One advantage of using a structured interview format is that it allows the clinician to:

The Clinical Interview

The clinical interview is by far the most common assessment method of SAD, or any other form of psychopathology for that matter. Clinical interviews vary along as many dimensions as there are interviewers. For example, some clinicians use a highly directive, structured format, whereas others prefer a more unstructured, free-flowing approach.

Regardless of style, there are typically three goals of the clinical interview when working with persons with social anxiety: (1) establishing rapport, (2) accurate diagnosis, and (3) assessment of symptom patterns, phobic stimuli, and impairment in functioning. The clinical interview is typically the first contact the patient has with the therapist or researcher, and as such the development of a good working rapport is critical. Although this is true with any patient, the nature of social anxiety presents special challenges to this task. It is difficult to overstate how difficult the first interview is for most persons with high social anxiety. These persons rarely realize how common their problems are, believing they are unique and perhaps even “crazy.” In addition, they often fear being judged negatively by the interviewer and are vigilant for signs of disapproval. Given the chronic, unremitting nature of SP, individuals frequently have come to view the condition as simply part of who they are and, therefore, have difficulty recognizing the ways in which their functioning has become impaired.

We recommend several strategies for interviewing persons with social anxiety. First, the clinician may begin the interview with a period of small talk to break the ice. Although open-ended questions are often preferred in clinical interviews (Greist, Kobak, Jefferson, Katzelnick, & Chene, 1995), we suggest frequently using simple closed-ended questions to help put at ease persons with social anxiety. It is especially important, however, that the interview not be perceived as an interrogation. The pace of the interview often needs to be slowed; we typically allot at least two hours for an initial interview. It is critical that the interviewer avoid signs that he or she is disapproving of something the patient says. Initial interviews with socially anxious children and adolescents can be especially challenging. We recommend beginning the initial session with some naturalistic activity away from the consultation office (e.g., an impromptu walk to purchase a drink from a vending machine), a strategy that often provides a valuable entrée into the interview process.

For adults, obtaining sufficient and reliable information to make a diagnosis according to standard criteria outlined in the DSM-IV (1994) is typically not problematic, because socially anxious adults are generally adequate informants regarding their own symptoms and the DSM-IV criteria for SAD are relatively straightforward. Such is not the case with children and adolescents, however, because they tend to under-report symptoms. Obtaining information from parents and teachers is often helpful once the child has been identified as having a problem. Unfortunately, initial identification of social anxiety in children is often difficult. In fact, SAD in children and adolescents frequently goes unnoticed by parents and school personnel alike, not being recognized unless it results in frequent school absences or outright school refusal (Kashdan & Herbert, 2001; Kearney & Albano, 2004).

The most common diagnostic dilemmas involve misdiagnosing SAD as agoraphobia and failing to recognize comorbid conditions. SAD is often misdiagnosed as agoraphobia when socially anxious individuals (SAIs) avoid so many situations that they spend a great deal of time at home. Although there is some evidence that the pattern of physiological symptoms tends to differ between the two conditions (Amies, Gelder, & Shaw, 1983), the critical distinction is made on the basis of the nature of the underlying fear: In the case of social anxiety the primary fear is of humiliation and negative evaluation by others, whereas in the case of agoraphobia it is the fear of having a panic attack. Diagnostic comorbidity with SAD is the rule rather than the exception (Schneier, Johnson, Hornig, Liebowitz, & Weissman, 1992). Among the most common comorbid diagnoses are major depression, substance abuse, and APD. In the case of depression, it is important to clarify the relationship between the two conditions over time. If the symptoms of anxiety clearly preceded the onset of depression, a separate diagnosis of SP may be warranted. If the anxiety covaries with the other symptoms of depression, the anxiety may be conceptualized as part of the depressive episode. Alcohol abuse among individuals with social anxiety is common, as many have learned to use alcohol prior to and during social situations to alleviate anxiety. Finally, the relationship between SAD and APD has been the subject of much debate (Huppert, Strunk, Ledley, Davidson, & Foa, 2008; Widiger, 1992). Although there appears to be little theoretical or empirical justification for qualitative distinctions between the two diagnostic categories, the DSM-IV rules permit both diagnoses to be made concurrently when their respective criteria are met.

