Art of psychiatric interview

Science
- is the analytical way of understanding and expressing the natural world
- will try to reduce the complexity of nature, to some fundamental laws
Art: - is the intuitive, imaginative way of understanding and expressing the natural world.
Intuition - is the mental exploration of the facts and
generalizing accumulated data in a domain,
on the basis of the information available
so that the solution is discovered.
Science and art - are complementary and not contrary

Science - is the constant interaction between reason and observation,

to obtain new tools for modeling natural phenomena

- have to face the challenge caused by :

- assimilating a new vision of the universe (fractal theory)
- the obseleting of many restricted patterns of thinking.
Art - is the understanding, the internalization of science data and
their personal, nuanced application
to produce aesthetic values
Medicine is a science, undoubtedly,
(it meets the current criteria for defining the sciences),
but which is practiced in the form of art,
due to the individual reactivity of each person,
to different social, personal, environmental circumstances
Physician activity performed with - sprit of observation, and reason
- sensing the essence,
along with professional talent and dexterity
human warmth and professional sincerity
make of medicine, first of all, science and
secondly, an art "by applying this to each individual case
Medicine is a mixture of science and art
which is based on the spirit of observation, logic, critical spirit and empathy,
which combines rational knowledge with affective-emotional.
Medical advances in technology
- it is not necessary to increase the power of a man over his fellow man
- applied with talent and dexterity, so with art,
must multiply the chances of aid and care of the patient

In other words, as Gadamer remarks

medical art is nothing but the application of science to humans
Psychiatry - scientific discipline in the medical field, with numerous definitions,
which highlights the complexity of human nature in general and of the human psyche
particular.
Psychiatric Interview - an instrument of psychiatry:
- to obtain primary, primary information in contact with the patient,
- which, through multiple, empathic, periodic applications, creates the premises
of the so-called therapeutic alliance with the patient - a true therapeutic factor

Applying by each doctor

of the psychiatry to the multitude of variables of the individuality of each patient,
converts it from science to art
not only when applied by experienced psychiatrists
to which we can say that intuition calls for rich theoretical accumulation and
practical expertise
but also to the psychiatrists in training
where the punctual application of the theoretical knowledge triggers the formation
of a practical dowry which increases with every patient interviewed, diagnosed,
treated, followed in outpatient or during other admissions
"To develop a complete mind you must study the science of art and the art of science.
You have to learn how to see, because all things are connected with each other "
(Leonardo da Vinci).
 In the looking for a definition ...

An unusual but frequent problem in the practice of the interview is

the meeting of a so-called
"the wanderer patient , " meaning
- a patient who is indirectly tangential or circumstantial to
the interviewer's questions
The feeding of the wanderer
= when the interviewer collaborates with the interviewee in the
tangentiality and circumstantiality of the interviewee
- is a maladaptive technique - if someone is trying to disclose
information specific to a domain
- is a beneficial technique - if someone tries to encourage a
favorable atmosphere for a free association that aims to
facilitate communication,
The fundamental feature of all good clinical interviews.
it is not just habit. performing the act itself
but is, the art of choice, and
the understanding of the talented interviewer;
The talented interviewer always tries to match
its techniques and interviewing strategies with:
- patient uniqueness,
- the clinical situation and
cultural vubrations of the patient
Allen Ivey - Professor of Psychology at the University of Massachusetts
(masəCHo͞osits)
introduces the concept of "intentionality" -
which is a feature of both physicians and patients.

Cultural Intentionality - represents the ability to:

- generate alternatives in a particular situation and
- tackle a problem in several ways,
using a variety of personal abilities and qualities,
adapting interviewing styles
to suit different people and cultures
Interaction, together with cultural intent,
acts with a sense of capacity and
decides in on a series of alternative actions.

The target person has more than one action, thought or behavior
to choose between responses
to changes
occurring throughout life
 Definition of the interview

= A verbal and non-verbal dialogue between two participants,

whose behaviors influence each other's style of communication, leading to
specific patterns of interaction.
= Ability to encourage the disclosure of personal information for professional
purposes

