diagnostic intervdiagnostic interviewing

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T h e U n s t r u c t u r e d l in i c a l I n t e r v i e wKaryn Dayle Jones

i n mental health, family, and community counseling settings, master s-level counselors e ngage in unstructured c linicalinterviewing to develop diagnoses based on theD iagnostic and Statistical Manual of M ental Disorders (4th ed., textrev.;DSM IV TR.American Psychiatric Ass ociation, 2000). Although counselors receive educ ation about diagnosisand the D SM classification system, the m ajority of them are not specifically trained in clinical interviewing. This articleprovides information about using the unstructured clinical interview to make aDSM IV TR diagnosis for adult clientswith Axis I and Axis disorders.

The initial interview is the most fundamental area of counselortraining; it is the beginning of every counseling relationshipand the cornerstone of assessment. In mental health andcommunity counseling settings, the initial interview, usingan unstructured, open-ended approach, remains the primaryassessment tool for diagnosing mental disorders based on theDiagnostic and Statistical Manual of Mental Disorders (4thed., text r e v . ; DSM IV TR;Am erican Psychiatric Association[APA],2000; Craig,2003;Miller,2003; Sommers-Flanagan& Sommers-Flanagan, 2003). When used for purposes of d iagno sis, the initial interview is known a s theclinicalinterviewor diagnostic interview.

Traditionally only a psychiatrist's task, the responsibilityof diagnosing now falls to almost all master's-level cou nselors(marriage and family, mental health, and com munity; B ogels,1 9 9 4 ; Mead, Hohenshil, & Singh, 1997). Diagnostic trainingin counselor education program curricula has existed forthe last 15 to 20 years, and the Co uncil for Accreditation ofCounseling and Related Educational Programs (CACREP,2009) m andates that community and mental health counselorsreceive training on the use of the DSM IV TR(APA, 2000).Despite the emphasis in CACREP requirem ents for diagnostictraining, the majority of counselors are trained in traditionalinterviewing techniques, no ti n clinical interviewing (Morrison,1 9 9 5 ; Turner, Hersen, & Heiser, 200 3). Traditional interview-ing techniques focus on gathering background history aboutthe client but do not emp hasize the identification of diagno sticsigns and symptoms that aid in determining a diagnosis. Theimportance o f clinical interviewing cann ot b e overemphasizedbecause a client'sDSM IV TRdiagnosis is the primary basisfor treatment planning . Being an effective clinical interviewerrequiresa b road knowledge of psychopathology and the currentdiagnostic system a smeanst oproperly evaluate the informationobtained d uring the initial interview.

Information about clinical interviewing is scarce in thecounseling literature or in counseling assessment textbooks. Theliterature that do es exist on clinical interviewing is publishedmostly in psychiatry journals and textbooks, and much ofthatliterature espouses the use of structured and semistmctured

interviews for accurate diagnosis (Basco, 2003). Despite tcurrent emphasis on the use of structured and semistmcturinterviews, the unstmctured clinical interview rem ains the mcommonly used clinical assessment among psychiatrists apsychologists, a s well as counselors (Craig,2003;M iller,20Sommers-Flanagan & Somm ers-Flanagan, 2003).

The ability to interview for diagnosis is an important skfor counselors to develop. Counselors should know whinformation they need to obtain during the clinical intervieand how that information is relevant to making aDSM IV (APA, 2000) diagno sis. This article provides (a) informatiabout clinical interviewing for th e purpose of making a DSIV TR diagnosis, (b) the format ofthe unstmctured cliniinterview, and (c) examples of diagnostic clues and q uestionThis article focuses on interviewing adult clients with DSIV TR xisI and Axis II disorders. The termclinical intervis used throughout this article to describe interviewing for tpurpose of developing aDSM IV TRdiagnosis. l i n i c a l I n t e r v i e w in gClinical interviews may be unstructured, semistructured, stmctured. Each approach has benefits and drawbacks, bthe primary purpose of all three types is to obtain accurainformation relevant in making a DSM IV TR (APA, 20diagnosis.Unstructuredinterviews consist of questions poby the counselor with the client responses and co unselor oservations recorded by the counselor. This type of intervieis considered unstmctured because there is no standardiztion of questioning o r recording of client respo nses; it is tcounselor who is entirely responsible for deciding whquestions to ask and how the resulting information is usedarriving at a diagn osis (Summ erfeldt & Antony, 200 2, p. The accuracy of diagnoses based on unstmctured interviedepends a great deal on the counselor's ability to recogniDSM IV TRdiagnostic symptoms.Structuredinterviews a type of diagnostic interview procedure that consists ofstandardized list of questions; a standardized sequence questioning, including follow-up questions; and the syste