Accurate diagnosis is only the beginning of the assessment process. There is substantial heterogeneity among persons with social anxiety, which is reflected in patterns of cognitive and physiological symptoms and behavioral avoidance, the stimulus parameters that elicit anxiety, and the degree of social and vocational functional impairment. A good clinical interview reviews each of these areas to generate a complete picture of the individual's clinical status. The construction of a fear hierarchy – a list of phobic social situations in order of degree of anxiety elicited and degree of avoidance – is especially important as a prelude for behaviorally oriented treatments.

The clinical interview

The clinical interview is by far the most common assessment method of SAD or any other form of psychopathology for that matter. Clinical interviews vary along as many dimensions as there are interviewers. For example, some clinicians use a highly directive, structured format, whereas others prefer a more unstructured, free-flowing approach.

Regardless of style, there are typically three goals of the clinical interview when working with persons with social anxiety: (1) establishing rapport, (2) accurate diagnosis, and (3) assessment of symptom patterns, phobic stimuli, and impairment in functioning. The clinical interview is generally the first contact the patient has with the therapist or researcher, and as such the development of a good working rapport is critical. Although this is true with any patient, the nature of social anxiety presents special challenges to this task. It is difficult to overstate how difficult the first interview is for most persons with high social anxiety. These individuals rarely realize how common their problems are, believing they are unique and perhaps even “crazy.” In addition, they often fear being judged negatively by the interviewer and are vigilant for signs of disapproval. Given the chronic, unremitting nature of SAD, individuals frequently have come to view the condition as a fundamental part of who they are and, therefore, have difficulty recognizing the ways in which their functioning has become impaired.

We recommend several strategies for interviewing persons with social anxiety. First, the clinician may begin the interview with a period of small talk to break the ice. Although open-ended questions are often preferred in clinical interviews (Greist, Kobak, Jefferson, Katzelnick, & Chene, 1995), we suggest frequently using simple closed-ended questions to help put at ease persons with social anxiety. It is especially important, however, that the interview not be perceived as interrogation. The pace of the interview often needs to be slowed; we typically allot at least two hours for an initial interview. It is critical that the interviewer avoid signs that he or she is disapproving of something the patient says. Initial interviews with socially anxious children and adolescents can be especially challenging. We recommend beginning the initial session with some naturalistic activity away from the consultation office (e.g., an impromptu walk to purchase a drink from a vending machine), a strategy that often provides a valuable entrée into the interview process.

For adults, obtaining sufficient and reliable information to make a diagnosis according to standard criteria outlined in the most recent fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013) is typically not problematic, because socially anxious adults are generally adequate informants regarding their own symptoms and the DSM-5 criteria for SAD are relatively straightforward. Such is not the case with children and adolescents, however, because they tend to under-report symptoms. Obtaining information from parents and teachers is often helpful once the child has been identified as having a problem. Unfortunately, initial identification of social anxiety in children is often difficult. In fact, SAD in children and adolescents frequently goes unnoticed by parents and school personnel alike, not being recognized unless it results in frequent school absences or outright school refusal (Kashdan & Herbert, 2001; Kearney & Albano, 2004).

