The psychodiagnostic interview is an essential component of mental health diagnosis in which mental health professionals collect specific information about an individual to label his or her mental health problems. A significant number of individuals involved in the criminal justice system have been diagnosed with a mental disorder. Many more may have undiagnosed problems. Misdiagnosed or undiagnosed problems pose a serious barrier to the rehabilitation of offenders as accurate diagnosis is an important early step to effective treatment. There is ongoing concern that untreated mental disorders may lead to violence or reoffense. This article introduces readers to the goals of psychodiagnostic interviewing, offers examples of different approaches to interviewing, and provides a brief overview of the key content covered in a typical interview.
Interview Goals
The goal of a psychodiagnostic interview appears clear: to diagnose a mental disorder. Yet, there remains debate about the best way to conceptualize mental disorders. The most commonly used system in the United States is described in the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association. Much of the rest of the world uses the International Classification of Diseases, published by the World Health Organization. Both of these are categorical classification systems in which each disorder is seen as a distinct collection of various symptoms. A threshold number of symptoms are typically required for each disorder, and an interviewer needs to assess for all possible symptoms, along with specific information on the length of time symptoms have been present and other possible explanations for them. For example, to diagnose a form of depression called major depressive disorder using the DSM, an interviewer would ask questions about nine specific symptoms outlined in the manual. The presence of five of these over at least a 2-week period qualifies for the diagnosis. The interviewer must also inquire about other possible explanations for any symptoms reported such as a medical problem or bereavement. This approach to diagnosis is not without limitations. Chiefly, categorical diagnosis allows for only two possibilities: One either has the disorder or one does not. Some people may be experiencing significant distress or impairment in functioning but not reach the number of symptoms specified or time requirements. In addition, symptoms of some disorders overlap, and interviewers may struggle to decide whether an interviewee’s report of problems with excess energy is evidence of a condition such as bipolar disorder, severe attention-deficit/hyperactivity disorder, or behaviors associated with substance abuse and/or antisocial personality disorder. Thorough interviewing can help sort through some of these challenges, but they may also reflect inherent weaknesses to a categorical approach to diagnostic classification.
In response to these concerns, it has been suggested that a better way to think about mental disorders is as symptoms that present on a continuum often with normal functioning. In this approach, what distinguishes symptoms of mental disorder from normal functioning is the severity of the problem. Rather than asking questions to fit a person into a specific category, an interviewer might instead seek to gather information about an individual’s overall level of functioning and place specific symptoms reported into larger factors. At the broadest level, internalizing disorders are those that generally involve emotional distress, whereas externalizing disorders involve problems with behavior or impulse control. Given the goal of locating an interviewee’s problems on a continuum, interviewers would likely supplement information they obtain from the individual with norm-referenced assessment measures that compare an individual’s symptoms to a comparison group.
While conceptual debates about the classification of mental disorders are likely to continue, as of 2018, the approach to diagnosis required by third parties such as health insurance companies remains the categorical one. The goals of mental health assessments conducted for the legal system vary, and interviewers must determine the specific nature of the question they are being asked to answer to appropriately focus their interview questions. Evaluations of claims of legal insanity often hinge on the presence of a recognized DSM or International Classification of Diseases mental disorder, for example, evaluating competency to stand trial may require no diagnosis at all and focus instead on a defendant’s dimensionally assessed functional capacity to understand legal concepts and assist in his or her defense.
Approaches to Psychodiagnostic Interviewing
Two main approaches to psychodiagnostic interviewing include unstructured clinical and structured interviews. Unstructured clinical interviews resemble a traditional dialogue between the interviewer and interviewee. While each interviewer may develop his or her own preferred phrasing or order of questions, the clinical interview allows for spontaneity, and the specific questions asked may vary from interview to interview (though the general content covered should be the same as discussed in the following section). Structured interviews, on the other hand, involve specific questions posed to each interviewee in the same way. Some structured interviews may be referred to as semistructured. These standardized guides to data collection ensure that all areas of importance are covered while allowing the interviewer to customize questions based on an interviewee’s answers and/ or ask additional questions deemed appropriate. Examples of structured interviews include the Structured Clinical Interview for DSM Disorders and the Diagnostic Interview Schedule.
Therapists often prefer clinical interviews and the personalized approach they provide while researchers typically use structured interviews to gather standardized data. Psychodiagnostic interviews completed for the legal system may use either depending on the specific question being asked.
Interview Content
Informed Consent and Establishing Rapport
A psychodiagnostic interview requires both consent and cooperation. This consent is generally described as informed consent and requires the interviewer to explain the purpose, time requirements, and any limits to confidentiality, among other things. Given that interviews completed for the legal system typically offer little to no confidentiality, interviewees may be understandably reluctant to participate or reticent about their thoughts and feelings. Thus, while developing treatment plans may or may not be the goal of the interview, skilled forensic interviewers must balance objectivity with empathy and positive regard for the interviewee to gain cooperation. Interviewers must also be prepared to take steps to protect the interviewee or the community from harm, should a significant risk of suicide or violence emerge during the interview regardless of its purpose.