Karyn Dayle Jones Counselor Education Program, Department of Child, Family and Community Sciences, University of CentralFlorida. 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]). 2010 by the American Counseling Association. All rights reserved.


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The Unstructured Clinical Interview

atic rating of client responses (Bagby, Wild, & Turner, 2003 ).Semistructured interviews are less uniform than structuredinterviews and allow some flexibility for clinicians in termsof follow-up questions (Craig, 2003). Num erous studies attestto the improved accuracy in diagnoses when sem istmctured orstructured interviews are used instead of the mo re traditionalunstructured clinical interviews (Basco, 2003).

A comprehensive initial clinical interview is the first stepin determining the initial DSM IV TR diagnosis and treat-ment plan. Despite its apparent weaknesses in accuracy ofdiagnosis, the unstructured clinical interview remains themost comm only used clinical assessment am ong psychiatrists,psychologists, and counselors (Craig, 2003; Miller, 2003;Sommers-Flanagan & Sommers-Flanagan, 2003), perhapsbecau se of its flexibility in establishing rap port w ith the client(Turner et al., 2003). Som e clinicians view the un structuredclinical interview as Just one form of the assessment process,which involves the collection an d integration of multiple formsof data from multiple sources (Bagby et al., 2003). Whethercounselors use unstructured clinical interviews alone or useother assessment instruments to supplement the u nstructuredinterview, they must be able to recognize diagnostic cluesand engage in diagnostic questioning through out the clinicalinterview to make aDSM IV TRdiagnosis. D i a g n o s t i c lu e s a n d Q u e s t io n sThe ability to interview for diagnosis without the counselorsounding as if he or she is reading off a checklist of symptom sand without getting sidetracked by less relevant information(Carlat, 2005, p. 2) is an important skill for counselors todevelop. The process of interviewing for diagnosis involvesthe counselor's ability to listen for diagnostic clues: signs andsymptoms ofDSM IV TR (APA, 2000) disorders expressedby or observed in the client during the unstructured clinicalinterview. These clues can be viewed as red flags that the cli-ent may have aDSM IV TRdisorder.

Counselors follow up diagnostic clues with diagnosticquestions to help specify a diagnosis. By using diagnosticquestioning, counselors focus on the client's signs, symp-toms, and behaviors, basing specific diagnostic questionson the diagno stic criteria of aparticular disorder (Othmer &Othmer, 2002, p. 2). Ideas for diagnostic questions can bederived directly from diagnostic criteria provided for specificdisorders in the DSM IV TR (APA, 2000), from publishedstructured iind semistructured interviews, or from textbookson diagnostic interviewing. T h e U n s t ru c t u r e d l in i c a l In t e rv i e wAlthough unstructured clinical interviews do not have astandardized format or standardized questions, it may beusefiil for counselors to follow a general outline consistingof several general content dom ains (APA, 2006; Carlat, 200 5;Morrison, 1995; Othmer & Othmer, 2002). Counselors may

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

The following section describes a general interviewoutline that counselors can follow when engaging in un-structured clinical interviews w ith adult clients. In addition,examples of diagnostic clues are provided for each sectionof the outline. In this article, I do not attempt to provide allthe possible diagnostic clues that could be presented duringan interview; however, I provide examples of diagnosticclues throughout the discussion with the goal of helpingcounselors understand the link between the backgroundinformation received during the interview and the identifica-tion of diagnostic signs and symptoms that aid in making adiagnosis. Although not discussed fully in this article, it isunderstood that the therapeutic alliance is vital in formingthe groundwork for the assessment process and effectivecounseling interventions. O u t l i n e f o r a n U n s t r u c tu r e d l in ic a lI n t e r v i e w F o r m a t

A Identifying InformationIdentifying information includes the client's nam e, sex, age,race/ethnicity, relationship status, and referral source.

