The psychiatric interview is the most important part of evaluating and treating mental illness. The initial interview aims to establish a diagnosis to predict the illness course, prognosis, and guide treatment. The patient-physician relationship formed in this first encounter can strongly influence treatment outcomes. Psychiatric interviews occur in various settings and vary in length depending on factors like setting and purpose. General principles include obtaining consent, ensuring privacy and confidentiality, treating the patient with respect, building rapport through empathy, and developing a helpful patient-physician relationship.
The psychiatric interview is the most important part of evaluating and treating mental illness. The initial interview aims to establish a diagnosis to predict the illness course, prognosis, and guide treatment. The patient-physician relationship formed in this first encounter can strongly influence treatment outcomes. Psychiatric interviews occur in various settings and vary in length depending on factors like setting and purpose. General principles include obtaining consent, ensuring privacy and confidentiality, treating the patient with respect, building rapport through empathy, and developing a helpful patient-physician relationship.
The psychiatric interview is the most important part of evaluating and treating mental illness. The initial interview aims to establish a diagnosis to predict the illness course, prognosis, and guide treatment. The patient-physician relationship formed in this first encounter can strongly influence treatment outcomes. Psychiatric interviews occur in various settings and vary in length depending on factors like setting and purpose. General principles include obtaining consent, ensuring privacy and confidentiality, treating the patient with respect, building rapport through empathy, and developing a helpful patient-physician relationship.
The psychiatric interview is the most important part of evaluating and treating mental illness. The initial interview aims to establish a diagnosis to predict the illness course, prognosis, and guide treatment. The patient-physician relationship formed in this first encounter can strongly influence treatment outcomes. Psychiatric interviews occur in various settings and vary in length depending on factors like setting and purpose. General principles include obtaining consent, ensuring privacy and confidentiality, treating the patient with respect, building rapport through empathy, and developing a helpful patient-physician relationship.
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PSYCHIATRIC
INTERVIEW PSYCHIATRIC INTERVIEW
The psychiatric interview is the most important element in the
evaluation and care of persons with mental illness. A major purpose of the initial psychiatric interview is to obtain information that will establish a criteria-based diagnosis. • helpful in the prediction of the course of the illness and the prognosis, leads to treatment decisions From the very first moments of the encounter, the interview shapes the nature of the patient-physician relationship, which can have a profound influence on the outcome of treatment. The settings in which the psychiatric interview takes place include psychiatric inpatient units, medical non-psychiatric inpatient units, emergency rooms, outpatient offices, nursing homes, other residential programs, and correctional facilities. The length of time for the interview, and its focus, will vary depending on the setting, the specific purpose of interview, and other factors (including concurrent competing demands for professional services). GENERAL PRINCIPLES Agreement as to Process • At the beginning of the interview the psychiatrist should introduce himself or herself and, depending on the circumstances, may need to identify why he or she is speaking with the patient. • Unless implicit (the patient coming to the office), consent to proceed with the interview should be obtained and the nature of the interaction and the approximate (or specific) amount of time for the interview to be stated. • A crucial issue is whether the patient is, directly or indirectly, seeking the evaluation on a voluntary basis or has been brought involuntarily for the assessment. • should be established before the interview begins Privacy and Confidentiality • Issues concerning confidentiality are crucial in the evaluation/ treatment process and may need to be discussed on multiple occasions. • Confidentiality is an essential component of the patient-doctor relationship. • The interviewer should make every attempt to ensure that the content of the interview cannot be overheard by others. • Generally, at the beginning, the interviewer should indicate that the content of the session( s) will remain confidential except for what needs to be shared with the referring physician or treatment team. • Some evaluations, including forensic and disability evaluations, are less confidential and what is discussed may be shared with others. • A special issue concerning confidentiality is when the patient indicates that he or she intends to harm another person. • When the psychiatrist's evaluation suggests that this might indeed happen, the psychiatrist may have a legal obligation to warn the potential victim. • Psychiatrists should also consider their ethical obligations. • Part of this obligation may be met by appropriate clinical measures such as increasing the dose of antipsychotic medication or hospitalizing the patient. • Often members of the patient's family, including spouse, adult children, or parents, come with the patient to the first session or are present in the hospital or other institutional setting when the psychiatrist first sees the patient. • If a family member wishes to talk to the psychiatrist, it is generally preferable to meet with the