Process Addictions

The Unstructured Clinical Interview
Karyn Dayle Jones

i n mental health, family, and community counseling settings, master’s-level counselors engage in unstructured clinical
interviewing to develop diagnoses based on the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text
rev.; DSM-IV-TR. American Psychiatric Association, 2000). Although counselors receive education about diagnosis
and the DSMclassification system, the majority of them are not specifically trained in clinical interviewing. This article
provides information about using the unstructured clinical interview to make a DSM-IV-TR diagnosis for adult clients
with Axis I and Axis 11 disorders.

The initial interview is the most fundamental area of counselor
training; it is the beginning of every counseling relationship
and the cornerstone of assessment. In mental health and
community counseling settings, the initial interview, using
an unstructured, open-ended approach, remains the primary
assessment tool for diagnosing mental disorders based on the
Diagnostic and Statistical Manual of Mental Disorders (4th
ed., text rev.; DSM-IV-TR; American Psychiatric Association
[APA], 2000; Craig, 2003; Miller, 2003; Sommers-Flanagan
& Sommers-Flanagan, 2003). When used for purposes of di-
agnosis, the initial interview is known as the clinical interview
or diagnostic interview.

Traditionally only a psychiatrist’s task, the responsibility
of diagnosing now falls to almost all master’s-level counselors
(marriage and family, mental health, and community; Bogels,
1994; Mead, Hohenshil, & Singh, 1997). Diagnostic training
in counselor education program curricula has existed for
the last 15 to 20 years, and the Council for Accreditation of
Counseling and Related Educational Programs (CACREP,
2009) mandates that community and mental health counselors
receive training on the use of the DSM-IV-TR (APA, 2000).
Despite the emphasis in CACREP requirements for diagnostic
training, the majority of counselors are trained in traditional
interviewing techniques, not in clinical interviewing (Morrison,
1995; Turner, Hersen, & Heiser, 2003). Traditional interview-
ing techniques focus on gathering background history about
the client but do not emphasize the identification of diagnostic
signs and symptoms that aid in determining a diagnosis. The
importance of clinical interviewing cannot be overemphasized
because a client’s DSM-IV-TR diagnosis is the primary basis
for treatment planning. Being an effective clinical interviewer
requires a broad knowledge of psychopathology and the current
diagnostic system as means to properly evaluate the information
obtained during the initial interview.

Information about clinical interviewing is scarce in the
counseling literature or in counseling assessment textbooks. The
literature that does exist on clinical interviewing is published
mostly in psychiatry journals and textbooks, and much ofthat
literature espouses the use of structured and semistmctured

interviews for accurate diagnosis (Basco, 2003). Despite the
current emphasis on the use of structured and semistmctured
interviews, the unstmctured clinical interview remains the most
commonly used clinical assessment among psychiatrists and
psychologists, as well as counselors (Craig, 2003; Miller, 2003;
Sommers-Flanagan & Sommers-Flanagan, 2003).

The ability to interview for diagnosis is an important skill
for counselors to develop. Counselors should know what
information they need to obtain during the clinical interview
and how that information is relevant to making a DSM-IV-TR
(APA, 2000) diagnosis. This article provides (a) information
about clinical interviewing for the purpose of making a DSM-
IV-TR diagnosis, (b) the format ofthe unstmctured clinical
interview, and (c) examples of diagnostic clues and questions.
This article focuses on interviewing adult clients with DSM-
IV-TR Axis I and Axis II disorders. The term clinical interview
is used throughout this article to describe interviewing for the
purpose of developing a DSM-IV-TR diagnosis.

