Assessment and Diagnosis “Under the Gun”

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CHAPTER

7 Intake

Interviewing

and Report

Writing

CHAPTER OBJECTIVES

In most mental health settings, treatment begins with an intake interview. During

an intake interview, you’re faced with the seemingly insurmountable task of

gathering a large amount of information about the client and his or her situation

while establishing and maintaining rapport. In this chapter, we review the nuts and

bolts of conducting an intake interview. Information is also provided on preparing

intake reports.

After reading this chapter, you will understand:

• The definition, nature, and objectives of a typical intake interview.

• Strategies for identifying, evaluating, and exploring client problems

and goals.

• Strategies for obtaining background or historical information about

clients, for evaluating their interpersonal styles, and for assessing their

current level of functioning.

• How agency or institutional policy, theoretical orientation, and other

factors might affect your intake interview process.

• A brief intake interviewing procedure for working with clients in

managed care or time-limited models.

• How to write a professional, but client-friendly intake report.

WHAT IS AN INTAKE INTERVIEW?

The intake interview is primarily an assessment interview. Before initiating

counseling, psychotherapy, or psychiatric treatment, it’s usually necessary and

always wise to conduct an intake interview. Intake interviews are designed to

answer a number of critical questions, which typically include:

• What is the client’s presenting problem or psychiatric diagnosis?

• Is the client motivated for treatment?

207 Sommers-Flanagan, John, and Rita Sommers-Flanagan. Coursesmart : Clinical Interviewing, John Wiley & Sons, Incorporated, 2013. ProQuest

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208 Part Three Structuring and Assessment

• What is the optimal treatment plan for this client and this problem?

• Who should provide the treatment and in what setting?

Over the past two decades, managed health care and limits imposed by thirdparty

payers have dramatically changed the nature of psychological help available

to most people. Ages ago, back when we had to walk five miles through the snow

to get to our graduate classes, our supervisors emphasized that several 50-minute

interviews were needed before enough assessment information could be obtained

to diagnose the client, develop an adequate treatment plan, and initiate treatment.

This was true even in the case of traditionally shorter therapies such as cognitive

or behavioral therapy.

Despite the fact that research data indicate longer-term treatment is more

efficacious (Lambert, 2007), many employee assistance programs and managed

care insurance plans set strict limits on the number of therapy sessions available

per year. This means practitioners must be faster and more efficient in identifying

client problems, establishing treatment goals, and outlining an expected treatment

course. For now, speed and brevity are the order of the day. In addition, treatment

goals are typically more modest in depth and breadth.

Although it’s reasonable for therapists to become more efficient in making

treatment decisions, efficiency isn’t always enhanced by speed or brevity. For

example, when individuals are pressured to work faster, it doesn’t matter whether

they’re baking cakes, building cabinets, repairing automobiles, or doing intake

interviews—the outcome is similar: Quality can be compromised.

As we discuss intake-interview procedures in this chapter, be aware that

we’re describing an intake procedure that’s more comprehensive and lengthy than

is usually expected, or even tolerated, when session numbers have an absolute

limit. We do so for several reasons. First, it’s important to learn what can be

accomplished in the context of an intake-interview assessment, even though it

may not accurately reflect what ordinarily will be accomplished. Second, insurance

companies are profit-driven organizations that regulate therapy services; they

don’t provide therapy, and it would be incorrect to assume they have expertise for

determining how mental health professionals should conduct intake interviews or

formulate treatment plans (Schoenholtz, 2012). Third, it would be unethical to

educate prospective mental health professionals using exclusively a “bare bones”

intake-assessment approach; trimming back and becoming more efficient is best

done from a broad and thorough understanding of the process. However, we

must be pragmatic; if you’re in graduate school today, chances are you will, at

some point in your career, work in settings that limit your counseling sessions.

Therefore, toward the end of this chapter, we provide an outline and checklist for

conducting brief intake interviews.

OBJECTIVES OF INTAKE INTERVIEWING

DVD Clip

In Chapter 7, the intake interview DVD chapter, John and Rita briefly

discuss the nature of the intake interview and introduce the Rita &

Michelle counseling demonstration.

Sommers-Flanagan, John, and Rita Sommers-Flanagan. Coursesmart : Clinical Interviewing, John Wiley & Sons, Incorporated, 2013. ProQuest

Chapter 7 Intake Interviewing and Report Writing 209

Broadly speaking, the three basic objectives of an intake interview are:

(1) identifying, evaluating, and exploring the client’s chief complaint and associated

therapy goals; (2) obtaining data related to the client’s interpersonal style,

interpersonal skills, and personal history; and (3) evaluating the client’s current

life situation and functioning.

Thus, the intake interviewer gathers information about:

1. The problem or problems.

2. The person.

3. The client’s current functioning.

This information is used to determine a working diagnosis (or problem formulation)

and treatment plan.

An additional objective associated with intake interviewing involves communicating

the results of your intake interview—most often to other professionals,

but sometimes to other interested parties. In mental health settings, you not only

conduct the intake interview, but also write or dictate the intake report following

your session (Zuckerman, 2010).

Identifying, Evaluating, and Exploring

Client Problems and Goals

Your first objective is to find out about your client’s chief complaint or main

problem. This begins with your opening statement (e.g., “What brings you here?”

or “How can I be of help?”; see Chapter 6). After the opening statement, at least

5 to 15 minutes should be spent tracking the client and trying to understand why

he or she has come to see you. In some cases, clients quickly identify their reasons

for seeking professional assistance; in other cases, they’re vague about why they’re

in your office. As clients articulate problems, nondirective listening responses

are used to facilitate rapport. After an initial impression of primary concerns is

obtained, questions are used more liberally.

Client problems are intrinsically linked to client goals (Jongsma, Peterson, &

Bruce, 2006). Unfortunately, many clients who come to therapy are unable to

see past their problems. Often, it’s up to you to help clients orient toward goals

or solutions early in counseling (Berg & DeJong, 2005; de Shazer et al., 2007;

J. Sommers-Flanagan & Barr, 2005). Remember that behind (or in front of) every

client problem (or complaint) is a client goal.

Common problems presented by clients include anxiety, depression, and

relationship conflicts. Other problems include eating disorders, alcoholism or

drug addiction, social skill deficits, physical or sexual abuse, stress reactions,

vocational confusion, and sexual dysfunction. Because of the wide range of

client symptoms or problems, it’s crucial that therapists have at least a general

knowledge of psychopathology and the DSM-5 (American Psychiatric Association,

2013). However, as noted, every problem has an inherent goal. Early in the intake,

therapists can help clients reframe problem statements into goal statements. For

example, problems with anxiety can be reframed as goals of calmness:

I hear you talking about feelings of nervousness and anxiety. If I understand

you correctly, you’d like to feel calm and in control more often. So,

one of your therapy goals might be to feel calm more often and to be able

to bring on those calm feelings yourself. Do I have that right?

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210 Part Three Structuring and Assessment

By reframing client problems into goal statements, therapists help clients feel

hopeful and begin a positive goal-setting process (Taylor, 2005). Goal-setting

reframes also provide useful assessment information; clients will be more or less

open to setting realistic therapy goals.

Prioritizing and Selecting Client Problems and Goals

Often, we wish clients would come to their intake interview with a single, easily

articulated problem and associated goal. For example, it might be nice (though a

bit intimidating) if a new client in the first session stated:

I have a social phobia. When in public, I worry about being scrutinized

and negatively judged. My anxiety about this is manifest through sweating,

worries about being inadequate, and avoidance of most, but not all, social

situations. What I’d like to do in therapy is build my self-confidence,

increase my positive self-talk, and learn to calm myself down when I’m

starting to get upset.

Unfortunately, most clients come to their intake interview with either a

number of interrelated complaints or with general vague symptoms. They usually

use problem-talk (verbal descriptions of what’s wrong) to express concerns about

their lives. Sometimes during an initial interview, clients will share a real, but

lower emotional-cost concern to “test out” how the therapist responds. Later,

if you pass the test, you may begin hearing about deeper concerns or problems

(Charlie Myers, personal communication, October 14, 2012).

After the initial 5 to 15 minutes of an intake interview your job is to begin

establishing a list of primary problems and goals identified by the client. Usually,

when a therapist begins helping a client identify problems and goals, it signals a

transition from general nondirective listening to a more structured, collaborative,

and/or directive approach. Transitioning from client free expression to more

structured interactions has a dual purpose. First, it allows the therapist to check

for any additional problems that the client has not yet talked about. Second, the

transition begins the process of problem prioritization, selection, and goal setting:

Therapist: So far, you’ve talked mostly about how you’ve been feeling so down

lately, how it’s so hard for you to get up in the morning, and how

most things that are usually fun for you haven’t been fun lately. I’m

wondering if you have any other major concerns or distress in your

life right now.

Client: As a matter of fact, I do. I get big butterflies. I feel so scared

sometimes. Mostly I feel scared about my career... or maybe lack

of career.

During problem exploration, therapists help clients identify their problems

or concerns. This process is truly exploratory; therapists listen closely to problems

that clients discuss, paraphrase or summarize what problems have been identified,

and inquire about the existence of additional significant concerns.

In the preceding exchange, the therapist used an indirect question to continue

exploring for problems. After several problems were identified, the therapist

moved to problem prioritization. Because all problems can’t be addressed

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Chapter 7 Intake Interviewing and Report Writing 211

simultaneously, therapist and client choose together which problem(s) need

attention during an intake. This collaborative activity is an ethical responsibility

associated with initial treatment planning (R. Sommers-Flanagan & SommersFlanagan,

2007).

Therapist: I guess so far we could summarize your major concerns as your

depressed mood, anxiety over your career, and shyness. Which of

these would you say is currently most troubling to you?

Client: Well, they all bother me, but I guess my mood is worst. When I’m

in a really bad mood and don’t get out of bed all day, I end up never

facing those other problems anyway.

This client has identified depression as his biggest concern. Of course, an

alternative formulation of the problem is that social inhibition and anxiety produce

the depressed mood and, therefore, should be dealt with first. Otherwise, the client

will never get out of bed because of his strong fears and anxieties. However, it’s

usually (but not always) best to follow client leads and explore their biggest

concerns first (psychiatrists refer to what the client considers the main problem as

the chief complaint). In this example, all three symptoms may eventually be linked

anyway. Exploring depression first still allows the clinician to integrate the anxiety

and shyness symptoms into the picture.

Even if you want to explore a different issue than the client identified (e.g.,

alcoholism), it’s best to wait and listen carefully to what the client thinks is

the main problem (chief complaint). Acknowledging, respecting, and empathizing

with the client’s perspective helps you be effective, gain trust, and keep the client in

counseling. From a motivational interviewing perspective, this process of coming

alongside clients as they discuss their concerns is essential for managing resistance

and facilitating an alliance (Miller & Rollnick, 2013). Miller and Rollnick (2013)

also warned against labeling the client’s concern as a “problem” if the client doesn’t

define it as such (e.g., with substance abuse). In time-limited circumstances (e.g.,

managed care), nondirective empathic responses are usually brief and intermittent

because there needs to be a quick transition from problems to goal setting. This

is reasonable given that goal setting has a positive effect on treatment outcome

(Latham & Locke, 2006, 2007). In Chapter 10, goal setting is discussed more

thoroughly, in the context of treatment planning.

