Psychiatric Interview By Dr. Wafaa L. Haggag Prof. of Psychiatry Suez Canal University
Principals of psychiatric interview:1. Time Psychiatric assessment and psychological treatments take time. Spending time listening to and clarifying patients problems, and making an attempt to understand how they feel and why they feel that way, is therapeutic in itself. Unfortunately, the pressure of work in general practice makes it difficult to find this time. Moreover, the financial incentives of Medicare are towards shorter, not longer, consultations. One solution is to spread the assessment out over several sessions.
Principals of psychiatric interview:2. Reassurance As a rule, it is better to try to understand a persons experience more clearly than to give bland reassurance. Although you may mean well, he or she may perceive a reassuring comment as presumptuous or rejecting. However, reassurance does have a place when it is true and does not dismiss the persons experience. Unhelpful comments: ‘ Helpful comment: (To a depressed man) When people are depressed, they often feel that nothing can be done to help. There are effective treatments for depression and I know that I can help you.‘
Principals of psychiatric interview: 3. Interview technique The following characteristics of interview style improve the likelihood of detecting mental illness: listening, clarifying and asking for an example . Not interrupting, especially at the beginning of the interview . Asking open-ended questions, especially at the beginning of the interview. Asking directive psychological questions . An empathic style - This involves putting yourself in the other persons position so as to understand how he or she feels, thinks and behaves, and why he or she feels that way. However, empathy is not simply an uncritical acceptance of a persons ideas and impulses ( pseudoempathy ). Picking up and responding to verbal and non-verbal cues . Maintaining control of the interview.
Principals of psychiatric interview:Examples of effective interview techniques: ClarificationYou ask a man to give you an example of what he means when he says he has suffered a panic attack.You summarise the persons complaints, their time course and the events happening at the time. Asking open-ended questionsAt the beginning of the interview, you ask, How are you feeling? Directive psychological questionsYou ask a man who presents with fatigue and insomnia if he has been feeling down or depressed. Later, you ask him about anhedonia, vegetative function change and suicidality. Response to a verbal cueA 47-year-old man complains of a number of vague physical symptoms including fatigue, abdominal discomfort and headaches. He says that he cannot even be bothered playing football any more. You ask, When did you last do something that you really did enjoy? He takes some time responding, and then says, It seems ages. I suppose I enjoyed the trip to sharm last winter. Then you ask if he has been feeling depressed. You pick up the mans cue about anhedonia and follow it up with direct questions about depression.
Principals of psychiatric interview:Examples of effective interview techniques: Response to a non-verbal cueA woman who has been attending your practice over the past five years is not herself. She looks tired and depressed and sits slumped in the chair. Usually well groomed, today her hair is untidy and her clothes rumpled. Her affect is flat and she speaks in a soft voice giving unelaborated responses to your questions. You say, You look tired today. How are you feeling? Later you ask if she has been feeling depressed. Empathic styleA middle-aged man becomes depressed after being overlooked for a promotion at work. You ask about his prospects for promotion in the future. This uncovers his fear that, at 52, he is unlikely ever to be promoted. The question that you ask leads the man to elaborate his concerns. Further questions may address the other developmental challenges of middle age that he is presently facing. Maintaining controlAn elderly man speaks at length about how unjustly he is treated by his neighbours. You say, I am sorry to hear that you are so upset by your neighbours, but could I take you back to what you were saying about feeling depressed.
Principals of psychiatric interview: 4. Transference and countertransference: Transference can be broadly defined as the feelings that the patient has for you. Some of these feelings are reality-based, for example, respect for your expertise in medicine. Others have unconscious origins and arise from the transference on to you of feelings that are held towards others who are significant in the person’s past or present. For example, being perceived by a young man as an authority figure, you may elicit transference feelings that he has towards his parents, teachers and other authority figures in his life. Countertransference refers to the feelings that you have towards the patient. Again, these will, in part, be reality-based. Some will arise in response to the transference. Some will be similar to feelings that are elicited in other people who deal with that person, while others will reflect aspects of your own past and present relationships transferred on to the patient. Most will be a combination of all of these. It is normal, of course, that you should experience these feelings. The important thing is to be aware of them and to acknowledge them to yourself, even if they seem unacceptable - for example, feeling angry or bored with a person, feeling overly concerned about or even feeling attracted to him or her. By acknowledging these feelings to yourself and making them conscious you are much less likely to act inappropriately upon them. For example, it is quite normal to feel angry with certain people, but it is likely to be damaging and unprofessional to act out this anger.
