Strategies for identifying

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?

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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.

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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

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

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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

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

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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

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