Analyzing Symptoms

Once you have identified a primary problem, in collaboration with your client,

attention should turn to a thorough analysis of that problem, including emotional,

cognitive, and behavioral aspects. Using a list of questions similar to the following

may be helpful. As you read the questions, think about different client problems

(e.g., panic attacks, low self-esteem, unsatisfactory personal relationships, binge

eating or drinking, vocational indecision) that you might be exploring through

the use of such questions:

• When did the problem or symptoms first occur? (In some cases, the symptom

is one that the client has experienced before. If so, explore its origin and more

recent development and maintenance.)

• Where were you and what exactly was happening when you first noticed the

problem? (What was the setting, who was there, etc.?)

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212 Part Three Structuring and Assessment

• How have you tried to cope with or eliminate this problem?

• What have you done that was most successful?

• What else has been helpful?

• Are there any situations, people, or events that usually precede your experience

of this problem?

• What exactly happens when the problem or symptoms begin?

• What thoughts or images go through your mind when it’s occurring?

• Do you have any physical sensations before, during, or after the problem

occurs?

• Where and what do you feel in your body? Describe it as precisely as possible.

• How frequently do you experience this problem?

• How long does it usually last?

• How does it usually end (or what do you do that makes it finally stop)?

• Does the problem affect or interfere with what you usually do at work, at

home, or when recreating?

• In what ways does it interfere with your work, relationships, school, or

recreational pursuits?

• Describe the worst experience you’ve had with this symptom. When the

symptom is at its worst, what thoughts, images, and feelings come up?

• Describe the best experience you’ve had with this problem, a time when you

handled it very well.

• Have you ever expected the symptom to occur and it did not occur, or it

occurred only for a few moments and then disappeared?

• If you were to rate the severity of your problem, with 1 indicating no distress

and 100 indicating so much distress that it’s going to cause you to kill yourself

or die, how would you rate it today?

• What rating would you have given your symptom on its worst day ever?

• What’s the lowest rating you would ever have given your symptom? Has it

ever been completely absent?

• As we’ve discussed your symptom during this interview, have you noticed any

changes? (Has it gotten any worse or better as we’ve focused on it?)

• If you were to give this symptom and its effects on you a title, like the title of

a book or play, what title would you give it?

These questions are listed in an order that flows well in many interview situations.

However, these particular questions and their order aren’t standard, and

you don’t need to use this list. Some practitioners might take issue with the fact

that the preceding approach to analyzing the client’s problem primarily uses internalizing

or problem-saturated language (Gonc¸alves, Matos, & Santos, 2009). For

example, solution-focused or narrative therapists would use questions specifically

designed to facilitate problem externalization or questions emphasizing problem

exceptions—when the client’s problems are absent. Although the list does include

some positive-focused or constructive questioning, it’s generally more problemfocused.

Before conducting an intake interview, you might want to review the preceding

question list. You can always reword them to fit your style. New questions can

be added and others deleted until you have a set of questions that meets your

needs. We encourage you to continually revise your list so that you can become

increasingly efficient and sensitive when questioning clients. Through practice,

you can develop a sense of how many questions you can fit reasonably into a

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Chapter 7 Intake Interviewing and Report Writing 213

single interviewing session, and you may end up memorizing a list of questions

that flows well for you.

Sometimes even best-laid plans fail. Clients can be skillful at drawing therapists

off track. And at times, it may be important to be drawn off track because shifting

from your planned menu of questions can lead to a different and perhaps

more significant area (e.g., reports of sexual or physical abuse or suicidal ideation).

While focusing on your planned task, use empathic statements such as paraphrases,

feeling validation, and nondirective reflection of feeling. Remain flexible to avoid

overlooking important clues clients give about other significant problem areas.

Using Problem Conceptualization Systems

Some authors recommend using problem conceptualization systems when analyzing

client problems (Cormier, Nurius, & Osborn, 2012). Usually, these systems

are theory-based, but some are more eclectic. Most conceptualization systems

guide therapists by analyzing and conceptualizing problems with strict attention

to predetermined, specified domains of functioning. For instance, Lazarus

(1976) developed a “multimodal” behavioral-eclectic approach. Lazarus used the

acronym BASIC ID to represent his seven-modality system:

B: Behavior. Specific, concrete behavioral responses are analyzed in Lazarus’s

system. He particularly attends to behaviors that clients engage in too

often or too infrequently. These include positive or negative habits or

reactions. A multimodal therapist might ask: “Are there some things

you’d like to stop doing?” and “Are there some things you’d like to do

more often?” as a way of determining what concrete behaviors the client

might like to increase or decrease through therapy.

A: Affect. Lazarus’s definition of affect includes feelings, moods, and other

self-reported and self-described emotions. He might ask, “What makes

you happy or puts you in a good mood?” or “What emotions are most

troubling to you?”

S: Sensation. This modality refers to sensory processing of information. For

example, clients often report physical symptoms associated with high

levels of anxiety (e.g., choking, elevated temperature, heart palpitations).

The multimodal therapist might ask, “Do you have any unpleasant aches,

pains, or other physical sensations?” and “What happens to cause you

those unpleasant sensations?”

I: Imagery. Imagery consists of internal visual cognitive processes. Clients

often experience powerful pictures or images of themselves or of future

events. A multimodal therapist could query, “When you’re feeling anxious,

what images or pictures pop into your mind?”

C: Cognition. Lazarus closely evaluates client thinking patterns and beliefs.

This process usually includes an evaluation of distorted or irrational

thinking patterns that lead to emotional distress. For example, a therapist

could ask, “When you meet someone new, what thoughts go through

your mind?” and “What are some positive things you say to yourself

during the course of a day?”

I: Interpersonal Relationships. This modality concerns variables such as communication

skills, relationship patterns, and assertive capabilities as manifest

during role-play and as observed in the client-therapist relationship.

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214 Part Three Structuring and Assessment

Possible relevant questions include, “What words would you use to

describe the positive or healthy relationships that you have?” and “Who

would you like to spend more time with, and who would you like to spend

less time with?”

D: Drugs. This modality refers to biochemical and neurological factors that

can affect behavior, emotions, and thinking patterns. It includes physical

illnesses and nutritional patterns. Questions might include, “Are you

participating in any regular physical exercise?” and “Do you take any

prescription drugs?”

Lazarus’s (1976) model is broad-based, popular, and useful to therapists of

different theoretical orientations. If you’re interested in learning more about his

model, his latest book is Brief but comprehensive psychotherapy: The multimodal way

(Lazarus, 2006).

Lazarus’s model slightly overemphasizes cognitive processes (two separate

cognitive modalities exist in his seven-modality system: cognition and imaging)

while neglecting or deemphasizing spiritual, cultural, and recreational domains.

As suggested previously, similar to every system designed to aid in problem

identification, exploration, and conceptualization, the multimodal system has its

imperfections. It’s important to be familiar with numerous systems so, as a competent

professional therapist, you can flex your questioning and conceptualizing

to your setting and individual client problems and needs.

Behavioral and cognitive theorists and practitioners emphasize the importance

of antecedents and consequences in problem development and maintenance. This

approach is founded on the belief that analyzing clients’ environments and their

interpretation of environmental stimuli allows counselors to explain, predict, and

control specific symptoms. Behaviorists have called this model of conceptualizing

problem behavior the ABC model (Thoresen & Mahoney, 1974): behavioral

Antecedents, the Behavior or problem itself, and Consequences. Although this

model has been criticized (Goldfried, Greenberg, & Marmar, 1990), it’s useful to

explore—at minimum—the following ABCs with their clients:

• What events, thoughts, and experiences precede the identified problem?

• What is the precise operational definition of the problem (i.e., what behaviors

constitute the problem)?

• What events, thoughts, and experiences follow the identified problem?

When following the ABC model, therapists can be meticulous in their search

for potential behavioral antecedents and consequences. For example, behavioral

antecedents and consequences could be assessed using all modalities identified by

Lazarus (1976):

Behavior: What behaviors precede and follow symptom occurrence?

Affect: What affective experiences precede and follow symptom occurrence?

Sensation: What physical sensations precede and follow symptom occurrence?

Imagery: What images precede and follow symptom occurrence?

Cognitions: What specific thoughts precede and follow symptom occurrence?

Interpersonal: What relationship events or experiences precede or follow

symptom occurrence?

Drugs: What biochemical, physiological, or drug-use experiences precede or

follow symptom occurrence?

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Chapter 7 Intake Interviewing and Report Writing 215

DVD Clip

In the Rita & Michelle, Part One counseling demonstration, Rita begins

an intake interview and collaboratively explores the problem(s) that

brought Michelle to counseling.

Obtaining Background and Historical Information

In an intake interview, three general information sources are used to assess the

client’s personality or interpersonal style and mental condition:

1. The client’s personal history.

2. The client’s manner of interacting with others.

3. Formal evaluation of client mental status.

The remainder of this section discusses methods and issues related to obtaining

a client’s personal history and evaluating a client’s interpersonal style (evaluating

mental status is the focus of Chapter 8).

Shifting to the Personal or Psychosocial History

After spending 15 to 25 minutes exploring the presenting complaint, you should

have a reasonable idea of the primary reasons the client is seeking counseling.

A useful bridge from problem exploration to personal or psychosocial history is

the why now question. Say to the client something like:

I’m pretty clear on the main reasons you’ve come for counseling, but

one thing I’d like to know more about is why you’ve chosen to come for

counseling now.

This question helps determine what specific factors, or precipitating events,

convinced the client to seek professional help at this particular time in his or her

life. The client’s response can also shed light on whether the client is a willing

participant in the interview or perhaps was coerced by friends or family to come

for assistance. If the client balks at your why now question, simply continue to

pursue the question, perhaps through alternative approaches, such as:

• Why didn’t you come in a few weeks ago when you were first jilted by your

girlfriend?

• You’ve had these symptoms so long, I’m a little puzzled over exactly what

prompted you to seek counseling now. Why not before? And why didn’t you

choose to wait and ‘tough it out’ as you have in the past?

After your client has responded to the why now question (and after you’ve

summarized or paraphrased his or her response), you can formally shift the

interview’s focus from the problem to the person. This shift can be made with a

statement similar to the following:

So far, we’ve spent most of our time discussing the concerns that led you

to come for counseling. Now I’d like to try to get a better sense of you.

One of the best ways for me to do that is to ask you some questions about

your past.

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216 Part Three Structuring and Assessment

Nondirective Historical Leads

Immediately following your shift to psychosocial history, in most cases, you should

again become nondirective. This is because you’re moving away from analyzing

specific symptoms and entering a new domain:

• How about if you begin by telling me some of your childhood memories?

• Maybe it would be easiest if you started with where you were born and raised

and then talk about whatever significant details come to mind.

• Tell me what you remember about growing up.

For assessment purposes, your first inquiry into psychosocial history should be

nondirective or open. Clients reveal significant information simply by what they

choose to focus on and by what they choose to avoid. After a brief nondirective

period (perhaps 2 to 5 minutes), you can provide clients with more structure and

guidance and begin asking specific questions about their past.

