Advantage: Increased Reliability

Perhaps the most important advantage of structured interviews centers on their ability to increase diagnostic reliability (reliability defined in this context refers to consistency or agreement about diagnoses assigned by different raters; Coolidge & Segal, 2010a). By systemizing and standardizing the questions interviewers ask, and the way answers to those questions are recorded and interpreted, structured interviews decrease the amount of information variance in diagnostic evaluations (e.g., Rogers, 2001). That is, structured interviews decrease the chances that two different interviewers will elicit different information from the same client, which may result in different diagnoses. Thus, interrater reliability, or the likelihood that two different interviewers examining the same individual will arrive at the same diagnosis, is greatly increased.

Increased interrater reliability has broad implications in clinical and research settings. Because many psychological and psychopharmacological treatments are intimately tied to specific diagnoses, it is imperative that those diagnoses be accurate (Segal & Coolidge, 2001). Thus, if different clinicians interviewing the same client arrive at different diagnostic conclusions, it would be challenging to make a definitive decision about treatment. Similarly, accurate diagnosis is also essential for many types of clinical research, for example, studies that address causes and treatments of specific forms of psychopathology (Segal & Coolidge). Imagine a study examining different treatments for bipolar disorder. In such a study, it would be imperative to be certain that those individuals in the treatment groups actually have accurate diagnoses of bipolar disorder. Researchers must be able to accurately and definitively diagnose participants with the disorder being studied before researchers can even begin to examine theories of etiology or the effectiveness of treatment for that particular mental disorder.

In addition to increasing interrater reliability, structured interviews increase the likelihood that the diagnosis is reliable across time and across different sources of information (Rogers, 2001). In many clinical and research settings, individuals are in fact assessed on different occasions. Making multiple assessments could be dangerous if an interviewer evaluates a client in a different manner with different questions on different occasions. The client’s presentation may be substantially altered because the manner in which the client is asked about those symptoms has changed instead of the client’s symptoms or diagnosis being different. Using a standardized interview for multiple assessments helps ensure that if a client’s presentation has changed, it is because his or her symptoms are actually different, not because of variance in interviews (Rogers). Likewise, in many settings, clinicians conduct collateral interviews with significant people in the client’s life to glean a broader picture of the client’s symptoms, problems, and experiences. Using a structured interview for both a client and a collateral source will likely increase the chances that discrepancies between the client and collateral informant are real, rather than a consequence of different interviewing styles (Rogers).

Advantage: Increased Validity

Validity of psychiatric diagnosis refers to the meaningfulness or usefulness of the diagnosis (Coolidge & Segal, 2010b). A required prerequisite for validity is reliability. Thus, by virtue of the fact that structured interviews greatly increase reliability of diagnosis, they also increase the likelihood that the diagnosis is valid. Structured interviews also improve the validity of diagnoses in other ways. The systematic construction of structured interviews lends a methodological validity to these types of assessments compared to unstructured approaches. Because structured interviews are designed to thoroughly and accurately assess well-defined diagnostic criteria, they are often better assessments of those criteria than unstructured interviews (Rogers, 2001). According to Rogers, clinicians who use unstructured interviews sometimes diagnose too quickly, narrow their diagnostic options too early, and miss comorbid diagnoses. Because structured interviews essentially force clinicians to assess all of the specified criteria for a broad range of diagnoses, they offer a more thorough and valid assessment of many disorders compared to unstructured interviews.

In our experience, it is common for beginning clinicians who are performing an unstructured clinical interview to gather information about the presence or absence of only a few common mental disorders. Coverage of other disorders may be neglected during an unstructured interview if the interviewer is unfamiliar with the specific criteria of some disorders. Some unstructured interviews may also provide limited information about whether comorbid psychopathology exists or about the severity of the psychopathology. Because they incorporate systematic ratings, structured and semistructured interviews easily provide information that allows for the determination of the level of severity and the level of impairment associated with a particular diagnosis. Structured interviews provide the same information about comorbid disorders as well.

Advantage: Utility as Training Tools

Structured interviews can be invaluable training tools for beginning mental health professionals as well as experienced clinicians who desire to enhance their diagnostic skills. Use of structured interviews in the training context may help clinicians develop or enhance their understanding of the flow, format, and questions inherent in a comprehensive diagnostic interview. With repeated administrations, much of a structured interview can be internalized by the clinician. In addition, use of structured interviews for training may reduce anxiety, especially among neophyte clinicians, because the format and flow of the interview is laid out clearly outlined for the interviewer. This type of structure can be helpful and calming for beginning clinicians, who may be initially overwhelmed by the diagnostic process and its inherent complexity.

Structured interviews can also be a useful means of training those who make preliminary mental health assessments, for example, intake staff at hospitals, so that clients are thoroughly and accurately evaluated in preparation for treatment planning. In the case of nonclinician interviewers, fully structured interviews are advisable because they minimize the amount of clinical judgment needed for accurate administration. Use of these trained paraprofessionals can make large-scale research studies cost effective.

