Structured versus Semistructured versus Unstructured Interviews

Structured versus Semistructured versus Unstructured Interviews Anne E. Mueller and Daniel L. Segal University of Colorado at Colorado Springs, U.S.A.

Among mental health professionals, the clinical interview is the most commonly used method for evaluating, or assessing, clients (Segal & Hersen, 2010). The purpose of the clinical interview is to develop rapport with the client while obtaining a comprehensive understanding of the client’s symptoms, including relevant biographical and historical information. This information is used to make an accurate psychiatric diagnosis, which typically guides the treatment process. Clinical interviews vary tremendously in terms of their degree of structure, ranging from completely unstructured to entirely structured. This entry reviews three types of clinical diagnostic interview (unstructured, semistructured, and fully structured interviews) and discusses the advantages and limitations of each.

The Unstructured Interview The unstructured clinical interview is a ubiquitous, time-honored, and significant contributor to the diagnostic and treatment processes in clinical psychology. In a sense, it is like a free-flowing conversation between the clinician and respondent, and there are no a priori parameters for the specific topics and relative depth of conversation. This unstructured approach provides ample opportunities for gathering general client information and a relatively rich description of the client’s experience (rather than an exclusively stringent focus on the client’s problems or symptoms). The flow, sequence, and content of this type of interview are largely determined

by the clinician’s theoretical model (e.g., psychodynamic, cognitive-behavioral, existential/humanistic, etc.), view of psychopathology, training, knowledge base, intuitions, and interpersonal style, as well as by the nature of the client’s responses. With the unstructured approach, clinicians are entirely responsible for determining the specific questions that are critical to successfully completing the diagnostic process. However, a clear advantage of this relatively unstructured approach is that it provides extensive opportunities for empathizing with the client and developing a strong therapeutic relationship. Another advantage associated with the unstructured clinical interview is its inherent flexibility with respect to topics of discussion, with no a priori guidelines limiting the boundaries of exploration. The lack of structure in this approach can be a serious disadvantage, however, as the clinician may not gather all the information needed for an accurate diagnosis and useful case conceptualization.

The Structured Interview On the other end of the spectrum, structured interviews conform to a standardized list of questions (including follow-up questions), a uniform sequence of questioning, and systematized ratings of the client’s responses. The most common types of structured interview are those that focus on the psychiatric diagnostic process. In structured diagnostic interviews, the standardized questions are designed to measure the specific criteria for mental disorders as defined in the DSM. These essential elements of structured diagnostic interviews serve several important purposes. Most notably, their use increases the coverage of many mental disorders that otherwise might be overlooked in a less standardized approach, enhances the diagnostician’s ability to accurately determine whether particular

The Encyclopedia of Clinical Psychology, First Edition. Edited by Robin L. Cautin and Scott O. Lilienfeld. © 2015 John Wiley & Sons, Inc. Published 2015 by John Wiley & Sons, Inc. DOI: 10.1002/9781118625392.wbecp069

2 STRUCTURED VERSUS SEMISTRUCTURED VERSUS UNSTRUCTURED INTERVIEWS symptoms are present or absent, and reduces variability among interviewers. Taken together, these elements serve to increase reliability, or replicability, of diagnosis. This is highly valued because diagnostic reliability is a prerequisite of diagnostic validity (discussed further below). There are two types of structured interview: fully structured and semistructured. In a fully structured interview, questions are asked verbatim to the respondent in a specific predetermined order, the wording of probes used to follow up on initial questions is specified, and interviewers are not to deviate from this format. In contrast, in a semistructured interview, although initial questions for each symptom are specified and are typically asked verbatim to the respondent, the interviewer has considerable latitude to follow up on responses. The interviewer can modify or augment the standard inquiries with individualized and contextualized probes to more accurately rate specific psychiatric symptoms. The amount of structure provided in an interview clearly impacts the extent of clinical experience and judgment needed to administer the interview appropriately: Semistructured interviews require clinically experienced examiners to administer the interview and to make diagnoses, whereas fully structured interviews can often be administered by nonclinicians who receive training on the specific instrument. This latter difference makes fully structured interviews popular and economical, especially in large-scale research studies in which an accurate diagnosis is essential (e.g., population-based epidemiological studies to determine the prevalence and incidence of various mental disorders in specific populations). Structured and semistructured interviews have been created to assist with the differential diagnosis of all major clinical and personality disorders in the DSM system, as they are specifically designed to assess the formal diagnostic criteria specified in the manual. Other structured interviews are narrower in focus, designed to assess a specific problem or form of psychopathology in great depth (e.g.,

