Chapter1. Interviewing.

One of the most critical tools a physician has is the ability to interview effectively.
A skillful interview is able to gather data, to understand and treat the patient. There are
three functions of the medical interview: to assess the nature of the problem, to develop
and maintain a therapeutic relationship, and implement a treatment plan. Those
functions are exactly the same as those of psychiatric and surgical interviews. Many
psychiatric problems present as medical illness and, conversely, many medical
problems present with psychiatric symptoms. For that reason alone, all psychiatrists
must recognize the importance of obtaining a comprehensive biopsychosocial history
for each of their patients.
But there are some differences between interviewing psychiatric and therapeutic
patients. Psychiatric patients often have stress and pressure not suffered by patients
who does not have psychiatric disorder. These stresses include the stigma attached to
being psychiatric patient because it is more acceptable to have a medical or surgical
problem than to have a mental problem. Difficulties in communication may be due to
disorders in thinking and oddities of behavior that makes compliance with treatment
particularly difficult. Because psychiatric patients often find it difficult to describe fully
what is going on, the physician must be prepared to obtain information from other
sources. Family members, friends and spouse can provide critical pieces of information
about the patient. Psychiatric patients may not be able to tolerate a traditional interview
format, especially in the most acute stages of a disorder. For instance a psychiatric
patient, suffering from increased agitation may not be able to sit 30 or 40 minutes of
questioning. In that case the physician must be prepared to conduct multiple brief
interactions over a period of time, - sitting or standing with the patient for as long as the
patient is able.
Many nonpsychiatric physicians see psychiatric patients. About 60% of all patients
with mental disorders visit

nonpsychiatric physicians during any six month period.

patients with mental disorders are twice as likely to visit a primary care physician as are

other patients. Nonpsychiatric physicians should be knowledgeable about the special

problems of psychiatric physicians and specific techniques used to treat them.
All psychiatrists begin the interview with establishing rapport. Establishing
rapport is the first step of an interview, and physicians often use their own empathic
responses to development of rapport.
Some psychiatrists defined the development of rapport as encompassing six
strategies:
1. Putting the patient and the interviewer at ease
2. Finding the pain and expressing compassion
3. Evaluating the patient's insight and becoming an ally.
4. Showing expertise.
5. Establishing authority as a physician and therapist.
6. Balancing the roles of empathic listener, expert and authority.
The presents of rapport implies that understanding and trust between doctor and
patient are present. Differences in social, intellectual, and educational status can
interfere seriously with rapport.
Beginning the interview. How a physician begin an interview provide a powerful
first impression in patients.
The psychiatry should initially sure that he or she knows the patient's name, and
that the patient knows the psychiatry's name. The physician should introduce himself or
herself to any other people, who are present with the patient. If relative or friends
accompany the patients, the physician should ascertain whether the patient would like
them to be present during the initial interview. However, the physician should also
attempt to speak the patient individually to make sure that the patient has a chance to
say anything he or she may not want to say in front of other.

Patient have the right to know the position and the professional status of the
persons involved with their care.
What questions psychiatry usually begin interviewing? They are : "Can you tell
me about the troubles that bring you in today?" or "Tell me about the problems you have
been having." Such remark as, "What other problems have you been experiencing?"
often elicits further information that the patient was reluctant to give initially. It also
indicates to the patient that the doctor is interested in hearing as much as the patient
wants to say.
A less directive approach is to ask the patient, "Where shall we start?" or "Where
would you prefer to begin?"
A patient may appear frightened or resistant at the beginning of an interview
and may not want to answer questions. If that seems to be the case, the physician may
ask the patient to talk about his or her feelings regarding the interview itself.
Acknowledging the patient's anxiety may be the first step in delineating what the anxiety
is about. An example of what could be said is, "I notice that you seem to be feeling
anxious about talking with me, and I wonder if there is any question I can answer that
will make it easier for you." Or "I know that it can be difficult or frightening to talk to a
doctor, but I would like to make it as comfortable for you as possible."
Another important initial question is, "Why now?" The physician should be clear
about why the patient has chosen that particular time to ask for help. Very often, people
seek out doctors as the result of particular events in their lives that have led to an
increase in stress. Examples of stressful precipitants include real or symbolic losses (for
example, death and separations), milestone events (for example, significant birthdays),
and physical changes (for example, the initiation of a new diet or a new drug).
Physicians who are unaware of such stresses in a person's life may miss unspoken
fears and questions that can compromise the patient's care and well being.
Interview Proper

