DIAGNOSTIC INTERVIEW

CONTENTS
 Intake
 Clinical Interview and Case history
 Essential elements of clinical interview
Rapport and Basic interviewing techniques
 Mental Status Examination
 Case history report writing format
DIAGNOSTIC DATA COLLECTION TOOLS

 INTAKE
 CLINICAL INTERVIEW/ CASE HISTORY
 MENTAL STATUS EXAMINATION
 OBSERVATION/INFORMAL ASSESSMENT
 FORMAL ASSESSMENT - TESTING
 EXAMINATION OF LIFE RECORDS
 INTEGRATION OF ALL INFORMATION
 INTAKE INTERVIEW

Intake is the first formal interaction between a

client and a mental health professional in a
clinical, educational or organizational
setting.
CONT.

 Intake is brief

 Purpose:to determine the nature of the client’s

problems; presenting complaints

 Theclinician can decide if he/she can offer his/her

services.

 Theclient can find out about the psychologist’s fees,

procedures and policies.
INTAKE
 CLINICAL INTERVIEW/ CASE HISTORY
 The purpose of a clinical interview is to obtain the client’s case history; a detailed
description of a client’s background. The areas generally covered in a clinical
interview include:
 Birth and development
 Family of origin
 Education
 Employment
 Recreational and leisure activities
 Sexual history
 Dating and Marital history
 Alcohol and drugs
 Physical health
 CLINICAL INTERVIEW ; INTAKE
 Demographic information
 Name, age, gender, education, occupation, marital status
 Contact details (phone numbers and address)
 Birth order and number of siblings, no of children
 Parent’s/spouse’s education, income, socioeconomic status
 Head of family
 Income group/ Earning members
 Heritage/ Languages
 Appearance
 CLINICAL INTERVIEW; INTAKE

 Referral Information
 Informant’s name, relationship
 Informant’s address/phone
 Referral source (General physician, psychiatrist, school,
employer or any other professional)
 CLINICAL INTERVIEW ; INTAKE

 Presenting problems
 Verbatim

 Entitled/non entitled
 Assigned to: (for assessment/therapy)
 Fee/Payer

 Other information (timings etc)

 CLINICAL INTERVIEW – CASE
HISTORY
 Presenting problems
 Problem(s)
 Nature of problems
 Precipitating events
 Patient’s feelings and thoughts about the problem

 History of Presenting Problem – HO-PC/HOPC

 Duration of present problem
 Changes in nature, intensity or frequency of problem over
time,
 Prodromal manifestations
 Other past problems of a psychological nature and their
frequency.
 CLINICAL INTERVIEW – CASE
HISTORY

 Prior treatment
 Details of treatment sought for presenting problems and
from whom; when and for what duration undergone
treatment

 Nature of treatment methods; names and dosages of

drugs taken
 Psychiatrist, psychologist, homeopathic, ECTs, faith healing etc.

 Response to treatments including adverse reactions or

side effects.
 CLINICAL INTERVIEW – CASE
HISTORY
 Medical History
 Most recent physical exam; date and results

 Current medications

 Health conditions since childhood including details of

serious illnesses/disabilities suffered and surgery
undergone

 Eating and sleeping habits

 Use of stimulants, alcohol and drugs

 CLINICAL INTERVIEW – CASE
HISTORY
 Birth history
 Planned or unplanned birth
 Normal birth, caesarian
 Milestones
 Birth order

 Family history
 Migrations
 Births, marriages in family
 Serious illnesses, deaths,
 Jobs of earning members
 Relationships with family members
 Family dynamics
 Family culture and norms
 CLINICAL INTERVIEW – CASE
HISTORY
 Academic history
 School, college, university,
 Grades, percentages,
 School changes, school problems,
 Relationship with peers and teachers,
 Extra-curricular activities
 Any other significant event

