Your first, and perhaps primary, objective is to find out about your client's distress. As an interviewer, your exploration of a client's chief complaint begins with your opening statement (e.g., "What brings you here?" or "How can I be of help?"; see Chapter 6). After the opening statement, at least 5 to 15 minutes should be spent tracking the client and trying to understand exactly why he or she has come to see you (Shea, 1998). In some cases, clients clearly identify their reasons for seeking professional assistance; in other cases, perhaps more often, they are vague as to why they are in your office. As clients begin to articulate their problems, nondirective listening responses can be used to facilitate rapport. Then, after an initial impression of primary concerns is obtained, directive information-gathering responses, including questions, should be used more liberally.
Client problems are intimately linked with client goals (Jongsma & Peterson, 1995). Unfortunately, many clients who come to therapy are unable to see past their problems. Consequently, it is the interviewer's task to help clients orient toward goals or solutions early in the counseling process (Bertolino & O'Hanlon, 2002; Murphy, 1997). Remember that behind (or in front of) every client problem is a client goal.
Common problems presented by clients include anxiety, depression, and relationship conflicts. Other problems include eating disorders, alcoholism or drug addiction, social skill deficits, physical or sexual abuse, stress reactions, vocational confusion, and sexual dysfunction. Because of the wide range of symptoms or problems clients present, it is crucial that interviewers have at least a general knowledge of psychopathology and DSM-IV-TR (American Psychiatric Association, 2000). However, every problem has an inherent goal. Therefore, early in the intake, interviewers can help clients reframe their problem statements into goal statements. For example, when clients begin talking about anxiety, interviewers can translate such language into a positive framework:
"I hear you talking about your feelings of nervousness and anxiety. If I understand you correctly, what you're saying is you really want to feel calm and relaxed more often. I guess maybe one of your general goals for therapy might be to feel calm and relaxed more often and to be able to bring on those calm and relaxed feelings yourself. Do I have that right?"
By reframing client problems into goal statements, interviewers help clients feel hopeful and also begin a positive, therapeutic goal-setting process (Selekman, 1993; J. Sommers-Flanagan & Sommers-Flanagan, 1997). Such goal-setting reframes can also provide useful assessment information regarding the client's openness, or resistance, to actually setting realistic goals for therapy.
Prioritizing and Selecting Client Problems and Goals
Often, we wish clients would come to their intake interview with a single, easily articulated problem and associated goal. For example, it might be nice (though a bit intimidating) if a new client in the first session stated:
"I have a social phobia. You see, when in public, I worry more than the average person about being scrutinized and negatively judged. My anxiety about this is manifest through sweating, constant worry about being inadequate, and avoidance of most, but not all, social situations. What I'd like to do in therapy is build my self-confidence, increase my positive self-talk, and learn to calm myself down when I'm starting to get upset."
Unfortunately, most clients come to their intake interview with either a number of interrelated complaints or with general vague symptoms. They usually use problemtalk (verbal descriptions of what's wrong) to express concerns about their lives. Consequently, after the initial 5 to 15 minutes of an intake interview, it's the interviewer's job to begin establishing a list of primary problems and goals identified by the client. Usually, when an interviewer begins helping a client make a problem/goal list, it signals a transition from general nondirective listening to specific identification and prioritization of emotional and behavioral problems and goals. Transitioning from client free expression to more structured interactions has a dual purpose. First, it allows the interviewer to check for any additional problems that the client has not yet talked about. Second, the transition begins the process of problem prioritization, selection, and goal setting:
Interviewer: "So far, you've talked mostly about how you've been feeling so down lately, how it's so hard for you to get up in the morning, and how most things that are usually fun for you haven't been fun lately. I'm wondering if you have any other major concerns or distress in your life right now." Client: "As a matter of fact, yes, I do. I get awful butterflies. I feel so apprehensive sometimes. Mostly these feelings seem connected to my career . . . or maybe I should say lack of career."
During problem exploration, interviewers help clients identify their problems or concerns. This process is truly exploratory; interviewers listen closely to problems that clients discuss, paraphrase or summarize what problems have been identified, and inquire about the existence of any other significant concerns.
In the preceding exchange, the interviewer used an indirect question to continue exploring for problems. After several problems are identified, the interviewer then moves to problem prioritization or selection. Because all problems cannot be addressed simultaneously, interviewer and client must choose together which problem or problems receive most attention during an intake.
Interviewer: "I guess so far we could summarize your major concerns as your depressed mood, anxiety over your career, and shyness. Which of these would you say is currently most troubling to you?"
Client: "Well, they all bother me, but I guess my mood is worst. When I'm in a really bad mood and don't get out of bed all day, I end up never facing those other problems anyway."
This client has identified depression as his biggest concern. Of course, an alternative formulation of the problem is that social inhibition and anxiety produce the depressed mood and, therefore, should be dealt with first. Otherwise, the client will never get out of bed because of his strong fears and anxieties. However, it's usually (but not always) best to follow client leads and explore their biggest concerns first (psychiatrists refer to what the client considers the main problem as the chief complaint). In this example, all three symptoms may eventually be linked anyway. Exploring depression first still allows the clinician to integrate the anxiety and shyness symptoms into the picture.