In the interview proper the physician discovers in detail what is troubling the patient. The
physician must do so in a systematic way that facilitates the identification of relevant
problems.
The psychiatrists should pay attention not only to the contents of the answers but
also on process. The content of an interview is literally what is said between the doctor
and the patient: the topics discussed. The process of the interview is what is occurring
nonverbally between the doctor and the patient: what is happening in the in terview
beneath the surface. Process involves feelings and reactions that are unacknowledged
or unconscious. For example, a patient may use body language to express feel ings he
or she cannot express verballya clenched fist or nervous tearing at a tissue in the
face of an apparently calm outward demeanor. A patient may shift the interview away
from an anxiety-provoking subject onto a neutral topic without realizing that he or she is
doing so. A patient may return again and again to a particular topic, regardless of what
direction the interview appeared to be taking.

OPEN ENDED VERSUS CLOSED ENDED QUESTIONS

Most experts on interviewing agree that the ideal interview is one in which the
interviewer begins with broad open-ended questioning, continues by becoming specific,
and closes with detailed direct questioning.
The early part of the interview is generally the most open-ended, in that the
physician allows the patient to speak as much as possible in his or her own words. A
closed-ended question or directive question is one that asks for specific information and
that does not allow the patient many options in answering. Too many closed-ended
questions, especially in the early part of an interview, can lead to a restriction of the
patient's responses. An example of an open-ended question is, "Can you tell me more
about that?" A closed-ended question, if the patient states that he or she has been
feeling depressed, might be, "Your mother died recently, didn't she?" That question can
be answered only "yes" or "no and the mother's death may or may not be the reason

the patient is depressed. More information is likely to be obtained if the doctor responds
with, "Tell me more about what you're feeling and what you think may be causing it."
Closed-ended questions, however, can be effective in generating specific and
quick responses about a clearly delineated topic. Closed-ended questions have been
shown to be effective in eliciting information about the absence of certain symptoms (for
example, auditory hallucinations and suicidal ideation). Closed-ended questions have
also been found to be effective in assessing such factors as the frequency, the severity,
and the duration of symptoms.
There are some techniques of interviewing.
REFLECTION.

In the technique of reflection, the doctor repeats to the patient in a

supportive manner something that the patient has said. The purpose of reflection is to
assure the doctor that he or she has correctly understood what the patient is trying to
say. It is an empathic response meant to allow the patient to know that the doctor is
both listening to the patient's concerns and understanding them. That reflection is not an
exact repetition of what the patient has said but, rather, a paraphrase that indicates that
the doctor has perceived what the patient is trying to say.
FACILITATION.

The doctor helps the patient continue in the interview by providing both

verbal and nonverbal cues that encourage the patient to keep talking. Nodding one's
head, leaning forward in one's seat, and saying, "Yes, and then. . .?" or "Uh-huh, go on"
are all examples of facilitation.
SILENCE.

Silence can be used in many ways in normal conversations, even to indicate

disapproval or disinterest. However, in the doctor-patient relationship, silence may be

constructive; in certain situations it may allow the patient to contemplate, to cry, or just
to sit in an accepting, supportive environment where the doctor makes it clear that not
every moment must be filled with talk.
CONFRONTATION.

The technique of confrontation is' meant to point out to a patient

something that the doctor thinks the patient is not paying attention to, is missing, or is in
some way denying. Confrontation must be done in a skillful way, so that the patient is

not forced to become hostile and defensive. The confrontation is meant to help the
patient face whatever needs to be faced in a direct but respectful way. For example, a
patient who has just made a suicidal gesture but is telling the doctor that it was not
serious may be confronted with the statement, "What you have done may not have
killed you, but it's telling me that you are in serious trouble right now and that you need
help so that you don't try suicide again."
CLARIFICATION

. In clarification the doctor attempts to get details from the patient about

what the patient has already said. For example, the doctor may say: "You are feeling
depressed. When is it that you feel most depressed?"
INTERPRETATION.

The technique of interpretation is most often used when the doctor

states something about the patient's behavior or thought that the patient may not be
aware of. The technique follows up on the doctor's careful listening to the underlying
themes and patterns in the patient's story. Interpretations usually help clarify
interrelationships that the patient may not have been seeing. The technique should
generally be used only after the doctor has established some rapport with the patient
and has a reasonably good idea of what some of the interrelationships are. For
example, the doctor may say: "When you talk about how angry you are that your family
has not been supportive, I think you're also telling me how worried you are that I won't
be there for you either. What do you think?"
SUMMATION.