 Work history
 Number of years of working, nature of work
 Full time or part time
 Job changes, reasons for job changes
 Relationships with co-workers; juniors, colleagues and
bosses.
 CLINICAL INTERVIEW – CASE
HISTORY
 History of Friendships/ Social history
 Nature and extent of relationships
 Number of close friends and nature of friendship
 Hobbies, recreational activities, extracurricular
activities and interests
 Degree of religiosity

 Sexual history
 Sexual orientation
 Premarital, marital and extramarital sexual
relationships
 Any other sexual experience(s)
 CLINICAL INTERVIEW – CASE
HISTORY

 History of abuse
 Drugs

 Physical

 Sexual

 Verbal

 Litigation
 CLINICAL INTERVIEW – CASE
HISTORY

Mental Status Examination (MSE)

Essential Elements of Clinical
Interview

Rapport and Basic Interviewing

Techniques/Effective
Communication Strategies
 RAPPORT
 ‘The sense of mutual trust and harmony that characterizes a good
relationship.’

 Rapport involves a comfortable atmosphere and a mutual

understanding of the purpose of the interview

 Rapport simply means a comfortable and warm environment that

serves to motivate examinee and elicit cooperation.

 “It refers to the examiner’s efforts to arouse the test taker’s

interest in the test, elicit their cooperation, and encourage them
to respond in a manner appropriate to the objectives of the test.”

 Conveying acceptance, understanding and respect for the client.

 INFLUENCE OF THE EXAMINER ON
RAPPORT

 Examiner’s sex, experience, race and attitude

 Other factors
 ESTABLISHING RAPPORT
 Good rapport: the client or their family perceives the clinician
as caring, interested, competent and trustworthy

 From the clinician’s side

 Unconditional positive regard: basic acceptance and
support of a person regardless of what the person says or
does.
 Genuineness
 Empathy

 Rapport is a necessary condition for further progress.

 ESTABLISHING RAPPORT AND
INTERVIEWING SKILLS
 How to establish rapport and clinical
interviewing skills?
Planning the interview

Use of verbal communication skills

Use of non-verbal communication or behavior/

Body language

Testing environment
 PLANNING THE INTERVIEW

 Materials

 Environment

 Competency

 Knowing the dos and don'ts

 USE OF COMMUNICATION - VERBAL
 Attentiveness

 Active listening
 Clarification
 Paraphrasing
 Reflection
 Elaboration
 Summarizing

 Conveying empathy
 Paraphrasing
 Reflection of feelings
 USE OF COMMUNICATION – VERBAL
 Showing interest through questioning
 Open-ended questions
 Closed-ended questions

 Purpose of conveying empathy through reflection of

feelings
 Feels understood
 Expresses more feelings
 Manage feelings
 Awareness of one’s own feelings
 Discriminate among various feelings
 USE OF COMMUNICATION – VERBAL

 Active listening
Clarification

Paraphrasing

Reflection

Summarizing

Elaboration
 CLARIFICATION
 Questioning that helps the clinician understand an ambiguous
message and confirms the accuracy of the clinician’s
perspective .

 Purposes of clarification
 To encourage elaboration
 To check accuracy of what you heard
 To clear up vague messages

 Examples
 Are you saying that….
 Could you describe for me….
 By this you mean….
 PARAPHRASING

 Rephrasing the content of the client’s message

OR
 Describing the content, thoughts of the client’s message

 Purposes
 Conveys that you are listening to the client
 Conveys that you are understanding him/her
 Provides an opportunity for client to clarify
 Encourages the client to say more about a topic
 Provides an opportunity to redirect client to the central
topic
 PARAPHRASING
 Example

 Client: School has always been really difficult for me. I

really have to work hard to do well. My grades have
always been good but it has not been easy. Not like my
sister. Amna has always just waltzed right through
school. She just reads a chapter once and its all there for
her when test time comes.
 Therapist: So while you have done well at school,
you’ve had to work very hard.
 REFLECTION
 Describing the feelings of the client’s message

 Purpose
 To convey empathy; that you understand how he/she is
feeling
 To encourage the client to express more of his feelings
 To have the client experience feelings more intensely and
freely – catharsis
 To help the client become more aware of his/her feelings
 To help the client discriminate among feelings
 REFLECTION

 Client: “So many things are going on right now. Another

hectic semester has started. My brother is sick, my mom’s
ill too. I find myself running around trying to take care of
everything. I am not sure I cant take it anymore.”

