by Michael D. Anestis, M.S.
As a clinician, I was trained to utilize a scientific approach to the diagnosis and treatment of mental illness. We have discussed the use of empirically supported treatments (ESTs) at great length on Psychotherapy Brown Bag, but we have spent less time talking about the manner in which a scientific orientation can impact diagnostics. I would like to address that weakness today by discussing a new study by Andrea Suppiger and colleagues (2009) published in the current edition of Behavior Therapy. In this study, the authors examined the degree to which clinicians and clients were comfortable with the use of a structured diagnostic interview both in clinical practice (inpatient and outpatient) and in research settings. The goal was to determine whether structured interviews - the approach favored by scientists - would be experienced as cumbersome, complicated, mechanical, unhelpful, or detrimental to the therapeutic relationship by clients and/or clinicians.
Before going any further, let me explain what I mean by a structured diagnostic interview (see our assessment tools page for a list and description of several such interviews). These interviews involve the use of a prescribed set of questions that cover each criterion for a mental illness. Clinicians read the prescribed question, note the client's answer, and then score each response based upon the protocol for the interview. A diagnostic decision is then based upon whether or not the client's answers fit the required criteria. Clinicians are certainly allowed to ask follow-up questions and pause the interview to interact with the client in a less formal manner, but diagnostic decisions are to be made based upon the systematic review of the client's symptoms as laid out by the structured interview protocol.
If you have ever received treatment for a mental illness, your interaction with your clinician did not likely involve a structured diagnostic interview. Instead, the clinician likely asked you a few pointed questions and made a snap judgment regarding a diagnosis. The clinician may or may not have told you what diagnosis or diagnoses for which you were thought to meet criteria (an issue discussed in the July 2009 PBB featured article). For a variety of reasons, all of these points are problematic:
- Different diagnoses have been shown to respond best to different treatments. In other words, arriving at an accurate diagnosis is important because, in order to know which treatment has the best evidence as being useful for your symptoms, we need to correctly identify what those symptoms actually are.
- As we have discussed in an earlier PBB article, misdiagnoses are common. Unstructured approaches often lead clinicians to make biased and sloppy decisions. The norm is for an individual to meet criteria for more than one diagnosis, but using unstructured approaches often leads to clinicians focusing on one primary symptom and making an assumption about the overall presentation, thus overvaluing some symptoms and ignoring others all together.
Structured diagnostic interviews are considered more valid and reliable than are unstructured approaches. That is, they tend to result in more accurate conclusions and, if more than one person administered or scored the same interview, they would be more likely to make the same diagnostic decision than would two individuals using unstructured approaches. Structured interview force the clinician to assess all of the client's symptoms, to record answers to ensure accuracy, and to assess for more than one mental illness rather than assuming the first issue that comes up is the only or most important issue.
So what's the problem? Many individuals believe that structured interviews involve several weaknesses that render them useless or at least less than ideal outside of research settings. Such individuals believe structured interviews are too long, too impersonal, too restrictive, and likely to interfere with the rapport between therapist and client. These assumptions, however, have not been subject to much empirical testing and, as any good scientist will tell you, an assumption is not worth a whole lot until its accuracy has been systematically studied.
Here is where the work of Suppiger and colleagues (2009) comes into play. They were interested in examining the reactions of clinicians and clients to the use of structured diagnostic interviews across a variety of settings, including inpatient and outpatients clinics and research environments. Using a modified and extended German version of the Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV; Brown, DiNardo, & Barlow, 1994), 183 structured interviews were administered across the three types of settings. Additionally, after each interview, both the clinician and the client filled out questionnaires regarding their impressions of and satisfaction with the interview. The interviewers were 10 female master's level clinical psychologists with an average age of 29.3. 77.6% of the sample met criteria for at least one DSM-IV-TR mental illness, with major depression (21.9%) serving as the most frequent diagnosis.
The interviews themselves ranged in length from 17 minutes to 241 minutes with an average length of 104.87 minutes. 96% of the clients were able to complete the entire interview protocol and all clients completed the questionnaire assessing their impression of and satisfaction with the interview. The questionnaire itself was scored from 0 (not at all satisfied) to 100 (totally satisfied) and the average level of client satisfaction with the interview was 86.55. Clients in the research setting (93.38) were, on average, more satisfied than were clients in inpatient (84.63) or outpatient (85.00) settings, but as you can see, the clients in clinical settings still reported high levels of satisfaction. Clients with no diagnosis were more satisfied with the interview than were clients diagnosed with depression, but clients with any other diagnosis were as satisfied with the interview as those without any diagnosis, so satisfaction did not hinge upon the severity of the client's presentation.