The most common diagnostic dilemmas involve misdiagnosing SAD as agoraphobia and failing to recognize comorbid conditions. SAD is often misdiagnosed as agoraphobia when socially anxious individuals (SAIs) avoid so many situations that they spend a great deal of time at home. Although there is some evidence that the pattern of physiological symptoms tends to differ between the two conditions (Amies, Gelder, & Shaw, 1983), the critical distinction is made on the basis of the nature of the underlying fear. In the case of social anxiety the primary fear is of humiliation and negative evaluation by others, whereas in the case of agoraphobia it is the fear of having a panic attack. Diagnostic comorbidity with SAD is the rule rather than the exception (Schneier, Johnson, Hornig, Liebowitz, & Weissman, 1992). Among the most common comorbid diagnoses are major depression, substance abuse, and APD. In the case of depression, it is important to clarify the relationship between the two conditions over time. If the symptoms of anxiety clearly preceded the onset of depression, a separate diagnosis of SAD may be warranted. If the anxiety covaries with the other symptoms of depression, the anxiety may be conceptualized as part of the depressive episode. Alcohol abuse among individuals with social anxiety is common, as many have learned to use alcohol prior to and during social situations to alleviate anxiety. Finally, the relationship between SAD and APD has been the subject of much debate (Huppert, Strunk, Ledley, Davidson, & Foa, 2008; Kose et al., 2009; Widiger, 1992). Although there appears to be little theoretical or empirical justification for qualitative distinctions between the two diagnostic categories, the DSM-5 rules permit both diagnoses to be made concurrently when their respective criteria are met.

Accurate diagnosis is only the beginning of the assessment process. There is substantial heterogeneity among persons with social anxiety, which is reflected in patterns of cognitive and physiological symptoms and behavioral avoidance, the stimulus parameters that elicit anxiety, and the degree of social and vocational functional impairment. A good clinical interview reviews each of these areas to generate a complete picture of the individual’s clinical status. The construction of a fear hierarchy—a list of phobic social situations in order of degree of anxiety elicited and degree of avoidance—is especially important as a prelude for behaviorally oriented treatments.

4.04.4.1 Ivey's Five Stages of Intentional Interviewing and Counseling

While unstructured interviews by definition generally lack standardization, Ivey and colleagues (Ivey et al., 2012) have offered a five-stage model of the unstructured clinical interview: (1) Relationship; (2) Story and strengths; (3) Goals; (4) Restory; and (5) Action. This model organizes the interview in ways that help clinicians anticipate the trajectory of the encounter. The relationship between the assessor and the client is the focus of the first stage of the session. As the session is initiated, the assessor should seek to build rapport and trust, and provide the client with a sense of what might happen over the course of the interaction. The following stage, story and strengths, is devoted to gathering data and eliciting the client's stories, as well as their strengths and weaknesses, conflicts, and concerns. In the third stage, the assessor engages the client in mutual goal setting. That is, the purpose and direction of the interview is established based on what each party hopes to get out of the interaction. The penultimate stage of the interview involves restorying or reframing, i.e., the assessor aids in the client's exploration of new ways of thinking, feeling, and behaving in their lives. The goal of the fifth and final stage is termination. The assessor brings the interaction to a conclusion by attempting to create a plan for how new learning will be generalized to the patient's day-to-day experience. In an assessment context, the termination session is typically where feedback about the assessment results, final formulation, and suggestions for intervention or additional follow-up are shared. The assessor's responsibility is to ensure the client has a clear understanding of what findings were obtained and can logically connect these findings with the recommendations being made; the client should have the opportunity to ask questions and to ensure they understand what the next steps are for implementing the recommendations made in the final assessment report.

Interviewing

Another field technique, unstructured interviews, usually involves open-ended conversations documented either by tape recording and transcription or by note taking, followed by writing up field notes after each session. Scholars then do multiple, close readings of the texts to look for patterns, sometimes aided by qualitative analysis software, which allows the researcher to tag ideas, relate them to other places where they occur or to other ideas, and develop a map of group understanding. Because ideas are expressed in many ways, not relying on the specific terms or phrases used in quantitative content analysis, such software is only an aid, like index cards. The scholar must still accomplish the qualitative tasks of exploring, thinking, and writing about a (usually extensive) body of text.