Diagnostic cluesBesides providing basic informationabout the client, identifying information can provide clues to apotential diagnosis. F o r example,aclient'ss e x canb e associatedwith vulnerabilityt o certain mental illnessesm enh vehigherrates of substance abuse and antisocial disorders, whereaswomen are more vulnerable to depression, anxiety disorders,and som atic complaints (Klose Jacobi, 2004). Referral sourcecan also provide diagnostic clues. If a client was referred bya psychiatric hospital or other clinical setting, the client mayh vea previousDSM IV TR( A P A , 2000) diagnosis that remainsapplicable to the current reason for counseling.

B Presenting Problem/Chief ComplaintThe presenting problem/chief com plaint is a statement aboutthe client's problems or concerns that brought him or her tocounseling. Presenting problems can be about the client'spsychological functioning (e.g., depression or anxiety), oc-cupational functioning, or social functioning (e.g., problemsin a current relationship).

Diagnostic cluesCounselors need to listen for psycho-logical symptoms, pattems of maladjusted behavior, stress-o r s , and interpersonal conflicts in order to pick up clues todiagnosis. For example, if th e client expresses that he or shehas problems sleeping, the counselor may wish to ask specificquestions about depression. Or, if th e client reports a recentdivorce, diagnostic questions about adjustment disorder mayneed to be explored.


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C History of Presenting ProblemThe history of the presenting problem is a chronologicalhistory of the client's complaint that can provide cou nselorswith many diagn ostic clues. Counselors should have the clientelaborate on the presenting problem in three main areas (APA,2006;Othmer Othmer, 2002; Seligman, 1996):

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

Severity: Do the prob lems interfere with the client'slife in terms of w ork, relationships, and leisure pursuitsand/or lead to suffering or distress?

Stressor: Does the client believe that some externalevent brought on the problems? Have there been anystressful life events associated with the problem?

iagnostic cluesObtaining a history of the presentingproblem is vital in establishing a diagnosis. For example,symptoms for major depressive disorder and dysthymicdisorder share similar symptoms, with differences in onset,duration, and severity. The depressed mood in major d epres-sive disorder is more severe and must be present for at least2 weeks, whereas dysthymic disorder has milder symptomsand a duration o f least2years. In addition,aclient's identifica-tion ofaStressor preceding the onset of symptom s (within 3mon ths) may indicate a diagnosis of adjustment disorder.

D. Family HistoryFamily history focuses on information about the client's fam-ily background, particularly abou t any history of psychiatricproblems among family mem bers. The following are commonareas of questioning regarding family history (APA, 2006 ):

Client's first-degre e relatives (paren ts, siblings, andchildren) and their mental health history Inform ation about the client's parents and siblingsage,education, and o ccupation Comp osition of the family during the client's child-hood and adolescence Medical history of family mem bers Quality of the client's relationships with family m em-bers,both past and present Any history of child abuse, substance abuse inthe family, domestic violence, or other traumaticexperiences Any family history of suicide or violent behavior

iagnostic cluesGatheringinformation abouttheclient'sfamily is important because many mental disorders are oftenassociated with or exacerbated by the client's current or pastinteractions with family members. Gathering informationabout family history can also help to uncover any previousexperiences, such as child abuse, that may be associated w ith

a mental disorder (e.g., posttraumatic stress disorder [PTSDIn addition, mental disorders seem to have a genetic component; thus , the mental health history of older, first-degrrelatives may predict the client's future in terms of potentimental health problems (O thmer Othmer, 2002). Disordefor which there is evidence of familial transmission inclubipolar disorder, schizophrenia, depression, panic disordealcoholism, and anxiety disorders.

E Relationship HistoryRelationship h istory consists of information about the cliencurrent living situation, current and previous m arital and n omarital relationships, number of children, and the nature his or her social life and friendships. Questions may incluthe following:

How many close friends do you have (aside froyour spouse/partner)? Describe problems, if anthat you think you have in developing and keepifriendships.

Are you in an intimate relationship or married? Ifyfor how long?

Tell me about your previous relationship. How lodid it last? What happ ened?

Describe problems, if any, that you think you havedeveloping and keeping intimate relationships.