Disadvantage: May Hinder Rapport

Despite the advantages of structured interviews, their application is not without controversy. The most common criticism of structured interviews is that their use may damage rapport or the therapeutic alliance (Segal, Maxfield, & Coolidge, 2008), which is widely viewed as an essential component of effective psychotherapy. Attaining a reliable and accurate diagnosis of a client achieves a hollow victory if the process prevents the therapeutic alliance from forming, or in a more dramatic example of clinical failure, the client does not return for continued treatment. The well-known joke poking fun at medicine, “the operation was a success but the patient died,” might be recast in terms of structured interviews as “the diagnosis was impeccable but the client never came back for another session.”

How exactly might structured interviews damage rapport? Perhaps most importantly, structured interviews may impede the connection between client and clinician because interviews are problem-centered rather than person-centered. There is a danger that interviewers may get so concerned with the protocol of their interview that they fail to demonstrate the warmth, empathy, and genuine regard necessary to form a therapeutic alliance. Indeed, the standardization of the interview may play out as “routinization” (Rogers, 2003). In addition, interviewers who are overly focused on the questions that they must “get through” in an interview may, as a consequence, miss important behavioral cues or other information that could prove essential to the case.

Proponents of structured interviews note that the problem of rapport-building during a structured interview can be overcome with training, experience, and flexibility (Rogers, 2003). We concur and emphasize the observation that “rapid inquiries or monotonous questioning represents clear misuses of structured interviews” (Rogers, 2003, p. 22). If interviewers make an effort to use their basic clinical skills, structured interviews can and should be conducted in such a way that establishes rapport and enhances understanding of the client. To ensure that this is the case, however, interviewers must be aware of the potential negative effects of structured interviews on rapport-building and make the nurturance of the therapeutic alliance a prominent goal during an interview, even when they are also focused on following the protocol. It behooves those who use structured interviews to engage their respondents in a meaningful way during the interview and to avoid a rote-like interviewing style that may alienate. On the other hand, not all clients have a negative perception of a structured interview that must be intentionally overcome. Some clients actually like the structured approach to assessment because it is perceived as thorough and detailed, and in these cases, rapport is easily attained.

Disadvantage: Limited by the Validity of the Classification System Itself

Earlier, we noted that proponents of structured interviews claim structured interviews may render more valid diagnoses in general. The assumption inherent in this argument is that the DSM diagnostic criteria are inherently valid, which is a debatable point. One should recognize that DSM diagnostic criteria were developed to operationalize theoretical constructs (e.g., depression, panic disorder, schizophrenia) so there is no absolute basis on which criteria were created. Furthermore, mental disorders are social constructions, which implies that they evolve over time as societies evolve.

Although successive editions of the DSM have been better grounded in empirical research, and the criteria for some disorders (e.g., major depression) have solid research support, other disorders (e.g., most of the personality disorders) and their criteria have not been examined as consistently or as completely, therefore leaving questions about their validity (Widiger & Trull, 2007). This point is also bolstered by the fact that the criteria for some disorders have changed significantly from one edition to another in the evolution of the DSM (Coolidge & Segal, 1998; Segal, 2010). Furthermore, criteria for many disorders in the DSM are impacted by cultural and subcultural variations in the respondent (see Chapter 4 in this book), as well as by the age of the respondent. Indeed, the diagnostic criteria for many mental disorders do not fit the context of later life and, therefore, some criteria do not adequately capture the presentation of the disorders among many older adults (e.g., Segal, Coolidge, & Rosowsky, 2006; Segal, Qualls, & Smyer, 2011). Thus, certain criteria may be valid only for a particular group of individuals, at a particular point in time, at a particular age. The primary method clinicians currently use to conceptualize diagnoses (the DSM), while improving, is far from perfect. Because the DSM generally does poorly in attending to these issues of age and diversity, interviews based on poor-fitting diagnostic criteria are similarly limited.

In addition to potential problems with DSM diagnostic criteria, another issue regarding structured interviews is that it is challenging to establish firmly the validity of any particular structured interview. The quandary is that our best means of establishing the validity of a structured interview is to compare diagnoses obtained from such interviews to diagnoses obtained by expert clinicians or by other structured interviews. This is inherently problematic because we cannot be certain that diagnoses by experts or other structured interviews are in fact valid in the first place (Segal et al., 2008).

Disadvantage: The Trade-Off of Breadth Versus Depth

A final criticism of structured interviews centers on the fact that no one structured interview can be all things in all situations, covering all disorders and eventualities. For example, if a structured interview has been designed to cover an entire diagnostic system (like the DSM, which identifies several hundred specific mental disorders), then inquiries about each disorder must be limited to a few inclusion criteria. In this case, the fidelity of the official diagnostic criteria has been compromised for the sake of a comprehensive interview. If the fidelity of the criteria is not compromised, then the structured interview becomes unwieldy in terms of time and effort required for its full administration. Most structured interviews attempt some kind of compromise between these two points of tension.

Thus, regarding breadth versus depth of approach, users of structured interviews are forced to make a choice about what is most useful in a given situation. Both choices have their limitations. If clinicians or researchers decide to use an interview that provides great breadth of information, they ensure that a wide range of disorders and a great many different areas of a respondent’s life are assessed. However, one may not have the depth of information needed to fully conceptualize a case. On the other hand, deciding to use an interview focused on a few specific areas will provide clinicians and researchers with a wealth of information about those specific areas, but it may result in missing information that could lead to additional diagnoses or a different case conceptualization. Thus, it is essential to understand that when choosing a particular structured or semistructured interview, there are often tradeoffs regarding breadth and depth of information.