•Clinical Interviewing
Clinical interviews may be unstructured, semistructured, or
stmctured. Each approach has benefits and drawbacks, but
the primary purpose of all three types is to obtain accurate
information relevant in making a DSM-IV-TR (APA, 2000)
diagnosis. Unstructured interviews consist of questions posed
by the counselor with the client responses and counselor ob-
servations recorded by the counselor. This type of interview
is considered unstmctured because there is no standardiza-
tion of questioning or recording of client responses; it is the
counselor who is “entirely responsible for deciding what
questions to ask and how the resulting information is used in
arriving at a diagnosis” (Summerfeldt & Antony, 2002, p. 3).
The accuracy of diagnoses based on unstmctured interviews
depends a great deal on the counselor’s ability to recognize
DSM-IV-TR diagnostic symptoms. Structured interviews are
a type of diagnostic interview procedure that consists of a
standardized list of questions; a standardized sequence of
questioning, including follow-up questions; and the system-

Karyn Dayle Jones, Counselor Education Program, Department of Child, Family and Community Sciences, University of Central
Florida. Correspondence concerning this article should be addressed to Karyn Dayle Jones, Counselor Education Program, Depart-
ment of Child, Family and Community Sciences, College of Education, University of Central Florida, Orlando, FL 32816-1250 (e-mail:
[email protected]).

220
© 2010 by the American Counseling Association. All rights reserved.

Journal of Counseling &c Development Spring 2010 • Volume 88

The Unstructured Clinical Interview

atic rating of client responses (Bagby, Wild, & Turner, 2003).
Semistructured interviews are less uniform than structured
interviews and allow some flexibility for clinicians in terms
of follow-up questions (Craig, 2003). Numerous studies attest
to the improved accuracy in diagnoses when semistmctured or
structured interviews are used instead of the more traditional
unstructured clinical interviews (Basco, 2003).

A comprehensive initial clinical interview is the first step
in determining the initial DSM-IV-TR diagnosis and treat-
ment plan. Despite its apparent weaknesses in accuracy of
diagnosis, the unstructured clinical interview remains the
most commonly used clinical assessment among psychiatrists,
psychologists, and counselors (Craig, 2003; Miller, 2003;
Sommers-Flanagan & Sommers-Flanagan, 2003), perhaps
because of its flexibility in establishing rapport with the client
(Turner et al., 2003). Some clinicians view the unstructured
clinical interview as Just one form of the assessment process,
which involves the collection and integration of multiple forms
of data from multiple sources (Bagby et al., 2003). Whether
counselors use unstructured clinical interviews alone or use
other assessment instruments to supplement the unstructured
interview, they must be able to recognize diagnostic clues
and engage in diagnostic questioning throughout the clinical
interview to make a DSM-IV-TR diagnosis.

•Diagnostic Clues and Questions
The ability to interview for diagnosis “without the counselor
sounding as if he or she is reading off a checklist of symptoms
and without getting sidetracked by less relevant information”
(Carlat, 2005, p. 2) is an important skill for counselors to
develop. The process of interviewing for diagnosis involves
the counselor’s ability to listen for diagnostic clues: signs and
symptoms of DSM-IV-TR (APA, 2000) disorders expressed
by or observed in the client during the unstructured clinical
interview. These clues can be viewed as red flags that the cli-
ent may have a DSM-IV-TR disorder.

Counselors follow up diagnostic clues with diagnostic
questions to help specify a diagnosis. By using diagnostic
questioning, counselors focus on the client’s signs, symp-
toms, and behaviors, basing specific diagnostic questions
on the diagnostic criteria of a particular disorder (Othmer &
Othmer, 2002, p. 2). Ideas for diagnostic questions can be
derived directly from diagnostic criteria provided for specific
disorders in the DSM-IV-TR (APA, 2000), from published
structured iind semistructured interviews, or from textbooks
on diagnostic interviewing.

• T h e Unstructured Clinical Interview
Although unstructured clinical interviews do not have a
standardized format or standardized questions, it may be
usefiil for counselors to follow a general outline consisting
of several general content domains (APA, 2006; Carlat, 2005;
Morrison, 1995; Othmer & Othmer, 2002). Counselors may

use the outline to guide the interview process and organize
interview questions on the basis of the diagnostic clues pro-
vided by the client. When counselors recognize diagnostic
clues, they formulate specific diagnostic questions to obtain
the information needed to determine a diagnosis.