eating disorders, substance abuse, borderline personality disorder features, gambling, autism spectrum disorder). In addition to the purpose of DSM differential diagnosis, structured interviews have been developed to assess one’s competency to stand trial or one’s personality traits according to the five-factor model of personality. Structured and semistructured interviews have many different uses or applications, including research, clinical practice, and clinical training. The research domain is the most common application in which structured and semistructured interviews are used. Such interviews may be used to formally select research participants based on particular diagnostic criteria so that etiology, comorbidity, and treatment approaches can be explored for a particular diagnosis or group of diagnoses. Sound empirical research on mental disorders requires that individuals assigned a diagnosis truly meet full criteria for that diagnosis, and thus structured and semistructured interviews help researchers achieve this need. Structured interviews also provide a standardized method for assessing change in psychopathology or diagnosis over time, which may be especially relevant in longitudinal studies. The next most common application for structured and semistructured interviews is in clinical settings, where administration of an interview is used as part of a comprehensive and standardized intake evaluation. Routine administration of a structured or semistructured interview is increasingly common in psychology training clinics, but doing so requires considerable training for clinicians and time for full administration. A variation on this theme is that sections of a structured or semistructured interview may be administered subsequent to a traditional unstructured clinical interview to confirm specific diagnoses. Finally, use of structured or semistructured interviews for training mental health professionals is an increasingly popular and ideal application because interviewers have the opportunity to learn (through repeated administrations) specific questions and follow-up

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probes used to elicit information and evaluate specific diagnostic criteria provided by the DSM. Modeling the questions, sequence, and flow from a structured or semistructured interview can be an invaluable source of training for beginning clinicians. In the mental health field, all diagnostic assessments have relative strengths and weaknesses, and structured and semistructured diagnostic interviews are no exception. Perhaps the most important advantage of structured and semistructured interviews centers on their ability to increase diagnostic reliability (which refers to consistency or agreement about diagnoses assigned by different raters). By systemizing and standardizing the questions interviewers ask and the way answers to those questions are recorded and interpreted, structured and semistructured interviews decrease the amount of information variance in diagnostic evaluations. That is, these interviews decrease the chances that two different interviewers will elicit different information from the same client, which may result in different diagnoses and subsequent treatment. Thus, interrater reliability, or the likelihood that two different interviewers examining the same individual will arrive at the same diagnosis, is greatly increased. In addition, structured and semistructured interviews increase the likelihood that the diagnosis is reliable across time and across different sources of information. In many clinical and research settings, individuals are in fact assessed on different occasions. Using a structured or semistructured interview for multiple assessments helps ensure that changes in a client’s presentation are due to changes in symptoms rather than variance in interview questions. Likewise, in many settings, clinicians conduct collateral interviews with significant people in the client’s life to glean a broader picture of the client’s symptoms, problems, and experiences. Using a structured or semistructured interview for both a client and a collateral source greatly increases the chances that discrepancies between the client and collateral informant reflect veridical

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differences, rather than consequences of different interviewing techniques. Validity of psychiatric diagnosis refers to the meaningfulness or accuracy of the diagnosis. Because reliability is a required prerequisite for validity, by virtue of the fact that structured and semistructured interviews greatly increase reliability of diagnosis, they also increase the likelihood that the diagnosis is valid. Structured interviews also improve the validity of diagnoses in other ways. The systematic construction of structured and semistructured interviews lends more methodological validity to these types of assessment as compared to unstructured approaches. Because structured and semistructured interviews are designed to thoroughly and accurately assess well-defined diagnostic criteria, they are often better assessments of those criteria than unstructured interviews. Clinicians who use unstructured interviews may diagnose too quickly, narrow their diagnostic options prematurely, and miss comorbid diagnoses. Indeed, it is not uncommon for trainee clinicians or MA/PhD level students in practicum performing an unstructured clinical interview to gather information about the presence or absence of only a few common mental disorders about which they are most conversant. Because structured and semistructured interviews require clinicians to assess all of the specified criteria for a broad range of mental disorders, they offer a more thorough and valid assessment of many disorders compared to unstructured interviews. Coverage of other disorders may be neglected during an unstructured interview if the interviewer is unfamiliar with the specific criteria of some disorders. Because they incorporate systematic ratings, structured and semistructured interviews easily provide information that allows for the determination of the level of severity and the level of impairment associated with a particular diagnosis. A final advantage of structured and semistructured interviews is their utility as training tools for trainee mental health professionals and experienced clinicians who desire to enhance their diagnostic skills.

