Structured And Semistructured Clinical Interviews

The past few decades have witnessed a shift among clinical psychologists and psychiatrists toward the increased use of a more formal clinical interview process. It has become commonplace to categorize clinical interviews, based on the degree of structure imposed by the interviewer, into one of three subtypes: structured, semistructured, and unstructured. The unstructured interview is characterized by the clinician's refraining from the use of prescripted queries or a predetermined order of content coverage (Shea, 1990; Wiens, 1990). In direct contrast, a structured interview comprises predetermined questions presented in a predefined order, with tightly operationalized criteria used for interpretation (Beutler, 1995). Semistructured interviews are something of a hybrid case. Like structured interviews, they consist of predetermined questions presented in a predefined order; however, following the predetermined questions, the interviewer is free to follow up as necessary to obtain sufficient information.

Semistructured interviewing, like structured interviewing, is concerned with obtaining sufficient information for reliable and valid rating with respect to some particular content domain (e.g., diagnostic category, symptom severity, level of function, etc.). It differs only in that it allows clinicians more latitude to formulate queries in making a rating. Accordingly, the present chapter subsumes both semi-structured and structured interviews under the rubric of the structured interview.

The Shift from Unstructured to Structured Interviews

The increasing use of structured interviews may be traced to the confluence of several historical developments. In the 1960s and 1970s there was growing recognition that the traditional method of diagnosis (i.e., the unstandardized, unstructured interview) was highly unreliable (see Hersen & Bellack, 1988). Structured interviews thereby became an invaluable means of assessing each disorder within the Diagnostic and Statistical Manual of Mental Disorder third edition (DSM-III; American Psychiatric Association, 1980) in a systematic fashion (Shea, 1990). Another development has been the recent increase in the influence of managed care organizations (MCOs). MCOs, by virtue of concerns for cost containment, have provided an impetus for the widespread use of structured interviews, inasmuch as such interviews allow more valid and accurate diagnosis with minimal prerequisite clinician training (Wiens, 1990).

The Structured Interview: Advantages and Disadvantages

There are several advantages in comparison with unstructured interviewing. Due to their explicit use of opera-tionalized criteria, structured interviews facilitate higher levels of interrater reliability than do unstructured interviews (Segal, 1997; Segal & Falk, 1998). Standardization in administration decreases the amount of both criterion and information variance (Segal, 1997; Segal & Falk, 1998). Structured interviews also attenuate the need for clinical judgment and permit the clinician to rely on operational-ized criteria and interpretation based on normative values. In addition, two different interviewers utilizing the same interview are less likely to elicit discrepant information due to differences in interviewing techniques. Due principally to its superior reliability and validity, structured interviewing is now the accepted gold standard ofDSM-based diagnostic assessment. Descriptions of the most commonly employed structured interviews are listed in Table 1.

Another advantage is that administration and interpretation of the interviews requires less training than for unstructured interviews. Nonetheless, they do require a considerable amount of specialized training, not only because the initial training in interview administration is extensive, but also because retraining is necessary to prevent interviewer drift.

Structured interviews are also capable of providing information tailored to the researcher's or clinician's needs. For example, the relevant sections of a structured interview may be employed to elicit information to address a specific referral question or diagnostic issue. Alternatively, for a more thorough intake assessment, an omnibus diagnostic interview may be employed to screen a patient across the entire spectrum of disorders.

There are a few notable limitations with structured interviews. They constrain an interviewer's freedom in exploring relevant issues to suit the needs of the client (Beutler, 1995). For example, clients may not reveal information unless they are comfortable with the interviewer; thus, questions that are not tailored to the needs of the patient or that proceed in a forced manner may actually result in the patient's revealing less information or being untruthful (Scheiber, 1994; Sullivan, 1954). Finally, clinicians who employ structured interviews lack flexibility in exploring their clinical intuitions when interviewing (Beutler, 1995).

Structured Interviewing: Clinical Considerations

Despite the limited amount of free time available during a structured interview, the clinician is faced with the need to establish rapport quickly with the client in order to obtain accurate and complete information (Beutler, 1995; Scheiber, 1994). Beutler (1995) recommended that the clinician "ensure that the desired expectation and mind set are developed by the patient" (p. 99) by interviewing in a quiet, protected area to provide a relaxing therapeutic milieu of safety and collaboration. In addition, the clinician can, with the skillful use of nonverbal communication (e.g., body posture, etc.), convey a sense of empathy and positive regard throughout the process. Finally, the interviewer will do well to provide the client beforehand with information (e.g., interview format, etc.) that gives the individual some sense of control during the interview process (Beutler, 1995). With such considerations in mind when administering an SI, the clinician can often ascertain important clinical information while simultaneously establishing a positive clinical alliance for subsequent assessment or intervention procedures.