Early on, researchers such as Harriet Zuckerman used the unstructured interview in political science to focus on the study of elites. Doug McAdam, however, published Freedom Summer, his study of young people involved in the U.S. civil rights movement, and Bill Gamson's Talking Politics explores the experiences of citizens. McAdam began with a questionnaire and followed up with interviews, but other research reverses the process, beginning with qualitative interviews, and then taking a quantitative direction once the analysis begins. A typical study, such as one John Kornacki included in his anthology, uses interviews to discover how members of a legislative body develop patterns of informal leadership, but reports the results in tables that reduce the texts to a few key questions. (The reduction would typify a different technique, i.e., structured interviewing, which occupies a middle ground between surveys and interviews, something like a questionnaire administered face to face). The study also describes its results as general, with little self-reflection, and uses a footnote to mention its methods. The footnotes also reveal that the interviews were part of a larger, funded project based on a systematic (quantitative) survey. Unlike field techniques as practiced elsewhere in social inquiry, their use in political science often springs from or leads into this sort of data processing and analysis.

In-Depth Interviews

In-depth interviews are unstructured interviews that have similarities with a conversation—albeit a conversation with a purpose, i.e., the research topic. In-depth interviews range in duration from 1 hour to upward to 5 hours and beyond. Interviews in excess of 2 hours may be conducted over a series of sessions. The keys to successful interviews are the establishment of rapport, mutual respect, and reciprocity. Advantages of in-depth interviews are that the researcher will be able to gain from the interview process information with richness and depth. Disadvantages are related to the time taken to gather and analyze information.

Range of Qualitative Interviews

As the name implies, unstructured interviews are less stringent about the assumptions of interviewing. Also referred to as open-ended interviews, they allow more fluid interaction between the researcher and the respondent. In most qualitative interviews, respondents are not required to choose from a predesigned range of answers; instead, they can elaborate on their statements and connect them with other matters of relevance. In fact, in some published manuscripts, this data-collection procedure is simply referred to as talking, signifying its informal and conversational style. The following is an example of an open-ended interview with a nursing home resident.

Jay: Everybody has a life story. Why don’t you tell me a little about your life?

Rita: Well there’s not much. I worked in a telephone company as a telephone operator before I was married. After I got married I moved to New Jersey and had two boys … (Gubrium, 1993: 20)

As seen in this example, unstructured interviewers are procedural minimalists: they simply provide a general sense of direction and allow respondents to tell their stories.

Two variants of the unstructured format are in-depth and ethnographic interviews. It is important to note, however, that the terms unstructured, in-depth, and ethnographic interviewing are sometimes used interchangeably in social science literature. Both in theory and in practice these orientations overlap. Furthermore, every study could and often does either create its own version of these techniques or uses them in combination. With these qualifications in mind, the following section offers an overview of these two interviewing techniques.

4.05.2 The Reliability and Validity of Structured Interviews

Structured interviews generally show superior evidence of validity over unstructured interviews, with convergent validity indices increasing along with the amount of structuring (Widiger and Coker, 2002). They are therefore the preferred diagnostic method in research settings (Widiger and Samuel, 2005). Some sources of inconsistency, error variance and subjective bias are reduced as the structuring of an interview increases—whereas in an unstructured interview the unique training, background, theoretical orientation, areas of expertize and focus of the examiner may guide the content and determine what specific symptoms or diagnoses are covered, and in what detail, structured interviews ensure that all potential areas of interest are followed up adequately. Simply asking each question in the same way each time eliminates a major source of variability between testing situations (i.e., information variability: Rogers, 2001). Furthermore, in many situations, interviewers form a diagnostic or other impression early on and seek to confirm these (Grossman et al., 1971; Metzger, 2005). This self-confirming bias, which may impact the content of questions in an unstructured interview or limit the exploration of alternative diagnoses, cannot determine the course of a structured interview to the same extent. Biases related to interviewer and client race, ethnicity, and other factors have been shown to be reduced with increasing interview structure as well, for example in the context of employment interviews (McCarthy et al., 2010). An additional source of variability, criterion variance, refers to inconsistencies in the way clinicians apply diagnostic criteria (Rogers, 2001). For example, clinicians may vary in terms of their relative weighting of some diagnostic factors over others depending on their favored model for a disorder's etiology or “core” features. Structuring, especially the structuring of responding and scoring options, reduces this bias as well.