The following section describes a general interview
outline that counselors can follow when engaging in un-
structured clinical interviews with adult clients. In addition,
examples of diagnostic clues are provided for each section
of the outline. In this article, I do not attempt to provide all
the possible diagnostic clues that could be presented during
an interview; however, I provide examples of diagnostic
clues throughout the discussion with the goal of helping
counselors understand the link between the background
information received during the interview and the identifica-
tion of diagnostic signs and symptoms that aid in making a
diagnosis. Although not discussed fully in this article, it is
understood that the therapeutic alliance is vital in forming
the groundwork for the assessment process and effective
counseling interventions.

•Outline for an Unstructured Clinical
Interview Format
A. Identifying Information

Identifying information includes the client’s name, sex, age,
race/ethnicity, relationship status, and referral source.

Diagnostic clues—Besides providing basic information
about the client, identifying information can provide clues to a
potential diagnosis. For example, a client’s sex can be associated
with vulnerability to certain mental illnesses—men have higher
rates of substance abuse and antisocial disorders, whereas
women are more vulnerable to depression, anxiety disorders,
and somatic complaints (Klose & Jacobi, 2004). Referral source
can also provide diagnostic clues. If a client was referred by
a psychiatric hospital or other clinical setting, the client may
have a previous DSM-IV-TR (APA, 2000) diagnosis that remains
applicable to the current reason for counseling.

B. Presenting Problem/Chief Complaint

The presenting problem/chief complaint is a statement about
the client’s problems or concerns that brought him or her to
counseling. Presenting problems can be about the client’s
psychological functioning (e.g., depression or anxiety), oc-
cupational functioning, or social functioning (e.g., problems
in a current relationship).

Diagnostic clues—Counselors need to listen for psycho-
logical symptoms, pattems of maladjusted behavior, stress-
ors, and interpersonal conflicts in order to pick up clues to
diagnosis. For example, if the client expresses that he or she
has problems sleeping, the counselor may wish to ask specific
questions about depression. Or, if the client reports a recent
divorce, diagnostic questions about adjustment disorder may
need to be explored.

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Jones

C. History of Presenting Problem

The history of the presenting problem is a chronological
history of the client’s complaint that can provide counselors
with many diagnostic clues. Counselors should have the client
elaborate on the presenting problem in three main areas (APA,
2006; Othmer & Othmer, 2002; Seligman, 1996):

• Onset/course: When did the problems begin? Was
there a time when the client felt worse or better? Was
there any particular pattern?

• Severity: Do the problems interfere with the client’s
life in terms of work, relationships, and leisure pursuits
and/or lead to suffering or distress?

• Stressor: Does the client believe that some external
event brought on the problems? Have there been any
stressful life events associated with the problem?

Diagnostic clues—Obtaining a history of the presenting
problem is vital in establishing a diagnosis. For example,
symptoms for major depressive disorder and dysthymic
disorder share similar symptoms, with differences in onset,
duration, and severity. The depressed mood in major depres-
sive disorder is more severe and must be present for at least
2 weeks, whereas dysthymic disorder has milder symptoms
and a duration of least 2 years. In addition, a client’s identifica-
tion of a Stressor preceding the onset of symptoms (within 3
months) may indicate a diagnosis of adjustment disorder.

D. Family History

Family history focuses on information about the client’s fam-
ily background, particularly about any history of psychiatric
problems among family members. The following are common
areas of questioning regarding family history (APA, 2006):

• Client’s first-degree relatives (parents, siblings, and
children) and their mental health history

• Information about the client’s parents and siblings—
age, education, and occupation

• Composition of the family during the client’s child-
hood and adolescence

• Medical history of family members
• Quality of the client’s relationships with family mem-

bers, both past and present
• Any history of child abuse, substance abuse in

the family, domestic violence, or other traumatic
experiences

• Any family history of suicide or violent behavior

Diagnostic clues—Gathering information about the client’s
family is important because many mental disorders are often
associated with or exacerbated by the client’s current or past
interactions with family members. Gathering information
about family history can also help to uncover any previous
experiences, such as child abuse, that may be associated with

a mental disorder (e.g., posttraumatic stress disorder [PTSD]).
In addition, mental disorders seem to have a genetic com-
ponent; thus, the mental health history of older, first-degree
relatives may predict the client’s future in terms of potential
mental health problems (Othmer & Othmer, 2002). Disorders
for which there is evidence of familial transmission include
bipolar disorder, schizophrenia, depression, panic disorder,
alcoholism, and anxiety disorders.

