Presenting Problem, History of Presenting Problem, and Social History

  • Thomas B. VirdenIIIEmail author
  • Melissa Flint


Most clients approach the first interview with a clinician seeking assistance to address a specific problem. The task of the interviewer is to gather information about the client, the problem, the circumstances and context, as well as the history, in order to conclude the intake with a diagnostic impression. The diagnosis sets the stage for intervention, because the first step in addressing a problem is to define it, and it must be defined carefully and accurately. The most skillfully implemented intervention will fail miserably if it seeks to address the wrong problem. Therefore, the successful diagnostic interview sets the stage for conceptualizing the case, goal setting, as well as treatment planning (Sommers-Flanagan & Sommers-Flanagan, 2017). It also relies on the clinician having the ability to draft a clear, yet comprehensive, intake evaluation report (Segal & Hutchings, 2007). In this chapter, we discuss three highly important areas of a clinical or diagnostic assessment, namely, the presenting problem, history of the presenting problem, and social history.


Presenting problem Social history Assessment Interviewing 


  1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.CrossRefGoogle Scholar
  2. Barnhill, J. W. (2018). The initial interview. In J. D. Avery, J. W. Barnhill, & R2 Digital Library, & American Psychiatric Publishing (Eds.), Co-occurring mental illness and substance use disorders: A guide to diagnosis and treatment. Arlington, VA: American Psychiatric Association Publishing.Google Scholar
  3. Chou, I. J., Kuo, C. F., Huang, Y. S., Grainge, M. J., Valdes, A. M., See, L. C., & Zhang, W. (2016). Familial aggregation and heritability of schizophrenia and co-aggregation of psychiatric illnesses in affected families. Schizophrenia Bulletin, 43(5), 1070–1078. Scholar
  4. Cormier, W. H., & Cormier, L. S. (1991). Interviewing strategies for helpers: Fundamental skills and cognitive-behavioral interventions (3rd ed.). Belmont, CA: Wadsworth.Google Scholar
  5. Fontes, L. A. (2008). Interviewing clients across cultures. New York, NY: Guilford Press.Google Scholar
  6. Gallardo, M. E., & Gomez, D. I. (2015). The clinical interview with Latina/o clients. In K. F. Geisinger (Ed.), Psychological testing of hispanics: Clinical, cultural, and intellectual issues (2nd ed., pp. 171–188). Washington, DC: American Psychological Association.CrossRefGoogle Scholar
  7. Jenkins, S. (2007). Unstructured interviewing. In M. Hersen & J. C. Thomas (Eds.), Handbook of clinical interviewing with adults (pp. 7–23). Thousand Oaks, CA: Sage.CrossRefGoogle Scholar
  8. Morrison, J. (2014). The first interview (4th ed.). New York, NY: Guilford Press.Google Scholar
  9. Morrison, J., & Flegel, K. (2016). Interviewing children and adolescents: Skills and strategies for effective DSM-5 diagnosis (2nd ed.). New York, NY: Guilford Press.Google Scholar
  10. Othmer, E., & Othmer, S. C. (2002). The clinical interview using DSM-IV-TR: Vol. 1 fundamentals. Washington, DC: American Psychiatric Publishing, Inc..Google Scholar
  11. Segal, D. L., & Hutchings, P. S. (2007). Writing up the intake interview. In M. Hersen & J. C. Thomas (Eds.), Handbook of clinical interviewing with adults (pp. 114–127). Thousand Oaks, CA: Sage.CrossRefGoogle Scholar
  12. Sommers-Flanagan, J., & Sommers-Flanagan, R. (2017). Clinical interviewing (6th ed.). Hoboken, NJ: Wiley.Google Scholar
  13. Tsai, H. H., Lin, H. W., Simon Pickard, A., Tsai, H. Y., & Mahady, G. B. (2012). Evaluation of documented drug interactions and contraindications associated with herbs and dietary supplements: A systematic literature review. International Journal of Clinical Practice, 66(11), 1056–1078. Scholar
  14. Watson, G. S., & Gross, A. M. (1998). History of the presenting complaint. In M. Hersen & V. B. Van Hasselt (Eds.), Basic interviewing: A practical guide for counselors and clinicians (pp. 57–71). Mahwah, NJ: Lawrence Erlbaum.Google Scholar
  15. Zuckerman, E. L. (2010). Clinician’s thesaurus (7th ed.). New York, NY: Guilford Press.Google Scholar

Copyright information

© Springer International Publishing AG 2019

Authors and Affiliations

  1. 1.Midwestern UniversityGlendaleUSA

Personalised recommendations