Behavioral Observations
A psychodiagnostic interview may actually start before a single question is posed, as the diagnosis of a mental disorder entails consideration of both information reported by an individual and observations made by the diagnostician. Symptoms are problematic thoughts, feelings, and behaviors an interviewee endorses. They are subjective. Signs are objective observations that have diagnostic meaning. For example, recurrent thoughts of death or suicide are a symptom of major depressive disorder one can only assess by explicitly asking about them. Excessive slowing of speech or movements known as psychomotor retardation is a sign of the disorder that can be observed by the interviewer. An interviewer generally takes note of an individual’s general appearance, activity level, speech patterns, and emotional expressiveness. Unusual behaviors or mannerisms may also be particularly important to identify.
Presenting Problem or Reason for Referral
Individuals who voluntarily seek assessment and treatment are usually able to clearly identify a problem for which they are seeking assistance (e.g., depression). The interviewer will question the nature of the problem, when it started, and for how long it has persisted to determine whether it meets criteria for a diagnosis like major depressive disorder. Those completing a psychodiagnostic interview as part of a court process or within a correctional setting may be less articulate and/or less forthcoming such that they may not endorse any problems at all. In such cases, information from the legal system may be particularly important, and the individual can be queried as to his or her perception for the reason for the referral (e.g., “What is your understanding of why you are here today?”). Discrepancies between the information provided by the court system and the individual’s account may speak to one’s level of insight into the problem, particularly if care has been taken to establish rapport, and it is believed the individual is honestly answering interview questions.
Current Functioning and Distress
After clarification of the presenting problem or reason for referral, most psychodiagnostic interviewers will complete a survey of the individual’s psychological functioning. Major areas to be considered include mood and emotional regulation, concentration and/or memory problems, and impulse control. In addition to current mood, the interviewee is asked about his or her regular mood and any periods of persistently negative mood or significant changes in any direction. Psychodiagnotic interviewers often find it helpful to ask whether others have ever told the individual that he or she seems different in some way as some features of certain mental disorders may not actually feel like a problem to the individual (e.g., manic episodes marked by euphoria in an individual with bipolar disorder, interpersonal difficulties in a person with antisocial personality disorder). The interviewee’s sleep patterns, current substance use, and general health are also typically explored.
Investigation of an individual’s social network and interpersonal functioning is also important. Interviewers ask about performance at school or work as well, particularly in relation to any significant problems with the aforementioned psychological issues. This is necessary as the diagnosis of mental health disorders with a system such as the DSM requires evidence of significant distress or impairment in functioning related to symptoms.
History
Accurate diagnosis puts the presenting problem and current functioning in context. As such, taking a thorough history of the individual’s psychological functioning is necessary. Major areas to consider are the interviewee’s developmental, social, legal, academic/work, medical, and substance use history. Children and adolescents are sometimes known to be poor historians, and this may be an area in which more information can be gleaned from parents. Adults may also struggle to recall aspects of their history (which may valuable information in and of itself). Any gaps in knowledge that could impact the ultimate diagnosis should attempt to be clarified. Some diagnoses may actually require historical information (e.g., the DSM diagnosis of antisocial personality disorder in adults requires evidence of conduct disorder before age 15 years). If significant gaps in history remain even after thorough interviewing, some degree of diagnostic uncertainty will be present and should be communicated to the interviewee or referral source.
Mental Status Examination and Risk Assessment
At this point, much data will have been covered, and clear risk issues may have emerged in the interview if the individual reported past suicidal thoughts or behavior or the reason for referral was a threat or past act of violence. All psychodiagnostic interviews should consider risk of harm to self or others. If this has not been covered in an earlier part of the interview, it will be in the mental status examination. The mental status examination involves consideration of the observations made of the individual along with specific questions about his or her current mood, perceptual experiences (i.e., hallucinations), and thought content (i.e., delusions, suicidal ideation, and homicidal or violent ideation). Suicide is associated with multiple mental health disorders and should not only be considered a possibility if the person appears depressed. Violent behavior shares a more complicated relationship with mental disorders but is also to be routinely assessed. Regardless of the interview context, mental health professionals have an ethical duty to protect others from harm and may have a legal duty to do so as well.
Final Thoughts
Effective rehabilitation of criminal offenders and/ or prevention of criminal behavior may often depend on an accurate mental health diagnosis. Although there is some debate about the nature of mental health disorders and the best way to classify them, accurate diagnosis with current diagnostic systems always requires a comprehensive psychodiagnostic interview by an interviewer who keenly observes an individual’s behavior and systematically collects information from the individual in the areas reviewed herein.
References:
- Nakash, O., Nagar, M., & Kanat-Maymon, Y. (2015). Clinical use of the DSM categorical diagnostic system during the mental health intake session. The Journal of Clinical Psychiatry, 76(7), e862–e869. doi:10.4088/ JCP.14m09214
- Nordgaard, J., Sass, L. A., & Parnas, J. (2013). The psychiatric interview: Validity, structure, and subjectivity. European Archives of Psychiatry and Clinical Neurosciences, 263, 353–364. doi:10.1007/ s00406-012-0366-z
- Shea, S. C. (2016). Psychiatric interviewing: The art of understanding (3rd ed.). New York, NY: Elsevier.