E. Relationship History

Relationship history consists of information about the client’s
current living situation, current and previous marital and non-
marital relationships, number of children, and the nature of
his or her social life and friendships. Questions may include
the following:

• How many close friends do you have (aside from
your spouse/partner)? Describe problems, if any,
that you think you have in developing and keeping
friendships.

• Are you in an intimate relationship or married? If yes,
for how long?

• Tell me about your previous relationship. How long
did it last? What happened?

• Describe problems, if any, that you think you have in
developing and keeping intimate relationships.

• Has there ever been any violence in your current
intimate relationship?

• Have you ever experienced violence in your past
intimate relationships?

Diagnostic clues—Relationship history is important in
determining whether the client has shown the ability to initi-
ate and sustain intimate relationships. A pattern of short-term
or the lack of long-term relationships may indicate a pattern
of maladjustment indicative of people with personality dis-
orders (Carlat, 2005; Othmer & Othmer, 2002). Questions
often arise concerning the client who has few, if any, friends.
Understanding why the client has few friendships is essen-
tial in determining whether the lack of friends is a sign of a
mental disorder. For example, a client whose fear of possible
humiliation causes him to avoid interacting with others may
have a social phobia; in contrast, an individual who neither
desires nor enjoys close relationships and has a pattern of liv-
ing a solitary life may be diagnosed with schizoid personality
disorder. Change in relationship status can also be associated
with mental disorders; for example, divorce or separation ap-
pears to be a risk factor for mood disorders, anxiety disorders,
and substance-related disorders in single mothers (Cairney,
Pevalin, Wade, Veldhuizen, & Arboleda-Florez, 2006). Any
history of violence in a relationship may be indicative of
antisocial behavior, substance-related disorders, narcissist
personality disorder, or anxiety problems in the perpetrator
(Stuart, Moore, Kahler, & Ramsey, 2003) and of depression.

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The Unstructured Clinical Interview

anxiety disorders (e.g., PTSD), suicidality, and substance-
related disorders in the victim (Golding, 1999).

F. Developmentai History

The purpose of developmental history is to identify risk
factors, cultural issues, and system variables (e.g., family,
community) associated with the later development of mental
disorders. Early developmental milestones (such as the age
at which the client learned to walk, learned to speak, was
toilet trained) are usually not worth asking about (Morrison,
1995). Questions should instead be focused on known child
and adolescent risk factors associated with the development
of mental disorders in adulthood. Areas to assess include the
following:

• Behavior problems in childhood
• School performance (including failed grades)
• Childhood diagnosis of attention-deficit/

hyperactivity disorder (ADHD)
• Childhood depression
• Child abuse
• Traumas and/or losses during childhood

Diagnostic clues—Most adult psychopathology is pre-
ceded by childhood mental disorders or other psychosocial
risk factors (Rutter, Kim-Cohen, & Maughan, 2006). For
example, child abuse and other childhood traumas have long
been associated with later problems, including PTSD and
antisocial behavior (Widom, 1989, 1998); conduct problems
in childhood predict substance abuse, antisocial personality,
and psychotic disorders in early adulthood (Sourander et al.,
2005); adolescent-onset depression denotes a strong, specific,
and direct risk for recurrence in adulthood (Rutter et a l , 2006);
and childhood ADHD is a precursor of later antisocial disorder
(Mannuzza, Klein, Abikoff, & Moulton, 2004).

G. Educational History

Educational history consists of information about the
client’s educational level and professional, technical, and/or
vocational training. If not addressed in the developmental
history section, education history can also include academic
performance, failed grades, and social interaction with peers.
Questions may include the following:

• Did you graduate from high school? If not, what was
the highest grade level achieved?

• Did you go to college or receive technical/vocational
training? If yes, describe the area of study.

Diagnostic clues—Problems in academic achievement
have been linked with substance abuse problems, antisocial be-
havior, and other mental disorders in adulthood (McConaughy,
2000). In addition, because the onset of mental disorders often
occurs early (i.e., 50% of all lifetime cases begin by age 14,

and 75% of all cases by age 24), poor academic performance
or interrupted education can be a sign of the early onset of
mental illness (e.g., anxiety disorders, impulse-control disor-
ders, and mood disorders; Kessler et al., 2005).