4 STRUCTURED VERSUS SEMISTRUCTURED VERSUS UNSTRUCTURED INTERVIEWS Use of such interviews in the training context helps clinicians to develop or enhance their understanding of the flow, format, and questions inherent in a comprehensive diagnostic interview. Structured interviews can also be a useful means of training those who make preliminary mental health assessments—for example, intake staff at psychiatric hospitals or mental health clinics—so that clients are thoroughly and accurately evaluated in preparation for treatment planning. In the case of nonclinician interviewers, fully structured interviews are advisable because they minimize the amount of clinical judgment needed for accurate administration. Use of these trained paraprofessionals can make large-scale research studies cost effective. The most common criticism of structured and semistructured interviews is that their use may damage the rapport or bond between clinician and client. There is a danger that interviewers may get so concerned with the protocol of their interview that they fail to demonstrate the warmth, empathy, and genuine regard necessary to form a therapeutic alliance. However, proponents of structured interviews note that the problem of rapport-building during a structured interview can be overcome with training, experience, and flexibility. Interviewers must be aware of the potential negative effects of structured interviews on rapport building and make the nurturance of the therapeutic alliance a prominent goal during an interview, even when they are also focused on following the protocol. It behooves those who use structured and semistructured interviews to engage their respondents in a meaningful way during the interview and to avoid a rote-like interviewing style that may serve to alienate. On the other hand, not all clients have a negative perception of a structured interview that must be intentionally overcome. Some clients may prefer the structured approach to assessment because it is perceived as thorough and detailed, and in these cases rapport is easily attained. Another disadvantage of structured and semistructured diagnostic interviews is that they are limited by the validity of the

classification system itself. Because structured interviews used for diagnosis are inherently tied to specific diagnostic systems (e.g., the DSM), they are only as valid as the systems upon which they are based. One should recognize that DSM diagnostic criteria were developed to operationalize diagnostic constructs (e.g., panic disorder, depression, schizophrenia) but there is no absolute basis on which criteria were created and no definitive gold standard for diagnosis (Segal & Coolidge, 2001). Mental disorders are social constructions that have evolved over time. Furthermore, the criteria for many mental disorders in the DSM are impacted by cultural and subcultural variations in the respondent, as well as by the age of the respondent. Thus, the accuracy of certain criteria may fluctuate across various editions of the DSM, thus requiring structured and semistructured interviews to be continually updated with newer versions of the DSM. With many significant changes in diagnostic criteria coming with the publication of DSM-5, all of the current structured and semistructured interviews will have to be revised in the coming years. A final criticism of structured and semistructured interviews centers on the fact that no one structured interview can be all things in all situations, covering all disorders and eventualities. For example, if a structured interview has been designed to cover an entire diagnostic system (like the DSM that identifies over several hundred specific disorders), then inquiries about each disorder must be limited to a few inclusion criteria. In this case, the fidelity of the official diagnostic criteria has been compromised for the sake of a comprehensive interview. If the fidelity of the criteria is not compromised, then the structured interview becomes unwieldy in terms of time and effort required for its full administration. Most structured and semistructured interviews attempt some kind of compromise between these two points of tension. As can be seen, there are meaningful advantages and disadvantages of all forms of clinical interview. Users of such instruments must make a choice about which is most useful in


a given situation. It is especially important to carefully contemplate what is needed in a particular clinical or research situation before choosing a structured or semistructured interview. These interviews can be invaluable tools in both clinical and research work; however, it is essential that one does not make use of such tools without accounting for some of the problems inherent in their use. In certain situations, unstructured interviews may meet the objectives of a particular clinical inquiry more efficiently than a structured interview. In other cases, greater assurances that diagnoses assigned are valid and meaningful would take priority, such as in clinical research or in the delivery of clearly defined psychotherapeutic intervention protocols.

