
domain is addressed directly with at least one statement.
Suicide Assessment Interviewing
The clinical interview is the gold standard for suicide
assessment and intervention (Sommers-Flanagan, 2018).
This statement is true, despite the fact that suicide assess-
ment interviewing is not a particularly reliable or valid
method for predicting death by suicide (Large & Ryan,
2014). The problem is that, although standardized written
assessments exist, they are not a stand-alone means for
predicting or intervening with clients who present with
suicide ideation. In every case, when clients endorse sui-
cide ideation on a standardized questionnaire or scale,
a clinical interview follow-up is essential. Although other
assessment approaches exist, they are only supplementary
to the clinical interview. Key principles for conducting
suicide assessment interviews are summarized below.
Contemporary suicide assessment principles. Historically,
suicide assessment interviewing involved a mental health
professional conducting a systematic suicide risk
assessment. Over the past two decades, this process has
changed considerably. Now, rather than taking an author-
itative stance, mental health professionals seek to estab-
lish an empathic and collaborative relationship with
clients who are suicidal (Jobes, 2016). Also, rather than
assuming that suicide ideation indicates psychopathology
or suicide risk, clinicians frame suicide ideation as
a communication of client distress. Finally, instead of
focusing on risk factors and suicide prediction, mental
health professionals gather information pertaining to
eight superordinate suicide dimensions or drivers and
then work with suicidal clients to address these dimen-
sions through a collaborative and therapeutic safety plan-
ning process (Jobes, 2016). The eight superordinate
suicide dimensions include:
• Unbearable emotional or psychological distress:
Unbearable distress can involve one or many trauma,
loss, or emotionally disturbing experiences.
• Problem-solving impairments: Suicide theory and
empirical evidence both point to ways in which depres-
sive states can reduce client problem-solving abilities.
• Interpersonal disconnection, isolation, or feelings of
being a social burden: Joiner (2005) has posited that
thwarted belongingness and perceiving oneself as
a burden contributes to suicidal conditions.
• Arousal or agitation: Many different physiological states
can increase arousal/agitation and push clients toward
using suicide as a solution to their unbearable distress.
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CLINICAL INTERVIEWING 117
• Hopelessness: Hopelessness is a cognitive variable
linked to suicide risk. It can also contribute to problem-
solving impairments.
• Suicide intent and plan: Although suicide ideation is
a poor predictor of suicide, when ideation is accompa-
nied by an active suicide plan and suicide intent, the
potential of death by suicide is magnified.
• Desensitization to physical pain and thoughts of death:
Fear of death and aversion to physical pain are natural
suicide deterrents; when clients lose their fear of death
or become desensitized to pain, suicide behaviors can
increase.
• Access to firearms: Availability of a lethal means, in gen-
eral, and access to firearms, in particular, substantially
increase suicide risk.
(For additional information on suicide assessment inter-
viewing and the eight suicide dimensions, see Sommers-
Flanagan, 2018; and Chapter 23 in this volume.)
LIMITATIONS, CULTURAL ISSUES,
AND INNOVATIONS
Although clinical interviews are a flexible assessment and
therapy tool, they also have limitations. These limitations
vary depending on the particular approach being
implemented.
Diagnostic Reliability and Validity
The publication of the third edition of the Diagnostic and
Statistical Manual of Mental Disorders (DSM-III; American
Psychiatric Association, 1980) was greeted with high praise
from the psychiatric-medical community. Previous ver-
sions of the DSM adhered to a psychoanalytic model and
had vague symptom criteria sets. Advocates for psychiatric
diagnosis emphasized that DSM-III’s improved specificity
and atheoretical model approach had solved previous pro-
blems with diagnostic reliability. Later, with the publica-
tion of the DSM-III-R (American Psychiatric Association,
1994), structured diagnostic interviewing protocols like the
Structured Clinical Interview for DSM-III-R (then the SCID-
III-R, now the SCID-5; First et al., 2016) were praised as
greatly improving clinician inter-rater reliability. Currently,
most diagnostic interview protocols or schedules are based
on diagnostic criteria from the DSM-5 (American
Psychiatric Association, 2013).