 Clinician: “You’re feeling pretty overwhelmed by all the

things that are going on right now.”
 REFLECTION
 Client:
Since I have had the baby, my husband is
always busy at work and I have to do everything
by myself and it is hard to keep up.

 Therapist:
You are feeling overwhelmed by
becoming a new mother?
 PARAPHRASING AND REFLECTION
 Client: everything is humdrum. There is nothing new
going on, nothing exciting. All my friends are away. I
wish I had money to do something different

 Paraphrase: With your friends gone and no money

around, there is nothing for you to do right now.

 Reflection: You feel bored with the way things are for
you right now
 SUMMARIZING
 Two or more paraphrases or reflections that condense
the client’s message or the session.
 Covers a longer period of client’s discussion

 Purposes
 To tie together multiple elements of client’s message
 To identify a common theme or pattern
 To interrupt excessive rambling
 To start a session
 To end a session
 To review progress
 To serve as a transition when changing topics.
 USE OF COMMUNICATION – VERBAL
 Open-ended questions
 Questions that clients cannot
easily answer with ‘yes’, ‘no’
or ‘one-word’ responses.
 Purposes
 To begin an interview
 To encourage client
elaboration
 To elicit information or
specific examples
 To motivate clients to
communicate
 Closed-ended questions
 Questions that a client can easily
answer with a ‘yes’, ‘no’ or ‘one-
word’ response
 Purposes
 To obtain specific
information
 To identify parameters of a
problem (rating)
 To narrow the topic of
discussion
 To interrupt an over
talkative client
 USE OF COMMUNICATION – VERBAL
 Open-ended questions
 How do you feel?
 What do you think you might do
if the test results are positive?
 Tell me about your relationship
with your husband?
 Closed-ended questions
 Are you scared?
 Are you concerned about what you
will do if the test results are
positive?
 Is your relationship with your
husband a good one?
 USE OF COMMUNICATION – VERBAL
 What do you think of the movie?

 Do you have a good relationship with your parents?

 Did you like the movie?

 How would you describe your relationship with your

parents?
 RAPPORT BUILDING – DON'TS
 Lack of interest or not attending
 Sarcasm
 Lecturing
 Interrupting
 Commands
 Criticism
 ‘Why’ questions
 Judgmental statements
 Should statements
 No eye contact
BODY LANGUAGE/ NON-VERBAL BEHAVIOR

 SOLERF method

 S: Squarely face the person

 O: Use open posture vs closed arms and legs

 L: Lean a little forward (towards) the person vs sitting back in

your chair
 E: Use eye contact vs staring off into deep space

 R: Relax, keep it natural vs sitting like a board

 F: Look friendly vs neutral or scowling

BODY LANGUAGE/ NON-VERBAL BEHAVIOR
 Positive behaviors  Negative behaviors
 Good eye contact  Avoiding eye contact, staring

 Body posture – leaning or looking away

towards the client  Posture: laid back

 Interested, natural voice  Interrupting often

 Not engaging in  Looking at watch, chewing

distracting gestures gum, using cell phone,
 Taking minimal notes running hands through your
while continuing to make hair etc
frequent eye contact  Taking excessive notes and
seldom looking at the client.
 TESTING ENVIRONMENT
 Testing room

 Room should be free from undue noise and distraction

 Adequate lighting, ventilation, seating facilities and

 Working space for examiner and test taker should be

provided