family member( s) and the patient together at the conclusion of the session and after the patient's consent has been obtained. • The psychiatrist should not bring up material the patient has shared but listen to the input from family members and discuss items that the patient introduces during the joint session. • Occasionally, when family members have not asked to be seen, the psychiatrist may feel that including a family member or caregiver might be helpful and raise this subject with the patient. • As always, the patient must give consent except if the psychiatrist determines that the patient is a danger to himself or herself or others. • Except in an emergency, consent should be obtained from the patient before the psychiatrist speaks to the relative. • In educational and, occasionally, forensic settings, there may be occasions when the session is recorded. • The patient must be fully informed about the recording and how the recording will be used. • The length of time the recording will be kept and how access to it will be restricted must be discussed. • Occasionally in educational settings, one-way mirrors may be used as a tool to allow trainees to benefit from the observation of an interview. • The patient should be informed of the use of the one-way mirror and the category of the observers and be reassured that the observers are also bound by the rules of confidentiality. • The patient's consent for proceeding with the recording or use of the one-way mirror must be obtained, and it should be made clear that the patient's receiving care will not be determined by whether he or she agrees to its use. Respect and Consideration • As should happen in all clinical settings, the patient must be treated with respect, and the interviewer should be considerate of the circumstances of the patient's condition. • Because of the stigma of mental illness and misconceptions about psychiatry, the patient may be especially concerned, or even frightened, about seeing a psychiatrist. • The skilled psychiatrist is aware of these potential issues and interacts in a manner to decrease, or at least not increase, the distress. • The success of the initial interview will often depend on the physician's ability to allay excessive anxiety. Rapport/Empathy • In the clinical setting, rapport can be defined as the harmonious responsiveness of the physician to the patient and the patient to the physician. • It is important that patients increasingly feel that the evaluation is a joint effort and that the psychiatrist is truly interested in their story. Empathic interventions ("That must have been very difficult for you" or "I'm beginning to understand how awful that felt") further increase the rapport. • Frequently a nonverbal response (raised eyebrows or leaning toward the patient) or a very brief response ("Wow") will be similarly effective. • Empathy is understanding what the patient is thinking and feeling and it occurs when the psychiatrist is able to put himself or herself in the patient's place while at the same time maintaining objectivity. • For the psychiatrist to truly understand what the patient is thinking and feeling requires an appreciation of many issues in the patient's life. • Early in the interview, the psychiatrist may not be as fully confident of where the patient is or was (although the patient's nonverbal cues can be very helpful). • If the psychiatrist is uncertain about the patient's experience, it is often best not to guess but to encourage the patient to continue. • Head nodding, putting down one's pen, leaning toward the patient, or a brief comment, "I see," can accomplish this objective and simultaneously indicate that this is important material. • An essential ingredient in empathy is retaining objectivity. • Maintaining objectivity is crucial in a therapeutic relationship and it differentiates empathy from identification. • With identification, psychiatrists not only understand the emotion but also experience it to the extent that they lose the ability to be objective. • This blurring of boundaries between the patient and psychiatrist can be confusing and distressing to many patients, especially to those who as part of their illness already have significant boundary problems (e.g., individuals with borderline personality disorder). • Identification can also be draining to the psychiatrist and lead to disengagement and ultimately burnout. Patient-Physician Relationship • The patient-physician relationship is the core of the practice of medicine. • Although the relationship between any one patient and physician will vary depending on each of their personalities and past experiences as well as the setting and purpose of the encounter, there are general principles that, when followed, help to ensure that the relationship established is helpful. • The patient comes to the interview seeking help. • Even in those instances when the patient comes on the insistence of others (i.e., spouse, family, courts), help may be sought by the patient in dealing with the person requesting or requiring the evaluation or treatment. • This desire for help motivates the patient to share with a stranger information and feelings that are distressing, personal, and often private. • Right from the very first encounter (sometimes the initial phone call), the patient's willingness to share is increased or decreased depending on the verbal and often the nonverbal interventions of the physician and other staff. • As the physician's behaviors demonstrate respect and consideration, rapport begins to develop. • This is increased as the patient feels safe and comfortable. • The sharing is reinforced by the nonjudgmental attitude and behavior of the physician. • The patient may have been exposed to considerable negative responses, actual or feared, to their symptoms or behaviors, including