Periodically during the interview, the doctor can take a moment and briefly

summarize what the patient has said thus far. Doing so assures both the patient and the
doctor that the information the doctor has heard is the same as what the patient has
actually said. For example, the doctor may say, "OK, I just want to make sure that I've
gotten everything right up to this point.
EXPLANATION.

The doctor explains the treatment plan to the patient in easily

understandable language and allows the patient to respond and ask questions. For
example, the doctor may say: "It is essential that you come into the hospital now
because of the seriousness of your condition. You will be admitted tonight through the
emergency room, and I will be there to make all the arrangements. You will be given a

small dose of medication that will make you sleepy. The medication is called triazolam,
and the dose you will be getting is 0.125 mg. I will see you again first thing in the
morning, and we'll go over all the procedures that will be required before anything else
happens [etc., etc.]. Now, what are your questions? I know you must have some."
TRANSITION.

The technique of transition allows the doctor to convey the idea that enough

information has been obtained on one subject; it encourages the patient to continue on
to another subject. For example, the doctor may say:
"You've given me a good sense of that particular time in your life. It would be good now
if you told me a bit more about an even earlier time in your life."
SELF-REVELATION.

Limited, discreet self-disclosure by the physician may be useful in

certain situations. The physician should feel natural and communicate a sense of selfcomfort. Conveying that sense may involve answering questions from the patient
about whether the physician is married and where he or she comes from. If the doctor
feels that some piece of information will help the patient be more comfortable, the
doctor can decide in each case whether to be self-revealing. It depends on whether
the information will further the patient's care or whether it will provide nothing useful.
Even if the doctor decides that self-revelation is not warranted, he or she should be
careful not to make the patient feel embarrassed for asking. For example, the doctor
may say: "I'm not sure whether you are really asking if I'm married. Let's talk about it a
little more, so that I can understand why that information is important to you. Maybe it
has more to do with some concerns you have about my commitment to your care."
Many questions, especially personal ones, convey not just natural curiosity about the
doctor but also hidden concerns that should not be ignored.
POSITIVE REINFORCEMENT.

The technique of positive reinforcement allows the patient to

feel comfortable in telling the doctor anything, even about such things as
noncompliance with treatment. The doctor encourages the patient to feel that the doctor
will not be upset by whatever the patient has to say and thereby facilitates an open
exchange. For example, the doctor may say: "I appreciate your telling me that you have
stopped taking your medication. Can you tell me what the problem was with the

medication? The more I know what's going on with you, the better I'll be able to treat
you in a way that you will feel comfortable with."
REASSURANCE.

Truthful reassurance of a patient can lead to increased trust and

compliance and can be experienced as an empathic response of a concerned

physician. False reassurance, however, is essentially lying to the patient and can badly
impair the patient's trust and compliance. False reassurance is often given in the desire
to make a patient feel better, but, once a patient knows that the doctor has not told the
truth, the patient is not likely to accept or believe truthful reassurance. In an example of
false reassurance, a patient with a terminal illness asks, "Am I going to be all right,
doctor?" and the doctor responds, "Of course, you'll be all right; everything is fine." In an
example of truthful reassurance, the doctor responds: "I am going to do everything I
can to make you feel as comfortable as possible, and part of being comfortable is for
you to know as much as I know about what is going on with you. We both know that
what you have is serious. I'd like to know exactly what you think is happening to you and
to clarify any questions or confusion you have."
ADVICE.

In many situations it is not only acceptable but desirable for the physician to

give advice to a patient. The advice should be given only after the patient is allowed to
talk freely about whatever the problem is, so that the physician has an adequate
information base from which to make suggestions. At times, after the doctor has listened
carefully to a patient, it is clear that the patient does not, in fact, want advice as much as
an objective, caring, non judgmental ear. Giving advice too quickly can lead the patient
to feel that the doctor is not really listening but, rather, is responding either out of anxiety
or from the belief that the doctor inherently knows better than the patient what should be
done in a particular situation. In an example of advice given too quickly, the patient
states, "I cannot take this medication; it's bothering me," and the physician responds:
"Fine. I think you should stop taking it, and I'll start you on something new." A more
appropriate response is the following: "I'm sorry to hear that. Tell me what about the
medication is bothering you, so that I have a better idea of what we may do to make you
feel more comfortable." In another example the patient states, "I've really been feeling
down lately," and the doctor responds, "Well, I think in that case it would be a good idea