Principals of psychiatric interview:5. Boundary issues: Doctors are sanctioned to ask about private and intimate aspects of their patients lives and to conduct physical examinations. There is a clear power differential in the relationship between patient and doctor. In particular, people presenting for counseling or any type of psychological therapy are often at their most vulnerable. The transference of flattering feelings and impulses onto the doctor - respect for authority, attraction to power and success, desire for approval - may tempt the doctor into abusing his or her power. To exploit such a position to fulfil ones own needs is unethical and potentially damaging to patients. It is essential to be clear about your role as a professional. You are not a friend of the patient. Indeed, it is wise to avoid, if possible, treating your friends. It is always unethical to have sexual relations with a patient. For professional therapists, it is prohibited to have intimate relations even after therapy has finished. Monitor your countertransference feelings and impulses and take care not to act out in ways that breach professional boundaries. Transgressions of these boundaries typically occur in a stepwise progression. They may begin with the acceptance of expensive gifts, financial advice. There may be a temptation to disclose and discuss ones own problems. Appointments may be made that are longer than usual, or regularly scheduled at the end of the day when other staff members have left the practice. Fees may be waived. Unnecessary home visits may be made. This may progress to the performance of unnecessary physical examinations, meeting patients outside the consulting room, and to involvement in social situations and sexual relations.
Doctors who are vulnerable to boundary transgressions:Include those experiencing life crises,1. Those with problems in their own marriages or personal relationships.2. Perfectionists who are excessively self-sacrificing and work unnecessarily long hours may have difficulty setting limits on the demands of certain patients and begin taking extraordinary measures in attempt to rescue them.3. Patients with histories of sexual abuse may be particularly prone to evoke such countertransference responses, especially when they express recurrent suicidal ideation.4. Doctors who deny their dependency needs and give the appearance of being self-contained may be prone to seeking gratification for their needs for love and nurturance through their patients: while denying their own dependency needs, they may perceive others as being dependent on and needy of them.5. A doctor suffering a psychosis might violate professional boundaries as a consequence of the illness. Psychopathic doctors who willfully exploit patients for the gratification of their own needs have no place in the medical profession.
Dealing with countertransference:By acknowledging to yourself your countertransference responses, you lessen the likelihood of acting out upon them. Monitoring your countertransference responses can provide you with valuable information about a person. For example, when seeing a young woman who repeatedly self-harms, you may feel frustrated and angry and you may even imagine being cruel to her. Recognising these feelings and impulses, you take care not to act out upon them. Reflecting upon them, you recognise their origin in the physical and sexual abuse that she suffered at the hands of her step father. You gain a deeper understanding of her and the way people react towards her. By containing the impulse to act out, you avoid repeating and reinforcing the abusive patterns of her previous relationships. At the same time, you take care not to act upon unrealistic fantasies of rescuing her . Monitoring the countertransference can improve your understanding of the patient.
Principals of psychiatric interview:6. Understanding versus explanation: In formulating a persons problems, we seek to answer the question, Why does this individual feel, think and act this way at this time? The method of understanding helps us find reasons for his or her experience; the method of explanation seeks causes. We understand a persons experience when, through listening to his or her story and clarifying the experience, we are able to empathise with him or her and to imagine how we might feel under similar circumstances. We can understand experiences in the mind of another. For example, we understand the grief of the bereaved, the anger of someone who is frustrated, the guilt of the person who has hurt another and the shame of someone who has done something foolish. We can also understand the meaning of an event for that person, and we can look for reasons why he or she feels that way.
Principals of psychiatric interview:7.The dialectical principle: In the philosophy of Hegel, dialectics is a process in which a proposition is made (thesis), then negated (antithesis), and finally replaced by a new proposition that resolves the conflict between the two (synthesis)4. Although this may seem a little obscure, this way of thinking is common in making decisions about mental health problems. You will often have to make choices between apparently contradictory propositions. Always consider the possibility that the best course of action lies in a synthesis of the two. There are very few propositions in psychiatry that hold true in every case.