Has there ever been any violence in your cur reintimate relationship?

Have you ever experienced violence in your paintimate relationships?

iagnostic cluesRelationship history is important determining w hether the client has shown the ability to iniate and sustain intimate relationships. A pattern of sh ort-teror the lack of long-term relationships may indicate a patteof maladjustment indicative of people w ith personality diorders (Carlat, 200 5; Othm er Othmer, 2002 ). Questiooften arise concerning the client who has few, ifany,frienUnderstanding why the client has few friendships is essetial in determining whether the lack of friends is a sign ofmental disorder. For example, a client whose fear of p ossibhumiliation causes him to avoid interacting with others mhave a social phobia; in contrast, an individual who neithdesires nor enjoys close relationships and has a pattern of liing a solitary life may be d iagnosed with schizoid personalidisorder. Change in relationship status can also be associatwith mental disorders; for example, divorce or separation apears to bearisk factor for mood disorders, anxiety disordand substance-related disorders in single mothers (CairnePevalin, Wade, Veldhuizen, Arboleda-F lorez, 200 6). Anhistory of violence in a relationship may be indicative antisocial behavior, substance-related disorders, narcisspersonality disorder, or anxiety problems in the perpetrat(Stuart, Mo ore, Kahler, Ramsey, 2003) and of depressio


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

F Developmentai HistoryThe purpose of developmental history is to identify riskfactors, cultural issues, and system variables (e.g., family,comm unity) associated with the later development of men taldisorders. Early developmental milestones (such as the ageat which the client learned to walk, learned to speak, wastoilet trained) are usually not worth asking about (Morrison,1995).Questions should instead be focused on known childand adolescent risk factors associated w ith the developmentof mental disorders in adulthood. Areas to assess include thefollowing:

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 cluesMost adult psychopathology is pre-ceded by childhood mental disorders or other psychosocialrisk factors (Rutter, Kim-Cohen, & Maughan, 2006). Forexample, child abuse and other childhood traumas have longbeen associated with later problems, including PTSD andantisocial behavior (Widom, 1989, 1998); conduct problemsin childhood predict substance abu se, 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 (Rutteretal , 2006);and childhood ADH D isaprecursor o f later antisocial disorder(Mannuzza, Klein,Abikoff & M oulton, 2004).

G. Educational HistoryEducational history consists of information about theclient's educational level and professional, technical, and/orvocational training. If not addressed in the developmentalhistory section, education h istory can also include academicperformance, failed g rades, and social interaction w ith peers.Questions may include the following:

Did you graduate from high school? If not, what wasthe highest grade level achieved? Did you go to college or receive technical/vocationaltraining? Ifyes,describe the area of study.Diagnostic cluesProblems in academic achievementavebeen linked with substance abuse prob lems, antisocial be-havior, and other mental disorders in adulthood (M cConaughy,2000).In addition, because the onset of mental disord ers oftenccurs early (i.e., 50 of all lifetime case s begin by age 14,

and 75 of allcases byage 24), poor academic perform anceor interrupted education can be a sign of the early onset ofmental illness (e.g., anxiety disorders, im pulse-control disor-ders,and mood disorders; Kessler et al., 2005).

H Work HistoryWork history consists of specific information about currentemployment status, length of tenure on pastjobs,job losses,leaves of absence, and occupational injuries. The followingare sample questions:

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

Wh ere did you last work? What was your position?How long did you work there? Why did you leave? Note.A sk these questions to document jobs held overa period of several years. Ask about any periods oftime when the client did not w ork.)

Were you ever in the military service? Ifyes,for howlong? Did you experience combat? What was yourdischarge (e.g., honorable, general, dishono rable)? iagnostic clues orkhistorycanprovide manycluesthatmight indicate potential DSM-IV-TR (APA, 2000) disorders.Individuals with disabling mental disorders are less likely tobe working and m ore likely to be unemployed, out of the laborforce, or xmderemployed than are those without such disor-ders (Cook, 2006). Severe, disabling mental disorders such asschizophrenia are comm only known tobeassociated with workdisability. However, research indicates that mood disorders,

anxiety disorders, and substance abuse disordersnot the se-verely disabling typ es are also associated v^ath w ork-relatedproblems suchasreduced w ork 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 aboutprevious and current medical problems (major illnesses andinjuries), medications, hospitalizations, and disabilities. Qu es-tions may include the following: Wh at is your current, overall health? Have you ever had a serious medical illness or injury? Have you ever been hospitalized for a medicalproblem? Are you taking any medications related to a medicalproblem?

