A.

GUIDE FOR THE DEVELOPMENT OF THE CLINICAL INTERVIEW

1. 1Sociodemographic data:

- Client’s name:
- Age:
- Studies:
- Civil status:
- Profession:
- Work:
- Disabilities:
- Address:
- Home and work telephone number:
- E-mail:
- Name of another person to contact in case of emergency:
- Behavioral observations:
- General appearance and demeanor.
- Client communication patterns.

2. Presenting psychological problems (concerns):

a) To start the interview: Here are examples of range-of-concerns leads:

- “What are your concerns in your life now?”
- “Please describe some of the things that seem to be bothering you.”
- “What are some present stresses in your life?”
- “What situations are not going well for you?”
- “Tell me about anything else that concerns you now.”

b) For the present and most relevant problem (quote the client directly). Do it for each
problem that the client presents:
- When did it start? What other events were occurring at that time?
- How often does it occur?
- What thoughts, feelings, and observable behaviors are associated with it?
- Where and when does it occur most? Least?
- Are there any events or persons that precipitate it? Make it better? Make it worse?
- How much does it interfere with the client’s daily functioning?
- What previous solutions/plans have been tried and with what result?
- What made the client decide to seek help at this time (or, if referred, what influenced the
referring party to refer the client at this time)?

2.1. Functional analysis for every presenting problem, starting with the most relevant

2.1.1. Antecedents (Context: Time, Place, Concurrent Events, and Environment)

- “Describe some recent situations in which the issue occurred. Where were you? When was
it?”
- “Does this go on all the time or only sometimes?”
- “Does the same thing happen at other times or places?”
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- “At what time does this not occur? Places? Situations?”
- “What effect does your cultural/ethnic background have on this issue?”
- “What effects do the sociopolitical structures of the society in which you live have on this
issue?”
- “Describe the relationship between yourself, your concerns, and your current environment”.
- “To what extent is your concern affected by oppression and discrimination that you
experience in your environment?”
- “To what extent does your environment give or deny you access to power, privilege, and
resources?”
- “What opportunities do you have in your environment for sharing spiritual and cultural
values and activities?”

2.1.2. Cognitions (automatic, helpful, unhelpful, rational, irrational thoughts and beliefs;
internal dialogue; perceptions and misperceptions):

- “What do you say to yourself when this happens –before and after?”
- “What are you usually thinking about during this problem –before and after?”
- “What was going through your mind then –also before and after?”
- “What kinds of thoughts can make you feel ____?”
- “What beliefs [or images] do you hold that affect this issue?”
- Sentence completions: I should ____, people should ____, it would be awful if ____, ____
makes me feel bad.

2.1.3. Affective aspects (positive and negative feelings, emotions, mood states):

- “What are you feeling when this happens –before and after?”
- “How does this make you feel when this occurs –before and after?”
- “What other feelings do you have when this occurs –before and after?”
- “What feelings is this issue hiding or covering up?”
- “What positive feelings do you have surrounding this issue?”
- “Negative ones?”

2.1.4. Psychophysiological responses (skin conductance, heart rate, breathing rate, blood
pressure) and body sensations, organic dysfunction and illness, medications:

-“Which kind of reactions and/or responses are you experiencing when this happens –before
and after?”
- “What goes on inside you then –before and after?”
- “What do you notice in your body when this happens –before and after?”
- “When this happens, are you aware of anything that goes on in your body that feels bad or
uncomfortable—aches, pains, and so on –also before and after?”

2.1.5. Motoric and/or Behavioral responses (overt behavior/ actions):

- “In photographing this scene, what actions and dialogue would the camera pick up –also
before and after?”
- “What are you doing when this occurs- also before and after?”
- “Describe what you did the last few times this occurred.”

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2.1.6. Consequences (identify the consequences that strengthen, weaken or diminish the
psychological problem):
a) Short Term:

- Behavioral consequences (in problems related with fear and anxiety analyze avoidance
and escape behaviors –Ref-):
- “What do you do after this happens, and how does this make the problem better? Worse?”
- “How do you usually react after this is over?”
- “Identify any particular behavior patterns that occur after this.”
- “How do these patterns keep the problem going? Stop it?”

- Relational consequences (attention (Rf+) :

- “Can you identify any particular reactions from other people that occur following the
occurrence of the psychological problem?”
- “In what ways do their reactions affect the problem?”
- “Identify any particular people who can make the problem worse. Better? Stop it? Keep it
going?”
- “How do the people who have power in your life situation perpetuate this concern?”