As discussed in Chapter 6, clients may be hesitant to talk freely about their

childhood experiences; they may ask for more structure and guidance. For a few

minutes during history taking, we believe it can be useful to avoid giving structure

and guidance. If you immediately provide structure and ask specific questions, you

may never know what the client would have spontaneously chosen to talk about.

If your client presses you on this issue, you can state directly:

I’ll ask you some specific questions about your childhood in a few minutes,

but right now I’m interested in whatever past experiences and memories

come into your mind. Just tell me a few memories that seem important

to you.

At times, clients may be anxious and uncomfortable, and may resist delving into

their personal history. Personal histories are sometimes traumatic and disturbing.

Significant historical events may be hard to recall or purposely not considered or

remembered very often. In our experience, clients frequently claim, “I really can’t

remember much of my past” or “My childhood is mostly a blank.” If this happens,

provide supportive and reassuring psychoeducation:

Memory is a funny thing. Sometimes bits will come back to you as we

discuss it. Of course, most of us have memories we’d rather not recall

because they’re painful or unpleasant. My job isn’t to force you into

talking about difficult past experiences but to let you talk about whatever

past events you want to talk about.

Obtaining a psychosocial history is a delicate and sensitive process. For the

most part, intake interviews don’t involve direct questioning about specific trauma

experiences. On the other hand, opening up and sharing about traumas can be a

therapeutic and emotionally ventilating experience (Goodman & Epstein, 2008;

Simha-Alpern, 2007). Effective intake therapists give clients an opportunity to

appropriately disclose past traumatic events, but they don’t encourage disclosure

of details until an adequate therapy relationship has been established.

It’s important to be able to shift back to nondirective listening if the client

reveals significant traumatic memories or events. Many times, our students have

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Chapter 7 Intake Interviewing and Report Writing 217

asked, “What if my client has been sexually abused?” or “What if my client’s

parents died when she was a young child; what do I do then?” When you delve

into a client’s personal history, you should anticipate the possibility of hearing

emotionally charged material. When this happens, the best thing you can do is

simply listen well. You cannot fix the memories or change the past. When clients

first disclose traumatic experiences, mostly they need a supportive and empathic

ear. Comments that track your client’s experience, such as “Sounds like that was

an especially difficult time” or “That was a time when you were really down (or

angry, or anxious),” might be the most important type of response you can offer.

Some clients may have trouble pulling themselves out of emotionally distressing

memories. In such cases, clear distinctions can be made between what

happened then and what’s happening now. Explore with clients how they managed

to handle the trying times in their lives. Solution-focused approaches that involve

exploring, identifying, and emphasizing how clients coped and survived during a

difficult past situation can be very helpful. In fact, you may be able to point out

ways your clients were strong during their most difficult times. For example:

You’ve been through some very hard times, there’s no doubt about that.

And yet, it’s also clear, as I listen to you, that back then, when things

were at their worst, you reached out and got help and got yourself back

on your feet again.

It’s also helpful to gradually lead clients back to the present as you gather

historical information. You can make comments or ask questions that lead from

the past to the present, such as, “When your daughter was born, your family wasn’t

very supportive. How old is she now?” As you move into the present, your clients

may be able to gain distance from painful past experiences. On rare occasions,

a client will remain consumed with negative emotions. Sometimes, this happens

because of the powerful nature of traumatic memories. Other times, clients get

stuck because they don’t view the present as an improvement over bad times in the

past. Whatever the case, when clients get stuck in negative or traumatic memories,

it can be disheartening or frightening. We write about strategies for assessing

and managing clients who are overwhelmed by negative or suicidal thoughts in

Chapter 9 and specific approaches for moving clients to a more positive emotional

state are illustrated in Putting It in Practice 7.1.

Directive Historical Leads

After briefly allowing clients to freely discuss whatever they feel is significant in

their past, you should initiate another transition in the interview and become a

more directive explorer of your client’s past. You can potentially obtain literally

a lifetime of historical material from a client. Because you have limited time in

a typical intake, you must choose your areas of focus. A good place to begin a

directive exploration of a client’s past is with an early memory (Clark, 2002):

Counselor: What’s your earliest memory—the first thing you can remember

from your childhood?

Client: I remember my brothers trying to get me to get into my dad’s

pickup. They wanted me to pretend I was driving it. They were

laughing. I got into the cab and somehow got the truck’s brake off,

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218 Part Three Structuring and Assessment

because it started to roll. My dad got pretty mad, but my brothers

were always trying to get me to do these outrageous things.

Counselor: How old were you?

Client: I suppose about 4, maybe 5.

Memories clients report can hold significance for their present lives; the

memories represent major themes or issues the client is currently struggling with

(Carlson, Watts, & Maniacci, 2006; Sweeney, 2009). For example, the client

who revealed the preceding memory reported that his life was characterized by

performances that he put on for others. He admitted having strong urges to do

outrageous things to get attention and approval.

When clients reveal memories that are either strikingly positive or strikingly

negative, it’s useful to follow up with questions that seek an opposite type of

memory. Virtually everyone has both positive and negative childhood memories.

A good practice is to assess whether your client can produce a balanced report

of positive and negative childhood experiences. Clients who remember mostly

negative childhood experiences may be suffering from a depressive disorder,

whereas clients who never mention negative experiences may be using defense

mechanisms of denial, repression, or dissociation (Mosak, 1989):

Client: I remember breaking a pipe down in the basement of my house.

I had gotten into my dad’s tools and was striking an exposed pipe

with a hammer. It started leaking and flooded the basement. I was

in big trouble.

Counselor: It sounds like that memory was mostly of negative times when you

got in trouble. Can you think of an early memory of something

with a more positive flavor?

Client: Oh yeah, my memories of playing with my next-door neighbor are

great. My mom used to have him over and we would play with every

game and toy in the house.

Counselor: Do you remember a specific time when he came over and you

played?

Client: Uh ... yeah. He always wanted to play army, but I liked dinosaurs

better. We got in a fight, and I ended up throwing all the army men

out into the front yard. Then we stayed in and played dinosaurs.

Sometimes, even when you ask for a positive client memory, you will get a

response with negativity and conflict. On the other hand, some clients deny any

negative memories. There is probably no use in pointing out to clients, unless

they note it themselves, the fact that they reported another largely negative (or

positive) event. Instead, merely take note of the quality of their memories and

move on.

Another method for exploring childhood or, more specifically, parent-child

relationships is to ask clients to provide three words to describe their parents.

Counselor: Give me three words to describe your mother.

Client: What do you mean?

Counselor: When you think of your mother and what she’s like, what three

words best describe her?

Client: I suppose ... clean, ... and proper, and uh, intense. That’s it, intense.

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Chapter 7 Intake Interviewing and Report Writing 219

As noted, there is a high likelihood of stumbling into strong, affectively

charged memories when exploring your clients’ psychosocial history. This is

especially true when exploring parent-child relationships. Words used by clients

to describe their parents may require follow up. You can do so by asking clients

to provide specific examples:

You said your mother was intense. Can you give me an example of

something she did that fits that word?

A natural flow while history taking is: (a) first memories, (b) memories of

parents and siblings (if any), (c) school and peer relations, (d) work or employment,

and (e) other areas (see Table 7.1). Psychosocial history information that might

be covered in a very thorough intake interview is listed in Table 7.1. Note that

this is a fairly comprehensive list. In a typical clinical intake, you’ll need to be

selective regarding history taking. It’s impossible to cover everything in the 15

to 20 minutes you have to devote to personal history taking. In fact, even in a

50-minute interview exclusively dedicated to history taking, judicious selection

from the areas listed in Table 7.1 is necessary.

Table 7.1 provides an array of areas to explore in psychosocial history-taking.

Other interviewing guides are available for many of the content areas (or domains)

listed in the table (see Suggested Readings and Resources at the end of the chapter).

Because it’s often difficult to choose which domains to explore during a brief

intake interview, agencies and individual clinicians often use registration forms or

intake questionnaires for new clients. These forms provide therapists with client

information before they see the client for the first time so they can select which

domains to emphasize with a new client. Some research has examined the effects

of computer-administered intake interviews and mental status examinations.

Although this approach is impersonal, it has some advantages: Computers don’t

forget to ask particular questions, and some clients actually feel more comfortable

disclosing their drug abuse history, sexual history, or other sensitive facts (e.g.,

HIV status) to a computer rather than to an therapist (DiLillo, DeGue, Kras,

Di Loreto-Colgan, & Nash, 2006; Garb, 2007).

DVD Clip

In the Rita & Michelle, Part Two counseling demonstration, Rita explores

the possible contributions of Michelle’s personal history to the main

problem that she’s brought to counseling.

Evaluating Interpersonal Style

The claim that individuals have personality traits resulting in consistent or

predictable behavior patterns is more or less controversial, depending on your

theoretical orientation (Bem & Allen, 1974). Psychoanalytic and interpersonal

psychotherapists base their therapy approaches on the assumption that individuals

behave in highly consistent ways (Fairbairn, 1952). In contrast, cognitive and

behavioral psychotherapists are more likely to reject the concept of personality

and claim that behavior is a function of the situation or a person’s cognitions

about the situation (Beck, 1976; Mischel, 1968; Ullman & Krasner, 1969).

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220 Part Three Structuring and Assessment

Table 7.1 Personal History Interview Sample Questions

Content Areas Questions

1. First memories What is your first memory?

How old were you then?

Do you have any very positive (or negative) early

memories?

2. Descriptions and

memories of

parents

Give me three words to describe your mother (or father).

Who did you spend more time with, Mom or Dad?

What methods of discipline did your parents use with you?

What recreational or home activities did you do with your

parents?

3. Descriptions and

memories of

siblings

Did you have any brothers or sisters? (If so, how many?)

What memories do you have of time spent with your

siblings?

Who was your closest sibling and why?

Who were you most similar to in your family?

Who were you most dissimilar to in your family?

4. Elementary school

experiences

Do you remember your first day of school?

How was school for you? (Did you like school?)

What was your favorite (or best) subject in school?

What subject did you like least (or were you worst at)?

Do you have any vivid school memories?

Who was your favorite (or least favorite) teacher?

What made you like (or dislike) this teacher so much?

Were you ever suspended or expelled from school?

Describe the worst trouble you were ever in when in

school.

Were you in any special or remedial classes in school?

5. Peer relationships

(in and out of

school)

Do you remember having many friends in school?

What kinds of things did you do for fun with your friends?

Did you get along better with boys or girls?

What positive (or negative) memories do you have from

relationships you had with your friends in elementary

school?

6. Middle school,

high school,

and college

experiences

Do you remember having many friends in high school?

What kinds of things did you do for fun with your friends?

Did you get along better with boys or girls?

What positive (or negative) memories do you have from

high school?

Do you remember your first day of high school?

How was high school for you? (Did you like high school?)

What was your favorite (or best) subject in high school?

What subject did you like least (or were you worst at)?

Do you have any vivid high school memories?

Who was your favorite (or least favorite) high school

teacher?

What made you like (or dislike) this teacher so much?

Were you ever suspended or expelled from high school?

Describe the worst trouble you were ever in when in high

school.

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Chapter 7 Intake Interviewing and Report Writing 221

Table 7.1 (continued)

Content Areas Questions

What was your greatest high school achievement (or

award)?