In the interview:
- a participant, is "interviewer"
tends to ask questions in an attempt to achieve specific goals,
- the other participant is the "interviewee"
generally assumes the role of "answering questions",
but he has undoubtedly his goals.
This definition emphasizes the interactive process of the interview.
Specific objectives of the interview:
1. Establish a solid involvement of the patient in a therapeutic
alliance
2. Collectsh a complete and valid database
3. To develop an understanding and compassionate
understanding of the interviewee
4 To develop an assessment from which a diagnostic attempt
can be made
5. To collaborate in defining a set of practical issues to be
addressed and set therapeutic goals
6.To collaborate on the development of goals and the temptation
of a therapeutic plan to achieve these goals
7.To start the healing process by making a certain decrease in
anxiety and pain of the patient
8. To Inspire hope and make sure the patient returns for the
next meeting
 The objectives of the initial interview will vary depending on
requirements to assess the situation including issues such as :
1.- time constraints
One of the common challenges that the initial interviewer faces is:
obtaining a complete and valid database within a ,, limited amount of time,,
in which a patient's sensitivity is also involved
2.- determining the interviewer (have a proper mood) to collect data that is clinically
necessary
E.g,:
- a clinician in crisis called , who is extremely busy, called in an emergency department
to interview a victim of domestic violence
will clearly perform another interview
than a therapist who performs a first interview at a mental health center
which in turn will be different from
an analyst asked to spend an hour or two with a well-educated patient who requires
psychotherapy for chronic depression.

In short, the needs of the clinical situation should determine the style of the interview,
only if the physician remains willing to intentionally and flexibly change
his approach.
The Styl of Interview can be :
• Oriented to insight:
interviewing tries to provoke - unconscious conflicts,
- anxiety and defense
• Oriented to symptom-:
-to emphasize the classification of patient complaints and dysfunctions as
defined by the specific diagnostic categories.

Diagnosis can be defined by symptoms,

the evolution of the disease,
family history,
historical development etc
 The interview process includes:
engagement process,
data collection,
of understanding,
evaluation
treatment planning
 Engagement
Engagement refers to the continuous development of a sense of security and
respect
to which patients feel more and more free to share their problems,
while at the same time gaining increased trust in the clinician's potential to
understand of their problems.

In the engagement, (involvement), is carried out and

the data collection process,
which leads to a progressive understanding of the patient.
This understanding of the patient as a unic person depends on the clinician's
ability to:
- observ the point view of the patient about the world
- recognize patient fears, pains and hopes.
As the interview progresses,
the clinician begins to formulate:
- a clinical evaluation, including the attempt of
a differential diagnosis, and
- a practical list of patient concerns and goals.

Clinical evaluation of the patient

It is done by:
- simple observation during the interview
- which provides about half of the data obtained from the
status evaluation mental health of the patient
- questions - for the other half of the interview

- It is necessary to identify any mental health difficulties.

- It can be therapist
- Very variable depending on time, place and patient
As the interview progresses,
the clinician begins to formulate:
- a clinical evaluation, including the attempt of a differential diagnosis, and
- a practical list of patient concerns and goals.

- Starting from - assessing the patient 's situation and

- understanding the patient as a person,
clinician and patient
can make an adapted treatment plan, the individual needs of the interviewee,
while recognizing the constraints imposed on the treatment
through the limitations of the mental health system itself.

These processes of engagement, data collection, understanding, evaluation and

planning of treatment are in fact processes of longitudinal interconnection
 Engagement and blending
Engagement
- refers to - the continuous development of a sense of security and respect
to which patients feel more and more free
to share their problems,
- at the same time, gaining increased confidence
in the clinician's potential to understand their problems
- starts from the first moment when the interviewer and the interviewee
they see, hear, smell and touch each other
Blending represents :
- a method of monitoring the effectiveness of the strategies used to achieve
these objectives of the engagement
- an active self-monitoring path through: 1. subjective method
2. the objective method
3. Self-report of the patient
The subjective method
- The interviewer knows what senses he has when blending is optimal

a - "when he feels more like a conversation and much less like an interview or
an interrogation."
b.- "When suddenly I realize during the interview that I actually talk to
someone with real pain, not an imagined defense case."
c - "When I feel more relaxed, sometimes I even sigh.

The objective method - the behavioral characteristics of the interview.

 Objective method - the behavioral characteristics of the interview.
The concept of behavior in verbal exchange.
- There are three major variables that help analyze the temporal characteristics
of speech:
-1) duration of expression (duration of utterance (DOU),
is the time taken by the interviewer's answer after a question

-2) reaction time latency (RTL),

represents the length of time an interviewer needs to answer a question

- 3) the percentage of interruptions

is the interviewee's tendency to stop the clinician before concluding a
question
Blending with a guarded or suspect patient often produces :
- short answers to questions (a short DOU),
-long pauses before answering (long RTL) and
- occasional interruptions because the patient corrects the interviewer
for inaccuracies in statements
- It is an indication of inefficient engagement.