Despite apparent improvements, inter-rater reliability
for specific diagnostic conditions remains questionable
(Lobbestael, Leurgans, & Arntz, 2011; Salamon et al.,
2018). In 1997, Kutchins and Kirk wrote, “Twenty years
after the reliability problem became the central scientific
focus of DSM, there is still not a single major study showing
that DSM (any version) is routinely used with high reliabil-
ity by regular mental health clinicians . . . The DSM revolu-
tion in reliability has been a revolution in rhetoric, not in
reality” (Kutchins & Kirk, 1997, p. 53).
 118 JOHN SOMMERS-FLANAGAN, VERONICA I. JOHNSON, AND MAEGAN RIDES AT THE DOOR
Over the past twenty years, researchers and reviewers
have described structured diagnostic interviews as demon-
strating “adequate” or “moderate” or “excellent” inter-rater
reliability (Lilienfeld et al., 2013; Lobbestael et al., 2011;
Tolin et al., 2018). Although these claims provide surface
support for diagnostic reliability, a deeper examination
raises questions and doubts. Specifically, studies focusing
on inter-rater reliability utilize highly trained diagnostic
raters. These raters are not clinicians in everyday practice;
consequently, results based on their inter-rater reliability
are unlikely to generalize to real-world clinical practice.
Additionally, the language used to describe and label the
acceptability of kappa coefficients (a reliability measure) is
derived from DSM field trial recommendations. For exam-
ple, following the DSM-5 field trial recommendations, one
study described the kappa coefficient for an attention-
deficit/hyperactivity disorder (ADHD) diagnosis as “very
good.” The label very good was used despite researchers
reporting a confidence interval for the ADHD-related
kappa reliability index as in the range “0.33–0.87” (Tolin
et al., 2018). In this case, using the DSM convention for
labeling kappa coefficients made a coefficient with an R2
(coefficient of determination) ranging as low as R2 = 0.10
sound “very good” (which is clearly misleading). Further,
even highly trained diagnostic interviewers have only mod-
est agreement regarding specific diagnoses; they perform
more acceptably when using the simple categorical criter-
ion of determining the presence or absence of a mental
disorder (Widiger & Edmundson, 2011).
Beyond reliability issues, many practicing clinicians
avoid using structured diagnostic interviews because
they take too much time and are not helpful for establish-
ing therapy relationships. Nevertheless (and this makes
both sides of the argument more complex), if the purpose
of a clinical interview is psychiatric diagnosis, using
a structured diagnostic interviewing protocol based on
the DSM system has significant scientific support, espe-
cially if clinicians are trained to use these protocols. In
fact, diagnostic reliabilities for major mental disorders
(e.g., depression, anxiety) typically have alpha or kappa
coefficients similar to what physicians obtain when diag-
nosing medical disorders (Lilienfeld et al., 2013).
Diagnostic validity is a more difficult issue. There are no
genetic markers or gold standard for determining whether
a specific diagnosis is true or valid. To support diagnostic
validity, researchers often rely on longitudinal studies
focusing on predictive validity. Unfortunately, results
from diagnostic predictive validity studies tend to be
mixed (Edens et al., 2015).
Noncredible or Invalid Client (Self-) Report
Diagnostic clinical interviews rely on clients disclosing truth-
ful or accurate information via self-report. Unfortunately,
client self-report is notoriously suspect (Rogers, 2008;
Sommers-Flanagan & Sommers-Flanagan, 1998; Suhr,
2015). It is not unusual for clients to over- or underreport
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their symptoms, particularly in some contexts where indivi-
duals have a substantial incentive (e.g., a forensic
assessment).
Contemporary researchers and practitioners refer to
inaccurate client responses as noncredible responding
(Suhr & Berry, 2017). As Suhr (2015) summarized, non-
credible responding is a substantial problem for clinical
interviewers; under certain circumstances, “the base rate
for noncredible responding in individuals reporting psy-
chological, physical, and/or cognitive symptoms and con-
cerns is higher than the base rate of most actual
disorders!” (p. 61).
Overreporting symptoms. Clients who exaggerate symp-
toms to obtain external gain are often referred to as mal-
ingering or feigning (Green & Rosenfeld, 2011; Rogers,
2008). Several assessment tools have been designed to
detect malingering. An interview-based example is the
Structured Interview of Reported Symptoms-2 (SIRS-2;
Rogers, Sewell, & Gillard, 2010). The SIRS-2 includes 172
interview items (with thirty-two items repeated to evaluate
for consistency) and takes one to two hours to administer.