H. Work History

Work history consists of specific information about current
employment status, length of tenure on past jobs, job losses,
leaves of absence, and occupational injuries. The following
are sample questions:

• Where is your current employment? What is your
position? How long have you worked there?

• Where did you last work? What was your position?
How long did you work there? Why did you leave?
(Note. Ask these questions to document jobs held over
a period of several years. Ask about any periods of
time when the client did not work.)

• Were you ever in the military service? If yes, for how
long? Did you experience combat? What was your
discharge (e.g., honorable, general, dishonorable)?

Diagnostic clues—Work history can provide many clues that
might indicate potential DSM-IV-TR (APA, 2000) disorders.
Individuals with disabling mental disorders are less likely to
be working and more likely to be unemployed, out of the labor
force, or xmderemployed than are those without such disor-
ders (Cook, 2006). Severe, disabling mental disorders such as
schizophrenia are commonly known to be associated with work
disability. However, research indicates that mood disorders,
anxiety disorders, and substance abuse disorders—not the se-
verely disabling types—are also associated v̂ ath work-related
problems such as reduced work activity, increased absenteeism,
and lost productivity time (Kessler & Frank, 1997; Stewart,
Ricci, Chee, Hahn, & Morganstein, 2003).

I. Medical History

The client’s medical history consists of information about
previous and current medical problems (major illnesses and
injuries), medications, hospitalizations, and disabilities. Ques-
tions may include the following:

• What is your current, overall health?
• Have you ever had a serious medical illness or injury?
• Have you ever been hospitalized for a medical

problem?
• Are you taking any medications related to a medical

problem?

Diagnostic clues—A number of medical illnesses and
medications have resulting psychiatric symptoms or may ag-
gravate existing psychiatric problems. Clients with increased
risk for medical problems associated with their psychological
difficulties include indigent persons (because of limited access

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Jones

to medical care); persons with well-established histories of
medical illnesses or injuries; individuals with severe, disabling
mental disorders (e.g., schizophrenia); and older adults (Pol-
lak. Levy, & Breitholtz, 1999). Common medical problems
associated with psychiatric symptoms include (among others)
thyroid disorders, head trauma, neurological disorders, circu-
latory disorders, hepatitis, seizure disorder, lupus, electrolyte
disturbances and B-vitamin deficiencies. Clues that a medical
problem could be related to a client’s sjonptoms include the
following (PoUak et al., 1999):

• Psychiatric symptoms begin following the onset
of the general medical condition or while taking
medications

• Psychiatric S5anptoms vary in severity with the severity
of the general medical condition

• Psychiatric symptoms disappear when the general
medical condition resolves

• Psychiatric symptoms onset after age 40
• Family history of heritable medical problems
• Signs during the interview of an altered state of con-

sciousness, fluctuations in alertness and attention,
disorientation, confijsion, short-term memory loss,
hallucinations, and changes in motor functioning (e.g.,
speech problems, unsteady gait, tremor, or problems
with coordination)

J. Substance Use

Regardless of the client’s presenting problem, screening for
alcohol and drug use is advisable (Hodgins & Diskin, 2003).
Often, individuals who seek counseling have existing sub-
stance use problems, but they do not cite the substance use as
a presenting problem to the counselor. It is important to rule
out alcohol or drug use as the underlying cause or contribu-
tor to a client’s difficulties. When questioning for alcohol or
drug use, it is helpful to begin with general questions about
behaviors consistent with problematic substance use such as
the following (Antick & Goodale, 2003):

• Do you drink coffee? Caffeinated? If yes, how many
cups per day?

• Do you smoke (e.g., cigarettes)? If yes, how much do
you smoke? For how long have you smoked? Have
you tried to quit?

• Have you smoked in the past? If yes, when did you
quit?

After asking about caffeine and smoking, move on to ques-
tions about alcohol and drug use such as the following:

• Do you enjoy a drink now and then? If yes, what kinds
(e.g., beer, wine, distilled spirits)?