78.5% of the clients reported that they either completely agreed or almost completely agreed that the structured interview was helpful. Similarly 86.7% completely or almost completely agreed that the relationship with the interviewer was positive. Greater than 90% reported that the interview took their problems seriously and asked for enough details to fully understand their individual situation. Only 14.2% of the clients found the interview to be exhausting, less than 15% reported that there were too many questions or the questions were confusing, and only 13.1% reported that the interview did not allow for them to report everything that was bothering them.
These results quite clearly demonstrate that structured interviews are enthusiastically embraced by clients across a variety of settings, even when they meet criteria for one or more mental illnesses. What about the clinicians though? Were they equally satisfied with this process? The mean satisfaction rating for the clinicians was 85.82. 96.9% felt qualified in administering the interview and 92.6% felt that they could adequately respond to the client. 83.6% completely or almost completely agreed that the relationship with the client was positive. Only 16.3% found the interview to be exhausting.
Okay, so that was a lot of numbers, but what do they actually tell us? Quite simply, both clinicians and clients experience structured diagnostic interviews as a positive and helpful process. Fears that the interviews are too long, too restrictive, too impersonal, or likely to interfere with the therapeutic relationship simply do not hold up when we look at these data. In fact, the logical conclusion is quite the opposite. In addition to providing more valid and reliable diagnostic information, these interviews appear to foster a positive relationship between the therapist and the client and to help ensure that the clinician focuses on all of the client's symptoms rather than narrowly focusing on a few and thereby making diagnostic decisions based upon incomplete and improperly weighted information.
Keep in mind that this study was not perfect. There was no comparison group in which unstructured approaches were utilized, so we can not compare these responses to the responses that would result from a different approach. Still, given that there is little room for improvement in the satisfaction ratings, the superior validity and reliability of structured approaches seem to make such questions effectively moot. Additionally, however, it would have been useful for the authors to assess both the clinicians' and the clients' thoughts about a structured interview prior to the interview administration. My reason for this thought is based on my clinical experience.
In my intake sessions with new clients, I have often sensed a degree of concern on their part regarding my use of structured interviews. Most individuals are not accustomed to a scientific approach to clinical psychology and they do not expect interviews to have set protocols. They report being worried that I will not focus on their individual problem, understand them as individuals, or truly listen to what they are saying. Additionally, the interview is seen as an obstacle keeping them from the start of treatment. I always express empathy to this response, telling the client that I am, in fact, very concerned with who they are as an individual and that I am also eager to start treatment but that my concern for their well-being requires that I hold myself to the highest of professional standards. In other words, because of my concern, I want to make sure that I make the right diagnostic decisions so that I can ensure that we pick the most effective treatment. I promise clients that I will in fact listen intently to everything they say and that, if they feel as though the interview is ignoring an important aspect of what is bringing them to see me, they can absolutely raise that point during the course of the session. Almost invariably, once the interview starts, all of my client's fears recede. The point then, is that the concerns many individuals - both clients and clinicians - have about structured interviews appear to often be based in a lack of understanding of how these interviews work. The results from Suppiger et al. (2009) seem consistent with this idea, as individuals across a variety of settings, some with no diagnoses and others with several, appear highly satisfied with structured interviews.
So what should you take home from this article? If you are seeking help for a mental illness, try to find a clinician who uses structured diagnostic interviews. Even if you are skeptical about them, give them a shot. If you are a clinician who has not used structured interviews before, consider attending a continuing education seminar that will provide you with training in their use. They require minimal training and, as you can see, many of the drawbacks pointed to by skeptics simply are not backed up by any legitimate evidence.
If you would like to learn more about diagnostic interviews, we recommend the following sampling of resources and encourage you to consult our online store:
- Anxiety Disorder Interview Schedule ADIS-IV and ADIS-IV-L Combination Specimen Set
- User's Guide for the Structured Clinical Interview for Dsm-IV Axis I Disorders: Scid-1 Clinician Version
- Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II)
Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University.
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