The standardization and manualization of structured interviews also permits nomothetic research into each interview schedule's reliability and validity, and thereby gives the clinician a body of research work on a given interview schedule that can be used to support the reliability and validity of conclusions drawn, and alert the clinician to limitations of their method (e.g., cultural limitations, altered validity with individuals with lower cognitive functioning, age or other demographic factors). Clinical application of structured interviews ensures empirically-supported, comprehensive and consistent coverage of information relative to unstructured interviews, and can be an asset in situations in which diagnosis is likely to be challenged such as in a courtroom setting (Rogers, 2003). The degree to which this enhanced reliability and validity apply to a given administration of a structured interview depends on the degree to which the structure of the interview is standardized, the fidelity with which the clinician applies it, the adequacy of the clinician's background familiarity with the tool and with basic psychopathology, and the degree to which the client is similar to the reference groups tested during the measure's validation.

Structured and Semistructured Diagnostic Interviews

Assessment data obtained from unstructured clinical interviews tend to vary considerably and are largely interviewer dependent. As a result, unstructured interviews have particularly poor reliability and validity. When the primary assessment goal is to provide a diagnosis or a specific judgment with high interassessor reliability, as would be desired in research studies on specific psychiatric diagnoses, standardized, structured psychiatric interviews are often preferable. Structured interviews contain specific, predetermined questions with a format designed to elicit information efficiently and thoroughly. Key questions are followed by specified branch questions with restricted, closed (“yes”/“no”) or brief responses.

An example of a structured interview is the National Institute of Mental Health Diagnostic Interview for Children—IV.8 This instrument is a highly structured interview with nearly 3000 questions designed to assess more than 30, psychiatric disorders and symptoms listed in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)8a in children and adolescents aged 9 to 17 years. Parent and child versions in English and Spanish are available, and lay interviewers can administer it for epidemiological research. The Diagnostic Interview for Children and Adolescents9 is another structured diagnostic interview for children ages 6 to 17. This instrument consists of nearly 1600 questions that address 28 DSM-IV diagnoses relevant to children. Interrater reliability estimates of individual diagnoses range from poor to good, and diagnoses are moderately correlated with clinicians' diagnoses and self-rated measures.

Structured interviews result in higher interrater (or interobserver) reliability because there is little opportunity for the interviewer to influence the content of data collected. Although sometimes considered to be the “gold standard” for psychiatric diagnostic and epidemiological research, standardized interviews are not impervious to reporter bias. In addition, structured diagnostic interviews tend to rely on DSM-IV symptoms which may not be developmentally appropriate, particularly for very young children. Moreover, structured diagnostic interviews may take 1 to 3 hours to complete, which renders them impractical for most clinical settings, especially because they typically do not assess background and family factors that are necessary for developing and implementing an intervention plan.

Semistructured interviews combine aspects of traditional and behavioral interviewing techniques. Specific topic areas and questions are presented, but, in contrast to structured interviews, more detailed responses are encouraged. Semistructured formats also support use of empathic communication described previously (e.g., reflecting, paraphrasing). For example, the Semistructured Parent Interview3 contains sample questions organized around six topic areas: concerns about the child (open ended), behavioral or emotional problems (eliciting elaboration to begin a functional analysis of behavior), social functioning, school functioning, medical and developmental history, and family relations and home situations. Like other semistructured formats, the Semistructured Parent Interview encourages parent interviews built around a series of open-ended questions to introduce a topic, followed by more focused questions about specific areas of concern.