Blending with a histrionic, hypomanic or anxious patient often presents

- a long DOU and
- a very short RTL and can also,
- The frequent interruption of the interview, is a process triggered by
overloading the patient to make his / her views known
- these patients have a unipolar-superficial blending with inappropriate
spontaneity
In contrast to
the gradual increase in blending observed in most patients.
Of the two methods, it seems none more valuable than another method;
rather, each method complements the other
Self-report of the patient
-is the third method of determining the degree of mixing (blending)
Occasionally, a patient spontaneously tells an interviewer to what extent the interaction
is enjoyable.
More often, the interviewer may ask:
"How about if today, you talking about me?"
- some patients may express specific concerns,
sometimes providing adequate and constructive criticism.
- Other patients will respond that everything is good, even if it is not
but non-verbal responds, can betray their true feelings
- A hesitant "yes" certainly indicates some discomfort from the patient,
giving us a rich chance to discover our concerns
to approach them without defense.
In such moments of hesitation, the clinician may comment:
"Do you know you seem a little hesitant," Is that something I did?
What did I do, feel uncomfortable? "
The answers are sometimes surprising.

Through non-defensive exploration, of the patient concerns, we will greatly increase the
probability of having a second interview.
The clinician can learn about:
- how to judge mixing by combining subjective, objective and self-report approaches
- how to creatively change the interview process itself.
- the degree itself of the process of involvement ,with certain patients at any given time.
A low involvement process suggests one of the following three conditions:
1. The interviewer's actions actively disable the patient
2. Interviewer's psychopathological processes or defense interfere with commitment
3. A combination of the first two
If the clinician thinks the damaged blending can be attributed for :
- firstl condition, then the doctor may try to consciously modify the style of interaction.
For example, a paranoid patient may be extinguished by an extrovert interviewing style.
In this case, the clinician may decide to attenuate his extroversion
in an effort to ease the patient's fears.
- second condition, the doctor may be warned about the types of psychopathology
that could block the blending,
such as the previously described histrionic process.
- third condition, greater attention can be paid to both interaction style and
psychopathology
At this point we have analyzed three methods of direct blending,
which allow us to indirectly evaluate the engagement process itself.
The interviewer starts with the hiring process for a good reason.
The engagement process (engagement) affects all the later objectives of the
interview.
More specifically, poor engagement raises significant doubts about :
- the validity of the database as patients generally do not freely share with
people who do not like (not involved)
Therefore, the clinician
- has only a superficial understanding of patient pain.
- and will never have access to the intimate places of the dark room of the
patient's life
(allusion to the comparison of the interview with the orientation in a dark room)
- Clinician evaluation and diagnosis that are frequently dangerous ,
without a valid database
- the possibility of a patient's turn over for a second interview,
due to the irrelevance of the first interview.
It is noticed that engagement seems to be the central process
on which a great deal of clinical practice is based.
The engagement begins with empathy.
 Empathy vs identification

Engagement begins with empathy.

Definition of empathy - after Carl Rogers
(the author of the interview centered on the person)
= is the clinician's ability to "perceive the other's internal frame of reference with
accuracy and with the emotional components and meanings that belong to him, as if
he were another person, but never lose the" as if "condition.
=. is the ability to accurately recognize the immediate emotional perspective of
another person, while maintaining their own perspective.

Barrett-Lennard's empathic cycle consists of the following stages:

(1) the patient expresses a feeling,
(2) the clinician recognizes this feeling,
(3) the clinician transmits the recognition of patient sentiment,
(4) the patient receives this recognition acknowledgment and
(5) the patient provides feedback to the clinician that recognition has been received
 According to Rogers, there is an important distinction between empathy and
identification, although they can overlap.

The empathic interviewer

- quickly recognizes the patient's feelings.
- may even begin to "automatically" feel the patient's feelings (sadness,
anger, etc.), but only briefly.
- has the ability to quickly withdraw from the process as far as it is concerned
your own emotional state.
-has no invested acceptance of the patient's feelings as
"right" or
"just like mine would be in such a situation."
The interviewer who identifies:
- recognizes - and briefly shares - the feelings of patient
- Continue to experience the anger or sadness of the patient.
- incorrect embrrassemnt of the patient's feelings as unconscious.
- agrees with the patient 's feelings
- it is personally invested in accepting these symptoms
as being both accurate and reasonable.