Table 1. Commonly Employed Structured Diagnostic Interviews

Name

Description

Psychometric Properties

Strengths

Limitations

Structured Clinical Interview for DSM-IV (SCID; First et al., 1995)

Schedule for Affective Disorders and Schizophrenia (Endicott & Spitzer, 1978)

Diagnostic Interview Schedule (Robins et al., 1981)

International Personality Disorder Examination (Loranger et al., 1994)

Structured Clinical Interview for DSM-IV (SCID-II; First et al., 1994)

Semistructured; patient and nopatient versions; specified modules; assesses Axis I disorders

Semistructured; based on Research Diagnostic Criteria for Axis I disorders; specified modules

Structured; investigation of mental illness in general population; assesses Axis I disorders

Semistructured; specified modules; assesses Axis II disorders based on DSM and ICD-10 criteria

Semistructured; screening questionnaire available; specified modules; assesses Axis II disorders kappa = .72-.84 (Williams et al., 1992)

ICC = .84-1.00 (Endicott & Spitzer, 1978); kappa = .63-1.00 (Spitzer et al., 1979)

kappa = .51-.87; stability = .52 (Loranger et al., 1994)

Length based on need; computer scoring

Assesses past and present psychopathology

Designed for nonprofessionals; 1-hour administration; computer scoring

Uses 5-year inclusion rule; requests examples for scoring

Screening component; open-ended follow-up questions

Limited Likert scale; moderate training

Limited Likert scale; no reliable computer scoring; reliance on clinical judgment; extensive training

Closed-ended questions; dichotomous scoring with no clarification; assesses only symptoms

Limited Likert scale; requires extensive training and clinical judgment; 2-3 hour administration

Limited Likert scale; questions grouped together by disorder; extensive training and clinical judgment required

Note: Information on instrument strengths and limitations is abstracted from Segal and Falk (1998).

REFERENCES

American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author.

Beutler, L. E. (1995). The clinical interview. In L. E. Beutler & M. R. Berren (Eds.), Integrative assessment of adult personality. New York: Guilford Press.

Endicott, J., & Spitzer, R. L. (1978). A diagnostic interview: The Schedule for Affective Disorders and Schizophrenia. Archives of General Psychiatry, 35, 837-844.

First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. W. (1995). Structured Clinical Interview for Axis I DSM-IV Disorders-Patient Edition (SCID-I/P, Version 2.0). New York: Biometrics Research Department, New York State Psychiatric Institute.

First, M. B., Spitzer, R. L., Gibbon, M., Williams, J. B. W., & Benjamin, L. (1994). Structured Clinical Interview for DSM-IV Axis IIPersonality Disorders (SCID-II, Version 2.0). New York: Biometrics Research Department, New York State Psychiatric Institute.

Helzer, J. E., Robins, L. N., Taibleson, M., Woodruff, R. A., Reich, T., & Wish, E. D. (1977). Reliability in psychiatric diagnosis. Archives of General Psychiatry, 34, 129-133.

Hersen, M., & Bellack, A. S. (1988). DSM-III and behavioral assessment. In A. S. Bellack & M. Hersen (Eds.), Behavioral assessment: A practical handbook (pp. 67-84). New York: Pergamon.

Loranger, A. W., Sartorius, N., Andreoli, A., Berger, P., Buchheim, P., Channabasavanna, S. M., Coid, B., Dahl, A., Diekstra, R. F. W., Ferguson, B., Jacobsberg, L. B., Mombour, W., Pull, C., Ono, Y., & Reiger, D. A. (1994). The International Personality Disorder Examination. Archives of General Psychiatry, 51, 215224.

Maffei, C., Fossati, A., Agostoni, I., Barraco, A., Bagnato, M., Donati, D., Namia, C., Novella, L., & Petrachi, M. (1997). Interrater reliability and internal consistency of the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II), version 2.0. Journal of Personality Disorders, 11, 279-284.

Robins, L. N., Helzer, J. E., Croughan, J., & Ratcliff, K. S. (1981). National Institute of Mental Health Diagnostic Interview Schedule. Archives of General Psychiatry, 38, 381-389.

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Segal, D. L. (1997). Structured interviewing and DSM classification. In S. M. Turner & M. Hersen (Eds.), Adultpsychopathol-ogy and diagnosis. New York: Wiley.

Segal, D. L., & Falk, S. B. (1998). Structured interviews and rating scales. In A. S. Bellack & M. Hersen (Eds.), Behavioral assessment: A practical handbook (4th ed., pp. xxx). Needham Heights, MA: Allyn & Bacon.

Shea, S. C. (1990). Contemporary psychiatric interviewing: Integration of DSM-III-R, psychodynamic concerns, and mental status. In G. Goldstein & M. Hersen (Eds.), Handbook of psychological assessment (2nd ed.). New York: Pergamon Press.

Spitzer, R. L., Williams, J. B. W., & Nee, J. (1979). DSM-III field trials: Initial interrater diagnostic reliability. American Journal of Psychiatry, 136, 815-817.

Sullivan, H. S. (1954). The psychiatric interview. New York: Norton.

Wiens, A. N. (1990). Structured clinical interviews for adults. In G. Goldstein & M. Hersen (Eds.), Handbook of psychological assessment (2nd ed.). New York: Pergamon Press.

Williams, J. B. W., Gibbon, M., First, M. B., Spitzer, R. L., Davies, M., Borus, J., Howes, M. J., Kane, J., Pope, H. G., Rounsaville, B., & Wittchen, H. (1992). The Structured Clinical Interview for DSM-III-R (SCID): Multisite test-retest reliability. Archives of General Psychiatry, 49, 630-636.

Phan Y. Hong Stephen S. Ilardi University of Kansas

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