criticism, disdain, belittlement, anger, or violence. • Being able to share thoughts and feelings with a nonjudgmental listener is generally a positive experience. • There are two additional essential ingredients in a helpful patient- physician relationship. • One is the demonstration by physicians that they understand what the patient is stating and emoting. • The other essential ingredient in a helpful patient-physician relationship is the recognition by the patient that the physician cares. • The patient-physician relationship is reinforced by the genuineness of the physician. • Being able to laugh in response to a humorous comment, admit a mistake, or apologize for an error that inconvenienced the patient (e.g., being late for or missing an appointment) strengthens the therapeutic alliance. • It is also important to be flexible in the interview and responsive to patient initiatives. • If the patient brings in an item, for example, a photo that he or she wants to show the psychiatrist, it is good to look at it, ask questions, and thank the patient for sharing it. • The psychiatrist should be mindful of the reality that there are no irrelevant moments in the interview room. • At times patients will ask questions about the psychiatrist. • A good rule of thumb is that questions about the physician's qualifications and position should generally be answered directly (e.g., board certification, hospital privileges). • On occasion, such a question might actually be a sarcastic comment ("Did you really go to medical school?"). • In this case it would be better to address the issue that provoked the comment rather than respond concretely. There is no easy answer to the question of how the psychiatrist should respond to personal questions ("Are you married?," "Do you have children?," "Do you watch football?"). Advice on how to respond will vary depending on several issues, including the type of psychotherapy being used or considered, the context in which the question is asked, and the wishes of the psychiatrist. Often, especially if the patient is being, or might be, seen for insight-oriented psychotherapy, it is useful to explore why the question is being asked. In this instance, part of the psychiatrist's response may be that he or she has had considerable experiences in helping people deal with issues of parenting. A major reason for not answering personal questions directly is that the interview may become psychiatrist centered rather than patient centered. • Occasionally, again depending on the nature of the treatment, it can be helpful for the psychiatrist to share some personal information even if it is not asked directly by the patient. • The purpose of the self-revelation should always be to strengthen the therapeutic alliance to be helpful to the patient. • Personal information should not be shared to meet the psychiatrist's needs. Conscious/Unconscious • In order to understand more fully the patient-physician relationship, unconscious processes must be considered. • In the interview, unconscious processes may be suggested by tangential references to an issue, slips of the tongue or mannerisms of speech, what is not said or avoided, and other defense mechanisms. • For example, phrases such as "to tell you the truth" or "to speak frankly" suggest that the speaker does not usually tell the truth or speak frankly. • In the initial interview it is best to note such mannerisms or slips but not to explore them. • It may or may not be helpful to pursue them in subsequent sessions. • In the interview, transference and countertransference are very significant expressions of unconscious processes • Transference is the process of the patient unconsciously and inappropriately displacing onto individuals in his or her current life those patterns of behavior and emotional reactions that originated with significant figures from earlier in life, often childhood. • It is important that the psychiatrist recognizes that the transference may be driving the behaviors of the patient, and the interactions with the psychiatrist may be based on distortions that have their origins much earlier in life. • The patient may be angry, hostile, demanding, or obsequious not because of the reality of the relationship with the psychiatrist but because of former relationships and patterns of behaviors. • Failure to recognize this process can lead to the psychiatrist inappropriately reacting to the patient's behavior as if it were a personal attack on the psychiatrist. • Similarly, countertransference is the process where the physician unconsciously displaces onto the patient patterns of behaviors or emotional reactions as if he or she were a significant figure from earlier in the physician's life. • Psychiatrists should be alert to signs of countertransference issues (missed appointment by the psychiatrist, boredom, or sleepiness in a session). • Supervision or consultations can be helpful as can personal therapy in helping the psychiatrist recognize and deal with these issues. • Although the patient comes for help, there may be forces that impede the movement to health. • Resistances are the processes, conscious or unconscious, that interfere with the therapeutic objectives of treatment. • The patient is generally unaware of the impact of these feelings, thinking, or behaviors, which take many different forms including exaggerated emotional responses, intellectualization, generalization, missed appointments, or acting out behaviors. • Resistance may be fueled by repression, which is an unconscious process that keeps issues or feelings out of awareness. • Because of repression, patients may not be aware of the conflicts that may be central to their illness. • In the initial session, interpretations are generally avoided. • The psychiatrist should make note of potential areas for exploration in subsequent