The Semistructured Clinical Interview for Children and Adolescents (SCICA)10 is an interview designed for children aged 6 to 16. It is part of the Achenbach System of Empirically Based Assessment (ASEBA)11 and was designed to be used separately or in conjunction with other ASEBA instruments (e.g., Child Behavior Checklist [CBCL], Teacher Report Form). The SCICA contains a protocol of questions and procedures assessing children's functioning across six broad areas: (1) activities, school, and job; (2) friends; (3) family relations; (4) fantasies; (5) self-perception and feelings; and (6) problems with parent/teacher. There are additional optional sections pertaining to achievement tests, screening for motor problem, and adolescent topics (e.g., somatic complaints, alcohol and drug abuse, trouble with the law). Interview information (observations and self-report) are scored on standardized rating forms and aggregated into quantitative syndrome scales and DSM-IV—oriented scales. Test-retest, interrater, and internal consistency evaluations indicate excellent to moderate estimates of reliability. Accumulating evidence for validity of the SCICA includes content validity, as well as criterion-related validity (ability to differentiate matched samples of referred and nonreferred children).

The Child and Adolescent Psychiatric Assessment12 is another semistructured diagnostic interview for children and adolescents aged 9 to 17. One interesting feature of this instrument is the inclusion of sections assessing functional impairment in a number of areas (e.g., family, peers, school, and leisure activities), family factors, and life events.

Interviews

Clinical interviewing helps to both establish rapport and obtain information. There are three general types of clinical interviews: unstructured, semistructured, and structured interviews. Unstructured interviews are free-flowing, and are generally guided by the client. The interviewer does not prepare a list of set questions in advance, but rather begins with a general question and allows the client to determine the content of the interview, and then uses probes to gather more information on certain topics. Structured interviews consist of a precise set of questions, with specific wording. The interviewer follows a script and takes responsibility for guiding the interview in order to obtain the specific requested information.

Semistructured interviews are structured, in that they provide a set list of questions; however, the client’s responses to the questions will lead the interview in different directions. For example, if a client responds ‘no’ to questions about the two key diagnostic criteria for depression, the interviewer may discontinue assessing for depression and proceed to ask questions about the next diagnosis under investigation. The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), the Autism Diagnostic Interview Revised (ADI-R), and mental status exams are good examples of semistructured interviews.

There are advantages and disadvantages to each type of interview. The risk in conducting an unstructured interview is that interviewer biases may affect the direction of the interview and the interpretation of the results. For example, the interviewer may focus on one outstanding piece of information provided by the client and make global inferences from that piece of information, about the client, without adequate further inquiry. Alternatively, the interviewer may exercise a confirmatory bias, by making an inference about a certain topic and asking questions to confirm the inference. Last, the interviewer may infer certain personality traits in the client based on limited situational information. Unreliability in structured interviews can derive from an inappropriate choice of interview that does not target the real issues at hand, inaccurate observations on the part of the interviewer, differences in the criteria assessed by the interview and the diagnostic nomenclature, and inaccurate or selective information provided by the interviewee. Structured interviews pose less of a threat of lack of reliability, but they take longer to conduct. Further, unstructured interviews are superior to structured interviews because they permit the development of rapport between interviewer and interviewee. The choice of interview should be selected based on the purpose of the assessment and the training of the diagnostician.

4.01.5.1.1 Unstructured Interviews

This type of in interview is the most frequently employed technique. Many would view it as the cornerstone of clinical psychology practice (Sommers-Flanagan et al., 2020). An unstructured interview is often conducted to obtain an initial clinical impression of the client, build rapport/establish a therapeutic relationship, clarify symptomatology, and test for discrepancies across various sources of information. Unstructured interviews allow for greater flexibility, depth, and insight into the nature of a client's problems, behaviors, and other modes of functioning, and many times they help gather information not typically accessible via other means (Sommers-Flanagan et al., 2020). Interview information is interpreted primarily through the clinician's expert judgment. Lewis et al. (2022) provide an in-depth examination of the strengths and limitations of unstructured clinical interviews, guidance on approaching the interview, and discussion of clinical formulation.