for you to go out and really do some things that are fun, like going to the movies or
walking in the park." In that case a more appropriate and helpful response is the following: ''Tell me what you mean by 'feeling down.' The more I know about what you're
feeling, the more likely it will be that I can help."
Interviewing psychotic patients. Psychotic patients often have limited insight, are
more concrete than abstract in their thinking, and are not always psychologically minded
or introspective. In fact, many psychotic patients experience insight and introspection as
frightening and threatening, because their perceptions are distorted and they are unable
to integrate certain feelings, fantasies, and ideas about themselves without
decompensating (becoming more psychotic than before).
Specific therapy techniques to be used with psychotic patients involve the following:
(1) Do not attempt to talk patients out of delusional beliefs. (2) Do not laugh at bizarre,
psychotic material that may sound funny but is clearly not meant to be funny. (3)
Maintain a certain formality with the patients, so that they do not feel threatened by what
is perceived as frightening closeness. (4) Focus on concrete, day-to-day survival and
social skills. (5) Decrease pressure on the patients to achieve more than they may feel
capable of achieving (including answering interview questions). (6) Structure the interview sessions so that the patients know what to expect and are not left, for instance,
with long periods of silence if those periods seem to increase anxiety. (7) Be sensitive to
how easily humiliated or shamed the patients may feel over relatively minor
inadequacies (such as the inability to remember a past medication).
Concluding the Interview
The doctor wants the patient to leave the interview feeling understood and respected
and feeling that all the pertinent and important information has been conveyed to an
informed, empathic listener. To that end, the doctor should give the patient a chance to
ask questions and should let the patient know as much as possible about the plans for
the future.

COMPLIANCE
Compliance, also known as adherence, is the degree to which a patient carries out the
clinical recommendations of the treating physician. Compliance behavior depends on
the specific clinical situation, the nature of the illness, and the treatment program. In
general, about one third of all patients comply with treatment, one third sometimes
comply with certain aspects of treatment, and one third never comply with treatment.
The doctor-patient relationship is the most important factor in compliance issues.
When the doctor and the patient have different priorities and beliefs, different styles of
communication, and different medical expectations, the patient's compliance diminishes.
Compliance can be increased if the physician explains the value to the patient of a
particular treatment outcome and explains that following the recommendation will
produce that outcome. Compliance can also increase if the patients know the names
and the effects of each drug they are taking. A highly significant factor in compliance
seems to be the patient's subjective feeling of distress or illness. Patients must believe
that they are ill. Thus, asymptomatic patients, such as those with hypertension, are at
greater risk for noncompliance than are patients with symptoms. Studies have shown
that noncompliance is associated with doctors who are perceived as rejecting and
unfriendly. Noncompliance is also associated with asking a patient for information
without giving feedback and with failing to explain a diagnosis or the cause of the
presenting symptoms.
Strategies suggested to improve compliance include asking patients directly to
describe what they themselves believe is wrong with them, and what they believe to be
the risks and the benefits of following the prescribed treatment. Common errors are
patients' not taking medications as often or as long as they are supposed to and not
taking the right number of pills or treatments. Patients are generally non-compliant if
they have to take more than three types of medications a day or if their medications
must be taken more than four times a day. Purely verbal instructions by the doctor is
associated with increased error and noncompliance. Elderly persons who may have
trouble hearing or reading small type may become non-compliant if they cannot hear the
verbal instructions or read the prescription labels. Sometimes, instead of making errors,

patients deliberately change the treatment regimen. In those instances, the doctor
needs to negotiate a compromise with the patient, what has been termed a patient
contract. In that case, the doctor and the patient together specify what they can expect
from each other.

PSYCHIATRIC INTERVIEW
To treat a psychiatric patient the psychiatrist must make a reliable and accurate
diagnosis. To formulate such a diagnosis, the psychiatrist must learn as much as
possible about who the patient is in terms of genetic, temperamental, biological,
developmental, social, and psychological influences. The psychiatrist must develop
interviewing skills and techniques that most effectively allow the patient to describe the
signs and the symptoms. Some techniques are universal to all situations, other
techniques are especially applicable to certain types of interviews.
There are 11 techniques common to most psychiatric interview situation.
1. Establish rapport as early in the interview as possible.
2. Determine the patient's chief complaint.
3. Use the chief complaint to develop a provisional differential diagnosis.
4. Rule the various diagnostic possibilities out or in by using focused and detailed
questions.
5. Follow up on vague or obscure replies with enough persistence to accurately
determine the answer to the question.
6. Let the patient talk freely enough to observe how tightly the thoughts are connected.
7. Use a mixture of open-ended and closed-ended questions.
8. Don't be afraid to ask about topics that you or the patient may find difficult or
embarrassing.
9. Ask about suicidal thoughts.
10. Give the patient a chance to ask questions at the end of the interview.
11. Conclude the initial interview by conveying a sense of confidence and, if possible, of
hope.