Some dialectical dilemmas: Since she has a terminal illness, it is understandable that she is depressed, so I should not prescribe medication. Wrong: although her depression is understandable, if her symptoms persist and include feelings of worthlessness and guilt, suicidality or psychotic symptoms, she should be treated with an antidepressant (and possibly an antipsychotic or ECT) in addition to some form of psychotherapy to deal with her grief. Should I make a formulation specific to this woman’s problems or should I make a diagnosis and treat the condition from which she suffers? Do both. Is substance abuse or an underlying psychosis causing his psychotic symptoms? It could be a combination of the two. Are his cognitive deficits due to dementia or major depression? A third possibility is that he suffers both conditions. Her panic attacks are probably just secondary to her depression so if I treat the depression they should also improve. Isolated panic attacks can occur in major depression, but if they are recurrent and accompanied by persistent concern about having more attacks, worry about the implications of the attacks, or significant behaviour change, then both diagnoses should be made. In general practice settings, mixed anxiety/depression is more common that either one alone. Treat both. I should strive to be decisive and make the final diagnosis in the first session. Make a working diagnosis in the first session, but be prepared to tolerate some uncertainty about the final diagnosis. The formulation will continue to evolve and deepen so long as you continue to see the person. I must never breach a patients confidentiality. There are exceptions. For example, if the person makes a direct threat against someone else, you may be obliged to contact the police or to warn the intended victim. With most mental health treatment now being delivered in the community, a larger responsibility for care now falls on the family or other carers. Unless expressly forbidden to do so by the individual, carers should, whenever possible, be involved in treatment. Ask the person if you can meet his or her spouse and family at the next consultation.
Some dialectical dilemmas: During an exacerbation of his psychosis, a man with schizophrenia develops obsessive - compulsive symptoms. Should I diagnose obsessive–compulsive disorder? Here, the hierarchical principle of diagnosis applies. The anxiety symptoms are subsumed under the diagnosis of a psychotic disorder. An elderly woman becomes delirious post-operatively and experiences hallucinations and persecutory delusions. Should an additional diagnosis of schizophrenia be made? No. Organic disorders stand at the top of the diagnostic hierarchy and may be manifest by any neurotic or psychotic symptoms. A man subjected to severe road accident presents with a number of anxiety and depressive symptoms in addition to re-experiencing the traumatic accident scene. Should I diagnose depression, generalized anxiety and agoraphobia? The most parsimonious explanation is post-traumatic stress disorder, though this disorder may be complicated by major depression or an anxiety disorder.
Principals of psychiatric interview:8.Impairment, disability and handicap: When assessing people with mental health problems, it is useful to classify their complaints as impairments, disabilities or handicaps. Mental impairment is any loss or abnormality in psychological functioning. It includes the signs and symptoms of mental illness. Disability is any restriction or lack in ability to perform an activity normal for a human being. Handicap is a disadvantage, resulting from impairment or disability, that limits or prevents the fulfilment of a social role that is normal for that individual, given his or her age, sex and cultural expectations. It is helpful to make this distinction when planning management. In general, the alleviation of impairments is the focus of treatment, while the prevention and minimisation of disabilities and handicaps constitutes disability support and rehabilitation. As a general practitioner, you will mainly be involved in the delivery of treatment. However, you need to be familiar with the rehabilitation services in your area, to know the appropriate referral procedures and to be able to work in partnership with them.
Examples of impairment, disability and handicap: A woman with schizophrenia hears her thoughts spoken out loud (thought broadcast, an impairment). As a consequence, she withdraws, spending much of her time at home, and she no longer goes shopping (agoraphobia, a disability). She has not managed to work since the onset of her illness five years before, she has no social contacts outside her immediate family and she depends on her husband to do all of her shopping (handicap). A man has developed agoraphobia (disability) after having a panic attack (impairment) in a bank three months before. He remains on sickness allowance and sees little of his friends. His wife is becoming increasingly angry by his dependence on her (handicap). A man with early dementia suffers memory deficits, disorientation in place and mild agnosia (impairments). He has left the gas on twice after heating the kettle, he got lost on the way back from the shops and his wife has to remind him to attend to his personal hygiene (disabilities). He had to give up his job as an architect a year ago and is now becoming increasingly dependent on his wife for care and supervision (handicap).