Did you go to college?

What were your reasons for going (or not going) to

college?

What was your major field of study in college?

What is the highest degree you obtained?

7. First employment

and work

experience

What was your first job or the first way you ever earned

money?

How did you get along with your coworkers?

What kinds of positive and negative job memories do you

have?

Have you ever been fired from a job?

What is your ultimate career goal?

How much money would you like to make annually?

8. Military history and

experiences

Were you ever in the military?

Did you volunteer, or were you drafted?

Tell me about your most positive (or most negative)

experiences in the military. What was your final rank?

Were you ever disciplined? What was your offense?

9. Romantic

relationship

history

Have you ever had romantic feelings for someone?

Do you remember your first date?

What do you think makes a good romantic or loving

relationship?

What do you look for in a romantic (or marital) partner?

What first attracted you to your spouse (or significant

other)?

10. Sexual history

(including first

sexual

experience)

What did you learn about sex from your parents (or

school, siblings, peers, television, or movies)?

What do you think is most important in a sexual

relationship?

Have you had any traumatic sexual experiences (e.g.,

rape or incest)?

11. Aggressive history What is the most angry you have ever been?

Have you ever been in a fight?

Have you ever been hit or punched by someone else?

What did you learn about anger and how to deal with it

from your parents (or siblings, friends, or television)?

What do you usually do when you get angry?

Tell me about a time when you got too angry and

regretted it later.

When was your last fight?

Have you ever used a weapon (or had one used against

you) in a fight?

What is the worst you have ever hurt someone physically?

(continued)

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222 Part Three Structuring and Assessment

Table 7.1 (continued)

Content Areas Questions

12. Medical and health

history

Did you have any childhood diseases?

Any medical hospitalizations? Any surgeries?

Do you have any current medical concerns or problems?

Are you taking any prescription medications?

When was your last physical examination?

Do you have any problems with eating or sleeping or

weight loss or gain?

Have you ever been unconscious?

Are there any major diseases that seem to run in your

family (e.g., heart disease or cancer)?

Tell me about your usual diet.

What kinds of foods do you eat most often?

Do you have any allergies to foods, medicines, or

anything else?

What are your exercise patterns?

How often do you engage in aerobic exercise?

13. Psychiatric or

counseling

history

Have you ever been in counseling before?

If so, with whom and for what problems, and how long

did the counseling last?

Do you remember anything your previous counselor did

that was particularly helpful (or particularly unhelpful)?

Did counseling help with the problem? If not, what did

help?

Why did you end counseling?

Have you ever been hospitalized for psychological

reasons?

What was the problem then?

Have you ever taken medication for psychiatric

problems?

Has anyone in your family been hospitalized for

psychological reasons?

Has anyone in your family had significant mental health

problems?

Can you remember that person’s problem or diagnosis?

14. Alcohol and drug

history

When did you have your first drink of alcohol (or pot,

etc.)?

About how much alcohol do you consume each day (or

week or month)?

What is your drink/drug of choice?

Have you ever had any medical, legal, familial, or work

problems related to alcohol?

Under what circumstances are you most likely to drink?

What benefits do you believe you get from drinking?

15. Legal history Have you ever been arrested or ticketed for an illegal

activity?

Have you been issued any tickets for driving under the

influence?

Have you been given any tickets for speeding?

How many or how often?

Have you ever declared bankruptcy?

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Chapter 7 Intake Interviewing and Report Writing 223

Table 7.1 (continued)

Content Areas Questions

16. Recreational

history

What is your favorite recreational activity?

What recreational activities do you hate or avoid?

What sport, hobby, or leisure time pursuit are you

best at?

How often do you engage in your favorite (or best)

activity?

What prevents you from engaging in this activity more

often?

Whom do you do this activity with?

Are there any recreational activities that you’d like to do,

but you’ve never had the time or opportunity to try?

17. Developmental

history

Do you know the circumstance surrounding your

conception?

Was your mother’s pregnancy normal?

What was your birth weight?

Did you have any significant health or medical problems?

When did you sit, stand, and walk?

18. Spiritual or

religious history

What is your religious background?

What are your current religious or spiritual beliefs?

Do you have a religious affiliation?

Do you attend church, pray, meditate, or otherwise

participate in religious activities?

What other spiritual activities have you been involved in

previously?

For the purposes of this section, we assume that people engage in consistent

behavior patterns, but recognize that these patterns may vary greatly depending

on particular persons and situations.

Interpersonal Styles

People tend to assume specific roles in their interpersonal relationships. Some

behave in dominant ways; others are more submissive and self-effacing. Other

individuals adopt a hostile or aggressive stance in interpersonal relationships; still

others prefer to be warm and affiliative when relating to others. Some people seem

to stay consistently in one role; others behave much differently depending on the

situation and people involved. This interplay between consistency and variance

can be informative and useful in assessing clients’ interpersonal problem areas.

During an intake interview, three primary sources of data help therapists

evaluate client interpersonal style. These include:

1. Client descriptions of how he or she has related to others in the past (e.g.,

during childhood, adolescence, and young adulthood).

2. Information about how your client relates to others in his or her contemporary

relationships.

3. Client behavioral interactions that occur with you during the interview

session.

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224 Part Three Structuring and Assessment

Some psychotherapy approaches place great importance on evaluating a

client’s interpersonal style. Luborsky (1984) referred to a client’s “core conflictual

relationship theme” (p. 98). He believed psychotherapy involves helping clients

recognize the consistency in the troubles that emerge in their interpersonal relationships

and begin to have greater conscious choice regarding their interpersonal

behavior. To help clients develop greater freedom from their old interpersonal

relationship patterns, awareness of such patterns or interpersonal style is needed.

It’s not necessary and often not possible, to have a precise sense of a client’s

interpersonal style after a single interview. The goal, instead, is to have a few

working hypotheses about how your client generally relates to others. Further,

as noted by Teyber and McClure (2011), therapists should attend to feelings

elicited by clients. For example, some clients may cause you to feel bored, aroused,

depressed, or annoyed. Of course, it’s important to evaluate how much of the

reaction is a result of your client’s behavior, and how much is simply your own.

As noted previously, personal and emotional reactions you have toward clients are

a sign of countertransference (Luborsky & Barrett, 2006). Teyber and McClure

(2011) suggested that if the reactions that the client evokes in you are also evoked

in others, it’s likely that the client’s behavior is causing those reactions. However,

if your reactions are unique, then the reactions might reflect countertransference

on your part.

Evaluating a client’s personal history and interpersonal style are formidable

tasks that could easily take several sessions. However, contemporary limits on psychotherapy

usually don’t allow for lengthy assessment procedures. Traditionally,

the main purpose of exploring interpersonal and historical issues during an intake

has been to formulate hypotheses and not to provide definitive treatment plans.

Assessment of Current Functioning

After exploring historical and interpersonal issues, therapists should make one

more major shift and focus on current functioning. It’s important to end the

intake interview with a focus on the present and future—not the past. The shift to

current functioning provides both a symbolic and a concrete return to the present.

The end of the interview is also a time to encourage clients to focus on personal

strengths and social or environmental resources.

Questions during this last portion should focus on current client involvements

or activities. The following statements and questions help clients talk about areas

of current functioning:

• We’ve talked about your major concerns and a bit about your past. I’d like to

shift back to what’s happening in your life right now.

• What kinds of activities fill up your usual day?

• Describe a typical day in your life.

• How much time do you spend at work?

• About how much time do you spend with your partner (spouse)?

• What do you and your partner do together? How often do you do these

activities?

• Do you spend much time alone?

• What do you most enjoy doing all by yourself?

Some clients have difficulty shifting from talking about their past to talking

about the present. This can be especially true with clients who had difficult or

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Chapter 7 Intake Interviewing and Report Writing 225

traumatic childhoods. In such cases, you can use two primary strategies so clients

can view their intake interviewing experience in an appropriate and realistic

context. When clients become upset during an intake interview, respond by (1)

validating the client’s feelings and (2) instilling hope for positive change. For

example, in a case of a mother who comes to counseling shortly after losing her

child to a tragic accident, you might state:

I can see that losing your son has been terribly painful. You probably

already know that your feelings are totally normal. Most people consider

losing a child to be the most emotionally painful experience possible.

Also, I want you to know how smart it is for you to come and talk with me

so openly about your son’s death and your feelings. It won’t make your

sad and horrible feelings magically go away, but in almost every case,

talking about your grief is the right thing to do. It will help you move

through the grieving process.

Feeling validation, as discussed in Chapter 3, involves acknowledgment and

approval of a client’s feelings. This technique is generally reassuring to clients and

is an appropriate tool toward the end of an intake when a client is experiencing

painful or disturbing feelings. Another more general example of what a therapist

might say to a client who is in emotional pain or distress toward the end of an

intake follows:

I can’t help but notice that you’re still feeling pretty sad about what we’ve

talked about today. I want you to know that it’s very natural to have sad

or upset feelings. Many people who come in to talk to a counselor leave

with mixed feelings. That’s because it’s hard to talk about your childhood

or your personal problems without having uncomfortable feelings, but

sort of good at the same time. What you’re feeling is natural.

It’s normal to feel bad when talking about sad, disappointing, or traumatic

events. Therapists should provide this factual information to clients in a reassuring,

validating manner. Reassurance and support are essential parts of an effective

closing (see Putting It in Practice 7.1).

PUTTING IT IN PRACTICE 7.1

Helping Clients Regain Emotional Control

It’s not unusual for clients to experience emotional distress during

an intake interview. Generally, this is a natural process and clients

also naturally pull themselves together and are in decent emotional

shape by the interview’s end. However, sometimes, toward the end

of an interview, your client may still be emotionally distraught and

you will need to help him/her regain emotional control before leaving

your office. Although there are no strategies that guarantee emotional

(continued)

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226 Part Three Structuring and Assessment

(continued)

reconstitution, the following techniques may be helpful. Of course, these

strategies or techniques should be prefaced with empathic comments.

[Focus or refocus on the present and immediate future] What are

your plans for the rest of the day? What will you do right after you leave

here? Is there anything in particular that you might want to do that

would be emotionally comforting?

[Ask the client about what s/he usually does for emotional soothing]

When you feel upset at home or outside therapy, what do you usually

do to help yourself feel better?

[Change the subject back to a more positive issue] Earlier when we

were talking I was very impressed with how you’ve been handling your

work stress.

[Give a compliment and suggestion] It takes lots of strength to be

as open as you’ve been with me today. I hope you recognize that and

can give yourself a pat on the back.

[Acknowledge the negative reality and then have the client review

some positives] Sometimes it’s hard to get refocused on the positive,

and so I’m going to ask you some questions that will take some thought

and help move you in that direction. What were the most positive things

you would say you’ll take from our meeting today?

Reviewing Goals and Monitoring Change

Another issue toward the end of the intake is the future. Clients come to counseling

or therapy because they want change, and change involves the future.