Diagnostic cluesA number of medical illnesses andmedications have resulting psychiatric sym ptoms or may ag-gravate existing psy chiatric problems. C lients w ith increasedrisk for medical problems associated with their psychologicaldifficulties include indigent person s (because of limited access


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to medical care); persons with well-established histories ofmedical illnesses or injuries; individuals with sev ere, disablingmental disorders (e.g., schizophrenia); and older adults (Pol-lak. Levy, Breitholtz, 1999). Comm on medical problemsassociated w ith psychiatric symptoms include (among o thers)thyroid disorders, head trauma, neurological disorders, circu-latory disord ers, hepatitis, seizure disorder, lupus, electrolytedisturbances and B-vitamin deficiencies. Clues that a medicalproblem could be related to a client's sjonptoms include thefollowing (PoUak et al., 1999):

Psychiatric symptoms begin following the onsetof the general medical condition or while takingmedicat ions

Psychiatric S5anptoms vary in severity withtheseverityof the general medical con dition

Psychiatric symptoms disappear when the generalmedical condition resolves Psychiatric symptom s onset after age 40

Family history of heritable medical problems Signs during the interview ofanaltered 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 problemswith coordination)

J Substance UseRegardless of the client's presenting p roblem, screening foralcohol 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 asa presenting problem to the counselor. It is important to ru leout alcohol or drug use as the underlying cause or contribu-tor to a client's difficulties. When questioning for alcohol ordrug us e, it is helpful to begin with general qu estions aboutbehaviors consistent with problematic substance use such asthe following (Antick Good ale, 2003 ):

Do you drink coffee? Caffeinated? Ifyes,how manycups per day? Do you smoke (e.g., cigarettes)? Ifyes,how much doyou smoke? For how long have you smoked? Haveyou tried to quit?

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

After asking about caffeine and smo king, move on to ques-tions about alcohol and drug u se such as the following:

Do you enjoy a drink now andthen?Ifyes,what kinds(e.g., beer, wine, distilled spirits)? Inthelast week, how many days did you drink alcohol(every day, 4- 5 times, 1-2 tim es)?

How much do you drink in one day (a case of be12-pack,6-pack to 2 beers)? How m any drinks you hold?

Do you sometimes drink or use drugs more than yplanned?

Have you used any drugs in the past year? Ifyes,wkinds? (Be sure to ask about prescription drugs.)

Have you ever had an arrest for driving under influence or had o ther legal problems associated wdrinking or using drugs?

iagnostic cluesW hen quest ioning about specisubstance use, it is important to know what is considerappro priate drink ing limits. A standard drink is definas one 12-ounce bott le of beer, one 5-ounce glaswine, or 1.5 ounces of dist i l led spiri ts . According epidemiologic research, men who drink 5 or more stdard drinks in a day (or 15 or more drinks per week) awomen w ho drink 4 or more drinks in a day (or 8 or modrinks per week) are at increased risk for alcohol-relaprob lems (Daw son, Gra nt, Li, 200 5). Often, red flfor substance use problems can be determined by askiabout problems at work, home, and school; problewith family or friends; or trouble with the law becauof substance use. For example, substance abusers ofhave unstable work histories with a pattern of brief perioof work interspersed with periods of not working. Otindicators of substance use problems include housiinstability, financial problems, violent behavior, moswings, hygiene and health problem s, and a family histoof substance abuse.

Counselors may use the CAGE questionnaire (Ewi1984) to assess alcohol abuse problems during the structured clinical interview. The CAGE questionnaire iverybrief relatively nonconfrontational questionnaire detection of alcoholism. Alcohol dependence is likely if client gives two or more positive answers to the followquestions (Ewing, 1984, p. 1907): Have you ever felt you should Cut down on ydrinking? HavepeopleAnnoyed you by criticizing your drinki Have you ever felt bad or Guilty about your drinki Have you ever had a drink first thing in the m oing to steady yournervesortogetri of a hangover (opener)?