Even if you believe an issue different from what the client identifies should be explored (e.g., alcoholism), it's best to wait and listen carefully to what the client thinks is the main problem (chief complaint). Acknowledging, respecting, and empathizing with the client's perspective and helps you be effective, gain trust, and keep the client in counseling. In time-limited circumstances (e.g., managed care), nondirective em-pathic responses arebrief and intermittent. Usually, there must be a quick transition from problems to goal setting (Jongsma & Peterson, 1995), which is reasonable given that goal setting has a positive effect on treatment outcome (Locke, Shaw, Saari, & Latham, 1981; J. Sommers-Flanagan & Sommers-Flanagan, 1996). Nonetheless, we proceed, for now, with a discussion of problem analysis, selection, and prioritization. In Chapter 10, goal setting is discussed more thoroughly—in the context of treatment planning.
Once you've identified a primary problem in collaboration with your client, attention should turn to a thorough analysis of that problem, including emotional, cognitive, and behavioral aspects. Seek answers to a list of questions similar to the following. As you read the questions, think about different client problems (e.g., panic attacks, low self-esteem, unsatisfactory personal relationships, binge eating or drinking, vocational indecision) that you might be exploring through the use of such questions:
1. When did the problem or symptoms first occur? (In some cases, the symptom is one that the client has experienced before. If so, you should explore its origin and more recent development and maintenance.)
2. Where were you and what exactly was happening when you first noticed the problem? (What was the setting, who was there, etc.?)
3. How have you tried to cope with or eliminate this problem?
4. Which efforts have been most effective?
5. Can you identify any situations, people, or events that usually precede your experience of this problem?
6. What exactly happens when the problem or symptoms begin?
7. What thoughts or images go through your mind when it is occurring?
8. Do you have any physical sensations before, during, or afterwards?
9. Where and what do you feel in your body? Describe it as precisely as possible.
10. How frequently do you experience this problem?
11. How long does it usually last?
12. Does the problem affect or interfere with your usual ability to function at work, at home, or at play?
13. In what ways does it interfere with your work, relationships, school, or recreational pursuits?
14. Describe the worst experience you have had with this particular symptom. When the symptom is at its worst, what are your thoughts, images, and feelings then?
15. Have you ever expected the symptom to occur and it did not occur, or it occurred only for a few moments and then disappeared?
16. If you were to rate the severity of your problem, with 1 indicating no distress and 100 indicating so much distress that it's going to cause you to kill yourself or die, how would you rate it today?
17. What rating would you have given your symptom on its worst day ever?
18. What's the lowest rating you would ever have given your symptom? In other words, has it ever been completely absent?
19. As we have discussed your symptom during this interview, have you noticed any changes? (Has it gotten any worse or better as we have focused on it?)
20. If you were to give this symptom and its effects on you a title, like the title of a book or play, what title would you give?
These questions are listed in an order that flows fairly well in many interviews. However, these particular questions and their order are not standard. Before conducting an intake interview, you might want to review a list of questions such as these and then reword them to fit your style. New questions can be added and others deleted until you believe you have a set of questions that meets your particular needs. We encourage you to continually revise your list so that you can become increasingly efficient and sensitive when questioning clients. A varying number of questions can be used during practice intake interviews so you can estimate how many specific questions you can fit reasonably into a single interviewing session.
Sometimes even best-laid plans fail. Clients can be skillful at drawing interviewers off-track. At times, it may be important for interviewers to allow themselves to be drawn off-track because diverging from your planned menu of questions can lead to a different and perhaps more significant area (e.g., reports of sexual or physical abuse or suicidal ideation). Therefore, you may not end up following your planned list of questions and content areas in a rigid manner. Although you should make efforts to stick with your planned task, at the same time, remain flexible so you do not inadvertently overlook important clues clients give about other significant problem areas.
Some authors recommend using organized problem conceptualization systems when analyzing client problems (Cormier & Cormier, 1998; Seay, 1978). Usually, these systems are theory-based, but several systems reflect a more eclectic orientation (Cormier & Cormier, 1998; Lazarus, 1976). Most conceptualization systems guide interviewers by analyzing and conceptualizing problems with strict attention to predetermined, specified domains of functioning.
Lazarus (1976, 1981) developed a "multimodal" behavioral-eclectic approach. He believes problems should be assessed and treated via seven specific modalities or domains. Lazarus (1976) developed the acronym BASIC ID to represent his seven-modality system:
B: Behavior. Specific, concrete behavioral responses are analyzed in Lazarus's system. He particularly attends to behaviors that clients engage in too often or too infrequently. These include positive or negative habits or reactions. A multi-modal-oriented interviewer might ask: "Are there some things you'd like to stop doing?" and "Are there some things you'd like to do more often?" as a way of determining what concrete behaviors the client might like to increase or decrease through therapy.
A: Affect. Lazarus's definition of affect includes feelings, moods, and other self-reported and self-described emotions. He might ask, "What makes you happy or puts you in a good mood?" or "What emotions are most troubling to you?"