Many therapists pose some form of the following question toward the end

of the intake: “Let’s say that therapy is successful and you notice some major

changes in your life. What will have changed?” Other future-oriented questions

may also be appropriate, including “How do you see yourself changing in the

next several years?” or “What kind of personal (or career) goals are you striving

toward?” Discussing therapy goals during an intake interview or in early therapy

sessions provide a foundation for termination (J. Sommers-Flanagan & SommersFlanagan,

2007b). Through establishing clear definitions of desired change, clients

and therapists can jointly monitor the progress of therapy and together determine

when the end of therapy is approaching. Client goals should be formulated from

client problems at the beginning of an intake interview. It’s also important to

review client goals in a positive and upbeat manner toward the interview’s end.

DVD Clip

In the Rita & Michelle, Part Three counseling demonstration, Rita closes

the intake with Michelle, tries an initial or early interpretation, and begins

planning for future sessions.

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Chapter 7 Intake Interviewing and Report Writing 227

FACTORS AFFECTING INTAKE

INTERVIEW PROCEDURES

To conduct an intake interview that thoroughly covers each area described in this

chapter within a traditional 50-minute period is impossible. As a professional, you

must make choices regarding what to emphasize, what to deemphasize, and what

to ignore. Several factors affect your choices.

Client Registration Forms

Some agencies and practitioners rely on client registration forms or intake

questionnaires for information about clients. This practice is especially helpful

for obtaining detailed information that might unnecessarily extend the clinical

hour. For example, registration forms that include space for listing names of

previous therapists, names and telephone numbers of primary care physicians,

and basic biographical information (e.g., date of birth, age, birthplace, educational

attainment) are essential.

Although intake questionnaires are acceptable in moderation, when used

excessively, they may offend or intimidate clients. For example, some agencies use

10- to 15-page intake questionnaires to screen potential clients. These questionnaires

contain many extremely personal questions, such as “Have you experienced

sexual abuse?” and “Describe how you were punished as a child.” This type of

questionnaire can be offensive and should not be used without first thoroughly

explaining its purpose to clients. It also may be appropriate, depending on your

setting, to include standardized symptom checklists or behavioral inventories

as a part of a pretherapy questionnaire battery (although the purpose of these

questionnaires should be explained to clients before administering them).

Institutional Setting

Often, information obtained in an initial interview is partly a function of agency or

therapist policy. Some institutions, such as psychiatric hospitals, require diagnostic

or historical information; other settings, such as health maintenance organizations,

place greater emphasis on problem or symptom analysis, goal setting, and treatment

planning. Your intake approach will vary depending on your employment

setting.

Theoretical Orientation

The therapist’s theoretical orientation can strongly influence both what information

is obtained during an intake session and how it’s obtained. Specifically,

behavioral and cognitively oriented therapists tend to focus on current problems,

and psychoanalytic therapists downplay current problem analysis in favor

of historical information. Person-centered therapists focus on the current situation

and how clients are feeling (e.g., whether any discrepancies exist between

clients’ real and ideal selves). Solution-oriented therapists focus on the future and

dwell on potential solutions rather than laboriously examining past or current

problems. Psychoanalytic, person-centered, and feminist therapists are also less

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228 Part Three Structuring and Assessment

likely to make use of detailed client registration forms, computerized interviewing

procedures, or standardized questionnaires.

Professional Background and Professional Affiliation

Your professional background and professional affiliation can have a strong influence

on what information is obtained in an intake interview. Before writing this

book, we asked professionals from different backgrounds for their opinions about

what was most needed in an interviewing textbook. The correlation between

response content and respondents’ areas of professional training was strikingly

high. Psychiatrists emphasized the importance of mental status exam and diagnostic

interviewing, based on the DSM-IV-TR or DSM-5. Clinical psychologists were

interested in assessment and diagnosis as well, but they also emphasized problem

assessment and behavioral and cognitive analysis. Counselors and counseling

psychologists focused less on formal assessment and more on listening skills and

helping strategies; clinical social workers expressed interest in psychosocial history

taking, treatment planning, and listening skills. Marriage and family therapists

stressed the importance of understanding the family and social systems and milieu

of the client. Actually, addressing all these areas is important. Your training,

theoretical orientation, and professional affiliations influence the major focus and

proportion of attention paid in certain areas, but in reality, none of these areas

should be systematically neglected.

BRIEF INTAKE INTERVIEWING

Given the current cost containment climate in health care, it’s essential for therapists

to be trained to conduct abbreviated intake interviews. Intake interview

objectives remain the same when operating under a limited session philosophy.

Obtaining information about clients’ problems and goals, the clients themselves,

and clients’ current situation is essential. However, three primary modifications

are necessary for obtaining this information within the usual employee assistance

or managed care guidelines. First, therapists must rely more extensively on

registration forms and questionnaire data obtained from clients before an initial

meeting. Second, therapists must use more questions and permit less time for

client-directed self-expression. Third, therapists must reduce time spent obtaining

personal history and interpersonal style information. Because using registration

forms and questionnaires and asking more questions are both relatively straightforward

modifications, the following discussion focuses on how to briefly obtain

personal history and interpersonal style information. We also provide an outline

for conducting brief intake interviews (see Table 7.2).

Obtaining Historical and Interpersonal Style Information

Time-limited mental health philosophy involves placing responsibility for client

well-being back on the client (Hoyt, 1996). In some ways this model empowers

clients to make greater contributions to their own mental health. To stay within

this model, when reviewing a client’s history, you might say:

We have only a few minutes to discuss your childhood and things that

have happened to you in the past. So, very briefly, tell me, what are the

most essential things I need to know about your past?

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Chapter 7 Intake Interviewing and Report Writing 229

Often, when given this assignment, clients can successfully identify a few

critical incidents in their developmental history. As an alternative, if therapists

see clients for a second or follow-up session, they can ask for a one- to twopage

biographical summary. This offers clients an opportunity to communicate

essential historical information in a time-sensitive manner.

Information pertaining to client interpersonal style is minimally relevant

when total sessions available are very limited. Therefore, although gathering

information associated with client interpersonal dynamics may be a part of a

time-limited intake, little or none of the therapist’s time can be directly devoted

to this task. Several approaches to dealing with this issue may be employed.

First, interpersonal information may be ignored unless clients exhibit DSM-5

personality disorder characteristics. In such cases, counselors can use a checklist

to indicate whether a client exhibits interpersonal behaviors consistent with one

or more of the three personality disorder clusters. If the presence of a personality

disorder is suspected, further and more definitive assessment may be pursued,

depending on the particular managed care policy.

Second, therapists may employ an abbreviated mental status examination

format. In such cases, notes or reports about the client would briefly state the

nature and quality of a client’s “attitude toward the interviewer” (see Chapter 8

for detailed information regarding mental status examinations).

Third, therapists may reflect, after the session, on how they were affected by

their client. After this reflection, some hypotheses can be generated and written

down to assure that, if necessary, attention can be paid to further understanding

of interpersonal dynamics during the next session.

A Brief Intake Checklist

A managed care or limited-session intake outline is included in Table 7.2. We

recommend that you practice full-scale intake interviews as well as abbreviated

intake interviews (see Putting It in Practice 7.2).

PUTTING IT IN PRACTICE 7.2

Prompting Clients to Stick With Essential Information

Using the limited-session intake-interviewing checklist provided in

Table 7.2, work with a partner from class to streamline your intake

interviewing skills. Therapists working in a managed care environment

must stay focused and goal-directed throughout the intake interview.

To maintain this crucial focus, it may be helpful to:

1. Inform your client in advance that you have only a limited amount

of time and therefore must stick to essential issues or key factors.

2. If your client drifts into some less-essential area, gently redirect him

or her by saying something such as:

“You know, I’d like to hear more about what your mother thinks

about global warming (or whatever issue is being discussed), but

(continued)

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230 Part Three Structuring and Assessment

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because our time is limited, I’m going to ask you a different set of

questions. Between this meeting and our next meeting, I want you to

write me an autobiography—maybe a couple of pages about your personal

history and experiences that have shaped your life. If you want, you

can include some information about your mom in your autobiography

and get it to me before our next session.”

Often, clients are willing to talk about particular issues at great

length, but when asked to write about those issues, they’re much more

succinct.

Overall, the key point is to politely prompt clients to only discuss

essential and highly relevant information about themselves. Either

before or after practicing this activity with your partner, see how many

gentle prompts you can develop to facilitate managed care intake

interviewing procedures.

THE INTAKE REPORT

Report writing constitutes a unique challenge to clinicians. You must consider at

least five dimensions:

1. Determining your audience.

2. Choosing the structure and content of your report.

3. Writing clearly and concisely.

4. Keeping your report confidential.

5. Sharing the report with your client.

Before discussing these dimensions, it should be emphasized that therapists

have a responsibility to keep and maintain client records. Although this responsibility

varies depending on your professional affiliation and theoretical orientation,

failure to maintain appropriate records is unethical and, in some cases, illegal. The

American Psychological Association’s (2010) ethical code includes the following

statement:

Psychologists create, and to the extent the records are under their

control, maintain, disseminate, store, retain, and dispose of records and

data relating to their professional and scientific work. (p. 1067)

The American Counseling Association (2005) has an almost identical statement

in its ethical code:

Counselors maintain records necessary for rendering professional services

to their clients and as required by laws, regulations, or agency or

institution procedures. (p. 4)

The guidelines as written by the American Counseling Association and

American Psychological Association imply a balancing act; they suggest, but don’t

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Chapter 7 Intake Interviewing and Report Writing 231

Table 7.2 A Brief Intake Checklist

When necessary, the following topics may be covered quickly and efficiently

within a time-limited model.

p 1. Obtain presession or registration information from the client in a

sensitive manner. Specifically, explain: “This background information

will help us provide you with services more efficiently.”

p 2. Inform clients of session time limits at the beginning of their session.

This information can also be provided on the registration materials.

All policy information, as well as informed consent forms, should be

provided to clients prior to meeting with their therapist.

p 3. Allow clients a brief time period (not more than 10 minutes) to introduce

themselves and their problems to you. Begin asking specific diagnostic

questions toward the 10-minute mark, if not before.

p 4. Summarize clients’ major problem (and sometimes a secondary problem)

back to them. Obtain agreement from them that they would like

to work on their primary problem area.

p 5. Help clients reframe their primary problem into a realistic long-term

goal.

p 6. Briefly identify how long clients have had their particular problem. Also,

ask for a review of how they have tried to remediate their problem

(e.g., what approaches have been used previously).

p 7. Identify problem antecedents and consequences, but also ask clients

about problem exceptions. For example: “Tell me about times when

your problem isn’t occurring. What happens that helps you eliminate

the problem at those times?”

p 8. Tell clients that their personal history is important to you, but that there

is obviously not time available to explore their past. Instead, ask them

to tell you two or three critical events that they believe you should

know about them. Also, ask them about (a) sexual abuse, (b) physical

abuse, (c) traumatic experiences, (d) suicide attempts, (e) episodes of

violent behavior or loss of personal control, (f) brain injuries or pertinent

medical problems, and (g) current suicidal or homicidal impulses.

p 9. If you will be conducting ongoing counseling, you may ask clients to

write a brief (two- to three-page) autobiography.

p 10. Emphasize goals and solutions rather than problems and causes.

p 11. Give clients a homework assignment to be completed before they

return for another session. This may include behavioral or cognitive

self-monitoring or a solution-oriented exception assignment.

p 12. After the initial session, write up a treatment plan that clients can sign

at the beginning of the second session.

directly state, that written documents must meet standards set by more than

one entity. This leads us to a discussion of the first challenge of report writing:

Determining your audience.