-can quickly destroy the therapeutic process.

- marks the way to such unrecognized therapeutic elves, (spirits)
such as exhaustion and unidentifiable counter-transfer

Attention! Most patients

- do not look for a person to feel how they feel
- look for someone who is trying to understand what I feel.
Interview centered on the person - according to Carl Rogers is:
1 - a concept - what surprisingly surprises the essence of our mission.
2 - a concept in which the clinician sees the interviewee as:
a - a series of unique moments over time,
in which biology, psychology, intimate relationships, family dynamics,
culture and spirituality of the patient
intersect to create the unique person in front of us.
b - a constantly changing array,
of which we are part of when the patient enters the understanding
problems and goals before we share it with us
c - a perspective that makes us understand easily
what the person wants, who is trying to give us help
before trying to supply it
3 - is a concept in which the patient is not regarded as a problem,
but as a unique individual, full of solutions
to the many problems that life invariably brings to everyone
 An interviewer centered on a person, is in difficulty because:
- does not know all the answers,
- he does not even know all the questions.
Thus, it is very important to listen:
- what we need to teach our patients and
- the questions that our patients are asking us to do

Our goal of clinicians is

- to understand this uniqueness,
- to help our patients better understand their strengths weak

- to learn how to navigate more efficiently in this complex human matrix.

Our interviewing principles, techniques, and strategies will be enriched by our

efforts to see the world :
both through the eyes of the patient,
as well as throught our own senses, to make sure we have a collaboration
The interview itself

• Includes
- the content of the interview:
what is said between the doctor and the patient, the topics discussed,
- the interview process: what appears non-verbal
involves feelings and
reactions that - are not recognized
- are unconscious
 The scene for the interview

- must be private and provide privacy, security

The doctor stays at a desk or a table in front of the patient
- this position provides space for
change the distance between you and the patient
as indicated by the patient's need for space and comfort
(The entire width of an office offers flexibility.)
- During the interview, try to avoid interruptions
- Tell the patient that the interview involves taking notes
 General Rules:
- Present to the patient
- Ask the patient to come forward
- the patient must be at ease
- Enter anyone who accompanies you and explain his role
- Specify the duration of the interview
- Relax and control even in difficult situations
- You must have permanent contact with the patient's eyes
- Start with a general question, eg "tell me about your problem"
- the approach is systematic but flexible
- The interview can be interrupted by the patient
- Talk must be free about the reasons for the evaluation
Personal safety measures during interview with patients:

1. Ensure an unobstructed exit from the interview room

(two doors, or sit closer to the door than the patient )
2. The camera should have an alarm or
someone should be in the reach of a call for help.
3. Be very careful about any patient
who has a history of violence or
who should take antipsychotic drugs, but they do not take them
4. Watch - Potential Violence Indicators in Patient Voice
(increasing the rhythm of the speech ),
- words (threats or insults) and
- body language (agitation, tight fists).
5. If you feel the danger, tell the patient that you are leaving the room
(the ad is to avoid the patient's astonishment),
then do so
6. Then get immediate help.
 Interview as a technique:

- establishes patient-psychiat ratio

- determines the main complaints
- Allows a temporary differential diagnosis using patient complaints
• allow the patient to speak freely
• should give patients the chance to ask questions
• Must contain questions :
- about the topics you can find strange embarrassment
- about suicidal thoughts
- open where possible
- closed when needed
• avoid driving questions (suggested answers) for example:
"You have a low appetite, are not you?
• must be ended by offering trust and hope
-It may be necessary to explain the rationale of certain questions,
eg abuse, criminal record, etc.
- Summarize what the patient has done to check the understanding of what the
patient has expressed
- Speak clearly (professional jargon can be confusing for the patient
- Do not take words at face value, for example "paranoid"
- The subtle, almost invisible non-verbal encouragement of the Interviewers:
"Yes" or "Mmhmm" - may indicate that you understand the patient, and
should continue to talk
- Encourage the patient by – tilt you body forward,
- head inclination
- assertion "continue"
"tell me more about
- Provide reassurance
Reinsurance - is what you do to increase patient confidence
feeling of well-being;
- must be honest, real and specific to the situation,
to be truly supportive
 Open questions
• are questions that allow a person to give a free, spontaneous, authentic
• Example: "Can you tell me more about this?"
They are often more useful in treating patients than closed questions.
Arguments
Pro: open questions - develop confidence,
- are perceived as less threatening,
- allow an unrestricted or free response.
Cons: open questions: - can consume long time,
- can lead to unnecessary information and
- may require more effort from the user.
Closed questions