Specific Diagnostic Instruments Fully structured and semistructured diagnostic interviews can be divided into those that focus on either clinical disorders or personality disorders. Diagnostic Instruments Focused on Clinical Disorders Anxiety Disorders Interview Schedule for DSM-IV. The Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV; Brown, DiNardo, & Barlow, 1994) is a semistructured clinician-administered interview designed to measure current episodes of anxiety disorders as defined by the DSM-IV. It provides differential diagnosis among anxiety disorders and includes sections on mood, somatoform, and substance-use disorders, as anxiety disorders are frequently comorbid with such conditions. Administration typically takes between 45 and 60 min. Diagnostic Interview Schedule for DSM-IV. The Diagnostic Interview Schedule for DSM-IV (DIS-IV; Robins et al., 2000) is designed to ascertain the presence or absence of the most common mental disorders in the DSM. It is unique among the multidisorder diagnostic interviews in that it is a fully structured interview specifically designed for use by nonclinician interviewers, whereas all of the other

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interviews are semistructured. By definition, a fully structured interview clearly specifies all questions and probes and does not permit deviations. Due to complex scoring algorithms, the DIS-IV is typically computer-scored. Administration usually takes between 90 and 150 min. Schedule for Affective Disorders and Schizophrenia. The Schedule for Affective Disorders and Schizophrenia (SADS; Endicott & Spitzer, 1978) is a semistructured diagnostic interview designed to evaluate a range of Axis I clinical disorders, with a focus on mood and psychotic disorders. Ancillary coverage is provided for anxiety symptoms, substance abuse, psychosocial treatment history, and antisocial personality features. The SADS provides in-depth but focused coverage of the mood and psychotic disorders and also supplies meaningful distinctions of impairment in the clinical range for these disorders. The SADS can be used to make many DSM-IV diagnoses but it is not completely aligned with the DSM system, which represents a significant point of concern. It usually takes between 90 and 150 min to administer the SADS. Structured Clinical Interview for DSM-IV Axis I Disorders. The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I; First, Spitzer, Gibbon, & Williams, 1997) is a flexible, semistructured diagnostic interview designed for use by trained clinicians to diagnose many adult DSM-IV Axis I clinical disorders. The SCID-I has widespread popularity as an instrument to obtain reliable and valid psychiatric diagnoses for clinical, research, and training purposes, and it has been used in more than 1,000 studies. Full administration typically takes between 45 and 90 min. Diagnostic Instruments Focused on Personality Disorders Diagnostic Interview for DSM-IV Personality Disorders. The Diagnostic Interview for DSM-IV Personality Disorders (DIPD-IV; Zanarini, Frankenburg, Sickel, & Yong, 1996) is a semistructured interview designed to assess the presence or absence of the 10 standard DSM-IV personality disorders as

6 STRUCTURED VERSUS SEMISTRUCTURED VERSUS UNSTRUCTURED INTERVIEWS well as depressive personality disorder and passive-aggressive personality disorder in the DSM-IV appendix. It typically takes about 90 min to administer the DIPD-IV. International Personality Disorder Examination. The International Personality Disorder Examination (IPDE; Loranger, 1999) is an extensive, semistructured diagnostic interview administered by experienced clinicians to evaluate personality disorders for both the DSM-IV and ICD-10 classification systems. The IPDE was designed as a standardized assessment instrument to measure personality disorders on a worldwide basis. As such, the IPDE is the only personality disorder interview based on worldwide field trials. The IPDE manual contains the interview questions to assess either the 11 DSM-IV or the 10 ICD-10 personality disorders. The two IPDE modules (DSM-IV and ICD-10) contain both a self-administered screening questionnaire and a semistructured interview booklet with scoring materials. Because of the instrument’s ties to the DSM-IV and ICD-10 classification systems and adoption by the World Health Organization, the IPDE is widely used for international and cross-cultural investigations of personality disorders. Administration typically takes about 15 min for the self-administered screen followed by 90 min for the full interview. Structured Clinical Interview for DSM-IV Axis II Personality Disorders. To complement the Axis I version of the SCID, a version focusing on Axis II personality disorders according to DSM-IV has been developed, and it is called the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II; First, Gibbon, Spitzer, Williams, & Benjamin, 1997). The SCID-II has a similar semistructured format as the SCID Axis I version but it covers the 10 standard DSM-IV Axis II personality disorders, as well as depressive personality disorder and passive-aggressive personality disorder. For comprehensive assessment, the SCID-II may be easily used in conjunction with the Axis I SCID that would be administered prior to personality disorder assessment. Administration typically takes