Determining Your Audience

Consider this question: When you write an intake report, are you writing it for

yourself, another professional, your client, your supervisor, and/or your client’s

insurance company? As you write, who might be looking over your shoulder?

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Having a diverse audience may be the hardest part of report writing. For

example, imagine giving your report to a supervisor. Depending on your supervisor,

you might emphasize your diagnostic skills through a sophisticated discussion

of your client’s psychopathology or you might try using behavioral jargon such as

“consequential thinking, response cost, and behavioral rehearsal.” On the other

hand, if you imagine your client reading your report, you may choose to avoid

the behavioral jargon—and certainly you will deemphasize complex discussions

of psychopathology (see Multicultural Highlight 7.1).

MULTICULTURAL HIGHLIGHT 7.1

Using Person-First and Constructive Language

For at least two decades there has been a strong movement within

education, rehabilitation, and psychology toward using person-first

language. This linguistic approach emphasizes the person first and his

or her disability second. For example, instead of referring to an individual

as “a visually impaired man,” using person-first language we would say,

“a man with a visual impairment.”

Of course, like all new ideas or movements, person-first language

has strong supporters and dissenters. For example, Jeanette Lim of the

Office of Civil Rights (OCR) of the U.S. Department of Education issued

a memorandum in support of person-first language in 1992, stating:

the preference of individuals with disabilities to use phraseology

that stresses the individuality of all children, youth, and adults,

and then the incidence of a disability. In all our written and oral

communications, care should be given to avoid expressions

that many persons find offensive. (quoted in Bickford, 2004,

pp. 120– 121)

In contrast, the National Federation of the Blind wrote:

We believe that it’s respectable to be blind, and although we

have no particular pride in the fact of our blindness, neither do

we have any shame in it. To the extent that euphemisms are

used to convey any other concept or image, we deplore such

use. We can make our own way in the world on equal terms

with others, and we intend to do it. (quoted in Bickford, 2004,

p. 121)

To make matters even more complex, preliminary research indicates

that people with disabilities often have either no preference for personfirst

versus disability-first language and sometimes report preferring

disability-first language (Bickford, 2004).

As professionals who wish to be advocates for individuals in need

of mental health services, we find this debate fascinating on many

levels. Although we believe language has the potential to shift attitudes

and increase consciousness, we also believe individuals with disabilities

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Chapter 7 Intake Interviewing and Report Writing 233

(AKA: disabled individuals) have a right to reject a movement that some

see as representing political correctness.

From another perspective, the domain of professional publications,

our mandate is clearly articulated in the American Psychological Association’s

Publication Manual, which states: “[t]he guiding principle for

‘nonhandicapping’ language is to maintain the integrity of individuals

and human beings. Avoid language that equates persons with their

condition ... .” (American Psychological Association, 2010, p. 69)

Somewhat surprisingly, we find that within the field of mental

health, this issue may be less controversial. For example, we find it

very important—and not particularly politically correct—to use terms

like “the boy with ADHD” rather than “the ADHD boy.” Somehow, at

least for us, we consider it very important to always lead with the person

when referring to individuals with mental disorders, even though it may

be easier to speak using mental-disorder-first language.

Recently, we found a “case study” in a textbook that helped clarify

our position on this issue. The case study was written using what we

consider to be old-fashioned positivistic language that we tend to

associate with medicine and psychiatry. For example, the following

words and language were used: “Lois Carter, a chronically depressed

European American woman, was torn with guilt over her perceived

failure to rear a child who could function adequately at home and in

school ... Mrs. Carter’s mother was a passive aggressive woman who

turned to religion for comfort in her later years ... . His mother was a

pleasant though ineffectual woman ... .”

For us, the language in this case study was too judgmental, too

pejorative, and too conclusive. After reading this language we were

able to clearly identify our position on person-first language. We find

it very important to speak about clients and write reports about clients

in ways that are respectful and that honor possibilities for change and

growth and possibilities that we may be incorrect in our conclusions.

When referring to mental health issues and diagnoses, we avoid “labelfirst”

language and try to write and speak in all formal communications

with enough respect that we wouldn’t mind if the client or patient were

to overhear our communication. Further, we believe it’s inappropriate to

give lifelong labels to individuals with mental health issues, when, given

the longstanding problems of reliability and validity associated with

psychiatric diagnosis, the lifelong labels may well be inappropriate (and

limiting). On the other hand, although we lean toward using person-first

language with individuals who have physical disabilities, we also remain

open to respecting their views on how they prefer to be addressed or

described.

After contemplating these issues, some beginning therapists throw up their

hands in frustration and consider writing two versions of the same report. This

solution might be fine, except that it requires too much extra work and, in the

end, your client has a right to read whatever you write about him or her anyway

(even the version of the report solely aimed at impressing your supervisor).

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234 Part Three Structuring and Assessment

In the end, the answer to the question posed earlier, “Who’s looking over

your shoulder?” is this: Just about everybody. As you write, include the following

list of people and agencies in your imagined audience:

• Your client

• Your supervisor

• Your agency administrator

• Your client’s attorney

• Your client’s insurance company

• Your professional colleagues

• Your professional association’s ethics board

• Your state or local ethics board

After the preceding discussion, you should feel either motivated to write a

carefully crafted intake report or flagrantly paranoid. We hope it’s the former. For

additional guidance regarding intake report writing, see Putting It in Practice 7.3:

The Intake Report Outline, as well as the case example at the end of this chapter.

PUTTING IT IN PRACTICE 7.3

The Intake Report Outline

Use the following outline as a guide for writing a thorough intake report.

Keep in mind that this outline is lengthy and, therefore, in practical

clinical situations, you will need to select what to include and what to

omit in your client reports.

Confidential Intake Report

NAME: DATE OF BIRTH:

AGE: DATE OF INTAKE:

INTAKE INTERVIEWER: DATE OF REPORT:

I. Identifying Information and Reason for Referral

A. Client name

B. Age

C. Sex

D. Racial/Ethnic information

E. Marital status

F. Referral source (and telephone number, when possible)

G. Reason for referral (why has the client been sent to you for a

consultation/intake session?)

H. Presenting complaint (use a quote from the client to describe

the complaint)

II. Behavioral Observations (and Mental Status Examination).

A. Appearance upon presentation (including comments about

hygiene, eye contact, body posture, and facial expression)

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B. Quality and quantity of speech and responsivity to questioning

C. Client description of mood (use a quote in the report when

appropriate)

D. Primary thought content (including presence or absence of

suicide ideation)

E. Level of cooperation with the interview

F. Estimate of adequacy of the data obtained

III. History of the Present Problem (or Illness)

A. Include one paragraph describing the client’s presenting

problems and associated current stressors.

B. Include one or two paragraphs outlining when the problem

initially began and the course or development of symptoms.

C. Repeat, as needed, paragraph-long descriptions of additional

current problems identified during the intake interview

(client problems are usually organized using diagnostic—

DSM—groupings, however, suicide ideation, homicide

ideation, relationship problems, etc., may be listed).

D. Follow, as appropriate, with relevant negative or rule-out

statements (e.g., with a clinically depressed client, it’s important

to rule out mania: “The client denied any history of

manic episodes.”).

IV. Past Treatment (Psychiatric) History and Family Treatment

(Psychiatric) History

A. Include a description of previous clinical problems or

episodes not included in the previous section (e.g., if the

client is presenting with a problem of clinical anxiety, but

also has a history of treatment for an eating disorder, the

eating disorder should be noted here).

B. Description of previous treatment received, including hospitalization,

medications, psychotherapy or counseling, case

management, and so on.

C. Include a description of all psychiatric and substance abuse

disorders found in all blood relatives (i.e., at least parents,

siblings, grandparents, and children, but also possibly aunts,

uncles, and cousins).

D. Also include a list of any significant major medical disorders

in blood relatives (e.g., cancer, diabetes, seizure disorders,

thyroid disease).

V. Relevant Medical History

A. List and briefly describe past hospitalizations and major medical

illnesses (e.g., asthma, HIV positive, hypertension).

B. Include a description of the client’s current health status (it’s

good to use a client quote or physician quote here).

C. Current medications and dosages.

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D. Primary care physician (and/or specialty physician) and telephone

numbers.

VI. Developmental History (This section is optional and is most

appropriate for inclusion in child/adolescent cases.)

VII. Social and Family History

A. Early memories/experiences (including, when appropriate,

descriptions of parents and possible abuse or childhood

trauma)

B. Educational history

C. Employment history

D. Military history

E. Romantic relationship history

F. Sexual history

G. Aggression/Violence history

H. Alcohol/Drug history (if not previously covered as a primary

problem area)

I. Legal history

J. Recreational history

K. Spiritual/Religious history

VIII. Current Situation and Functioning

A. A description of typical daily activities

B. Self-perceived strengths and weaknesses

C. Ability to complete normal activities of daily living

IX. Diagnostic Impressions (This section should include a discussion

of diagnostic issues or a listing of assigned diagnoses.)

A. Brief discussion of diagnostic issues

B. Diagnostic code and label from ICD-10 or DSM-5

X. Case Formulation and Treatment Plan

A. Include a paragraph description of how you conceptualize

the case. This description will provide a foundation for

how you will work with this person. For example, a behaviorist

will emphasize reinforcement contingencies that have

influenced the client’s development of symptoms and that

will likely aid in alleviation of client symptoms. Alternatively,

a psychoanalytically oriented therapist will emphasize personality

dynamics and historically significant and repeating

relationship conflicts.

B. Include a paragraph description (or list) of recommended

treatment approaches.

Choosing the Structure and Content of Your Report

The structure of your intake report varies based on your professional affiliation,

professional setting, and personal preferences. For example, psychiatrists are

more likely to emphasize medical history, mental status, and diagnosis, while

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social workers are more inclined to include lengthier sections on social and

developmental history. The following suggested structure (and accompanying

outline in Putting It in Practice 7.3) won’t please everyone, but it can be easily

modified to suit your particular needs and interests. Also, keep in mind that the

following structure errs on the side of being thorough; abbreviated intake reports

may be preferred.

Identifying Information and Reason for Referral

After listing client name, date of birth, age, date of the intake session, date of the

report, and interviewer’s name and professional credentials, most intake reports

begin with a narrative section to orient the reader to the report. This section is

typically one or two short paragraphs and includes identifying information and a

summary of the reasons for referral. Psychiatrists usually label this initial section

Identifying Information and Chief Complaint, but the substance of the section is

essentially the same as described here. It might read something like:

John Smith, a 53-year-old married Caucasian male, was referred for

psychotherapy by his primary care physician, Nancy Jones, MD (509-

555-5555). Dr. Jones described Mr. Smith as “moderately depressed”

and as suffering from “intermittent anxiety, insomnia, and general distress

associated with his recent job loss.” During his initial session,

Mr. Smith confirmed these problems and added that “troubles at home

with the wife” and “finances” were furthering his overall discomfort and

“shame.”