The original SIRS was often regarded as the gold standard
for measuring malingering. However, more recently,
researchers have critiqued the SIRS as being susceptible
to misclassifying patients as feigning (Green & Rosenfeld,
2011) and the SIRS-2 has been questioned as possibly hav-
ing less sensitivity and utility than the original SIRS (Green,
Rosenfeld, & Belfi, 2013).
Underreporting symptoms. Research on symptom under-
reporting is generally within the substance use arena
(Bahorik et al., 2014; Hormes, Gerhardstein, & Griffin,
2012). To avoid being viewed as ill, clients with addiction
problems are inclined to underestimate or deny substance
use. Underreporting is also common in settings where full
symptom disclosure could have significant negative con-
sequences or in situations where having mental disorder
symptoms are in violation of social norms (e.g., athletic or
military settings; Kroshus et al., 2015; Vannoy et al., 2017).
There are no published interview protocols designed to
identify underreporting. Often, clinicians feel an urge to
confront clients who appear to be minimizing their pro-
blems. Alternatives to using confrontation are integrated
into the next section.
Strategies for Addressing Noncredible
Responding in a Clinical Interview
Clinical interviewing strategies for dealing with noncred-
ible client responses include (1) developing clinician
awareness, (2) managing countertransference, (3) using
specific questioning or interpersonal strategies, and (4)
using additional or supplementary data sources.
Clinician awareness. Clinician awareness of the potential
for noncredible responding is the foundation for dealing

with this common client response style. Specifically, clin-
icians should be aware that, due to motivational, contex-
tual, and other factors, clients may systematically
overreport, underreport, or misreport their presenting
symptoms, personal history, social-cultural-sexual orienta-
tion, and/or current functioning (i.e., impairment). As Suhr
(2015) wrote, “It might help for the assessor to remember
that inaccuracy of self-report is normal and often adaptive
behavior, even outside of the clinical context” (p. 100).
To avoid decision-making biases, it is recommended
that clinicians adopt a “scientific mindedness” frame dur-
ing assessment interviews (S. Sue, 1998). Scientific mind-
edness was originally described as a means to help
clinicians avoid making premature cultural assumptions.
However, adopting a mentality of intentionally forming
and testing hypotheses about the accuracy of client self-
reports can also help mitigate clinician bias (Shea, 1998).
Managing countertransference. Clinicians can have
countertransference reactions to clients before, during,
or after clients engage in noncredible responding.
Countertransference reactions may, in turn, adversely
affect rapport and relationship development. When this
happens, clinicians may prompt clients to provide non-
credible responses. For example, countertransference or
lack of skills might lead clinicians to stray from an accept-
ing stance and ask a question that includes a judgmental
tone: “You aren’t using substances to help you sleep
are you?” This sort of question can easily stimulate
a noncredible, underreporting response of denial, “No.
I wouldn’t do that.”
Several strategies can be used to manage countertrans-
ference. Most commonly, personal therapy or additional
skills-based training is helpful. For example, motivational
interviewing was designed, in part, to help clinicians move
away from judgmental-confrontational approaches with
substance-using clients. The central philosophy of motiva-
tional interviewing is person-centered, with a strong
emphasis on the “profound acceptance of what the client
brings” (Miller & Rollnick, 2013, p. 16). If countertransfer-
ence reactions occur, rather than engaging in confronta-
tion, clinical interviewers can refocus on adopting an
attitude of profound acceptance. Otherwise, relational rup-
tures and under- or overreporting of symptoms may occur
(Sommers-Flanagan & Sommers-Flanagan, 2017).
Using specific questioning or interpersonal strategies.
Specific clinical skills or strategies can be used to address
underreporting. These skills and strategies include (1)
modeling openness, (2) using normalizing statements,
and (3) phrasing questions to make it easier for clients to
disclose symptoms.