Open versus closed questions: Closed questions Opened questionsA closed question can be answered with An open question is likely to receive either a single word (yes/no) or a a long answer. short phrase. Although any question can Thus How old are you? and Where receive a long answer, open do you live? are closed questions. questions deliberately seek Thus Are you happy? and Is that a longer answers, and are the book I see before me? are closed opposite of closed questions. questions, whilst How are you? Is Using open questions: not. Open questions have theUsing closed questions: following characteristics: They give you facts. They ask the respondent to They are easy to answer. think and reflect. They are quick to answer. They will give you opinions and They keep control of the feelings. conversation with the questioner. They hand control of the conversation to the respondent.
Open versus closed questions in psychiatric interview: Closed questions Opened questions Are often more useful in closed questions are more useful in therapeutic work with patients patients with marked loosening of associations. than closed questions. Closed questions are also useful in Pros: Open-ended questions patients with organic brain conditions develop trust, are perceived as (learning difficulties, delirium or dementia) who can loose track of less threatening, allow an longer answers. unrestrained or free response. Closed questions have a lot of Cons: Can be time-consuming, disadvantages: they don’t build rapport or allow the patient to open may result in unnecessary up, who can feel grilled. From the information, and may require point of view of the doctor, you can more effort on the part of the collect the facts but miss the person. It’s also easy to fall in to the trap of user. asking another question when you don’t know what to do.
Questions that must be avoided in psychiatricinterview:Type of questions: Examples:I. The loaded question :A question with a false, disputed, or question- .I begging presupposition.II. The upbraiding question: .IAsking a question to reproach or upbraid.III. Multiple questions: .II
Asking better questions: Good questions often begin who, what, when, how much, how many. Questions that begin with why are less useful as they tend to provoke defensiveness. How can also be problematic in that it provokes analysis rather than awareness/autonomy (compare how are you going to give up drinking? with what steps might you take to give up drinking?). They also encourage the use of descriptive rather than judgemental terminology (preventing defensiveness and unhelpful self criticism that may distort perception). It follows that good questions follow the line of interest of the patient, not the doctor: the aim is to raise his or her awareness, so questions must follow this lead. Going through a psychiatric assessment by rote can be profoundly alienating for a patient who isn’t led to their core worries.
The Socratic technique of questions: It is a way of structuring dialogue such that the teacher uses a set of prepared questions to engage the learner’s experience and knowledge to solve problems posed by the questions. The teacher leads the learner along a loosely predetermined path to develop knowledge and understanding in a particular direction. Socrates sees the advantage of this as leading someone to their ignorance: it is better to admit ignorance than to have a false belief. This (ideally) leads him or her to actively desire and pursue new learning through curiosity. The values of Socratic reasoning are active, reflective learning and the importance of a lifelong pursuit of wisdom: this start with an admission of our own ignorance.
6 types of Socratic questions:1. Questions for clarification: Why do you say that? How does this relate to our discussion?2. Questions that probe assumptions: What could we assume instead? How can you verify or disapprove that assumption?3. Questions that probe reasons and evidence: What would be an example? What is....analogous to? What do you think causes to happen...? Why:?4. Questions about Viewpoints and Perspectives: What would be an alternative? What is another way to look at it?5. Questions that probe implications and consequences: What are the consequences of that assumption? What are you implying?6. Questions about the question: What was the point of this question? Why do you think I asked this question? What does...mean? How does...apply to everyday life?
Use of Socratic Technique in CBT: Cognitive therapy use ‘Socratic’ questioning in a process of guided discovery. The therapist does not know in advance where the line of questioning is likely to lead: ‘if you are too confident of where you are going, you only look ahead and miss detours that can lead you to a better place’. The prime motivation of Socratic questioning is ‘to understand the client’s view of things, not simply to change the client’s mind’ The questions used should elicit a behavioural, non judgemental description of the issue at hand. Asking a patient to describe their inner thought processes often directs their attention to aspects of their experience which though relevant have previously gone unnoticed. This can be profoundly therapeutic in itself, besides being grist to the therapeutic mill.(Padesky 1993, 3).
Interviewing a paranoid patient: Don’t try to argue or rationally persuade the patient out of a delusion. This may lead to more assertion of delusional ideas. Don’t automatically laugh at a patient when something is said that seems funny. Laughing at a patient can convey disrespect and lack of understanding of the underlying terror and despair that many patient’s feel.