Behavioral Observations (and Mental Status Examination)

The intake report begins with concrete, objective data and eventually moves

toward more subjective therapist judgments. After the initial section, the intake

report turns to specific behavioral observations. Depending on your institutional

setting, these specific observations may or may not include a complete mental

status report (i.e., if you’re in a medical setting, inclusion of a mental status

examination is more likely, and possibly required). However, because we discuss

mental status examinations in the next chapter, the following example includes

a basic description of the therapist’s behavioral observations, with only minor

references to mental status.

Mr. Smith presented as a short and slightly overweight man who looked

approximately his stated age. His hair looked greasy and unkempt and

he had slight body odor. Mr. Smith’s eyes were sometimes downcast

and sometimes focused intensely on the therapist. He engaged in

frequent hand wringing, and his crossed legs bounced continuously.

He spoke deliberately, answering interview questions briefly and to the

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point; he responded directly to all therapist questions. He described

himself as feeling “pathetic” and “hyper.” He acknowledged suicidal

ideation, but denied suicidal intent, stating, “I’ve thought about ending

my life, but I’m the kind of person who would never do it.” Mr. Smith

was cooperative with the interview process; the following information is

likely an accurate representation of his past and present condition.

History of the Present Problem (or Illness)

Traditionally, psychiatrists include a section in the intake report entitled, History

of the Present Illness. This terminology reflects a medical model orientation and

may or may not be a good fit for nonphysicians or appropriate for nonmedical

settings. This section is for stating the client’s particular problem in some detail,

along with its unique evolution. The history and description of several problems

may be included.

Mr. Smith reported that he’s been feeling “incredibly down” for the

past 6 weeks, ever since being laid off from his job as a millworker

at a local wood products company. Initially, after losing his job, Mr.

Smith indicated he was “angry and resentful”at the company. For about

two weeks, he aggressively campaigned against his termination and,

along with several coworkers, consulted an attorney. After it became

apparent that he would not be rehired and that he had no legitimate

claim against the company, he went for two job interviews, but reported

“leaving in a panic” during the second interview. Subsequently, he

began having difficulty sleeping, started snacking at all hours of the day

and night, and quickly gained 10 pounds. He also reported difficulty

concentrating, feelings of worthlessness, suicide ideation, and minimal

constructive activity during the course of a typical day. He stated: “I’ve

lost my confidence. I got nothing to offer anybody. I don’t even know

myself anymore.”

When asked if he had previously experienced deep sadness or

anxiety, Mr. Smith responded with, “Never.” He claimed that this is

the “first time” he’s ever had any “head problems.” Mr. Smith denied

experiencing recurrent panic attacks and minimized the significance of

his “panic” during the job interview by claiming “I was just getting in

touch with reality. I don’t have much to offer an employer.”

Past Treatment (Psychiatric) History and Family Treatment

(Psychiatric) History

For many clients, this section is brief or nonexistent. For others, it’s extensive, and

you may need to reference other records you’ve reviewed regarding the client. For

example, you might simply make a summary statement such as: “This client has

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been seen previously by a number of mental health providers for the treatment

of posttraumatic stress disorder, substance abuse, and depression” unless there is

something in particular about the treatment that warrants specification (e.g., a

particular form of treatment, such as “dialectical behavior therapy” was employed

and associated with a positive or negative outcome). In this section, we also include

information on any family history of psychiatric problems (although some report

writers devote a separate section to this topic).

Mr. Smith has never received mental health treatment previously. In the

referral note from his primary physician, it was acknowledged that he

was offered antidepressant medications at his outpatient appointment,

but refused to take them in favor of a trial of psychotherapy.

Initially, Mr. Smith reported that no one in his family had ever seen a

mental health professional, but later admitted his paternal uncle suffered

from depression and received “shock therapy” back in the 1970s. He

denied the existence of any other mental problems with regard to both

himself and his family.

Very little information was provided by Mr. Smith’s primary care physician

regarding his medical history. During the interview, Mr. Smith described

himself as in generally good health. He denied having major illnesses

or hospitalizations during his childhood or teen years. He noted that he

rarely “gets sick”and that his employment attendance was exceptionally

good. To the best of his recollection, his only major medical problems

and associated treatments were for kidney stones (1996) and removal

of a benign polyp from his colon (1998). He reported taking vitamins

and glucosamine sulfate (for general health and joint pain), but currently

does not take any prescription medications. Mr. Smith’s primary care

physician is Dr. Emil Rodriquez.

Mr. Smith was born and raised in Kirkland, Washington, a suburb of

Seattle. He was the third of five children born of Edith and Michael

Smith. His parents, now in their late 70s, have remained married and

still live in the Seattle area, although they’re beginning to experience

significant health problems. Mr. Smith remains close to them, visiting

several times a year and expressing concern about their well-being. He

reported no significant conflicts or problems in his relationships with his

parents or siblings.

Early childhood memories were characterized by Mr. Smith as

“normal.” He described his parents as “loving and strict.” He denied

any experiences or knowledge of sexual or physical abuse in his family

of origin.

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Mr. Smith attended school in his hometown and graduated from

high school in 1977. He described himself as “an average student.” He

had some minor disciplinary problems, including numerous detentions

(usually for failing to turn in his homework) and one suspension (for

fighting on school grounds).

Following high school graduation, Mr. Smith moved to Spokane,

Washington, and briefly attended Spokane Falls Community College.

During this time, he met his eventual wife and decided to seek employment,

rather than pursue college. He worked briefly at a number of jobs,

including as a service-station attendant and roofer, eventually obtaining

employment at the local wood-products plant. He reported working at

the plant for 31 years. He emphasized that he has always been a hard

worker and has never been fired from a job. Mr. Smith never served in

the military.

In terms of overall demeanor, Mr. Smith indicated that he has always

been (until recently) “friendly and confident.” He dated a number of

young women in high school and continued to do so after moving to

Spokane. He met Irene, the woman he married, in 1977, shortly before

turning 20 years old. He described her as “the perfect fit”and described

himself as a happily married man. He denied any sexual difficulties, but

acknowledged diminished sexual interest and desire over the past month

or so. He stated that his “pathetic condition” following his job loss had

put a strain on his marriage, but he believed his marriage is still strong.

Mr. Smith and his wife have been married for 37 years. They have

three children (two sons and one daughter; ages 28 to 34), all of whom

live within 100 miles of Mr. and Mrs. Smith. According to Mr. Smith, all

of his children are doing fairly well. He reported regular contact with his

children and seven grandchildren.

Mr. Smith occasionally got in “fights” or “scuffles” during his school

years, but emphasized that such behavior was “normal.”He denied ever

using a weapon in a fight and reported that his most recent physical

altercation was just after quitting college, “back when I was about 20.”

Alcohol and drugs have never been a significant problem for Mr.

Smith. He reported drinking excessively a number of times in high

school and a number of times in college. He also noted that he went

out with his buddies for “some beers” every Friday after work and that

he also would have a few beers on Tuesdays, associated with his and his

wife’s participation in a bowling league. He briefly experimented with

marijuana while enrolled in college, but claimed, “I didn’t like it.” He’s

never experimented with any “harder” drugs and denied any problems

with prescription drugs, stating: “I avoid ’em when I can.”

Other than a few speeding tickets (usually on the drive from Spokane

to Seattle), Mr. Smith denied legal problems. His only nonvehicularrelated

citation was in his “college days” when he was cited for

“disorderly conduct” while “causing a ruckus” outside a bar with a

group of his “drinking buddies.”He was required to pay a small fine and

write a letter of apology to the business owner.

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Mr. Smith reported that his favorite recreational activities include

bowling, fishing, and duck hunting. He also acknowledged that he and

his wife enjoy traveling together and gambling small amounts of money

at casinos. He denied ever losing more money than he could “afford

to lose” and said he does not consider his small-scale gambling to

be a problem. He admitted that recently he has not been interested in

“having any fun.”Consequently, his involvement in recreational activities

has been curtailed.

Mr. Smith was raised Catholic and reported attending church “off

and on” for most of his life. He said he is currently in an “off” period, as

he has not attended for about nine months. His wife attends regularly,

but he indicates that his irregular attendance has not really been a

problem in their relationship. He considers himself a “Christian” and a

“Catholic.”

Relevant Medical History

Depending on how much information you have obtained from your client’s

physician and on how closely you have covered this area during the intake, you

may or may not have much medical history to include. At minimum, ask your

client about (a) his or her general health, (b) any recent or chronic physical

illnesses or hospitalizations, (c) prescription medications, and (d) when he or she

last had a physical. Additionally, if you have the name (and telephone number) of

your client’s primary physician, include that information as well.

Developmental History

The developmental history begins before birth and focuses primarily on the

achievement of specific developmental milestones. A developmental history is

most appropriate when working with child or adolescent clients. We discuss the

developmental history in Chapter 11.

Social and Family History

Writing a social and family history about your client can be like writing a fulllength

novel. Everyone’s life takes many twists and turns; your goal, as a historian, is

to condense the client’s life into a tight narrative. Be brief, relevant, organized, and

whenever possible, summarize or present highlights (or low spots) of the client’s

history. Once again, the depth, breadth, and length of your social/developmental

history depend on the purpose of your intake and your institutional setting (topics

to be covered are listed in Putting It in Practice 7.3).

Current Situation and Functioning

This section of the intake report focuses on three main topics: (1) usual daily

activities, (2) client self-perception of personal strengths, and (3) apparent ability

to adequately perform usual age-appropriate activities of daily living. Depending

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242 Part Three Structuring and Assessment

on your setting and preference, it’s also possible to expand on this section

by including a description of the client’s psychological functioning, cognitive

functioning, emotional functioning, or personality functioning. This provides the

therapist with an opportunity to use more of a subjective appraisal of current

client functioning in a variety of areas.

Currently, during a typical day, Mr. Smith rises at about 7 A.M., has coffee

and breakfast with his wife, reads the newspaper, and then moves to

the living room to watch the morning news. He indicated that he usually

reads the “classified” section closely for job opportunities, circling the

positions he may be interested in. However, after moving into the living

room, he reports doing everything he can to avoid having to go out

and seek employment. Sometimes he watches television, but he reports

being too “pent up” to sit around too long, so he goes out to the

garage or into his backyard and “putters around.” He usually makes

himself a sandwich or a bowl of soup for lunch and then continues his

puttering. At about 5:30 P.M., his wife returns home from her job as an

administrator at a local nonprofit corporation. Occasionally, she reminds

him of his plans to get a new job, but Mr. Smith indicated that he usually

responds with irritation (“It’s like I try to bite her head off.”) and then

she retreats to the kitchen and makes dinner. After dinner with his wife,

he “continues to waste time” by watching television until it’s time to

retire. His usual routine is interrupted on the weekends, often by visits

from his children and grandchildren and sometimes when he and his

wife venture out to a local casino to “spend a few nickels” (however, he

indicated their weekend activities are diminishing because of tightening

finances).

Mr. Smith sees himself as ordinarily having numerous personal

strengths, although he needed prompting to elaborate on these. For

example, he considers himself an honest man, a hard worker, and a

devoted husband and father. He further believes he is a good buddy to

several friends and fun to be around (“back when I was working and had

a life”). In terms of intelligence, Mr. Smith claimed he is “no dummy”

but that he is having some trouble concentrating and “remembering

anything” lately. When asked about personal weaknesses, Mr. Smith

stated, “I hope you got lotsa ink left in that pen of yours, Doc,” but

primarily focused on his current state of mind, which he described as

“being a problem of not having the guts to get back on that horse that

bucked me off.”