Clinicians who begin sessions with an open and trans-
parent informed consent process and role induction may
be able to mitigate underreporting. Transparency can also
include statements that invite collaboration. Examples
include “I’d like to be helpful, but you know yourself
https://doi.org/10.1017/9781108235433.010 Published online by Cambridge University Press
CLINICAL INTERVIEWING 119
best, and so I’ll need to rely on what you tell me” and
“Please ask me any questions at any time and I’ll do my
best to answer them.”
Normalizing statements are recommended for inter-
viewing potentially suicidal clients. Specifically, it can be
useful to precede direct questions about suicide ideation
with a statement like, “It’s not unusual for people who are
feeling stressed to have thoughts of suicide.” Similar nor-
malizing statements can be used with other symptoms
(e.g., “Lots of college students have difficulty sleeping,
I wonder if that’s the case for you?”).
When interviewing clients with high potential for sub-
stance use, Shea (1998) recommended using a questioning
strategy called gentle assumption. To use gentle assump-
tion, interviewers presume that specific embarrassing or
illegal behaviors are a regular occurrence in the client’s
life. For example, instead of asking, “Do you drink alco-
hol?,” an interviewer might ask, “When was your most
recent drink?”
Using multiple (collateral) data sources. Stand-alone clin-
ical interviews are especially vulnerable to over- or under-
reporting of symptoms. This is particularly true when
situational factors offer external rewards and/or the avoid-
ance of negative consequences for symptom exaggeration
or minimizing. For example, personal injury cases, learn-
ing disability or ADHD evaluations, athletic or military
settings, and assessments conducted for forensic purposes
can motivate clients to present as having more or fewer
symptoms (Sellbom & Hopwood, 2016; Suhr, Cook, &
Morgan, 2017; Sullivan, May, & Galbally, 2007; Vannoy
et al., 2017).
Collateral information is data or information
obtained via a third party. For example, when conduct-
ing child assessments, clinicians commonly conduct
collateral interviews with, or gather information via
questionnaire from, parents or teachers. Collateral
interviews can provide illuminating alternative perspec-
tives. Unfortunately, parents, teachers, and other col-
lateral informants also may have motivational and
memory issues that cause them to provide inaccurate
information. Finding significant discrepancies between
parents, teachers, and child reports is a common occur-
rence (see Chapter 11 in this volume; Sommers-
Flanagan & Sommers-Flanagan, 2017).
Medical, educational, and psychological/psychiatric
records constitute additional sources of collateral assess-
ment information. Unfortunately, clients’ previous
records also are not free from bias or inaccuracy.
Consequently, although gathering collateral information
is recommended for clinicians who are using a clinical
interview for assessment purposes, collateral information
is also susceptible to error. In the end, the best approach
typically involves gathering information from at least
three sources and then triangulating data in an effort to
present a reasonably accurate assessment report (see
Chapter 11, this volume).
 120 JOHN SOMMERS-FLANAGAN, VERONICA I. JOHNSON, AND MAEGAN RIDES AT THE DOOR

Cultural Considerations: Cultural Validity past; it will continue to flex along with various new social
and Cultural Humility and cultural dynamics, including the rise of technology in
the delivery of mental health services.
Cultural validity refers to how well assessment procedures
Technological advancements have affected mental and
address and are sensitive to client-specific cultural per-
behavioral health assessment and treatment in many
spectives (Basterra, Trumbull, & Solano-Flores, 2011).
ways. Some mental health professionals believe that tech-
Client cultural perspectives can include, but are not lim-
nology can improve their ability to acquire information,
ited to, “the sets of values, beliefs, experiences, commu-
support treatment plans, and track client outcomes.
nication patterns, teaching and learning styles, and
Others believe technology detracts from therapeutic rela-
epistemologies inherent in the [clients’] cultural back-
tionship development. Controversies around technology
grounds, and the socioeconomic conditions prevailing in
have been incorporated into professional ethical guide-
their cultural groups” (Solano-Flores & Nelson-Barber,
lines; clinicians should consult their respective ethical
2001, p. 55). If cultural validity is not considered, conclu-
codes when using technology (e.g., American Counseling
sions may be inaccurate and cause client harm.
Association, 2014; APA, 2010).