• are questions that allow a person to answer

- "Yes or no"
- with a limited set of possible responses (such as: A, B, C)
- for example: "How long have you taken medicines?"
How many years do you have and where do you live?
• are questions , very reliable and accurate

Closed questions are more useful

in patients with marked relaxation of associations.
in patients with organic brain disorders (learning difficulties, delirium or dementia)
who may lose in longer responses

Closed questions have many disadvantages:

does not create relationships and does not allow the patient to open, to feel at
ease.
From the doctor's point of view, I can collect the facts but lose the person.
It's also easy to get into the trap of asking another question when you do not know
what to do.
Minimum Interview Rules:
• Use the language the patient understands.
"Sleeping with" to "having sex" is an ordinary thing;
• Do not ask negative questions - wire the expected answer.
"You did not drink much, did you?" It essentially asks for the "no" answer.
• Avoid questions that lead to an expected response;
Instead of "consumption has ever caused serious problems,
such as lack of work? ",
Ask:
"Have you ever lost a job because of alcohol?"
• Avoid double questions.
("Did you have trouble sleeping or appetite?")
It may seem efficient, but double questions are often confusing.
Also, the patient can answer part of the question and
can ignore the other without realizing it.
• Encourage precision. If necessary, ask for dates, times and numbers
• Use short questions
Long questions with implicit explanatory details may confuse the patient;
 Collateral Information

Always useful, especially if the patient is cognitively impaired,

the patient hides information, etc.
Often, it is best to see the first patient and then talk to the
informant
Ensure good faith informants and collect information.
Interview patients in the first language where possible.
if necessary, use an interpreter
Symptomatology, cultural beliefs and treatment expectations
may vary
 History

Presenting the accusations

History of present charges
Family history - heredo collateral history
Personal history - personal antecedents
Past psychiatric history
Medical history
Consumption of substances
History of drugs
Forensic history
Personality
The current social situation
 The mental state examination
- represents the clinical assessment and observation of the examiner and
the impression of the psychiatric patient during the interview
• it includes:
1) appearance
2) Psychomotor and behavioral activity
3) Speech
4) Disposition
5) thinking
6) perception
7) Cognitia
8) Insight
9) judgment
Interviewing Techniques with Special Patients:
1) Psychotic: Use short questions as they are easier to follow
2) with thought disorders: repeat the questions
3) With hallucinations: Describe them appropriately and under what conditions they appea
4) suspicions that misinterpret neutral events,
try to maintain a formal and remote approach
5) Depressed and potentially suicidal:
by redirecting their feelings and repeating the questions several times, you determine the
intention to commit suicide, plans, means, perceived consequences
6) With agitation and violence: lead them in a quiet room and tell them to hand over their
weapons; Hide your fears
7) With somatization: make him feel that their complaints are not rejected, and
include special attention to yoga, meditation, acupuncture
8) Seducers: ignore it gently. And you clarify the idea of ​keeping one
friendly doctor-patient relationships that exclude the possibility of close, intimate
relationships
9) addicts: set limits when assuring the patient that their needs are taken seriously and tre
professionally
10) isolated: the physician should interview him about his private life
11) obsessive: explain in detail what is happening and
 End the interview
• Give patients the chance to ask questions
• thank the patient for sharing the necessary information
• the prescription must be written in a clear and simple way
• Set up the next meeting

When a doctor tells me that he adheres strictly to

one method of interviewing or another, I have doubts about its therapeutic effect. ...
I treat each patient individually, because the solution to the problem is always an
individual ...? Carl G. Jung

Conclusion:
To see it, I need to know
To recognait, I must have been seen
To apply I need to understand the problems
to introduce individual solutions of aesthetic value
based on rational emotional components
 BIBLIOGRAPHY
1.Kaplan J.H., Sadock B.J., Grebb J.A., Synopsis of Psychiatry,
Ninth Edition, Wiliams and Wilkins, Baltimore
2. Drima Eduard, Psychiatry -Notebook, Ed.Zigotto Galati, 2017
The Psychiatric Interview, Harry Stack Sullivan
4. Psychiatric Interviewing: The Art of Understanding: A Practical Guide
for Psychiatrists, Psychologists, Counselors, Social Workers,
Nurses, and Other Mental Health Professionals
5. General principles of the interview - Psychiatry
.