Clinical Interview

• History/comprehensive psychosocial-medical history
• Presenting problem
  Why are you here, what is it that brings you here?
  What kind of problem are you having?
  What I am interested in here is the client stating in his/her own words the difficulty — I want to know how he/she conceptualizes it as well as the level of insight and understanding of what is happening.
• History of presenting problem
• How long have you been having this problem and how is it affecting your life?
• Past personal history and current psychological functioning psychosocial history and current functioning
  occcupational history/current functioning
• Past psychiatric history
• Substance abuse history and current status
• Family history (psychosocial, psychiatric, medical, substance abuse)
• Obviously red flag these if there is a history of major thought disorder, mood disorder, or behavior or substance abuse disorder.

As noted above, the mental status observations can be made concurrently, paying attention to:

• appearance
• level of psychomotor activity
• speech and language
• mood and affect
• thought process and content
• insight and judgment
• symptoms of anxiety, depression, psychosis
• difficulty with impulse control
• indicators for substance abuse, speech, needle marks, unusual
• mannerisms, skin color, pupils, etc.

Risk Factors

Again, if psychosis, severe substance abuse, i.e., need for detox, suicide or homicide surface as issues they must be dealt with and that determines the course and direction of the rest of the interview. Assessment now beccomes intervention.

Assessment domains

The primary feature of assessment is finding out who the person is we may be treating or at least evaluating.

• coping skills
• ego functioning
• frustration tolerance, impulsivity
• repeated scripts and themes in life
• self-image, self-esteem
• personality dynamics and conflicts
• relationship patterns — dependent, ambivalent, distant, paranoid, angry, anxious
• strength, assets, coping abilities, internal resources
• specific vulnerabilities, weaknesses, liabilities
  

Concurrent Life Stressors

• Any recent losses, deaths, life changing events?
• Nature of loss, circumstances, secondary losses
• Tell me about what happened.
• How did it affect you?
• How did it change your life?
• Are you now having difficulty with it?
• How have you tried to deal with it? What has worked, what has not?
• Any previous trauma, loss or history of abuse?
• What type of support do you have in your life?
• Compared to previous times in your life how are you coping now?
• Do you have any important spiritual beliefs or affiliations which help you cope with your life difficulties?
• What is it you expect to gain from seeking help?
• What would normal look like for you?
• Expectations for recovery and image of desired life.
• Is there anything else you would like to tell me about yourself that we haven’t discussed?

Course of treatment, direction of intervention is all based on discovery of (1) problem, (2) premorbid conditions and predisposing factors, (3) concurrent stressors, and (4) current level of individual psychological functioning of person. As always, treatment is subject to less than ideal circumstances, i.e. client’s ability to pay, mental health resources in the community, and client’s ability to cooperate with and benefit from recommended intervention plan.

This assessment tool was developed by Gary W. Reece, PhD. Dr. Reece is a therapist, author, educator, lecturer and consultant. He is author of The Stepcare Recovery Guide for Substance Abuse, and The Hero’s Journey, A Course on Self-Esteem. He is founder and executive director of the Stepcare Institute in Sierra Madre, California. For more information contact Dr. Reece at 626-355-2407 or by email: This e-mail address is being protected from spam bots, you need JavaScript enabled to view it .