K Legal historyLegal history entails a description o f past or current involment with the legal system. This may include warranarrests, detentions, convictions, probation, or parole asadult as well as involvement with the juvenile justice stem. Specific questions may include the following (AP2006,p. 17):


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

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

Diagnostic cluesA history of legal problems may beassociated with aggressive behavior, antisocial personal-ity disorder, substance-abuse-related disorders, or a manicepisode of bipolar disorder (Morrison, 1995). Other past orcurrent interactions with the court system (e.g., family court,civil litigation) m ay serve as significant Stressors for the clientand may indicate adjustment or anxiety disorders.L. Previous Counseling

The history of previous counseling includes a chronologicalsummary of the previous counseling sought by the client.Questions about previous coun seling include the following: Have you ever been to counseling before (as an adultor a child)? If y e s why? How long did treatment last?Was it helpful? Have you ever been hospitalized for a psych iatricproblem? If y e s why? Have you ever been on medications for psychiatricproblems (e.g., antidepressants)?

Diagnostic cluesIn formation about the client's previouscounseling can provide clues about current diagnoses. Manydisorders commonly recur, and the reason for the client'sprevious counseling could apply to the client's current prob-lem. For example, at least 60 of individuals with a singleepisode of major depressive disorder can be expected to havea second episode (APA, 2000). Previous psychiatric hospital-ization u sually indicates that the client has experienced severepsychiatric symptoms such as suicidal behavior, homicidalor aggressive behavior, or psychosis (delusions or h allucina-tions).Thus, if the client reports being previously hospital-ized for delusions, the counselor may wish to direct specificdiagnostic questions about schizophrenia (or other psycho ticdisorders) or bipolar disorder. The client's current or previ-ous use of psychotropic medications may indicate disorderssuch as mood, anxiety, or psychotic disorder, depending onthe medication prescribed.

M. Mental Status Exam ination MSE)The MS E is a screening evaluation of a ll the important areasofthe client's emo tional and cognitive fimctioning. It is basedon observations ofth e client's nonverbal and verbal behavior,including the client's description of h is or her subjective ex-periences (Othmer & Othmer, 200 2; Turner et al., 2003 ). TheMSE consists ofthe following general domains: appearance

a n d behavior speech and language, thought process and content,mood and affect, and cognitive fiinctioning (e.g., orientation,concentration, memory, and intellectualfimctioning;Sommers-Flanagan & Sommers-Flanagan, 200 3). Although the MSE iscommonly identified as a separate part of the interview pro-cess,most elements ofthe MSE are evaluated simultaneouslythroughout the unstructured clinical interview.

Although mental status information is useful in thediagnostic process, the MSE is not a primary diagnosticprocedure and not appropriate for all clients (Sommers-Fla-nagan & S ommers-Flanagan, 2003 ). A good basic guidelineis that an MSE becomes more necessary as suspected levelof psychopathology increases. If the client appears to bewell-adjusted and the counselor is not working in a medi-cal setting, a full MSE is typically unnecessary. For morespecific information about the MSE, the reader is referredto Polanski and Hinkle (2000 ). o n c lu s i o nAs the role of cou nselors in mental health, family, and com-munity coimseling settings becomes more clinical, so doesthe need for more training on accurate diagnosing during theassessment process. Th e unstructured clinical interview is theprimary assessment strategy used among counselors for deter-mining a client'sDSM IV TR(APA, 2000) diagnosis. Becausemost m aster's-level counselors (m arriage and family, m entalhealth, and commun ity) must engage in clinical interviewing,they need to be aware of effective interviewing guidelines toaid in developing accurateDSM IV TRdiagnoses.

Counselors shouldknowwhat informationth yneedt o obtainduringt h e unstructured clinical interview and how that informa-tion is relevantt o making a DSM IV TR(APA, 2000) diagnosis.Counselorsa s k qu stionsassociatedwithseveral general contentdomains to receive comprehensive information to make a diag-nosis. Throughout the interview, counselors look for diagnosticcluesofDSM IV TRdisorders and follow up those clues withdiagnostic questions to help specify a diagnosis. e fe r e n c e sAmerican P sychiatric Association. (2000).Diagnostic and statisti

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