Interviewing a paranoid patient: Do listen. Listen to how patients experience the world. They may experience it as dangerous, bizarre , overwhelming and invasive. Try to understand what is their image of themselves. DO acknowledge these feelings to the patient simply and clearly. For example if the patient respond that “When I walk into a room people can see inside my head and read my thoughts”. The clinician might respond to it as “ What are your feelings then” or “How do you feel then”. Be straightforward with a patient. Do not pretend that a delusion is actually true, but convey that delusion is actually true for the patient. If a paranoid schizophrenic says that “people are watching me all the time and they could know what I am thinking and see what I am doing” the doctor should say that “I can understand what you are feeling but I could not see anyone here who is keeping an eye on you”.
Interviewing a paranoid patient: Do respect a paranoid’s patient’s need for maintaining distance and control. Sometimes the paranoid patients are more comfortable when they are aloof as opposed to the expressions of warmth and empathy. Allow, the patient to speak. This helps the patient to feel that he is somebody important and has something important to say. Be flexible about interview times. If the patient can tolerate only 10 minutes , tell him that the interview will resume later. DO pay attention, how the patient make you feel. Work over and analyze your feelings. Feel empathetic but do not get carried over by the feelings. If you feel annoyed find the reason for it.
Interviewing a patient with somatization: Encourage the development of trusting relationship. Don’t argue about the reality. Respectfully and systematically evaluate physical symptoms. Establish appropriate therapeutic goals. Regular follow-up independent of symptoms. Appropriate treatment of psychiatric condition. Only appropriate referrals, but maintain involvement. Minimize medicalization. Focus on positive aspects of patient’s personality and behavior.
Suicide assessment:Current presentation of suicidality: Suicidal or self-harming thoughts, plans, behavior, and intent. Specific methods for suicide, including their lethality and whether firearms are accessible. Evidence of hopelessness, impulsivity, anhedonia, panic attacks, or anxiety. Alcohol or substance abuse. Thoughts, plans, or intentions of violence toward others.Psychiatric illness: Current evidence of psychiatric disorder , mood(MDE or mixed episodes), schizophrenia, substance abuse, anxiety disorders, BPD. History: previous suicidal attempts, or other self-harming behavior. Family history of suicide. Previous and current medical diagnosis ,medications ,surgeries, hospitalizations.
Suicide assessment:Psychosocial situation: Acute and chronic psychosocial crises, interpersonal loss, financial difficulties, or change in socioeconomic status , family discord, domestic violence, past or current sexual or physical abuse or neglect. Employment, living situation, and presence or absent of external support. Family constellation and quality of family relationships. Cultural and religious beliefs about death or suicide.Individual strengths and vulnerabilities: coping skills. Personality traits. Past responses to stress. Capacity for reality testing. Ability to tolerate psychological pain and satisfy psychological needs.
Risk factors for violence and assessment ofdangerousness: Must be conducted in a safe environment, safe for patient and psychiatrist. Determine substance of abuse, alcohol, amphetamines. Severe akathisia may contribute to aggressive behavior. Inquire about thoughts of violence and determine the person to whom this is directed. When patient pose serious threat to others (having homicidal ideation with imminent plans , the psychiatrist must consider hospitalizaion. The psychiatrist must exercise his own best judgment in accord with the legal requirements and system.
How to deal with a violent patient: If the patient is acutely aggressive, the psychiatrist can try to calm the patient by “ de-escalation” technique. If restraint or seclusion is required it should be done with adequate numbers of well trained professional staff. When sedation is indicated and the patient refuse oral medication, intramuscular injection of antipsychotic (haloperidol 5mg) can be given with or without 1-2 mg of oral or intramuscular lorazepam. After seclusion, restraint or sedation, the mental status and vital signs of the patient should be monitored regularly. Release from seclusion or restraint can proceed in a graded fashion, as risk of harm to self or others diminishes.
De-escalation technique Appear confident · Displaying calmness · Create some space · Speak slowly, gently and clearly · Lower your voice · Avoid staring · Avoid arguing and confrontation · Show that they are listening · Calm the patient before trying to solve the problem Staff should adopt a non-threatening body posture: · Use a calm, open posture (sitting or standing) · Reduce direct eye contact (as it may be taken as a confrontation) · Allow the patient adequate personal space · Keep both hands visible · Avoid sudden movements that may startle or be perceived as an attack · Avoid audiences – as an audience may escalate the situation