Wright (2011). Clinical interviewing and hypothesis building.

The presenting problem (i.e. referral question) refers to determining in what way an individual’s functioning is impaired. The nature of this problem often becomes apparent through the process of the clinical interview (1), the collection of background information (2) and clinical observations (3).

The clinical interview consists of the presenting problem (1), a symptomatic evaluation (2) and a psychosocial evaluation (3).

The presenting problem includes whatever complaint the individual identifies as the reason for the assessment. The presenting problem can be straight-forward but can also be unclear because of numerous factors. A detailed history of the presenting problem (e.g. when it began, precipitating events, etc) needs to be developed. This can include using previous assessments.

Symptomatic evaluation refers to the symptomatic and medical features of what may be impairing the client’s functioning (i.e. the specific symptoms). To obtain a full symptomatic evaluation, the developmental history (1), medical history (2) and substance use history (3) needs to be obtained.

The developmental history includes information about the early developmental environment (1), significant events during childhood (2) and childhood behavioural problems (3). The psychiatric history, the history of psychiatric symptoms and treatments, is extremely important for understanding the course of the individual’s problems. Alcohol/substance use history refers to the history of any potential substance use and this should be discussed, even if the use was not with regards to an addiction. The attitudes about using or quitting any substances need to be obtained. Medical history includes information about serious medical illnesses, hospitalizations and medication use. Temporal changes in medical history and in the present problem and symptomology are important.

It is also relevant to ask about the family medical and psychiatric history because of a potential heritable illness/disorder.

The psychosocial evaluation helps to examine the context of the individual’s world. In this part, it is essential to consider that symptoms are manifested within a larger context of relating to others and that they will likely be affecting personal functioning, educational and work functioning and other areas of life.

The family structure and the relationships with family members needs to be assessed. The educational and vocational history should also be assessed, including the functioning within school and educational aspirations. The criminal and legal history should also be assessed. This includes legal involvement and a history of criminal behaviour. The social history, the history of socialization, should also be discussed. This includes the number of friends and the quality of these friendships. The social networks and social activities during development are also of interest.

The psychosexual history refers to all psychosocial issues related to sexuality, including history of romantic and sexual behaviour and exploration, sexual adjustment and attitudes, gender identification and sexual orientation. The multicultural evaluation refers to understanding the cultural environment in which a person is functioning.

MENTAL STATUS EVALUATION
Clinical observation is one of the most important tools for evaluating a person’s current functioning. The mental status evaluation is a method of organizing clinical observation data. The mental status evaluation consists of several components:

1. Appearance and behaviour
   This includes how someone appears and behaves.
2. Speech and language
   A person’s language functioning influences how a person can be assessed in other domains. Language should be evaluated separately for receptive (1) and expressive (2) elements.
3. Mood and affect
   This includes evaluating whether mood and affect are appropriate to the situation (1) and appropriate to each other (2).
4. Thought process and content
   This includes evaluating how an individual thinks (e.g. logical) and what the person thinks about.
5. Cognition
   This should be assessed by the clinician and by the tests which are used later on.
6. Prefrontal functioning
   This includes assessment of the functioning of the functions related to the prefrontal cortex. It is difficult to judge by clinical observation alone and will require tests as well.

Receptive language refers to language comprehension. Expressive language refers to the individual’s actual use of language. Mood refers to the current emotional state of an individual as reported by the individual. Affect refers to the observed emotional state of the individual.

HYPOTHESIS BUILDING
After the data collection, it is important to answer the question of what may be causing impaired functioning of a person. This requires proper knowledge of psychodiagnostics (1) and knowledge of cognitive, personality and emotional functioning from other theoretical perspectives (2).

Hypotheses should be generated for all likely causes of functional impairment. One hypothesis should always be that the individual’s functioning is normative and functional (i.e. null hypothesis).

The precise impairments in functioning need to be mapped. After this, all logical possible causes for the broad areas of impairment need to be summed up. It must be ruled out that the impairment of functioning is due to a substance-related disorder or due to a general medical condition.