Clinicians are encouraged to make cultural adaptations
Computer-based assessments sometimes outperform
to address cultural validity. These adaptations may involve
clinician-based assessments (Richman et al., 1999). This
administering assessments in the client’s native language,
is particularly true when clients are expected to reveal
consulting with cultural experts, and using multidimen-
sensitive personal information (e.g., sexual behavior, sui-
sional assessment models (Hays, 2016). Using cultural
cide ideation). Regardless of computer-based assessment
validity checks and balances is especially important
efficiency, therapeutic follow-up requires face-to-face or
when implementing diagnostic assessment and mental
virtual human contact. Integrating technology for data
status protocols (Sommers-Flanagan & Sommers-
gathering and note-taking appears to have no adverse
Flanagan, 2017).
effects on assessment process or the development of ther-
Cultural humility is also linked to successful clinical
apeutic relationships (Wiarda et al., 2014).
interviewing. Clinicians who demonstrate cultural humi-
Online assessment and psychotherapy is growing as
lity go beyond the core multicultural competencies of clin-
a method of mental health service delivery. Proponents
ician self-awareness, culture-specific knowledge, and
include research scientists and medical practitioners who
culturally specific skills. Culturally humble clinicians are
deliver services from a distance, as well as entrepreneurial
defined as (1) other-oriented, (2) seeing clients as experts
independent practitioners seeking to expand their practice
of their cultural experience, and (3) approaching relation-
domain. Technological methods for delivering assessment
ships from a position of respect and curiosity (Hook et al.,
and therapy services include (1) text-only synchronous or
2013). Clients’ perceptions of their clinician’s cultural
asynchronous communication, (2) voice-only synchro-
humility are associated with the development of
nous or asynchronous communication, and (3) video-link
a working alliance and positive therapy outcomes.
synchronous communication. Overall, researchers have
Cultural humility applies to all clinician–client relation-
reported that telephonic and online assessments are
ships. Clinical interviews inherently place clinicians in an
equal to face-to-face assessment interviewing (Sommers-
expert position and can leave clients feeling leery of clin-
Flanagan & Sommers-Flanagan, 2017). Similarly, non–
ician judgments. To collect valid and reliable information,
face-to-face therapy outcomes are similar to face-to-face
clinicians must create environments where clients feel
outcomes, at least for clients who choose non–face-to-face
welcomed, accepted, and valued no matter what informa-
therapeutic modalities (Hanley & Reynolds, 2009).
tion is shared. Adopting a culturally humble stance can
help clinicians communicate respect to clients.
Information gathered in the clinical interview can drive FUTURE DEVELOPMENTS
psychotherapy and should therefore be gathered in
The clinical interview is a time-honored and flexible pro-
a collaborative and culturally sensitive manner. The tricky
cedure that encompasses mental health assessment and
business of clinical interviewing is to integrate relevant
intervention. Given its traditional status and flexibility of
questions with the core conditions of congruence, uncon-
application, it is doubtful that the future of clinical inter-
ditional positive regard, and empathic understanding
viewing process or content will drastically change.
(Rogers, 1957; Suhr, 2015). These core conditions, parti-
However, for the past several decades, clinical and psycho-
cularly empathic understanding, transcend theory, set-
diagnostic interviewing has consistently, albeit slowly,
ting, and client presenting problems.
evolved and expanded its reach. Specifically, practitioners
who adhere to postmodern psychotherapy models have
used language to transform the form and function of tradi-
Technological Advances in Psychotherapy
tional clinical interviews. These transformations can be
and Clinical Interviewing
captured, in part, with the relabeling of the initial clinical
Clinical interviewing procedures shift and change with interview as an initial therapeutic conversation.
time. Clinical interviewing has flexed and changed in the Additionally, but in the opposite direction, substantial

https://doi.org/10.1017/9781108235433.010 Published online by Cambridge University Press


time and energy has been devoted to structuring clinical
interviews as a diagnostic procedure; this has involved
operationalizing and standardizing clinical interviewing
data collection and interpretation, as well as research
focusing on methods for discerning when clients are over-
reporting, underreporting, and/or providing inaccurate
assessment information. Finally, clinical interviews have
simultaneously evolved in a third direction – toward
greater cultural sensitivity, relevance, and validity. No
doubt, these past developments will continue forward
but the course and trajectory of clinical interviewing
appears predictable: learning and applying clinical inter-
views for assessment and treatment purposes will remain
central to the role and function of all mental health
professionals.
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