Management of time
The initial consultation lasts for 30 minutes to one hour, depending on the
circumstances. Interviews with psychotic s medically ill patients are brief because the
patient may find the interview stressful. Second visits and interviews also vary in length.
The psychiatrist's handling of time is also an important factor in the interview.
Carelessness regarding time indicates a lack of concern for the patient.
The considerable difficulties introduce interview with depressive and violent patient.
Depress patients are often unable to provide spontaneously an adequate account of
their illness because of such factors as psychomotor retardation and hopelessness. The
psychiatrist must be prepared to ask a depressed person spent calmly about history and
symptoms related to depression including questions about suicidal ideation, which the
patient may not initially volunteer. Another reason for being specific in questioning a
depressed patient is that the patient may not realize that such symptoms as waking
during the night or increased somatic complaints are related to depressive disorders.
Of special concern when interviewing depressed patients is the potential for
suicide. Being mindful of the possibility of suicide is imperative when interviewing any
depressed patient, even if there is no apparent suicidal risk. The psychiatrist must
inquire in some detail about the presence of suicidal thoughts. The psychiatrist should
ask specifically, "Are you suicidal now, or do you have plans to take your own life?" A
suicide note, a family toy of suicide, or previous suicidal behavior on the part lithe
patient increases the risk for suicide. If the psychiatrist decides that the patients is in
imminent risk for suicidal behavior, the patient mist be hospitalized or otherwise
protected.
Violent patient.
A violent patient should not be interviewed alone; at least one other person
should always be present, and in some situations that other person should be a security
guard or a police officer. That statement must be backed up by a unified, calm,

consistent staff presence that the patient understands is there to lend support in efforts
to maintain control, including the ability to subdue the patient physically if necessary.
Specific questions that need to be asked of violent patients include those
pertaining to their previous acts of violence and to violence experienced as a child. The
psychiatrist should determine under what specific conditions the patient resorts to
violence, and corroboration as to critical aspects of the patient's history must be
obtained from friends and family members.
Delusional patient. A patient's delusion should never be directly challenged.
Challenging a delusion by insisting that it is not true or possible only increases the
patient's anxiety and often leads the threatened patient to defend the belief ever more
desperately. It is inadvisable, however, to pretend that one believes the patient's
delusion. Often, the helpful approach is to indicate that one understands that the patient
believes the delusion to be true but that one does not hold the same belief. It is probably
most productive to focus on the feelings, fears, and hopes that underlie the delusional
belief to understand what particular function the delusion holds for the patient. The more
that patients feel that the psychiatrist respects, understands, and listens to them, the
more likely they are to talk about themselves, not about the delusion.
Delusions may be excessively fixed, immutable, and chronic, or they may be
subject to question and doubt by the patient and may last only a relatively brief time.
The patient may or may not be influenced by the delusional beliefs and may be able to
recognize their effects. Delusions, as with most psychiatric symptoms, occur on a
spectrum from severe to mild and must be evaluated for the degree of severity,
fixedness, elaborateness, power to influence the patient's actions, and deviation from
normal beliefs.
Interviewing relatives. Interviews with family members of a patient can be both
valuable and fraught will difficulties. For example, a spouse may be so closely identified
with the patient that anxiety overwhelms the spouse's ability to provide coherent
information. Family members may not realize that certain kinds of information are best
provided by an observer and that other kinds of information may be obtained only from

the patient. For example, family members may be able to describe the patient's social
activity, but only the patient can describe what he or she is thinking and feeling. The
psychiatrist must be highly sensitive to discussions with family members; if those
discussions are not properly handled by the psychiatrist, the relationship between the
patient and the clinician may break down.
confidentiality. Ultimately, the physician must learn to elicit information and to offer
hope to family members without revealing information that the patient does not want
revealed. Betraying a confidence can make treatment impossible. If the issues concern
suicidal or homicidal ideation, however, the patient must understand that the
information cannot remain entirely confidential, for the protection of the patient and
others.