Despite his poor hygiene and general lack of productiveness, Mr.

Smith seems capable of adequately performing most activities of daily

living. He reported occasionally cooking dinner, fixing the lawnmower,

and taking care of other household and maintenance tasks. His perception,

and it may be accurate, is that he is less efficient with most tasks

because of distractibility and intermittent forgetfulness. His interpersonal

functioning appears somewhat limited, as he described relatively

few current outside involvements.

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Chapter 7 Intake Interviewing and Report Writing 243

Diagnostic Impressions

For good reason, students are often reluctant to assign a diagnosis to clients.

Nonetheless, most intake reports should include some discussion of diagnostic

issues, even if you discuss only broad diagnostic categories, such as depression,

anxiety, substance use, eating disorders, and so on. In some cases, clients will need

a diagnosis in order to access their insurance benefits. Although simply listing

your diagnostic considerations is acceptable in some circumstances and including

a single psychiatric diagnosis is preferred by managed care companies, our preference

is for a brief discussion of diagnostic issues followed by a DSM-5 diagnosis.

The brief discussion orients the reader to how you conceptualized your diagnosis,

and it can even include an explanation of why you chose one particular diagnostic

label over another. In the following case, we use Morrison’s (2007) guidelines of

assigning the least severe label that adequately explains the symptom pattern.

This 53-year-old man is suffering from an adjustment disorder. Although

he meets the diagnostic criteria for major depression, I’m reluctant to

assign this diagnosis because his depressive symptoms are associated

with recent life changes and he has no personal and minimal family

history of a mood disorder. Mr. Smith is also experiencing numerous

significant anxiety symptoms, which may actually be more central than

his depressive symptoms in interfering with his ability to seek new

employment. Similarly, a case could also be made for assigning him

an anxiety disorder diagnosis, but again, the abrupt onset of these

symptoms is in direct association with his job loss suggests that his

current mental state is better accounted for with a less severe diagnostic

label.

His provisional **DSM-5 diagnosis follows:

Axis I: 309.28 (DSM) or F43.23 (ICD) Adjustment Disorder

with Mixed Anxiety and Depressed Mood

(Provisional)

Rule Out (R/O) 296.21 (DSM) or F32.0 (ICD) Major Depressive

Disorder, Single Episode, Mild

Note that in the preceding diagnosis we used a number of procedures

provided by the DSM for indicating diagnostic uncertainty.

Specifically, we used the “provisional” tag and included a “rule out”

diagnostic possibility (major depression).

Case Formulation and Treatment Plan

For this section, include a paragraph description of how you conceptualize the case.

This description provides you an opportunity to describe how you view the case

and how you’re likely to proceed in working therapeutically with this client. Not

surprisingly, behaviorists describe their cases in behavioral terminology, while

psychoanalytically oriented therapists describe their cases using psychoanalytic

terminology. Generally, keep your theoretical jargon to a minimum, in case your

client requests a copy of your intake report.

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244 Part Three Structuring and Assessment

Mr. Smith is a stable and reliable individual who is currently suffering

from severe adjustment to sudden unemployment. It appears that,

for many years, much of his identity has been associated with his

work life. Consequently, he feels depressed and anxious without the

structure of his usual workday. Furthermore, his depression, anxiety,

and lack of perceived constructive activities have considerably shaken

his confidence. For a variety of reasons, he feels unable to go out

and pursue employment, which, especially because of his strong values

of normality and employment, further reduces his confidence in and

respect for himself.

Psychotherapy with Mr. Smith should focus on two simultaneous

goals. First, although it’s impossible to provide him with new employment,

it’s crucial that Mr. Smith begin making a consistent effort to seek

and obtain employment. It seems unrealistic to simply suggest to him

(after 31 years of employment) that he reconstruct his identity and begin

valuing himself as an unemployed person. The treatment objectives

associated with this general goal include:

1. Analyze factors preventing Mr. Smith from following through on his

daily job searches.

2. Develop physical anxiety coping strategies (including relaxation and

daily exercise).

3. Develop and implement cognitive coping strategies (including cognitive

restructuring and self-instructional techniques).

4. Develop and implement social coping strategies (including peer or

spousal support for job-seeking behaviors).

5. Develop and implement social-emotional coping strategies. (Mr.

Smith needs to learn to express his feelings about his personal

situation to close friends and family without pushing them away

through irritable or socially aversive behaviors).

The second general goal for Mr. Smith is to help him expand his

identity beyond that of a man who is a long-term employee at a wood

products company. Objectives associated with this second goal include:

1. Helping Mr. Smith recognize valuable aspects of relationships and

activities outside an employment situation.

2. Helping Mr. Smith identify how he would talk with a person in a

similar situation, and then have him translate that attitude and “talk”

into a self-talk strategy with himself.

3. Exploring with Mr. Smith his eventual plans for retirement.

Although Mr. Smith’s therapy will be primarily individually oriented

treatment, it’s recommended that his spouse accompany him to some

sessions for assessment and support purposes. As he noted, there

have been increasing conflicts in their relationship, and it should prove

beneficial for them to work together to help him cope more effectively

with this difficult and sudden life change.

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Chapter 7 Intake Interviewing and Report Writing 245

Overall, it’s important to encourage Mr. Smith to use his alreadyexisting

positive personal skills and resources to address this new

challenge in his life. If, after 8 to 10 sessions using this approach, no

progress has been attained, I will discuss the possibility of medication

treatment and/or an alternative change in approach to his treatment.

Writing Clearly and Concisely

Writing a clear and concise intake report takes time and effort. Don’t expect to

sit down and write the report perfectly the first time. It may take several drafts

before you get it to the point where you want anyone else to see it. We have

several recommendations for making the writing process more tolerable.

• Write the report as soon as possible (immediately following the session is

ideal; the longer you wait, the harder it’s to reconstruct the session in your

mind and from your notes).

• Write an immediate draft without worrying about perfect wording or style;

then store it in a confidential location and return to it soon for editing.

• Closely follow an outline; although we recommend the outline in Putting It

in Practice 7.3, following virtually any outline is better than simply rambling

on about the client.

• Try to get clear information from your supervisor or employer about what’s

expected. If a standard format is available, follow it.

• If your agency has sample reports available, look them over and use them as a

model for your report.

• Remember, like any skill, report writing becomes easier with practice; many

seasoned professionals dictate a full intake report in 20 to 30 minutes—and

someday you may do so as well.

Another issue associated with writing concisely involves choosing what information

to put into your intake report. How brief and how detailed should you be?

How much deeply personal information should be included in the report? Our

position is to be only as detailed as is necessary and as can be accomplished while

remaining respectful (see Multicultural Highlight 7.1).

Keeping Your Report Confidential

It’s hard to overemphasize confidentiality. We all need to be reminded that our

clients are disclosing personal information about their lives, and we need to treat

that information like precious jewels. To help assure intake report confidentiality,

we always type or stamp the word CONFIDENTIAL on our reports. This is no

guarantee of confidentiality, but it’s a step in the right direction.

Be sure to have an adequately secure place for storing client records. Don’t

leave your report on your desk or open on your computer where clients and

unauthorized colleagues might accidentally discover it. Keeping your records

stored securely is simpler if you keep paper records (a locked file drawer in a

locked office should suffice).

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246 Part Three Structuring and Assessment

Organizations and individuals relying on electronic systems for maintaining

confidential records face unique problems and must closely adhere to the Health

Insurance Portability and Accountability Act of 1996 (HIPAA). Information about

HIPAA compliance is available widely on the Internet, in many books/journals,

and addressed briefly in Chapter 15.

Sharing the Report With Your Client

Although clients have a legal right to access their medical-psychologicalcounseling

records, its good practice to be careful when releasing a report directly

to a client. Once again, it’s a balancing act. Because of consumer rights, clients

have a right to their records. On the other hand, some clients may misunderstand

or misinterpret what you’ve written—meaning you can get yourself in trouble by

releasing the information.

In most cases, we follow these guidelines:

• Inform clients at the outset of counseling that you will keep records and that

they have access to them.

• When appropriate, inform clients that some portions of the records are written

in language designed to communicate with other professionals; consequently,

the records may not be especially easy to read or understand.

• If clients request their records, tell them you would like to review the records

with them as you release the records, so as to minimize the possibility that the

records are misinterpreted—you can even say that such a practice is suggested

in your professional ethical guidelines.

• When clients request records, schedule an appointment (free of charge) with

them to review the records together.

• If clients are no longer seeing you, are angry with you, or refuse to meet with

you, you can (a) release the records to them without a meeting (and hope

the records are not misinterpreted), or (b) agree to release the records only to

another licensed professional (who will review them with the client).

• Whatever the situation, always discuss the issue of releasing records with your

supervisor, rather than acting impulsively on your client’s request.

When clients request to see their records, it’s important to remain calm and

acknowledge their rights. It’s also important to have a procedure for sharing the

records and to follow that procedure closely. Most clients will be satisfied if you

treat them with compassion and respect and if your records about them are written

in a compassionate and respectful manner (see Multicultural Highlight 7.1).

SUMMARY

The intake interview is probably the most basic type of interview that mental

health professionals conduct. It involves obtaining information about a new

client to identify what type of treatment, if any, is most appropriate. The intake

is primarily an assessment interview, and usually involves the liberal use of

questions.

The three major objectives of intake interviewing involve evaluating the

client’s: (1) current problems (perhaps psychiatric diagnosis) and goals, (2) personality,

personal history, and mental condition, and (3) current situation.

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Chapter 7 Intake Interviewing and Report Writing 247

Evaluating a client’s problems and goals requires that therapists identify the

client’s main source of personal distress as well as the range of other problems

contributing to the discomfort. Problems and goals need to be prioritized and

selected for potential therapeutic intervention. Many theory-based assessment

systems are available to help therapists analyze and conceptualize client symptoms.

Usually, these systems involve identifying the factors or events that precede and

follow occurrence of client symptoms.

Obtaining personal history information about clients is a sensitive and challenging

process. Personal history flows from early memories to descriptions of

parents and family experiences to school and peer relationships to employment.

Therapists must be selective and flexible regarding the historical information

they choose to obtain from their clients; there’s always way too much historical

information than can be covered in a single interview.

The last focus in an intake is the client’s current functioning. Therapists

should focus on current functioning toward the interview’s end because it helps

bring clients back in touch with their current situation, both liabilities and

assets. The end of the interview should emphasize client personal strengths and

social-environmental resources and focus on the future and on goal setting.

Client registration forms and intake questionnaires can help therapists determine

in advance some of the areas to cover in a given intake. The therapist’s

theoretical orientation, therapeutic setting, and professional background and affiliation

also guide the focus of intake interviews. An approach to providing an initial

interview within managed care guidelines is outlined.

Writing the intake report is a major challenge for most therapists. When

preparing an intake report, consider your audience, the structure and content of

your report, how to write clearly and concisely, how you will keep the report

confidential, and how you might share it with your client.