S: Sensation. This modality refers to the sensory processing of information. For example, clients often report physical symptoms associated with high levels of anxiety (e.g., choking, elevated temperature, heart palpitations). The multimodal interviewer might ask, "Do you have any unpleasant aches, pains, or other physical sensations?" and "What happens to cause you those unpleasant sensations?"
I: Imagery. Imagery consists of internal visual cognitive processes. Clients often experience pictures or images of themselves or of future events that influence their functioning. A multimodal interviewer could query, "When you're feeling anxious, what images or pictures pop into your mind?"
C: Cognition. Lazarus believes in closely evaluating client thinking patterns and beliefs. This process usually includes an evaluation of distorted or irrational thinking patterns that occur almost automatically and lead to emotional distress. For example, an interviewer could ask, "When you meet someone new, what thoughts go through your mind?" and "What are some positive things you say to yourself during the course of a day?"
I: Interpersonal Relationships. This modality concerns interpersonal variables such as communication skills, relationship patterns, and assertive capabilities as manifest during role play and as observed in the client-interviewer relationship. Possible relevant questions include, "What words would you use to describe the positive or healthy relationships that you have?" and "Who would you like to spend more time with, and who would you like to spend less time with?"
D: Drugs. This modality refers to biochemical and neurological factors that can affect behavior, emotions, and thinking patterns. It includes physical illnesses and nutritional patterns. Questions might include, "Are you participating in any regular physical exercise?" and "Do you take any prescription drugs?"
Lazarus's (1976) model is broad-based, popular, and useful to interviewers of different theoretical orientations. If you're interested in learning more about his model, his latest book is Brief but Comprehensive Psychotherapy: The Multimodal Way (1997; see Readings and Resources at the end of this chapter).
Lazarus's model slightly overemphasizes cognitive processes (two separate cognitive modalities exist in his seven-modality system: cognition and imaging) while neglecting or deemphasizing spiritual, cultural, and recreational domains. As suggested previously, similar to every system designed to aid in problem identification, exploration, and conceptualization, the multimodal system has its imperfections. It is important to be familiar with numerous systems so, as a competent professional interviewer, you can be flexible in your questioning and conceptualizing and adapt to your setting and individual client problems and needs.
Behavioral and cognitive theorists and practitioners emphasize the importance of antecedents and consequences in problem development and maintenance. This approach is founded on the belief that analyzing clients' environments and their interpretation of environmental stimuli allows counselors to explain, predict, and control specific symptoms. Behaviorists have called this model of conceptualizing problem behavior the ABC model (Thoresen & Mahoney, 1974): behavioral Antecedents, the Behavior or problem itself, and behavioral Consequences. Although this model has been criticized (Goldfried, 1990), it is useful for all interviewers to explore—at the very least—the following ABCs with their clients:
• What events, thoughts, and experiences precede the identified problem?
• What is the precise operational definition of the problem (i.e., what behaviors constitute the problem)?
• What events, thoughts, and experiences follow the identified problem?
When following the ABC model, interviewers can be meticulous in their search for potential behavioral antecedents and consequences. For example, an interviewer could assess for behavioral antecedents and consequences using all modalities identified by Lazarus (1976):
Behavior: What behaviors precede and follow symptom occurrence?
Affect: What affective experiences precede and follow symptom occur rence?
Sensation: What physical sensations precede and follow symptom occurrence?
Imagery: What images precede and follow symptom occurrence?
Cognitions: What specific thoughts precede and follow symptom occurrence?
Interpersonal: What relationship events or experiences precede or follow symptom occurrence?
Drugs: What biochemical, physiological, or drug-use experiences precede or follow symptom occurrence?
The Diagnostic Look: Searching for a Syndrome
A syndrome is a set of symptoms that usually occur together. After you've identified a symptom, such as a sad or depressed mood, your next task is to explore it in greater depth. A client's reported depressed mood may represent nothing more than a single symptom (e.g., sadness) caused by the natural ups and downs of life. Alternatively, depressed mood may represent the tip of a diagnostic iceberg. Once a primary symptom has been identified and the client has acknowledged it as a significant concern, a search for accompanying symptoms is warranted (see Chapter 10 for more information on diagnostic interviewing).
The DSM-IV-TR (American Psychiatric Association, 2000) and the ICD-10 (World Health Organization, 1997a, 1997b) provide contemporary standards for diagnostic classification of mental disorders. There are numerous structured diagnostic interview systems designed to reliably identify a client's DSM diagnosis (R. Rogers, 2001). Structured diagnostic interviewing is a particular type of interviewing designed to confirm or rule out psychiatric diagnoses (Vacc & Juhnke, 1997). To maximize the reliability of such procedures, many standardized approaches have been developed. These approaches are essentially menu-driven; for example, if a client responds to a particular question with a yes, there is a specific question the evaluator must subsequently ask. Obviously, rigid adherence to standardized diagnostic interviewing protocols has its costs and benefits. On the one hand, rigid, diagnosis-oriented approaches can adversely affect rapport. On the other hand, if clients are adequately informed of the nature and purpose of the structured diagnostic interview, such approaches can be effective, efficient, and reliable. Specific diagnostic interviewing and treatment planning procedures are the focus of Chapter10.
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