- Identify possible secondary gains:

- “Has your problem ever produced any special advantages or considerations for you?”
- “As a consequence of your problem, have you got out of or avoided things or events?”
- “What do you get out of this situation that you don’t get out of other situations?”

b) Long Term consequences:

- In which way the psychological problem(s) is affecting:

- Personal life: goals, studies, etc.
- Family life:
- Interpersonal life: relationship with friends
-Work life:
- Hobbies and leisure life

2.2. Acquisition of every problem, starting with the most relevant (making a full analysis of
how the psychological problem was initiated and how it was evolving until the present):

- “When was the first time that you had this problem?”
- “Where were you?”
- “What happen at that time?”
- What did you think, how did you feel, how did your body react and what did you do?”
- When was the second time that you had this problem?” “How was your reaction in the four
response system?”
- “How was this problem evolving through time and how was your psychological reaction in
the four response system?”

3. Historical analysis

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3.1. Past psychiatric/counseling history: Previous counseling and/or
psychological/psychiatric treatment:

- Type of treatment.
- Length of treatment.
- Treatment place or person.
- Presenting concern.
- Outcome of treatment and reason for termination.
- Previous hospitalization.
- Prescription drugs for emotional and or psychological issues.

3.2. Educational /job history: Trace academic progress (strengths and weaknesses) from
grade school through last level of education completed:

- Relationships with teachers and peers.

- Types of jobs held by client and socioeconomic history, current employment, and
socioeconomic status.
- Length of jobs.
- Reason for termination or change.
- Relationships with co-workers.
- Aspects of work that are most stressful or anxiety producing.
- Aspects of work that are least stressful or most enjoyable.
- Overall degree of current job satisfaction.

3.3. Health/medical history: Childhood diseases, prior significant illnesses, previous

surgeries:

- Current health-related complaints or illnesses (e.g., headache, hypertension).

- Treatment received for current complaints: what type and by whom.
- Date of last physical examination and results.
- Significant health problems in client’s family of origin (parents, grandparents, siblings).
- Client’s sleep patterns.
- Client’s appetite level.
- Current medications (including such things as aspirin, vitamins, birth control pills,
recreational substance use as well as prescription medications).
- Drug and nondrug allergies.
- Disability history.
- Client’s typical daily diet, including caffeine-containing beverages/food, alcoholic
beverages, and use of nicotine or tobacco products.
- Exercise patterns.

3.4. Social/developmental history: Current life situation (typical day/week, living

arrangements, occupation and economic situation, contact with other people):

- Social/leisure time activities, hobbies

- Religious affiliation—childhood and current
- Spiritual beliefs and concerns

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- Contacts with people (support systems, family, and friends)
- Community and cultural affiliations
- Military background/history
- Significant events reported for the following developmental periods:
- Preschool (0–6 years)
- Childhood (6–13 years)
- Adolescence (13–21 years)
- Young adulthood (21–30 years)
- Middle adulthood (30–65 years)
- Late adulthood (65 years and over)

3.5. Family, marital, sexual history: Presence of physical, sexual, and/or emotional abuse
from parent, sibling, or someone else

- How well parents got along with each other.

- Identifying information for client’s siblings (including those older and younger and the
client’s birth order or position in family).
- Which sibling was most favored by mother? By father?
- Least favored by mother? By father?
- Which sibling did client get along with best? Worst?
- History of previous psychiatric illness /hospitalization among members of client’s family of
origin
- Use of substances in family of origin.
- Dating history.
- Engagement/marital history—reason for termination of relationship.
- Current relationship with intimate partner (how well they get along, problems, stresses,
enjoyment, satisfaction, and so on).
- Number and ages of client’s children.
- Other people living with or visiting family frequently.
- Description of previous sexual experience, including first one (note whether heterosexual,
homosexual, or bisexual experiences are reported).
- Present sexual activity.
- Any present concerns or complaints about sexual attitudes or behaviors.
- Current sexual orientation.

3.6. Victimization experiences

- Psychological abuse by parents (mother, father, siblings), other relatives, neighbors and/or
unknown people.
- Physical abuse by parents (mother, father, siblings), other relatives, neighbors and/ or
unknown people.
- Sexual abuse by parents (mother, father, siblings), other relatives, neighbors and/ or
unknown people.

4. Personal Resources

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4.1. Identify solutions already tried to solve the problem:

- “How have you dealt with this or other issues already tried to solve before? What was the
effect? What made it work the issue or not work?”
- “How have you tried to resolve this concern?”
- “What kinds of things have you done to improve this situation?”
- “What have you done that has made the issue better? Worse? Kept it the same?”
- “What have others done to help you with this?”