about 20 min for the self-administered screen followed by 60 min for the interview portion. Structured Interview for DSM-IV Personality. The Structured Interview for DSM-IV Personality (SIDP-IV; Pfohl, Blum, & Zimmerman, 1997) is a comprehensive semistructured diagnostic interview for DSM-IV personality disorders. It covers 14 DSM-IV personality diagnoses, including the 10 standard personality disorders, self-defeating personality disorder, depressive personality disorder, negativistic personality disorder, and mixed personality disorder. Full administration typically takes between 60 and 90 min. It is apparent that structured and semistructured diagnostic interviews have greatly facilitated both the objective measurement of psychiatric symptoms and the accurate diagnosis of mental disorders in a diverse range of clinical and research settings. The unstructured clinical interview is an acceptable and common alternative to a more structured interview, especially in situations in which depth and flexibility are needed. The field’s recent emphasis on empirically supported psychotherapeutic interventions and processes has necessitated refinement and use of clinically relevant, standardized, objective, and validated assessment procedures. Indeed, structured and semistructured diagnostic interviews play an important role in the advancement of the science of clinical psychology, and it is expected that they will continue to evolve as the field of clinical psychology similarly matures. SEE ALSO: Clinical Interview; DSM-IV; EvidenceBased Assessment; Personality Disorders; Structured Clinical Interview for the DSM (SCID)

References Brown, T. A., DiNardo, P. A., & Barlow, D. H. (1994). Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV). Albany, NY: Graywind Publications. Endicott, J., & Spitzer, R. L. (1978). A diagnostic interview: “The Schedule for Affective Disorders and Schizophrenia.” Archives of General Psychiatry, 35, 837–844.


First, M. B., Gibbon, M., Spitzer, R. L., Williams, J. B. W., & Benjamin, L. S. (1997). Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II). Washington, DC: American Psychiatric Press. First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. W. (1997). Structured Clinical Interview for DSM-IV Axis I Disorders – Clinician Version (SCID-CV). Washington, DC: American Psychiatric Press. Loranger, A. W. (1999). International Personality Disorder Examination (IPDE). Odessa, FL: Psychological Assessment Resources. Pfohl, B., Blum, N., & Zimmerman, M. (1997). Structured Interview for DSM-IV Personality. Washington, DC: American Psychiatric Press. Robins, L. N., Cottler, L. B., Bucholz, K. K., Compton, W. M., North, C. S., & Rourke, K. (2000). Diagnostic Interview Schedule for DSM-IV

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(DIS-IV). St. Louis, MO: Washington University School of Medicine. Segal, D. L., & Coolidge, F. L. (2001). Diagnosis and classification. In M. Hersen & V. B. Van Hasselt (Eds.), Advanced abnormal psychology (2nd ed., pp. 5–22). New York: Kluwer Academic/Plenum. Segal, D.L., & Hersen, M. (Eds.). (2010). Diagnostic interviewing (4th ed.). New York: Springer. Zanarini, M. C., Frankenburg, F.R., Sickel, A.E., & Yong, L. (1996). The Diagnostic Interview for DSM-IV Personality Disorders (DIPD-IV). Belmont, MA: McLean Hospital.

Further Reading Hunsley, J., & Mash, E. J. (Eds.). (2008). A guide to assessments that work. New York: Oxford University Press. Rogers, R. (2001). Handbook of diagnostic and structured interviewing. New York: Guilford Press.