• In the last week, how many days did you drink alcohol
(every day, 4-5 times, 1-2 times)?

• How much do you drink in one day (a case of beer,
12-pack, 6-pack, 1 to 2 beers)? How many drinks can
you hold?

• Do you sometimes drink or use drugs more than you
planned?

• Have you used any drugs in the past year? If yes, what
kinds? (Be sure to ask about prescription drugs.)

• Have you ever had an arrest for driving under the
influence or had other legal problems associated with
drinking or using drugs?

Diagnostic clues—When questioning about specific
substance use, it is important to know what is considered
appropriate drinking limits. A standard drink is defined
as one 12-ounce bottle of beer, one 5-ounce glass of
wine, or 1.5 ounces of distilled spirits. According to
epidemiologic research, men who drink 5 or more stan-
dard drinks in a day (or 15 or more drinks per week) and
women who drink 4 or more drinks in a day (or 8 or more
drinks per week) are at increased risk for alcohol-related
problems (Dawson, Grant, & Li, 2005). Often, red flags
for substance use problems can be determined by asking
about problems at work, home, and school; problems
with family or friends; or trouble with the law because
of substance use. For example, substance abusers often
have unstable work histories with a pattern of brief periods
of work interspersed with periods of not working. Other
indicators of substance use problems include housing
instability, financial problems, violent behavior, mood
swings, hygiene and health problems, and a family history
of substance abuse.

Counselors may use the CAGE questionnaire (Ewing,
1984) to assess alcohol abuse problems during the un-
structured clinical interview. The CAGE questionnaire is a
very brief, relatively nonconfrontational questionnaire for
detection of alcoholism. Alcohol dependence is likely if the
client gives two or more positive answers to the following
questions (Ewing, 1984, p. 1907):

• Have you ever felt you should Cut down on your
drinking?

• Have people Annoyed you by criticizing your drinking?
• Have you ever felt bad or Guilty about your drinking?
• Have you ever had a drink first thing in the morn-

ing to steady your nerves or to get rid of a hangover (Eye
opener)?

K. Legal history

Legal history entails a description of past or current involve-
ment with the legal system. This may include warrants,
arrests, detentions, convictions, probation, or parole as an
adult as well as involvement with the juvenile justice sys-
tem. Specific questions may include the following (APA,
2006, p. 17):

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The Unstructured Clinical Interview

• Do you have any past or current involvement with
the legal system (e.g., warrants, arrests, detentions,
convictions, probation, parole)?

• Do you have any past or current involvement with the
court system (e.g., family court, workers compensa-
tion dispute, civil litigation, court-ordered psychiatric
treatment)?

Diagnostic clues—A history of legal problems may be
associated with aggressive behavior, antisocial personal-
ity disorder, substance-abuse-related disorders, or a manic
episode of bipolar disorder (Morrison, 1995). Other past or
current interactions with the court system (e.g., family court,
civil litigation) may serve as significant Stressors for the client
and may indicate adjustment or anxiety disorders.

L. Previous Counseling

The history of previous counseling includes a chronological
summary of the previous counseling sought by the client.
Questions about previous counseling include the following:

• Have you ever been to counseling before (as an adult
or a child)? If yes, why? How long did treatment last?
Was it helpful?

• Have you ever been hospitalized for a psychiatric
problem? If yes, why?

• Have you ever been on medications for psychiatric
problems (e.g., antidepressants)?

Diagnostic clues—Information about the client’s previous
counseling can provide clues about current diagnoses. Many
disorders commonly recur, and the reason for the client’s
previous counseling could apply to the client’s current prob-
lem. For example, at least 60% of individuals with a single
episode of major depressive disorder can be expected to have
a second episode (APA, 2000). Previous psychiatric hospital-
ization usually indicates that the client has experienced severe
psychiatric symptoms such as suicidal behavior, homicidal
or aggressive behavior, or psychosis (delusions or hallucina-
tions). Thus, if the client reports being previously hospital-
ized for delusions, the counselor may wish to direct specific
diagnostic questions about schizophrenia (or other psychotic
disorders) or bipolar disorder. The client’s current or previ-
ous use of psychotropic …