4.2. Identify client coping skills, strengths, resources:

-“What skills or things do you have going for you that might help you with this problem?”
-“Describe a situation when this concern is not interfering.”
-“What strengths or assets can you use to help resolve this?”
-“When don’t you act this way?”
-“What kinds of thoughts or self-talk help you handle this better?”
-“When don’t you think in self-defeating ways?”
-“What do you say to yourself to cope with a difficult situation?”
-“Identify the steps you take in a situation you handle well—what do you think about and
what do you do? How could these steps be applied to the present issue?”
-“What resources are available to you from your community and your environment?”
- “What kinds of things in your community and environment do you consider to be strengths
and assets?”
-“What sorts of positive, purposeful relationships do you have now that help you with this
issue?”
-“What do you find meaning in from particular aspects of your culture?”

5. Identify client’s description/assessment of the problem

- “What is your understanding of this issue?” “How do you explain this concern to yourself?”
-“Tell me about what the issue means to you.”
- “What is your interpretation [analysis] of the concern?”
- “Sum up the issue in just one word.”
-“Give the concern a title.”

6. Estimate frequency, duration, or severity of behavior/symptoms (assign self-

monitoring homework, if useful)

-“How often [how much] does this occur during a day? A week?”
- “How long does this feeling stay with you?”
- “How many times do you ____ a day? A week?”
- “To what extent has this interfered with your life? How?”
-“You say sometimes you feel very anxious. On a scale from 1 to 10, with 1 being very calm
and 10 being very anxious, where would you put your feelings?”
- “What would happen if the issue were not resolved in a year?”

7. Assessment Instruments

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- MMPI 2-RF
- Other specific self-report inventories

8. Clinical case formulation

- Consider the most relevant variables to explain acquisition of the problem(s) from the
history
- Consider the most relevant variables to explain the maintenance of the psychological
problem(s) from the functional analysis and acquisition of the problem

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 B. CLINICAL PSYCHOLOGICAL REPORT

1. 2Sociodemographic data:

2. Presenting psychological problems (concerns):

2.1. Functional analysis for every presenting problem, starting with the most relevant:

2.1.1. Antecedents (Context: Time, Place, Concurrent Events, and Environment):

2.1.2. Cognitions (automatic, helpful, unhelpful, rational, irrational thoughts and beliefs;
internal dialogue; perceptions and misperceptions):

2.1.3. Affective aspects (positive and negative feelings, emotions, mood states):

2.1.4. Psychophysiological responses (skin conductance, heart rate, breathing rate, blood
pressure) and body sensations, organic dysfunction and illness, medications:

2.1.5. Motoric and/or Behavioral responses (overt behavior/ actions):

2.1.6. Consequences (identify the consequences that strengthen, weaken or diminish the
psychological problem):

a) Short Term:

- Behavioral consequences (in problems related with fear and anxiety analyze avoidance
and escape behaviors –Ref-):

- Relational consequences (attention (Rf+) :

- Secondary gains:

b) Long Term consequences:

2.2. Acquisition of every problem, starting with the most relevant (making a full analysis of
how the psychological problem was initiated and how it was evolving until the present):

3. Historical analysis

3.1. Past psychiatric/counseling history: Previous counseling and/or

psychological/psychiatric treatment:

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3.2. Educational /job history: Trace academic progress (strengths and weaknesses) from
grade school through last level of education completed:

3.3. Health/medical history: Childhood diseases, prior significant illnesses, previous

surgeries:

3.4. Social/developmental history: Current life situation (typical day/week, living

arrangements, occupation and economic situation, contact with other people):

3.5. Family, marital, sexual history: Presence of physical, sexual, and/or emotional abuse
from parent, sibling, or someone else:

3.6. Victimization experiences

4. Personal Resources

4.1. Identify solutions already tried to solve the problem

4.2. Identify client coping skills, strengths, resources

5. Identify client’s description/assessment of the issue (note which aspects of issue are
stressed and which are ignored)

6. Estimate frequency, duration, or severity of behavior/symptoms (assign self-

monitoring homework, if useful)

7. Results of Assessment Instruments

- MMPI-rf
- Other self-report inventories

8. Case formulation
Hypothesis that explains why the patient has the psychological problems and how
they were acquired, developed and maintained.

9. Goals for counseling and therapy:

- Client’s goals for treatment

- Client’s motivation for getting help at this time