sessions. Person-Centered and Disorder-Based Interviews • A psychiatric interview should be person (patient) centered. • That is, the focus should be on understanding the patient and enabling the patient to tell his or her story. • The individuality of the patient's experience is a central theme, and the patient's life history is elicited, subject to the constraints of time, the patient's willingness to share some of this material, and the skill of the interviewer. • The patient's early life experiences, family, education, occupation( s ), religious beliefs and practices, hobbies, talents, relationships, and losses are some of the areas that, in concert with genetic and biological variables, contribute to the development of the personality. • An appreciation of these experiences and their impact on the person is necessary in forming an understanding of the patient. • It is not only the history that should be person centered. • It is especially important that the resulting treatment plan be based on the patient's goals, not the psychiatrist's. • Even when the interviewer specifically asks about the patient's goals and aspirations, the patient, having been exposed on numerous occasions to what a professional is interested in hearing about, may attempt to focus on "acceptable" or "expected" goals rather than his or her own goals. • The patient should be explicitly encouraged to identify his or her goals and aspirations in his or her own words. • Traditionally, medicine has focused on illness and deficits rather than strengths and assets. • A person-centered approach focuses on strengths and assets as well as deficits. • During the assessment, it is often helpful to ask the patient, "Tell me about some of the things you do best," or, "What do you consider your greatest asset?" • A more open-ended question, such as, "Tell me about yourself," may elicit information that focuses more on either strengths or deficits depending on a number of factors including the patient's mood and self-image. Safety and Comfort • Both the patient and the interviewer must feel safe. • This includes physical safety. • On occasion, especially in hospital or emergency room settings, this may require that other staff be present or that the door to the room where the interview is conducted be left ajar. • In emergency room settings, it is generally advisable for the interviewer to have a clear, unencumbered exit path. • Sometimes it is useful to explicitly state, and sometimes demonstrate, that there are sufficient staff to prevent a situation from spiraling out of control. • The interview may need to be shortened or quickly terminated if the patient becomes more agitated and threatening. • A direct question may be helpful in not only making the patient feel more comfortable but also in enhancing the patient-doctor relationship. • This might include, "Are you warm enough?" or "Is that chair comfortable for you?" • As the interview progresses, if the patient desires tissues or water it should be provided. • Time and Number of Sessions • For an initial interview, 45 to 90 minutes is generally allotted. • For inpatients on a medical unit or at times for patients who are confused, in considerable distress, or psychotic, the length of time that can be tolerated in one sitting may be 20 to 30 minutes or less. • Even for patients who can tolerate longer sessions, more than one session may be necessary to complete an evaluation. • An interview is dynamic and some aspects of the evaluation are ongoing, such as how a patient responds to exploration and consideration of new material that emerges. • If the patient is coming for treatment, as the initial interview progresses, the psychiatrist makes decisions about what can be continued in subsequent sessions. P RO C E S S O F T H E I N T E RV I E W
Before the Interview
• It is important that whomever is receiving the call understands how to respond if the patient is acutely distressed, confused, or expresses suicidal or homicidal intent. • If the receiver of the call is not a mental health professional, the call should be transferred to the psychiatrist or other mental health professional, if available. • If not available, the caller should be directed to a psychiatric emergency center or an emergency hotline. • The receiver of the call should obtain the name and phone number of the caller and offer to initiate the call to the hotline if that is preferred by the caller. • Most calls are not of such an urgent nature. • Although the requested information varies considerably, it generally includes the name, age, address and telephone number( s) of the patient, who referred the patient, the reason for the referral, and insurance information. • The patient is given relevant information about the office including length of time for the initial session, fees, and whom to call if there are additional questions. • In many practices the psychiatrist will call the patient to discuss the reason for the appointment and to determine if indeed an appointment appears warranted. • The timing of the appointment should reflect the apparent urgency of the problem. • Asking the patient to bring information about past psychiatric and medical treatments as well as a list of medications (or preferably the medications themselves) can be very helpful. • Whether or not records are reviewed, it is important that the reason for the referral be understood as clearly as possible. • This is especially important for forensic evaluations where the reason for the referral and the question( s) posed will help to shape the evaluation. • It is critical to determine whether the patient is referred for only an evaluation with the ongoing treatment to be provided by the primary care physician or mental health provider (e.g., social worker) or if the patient is being referred for evaluation and treatment by the psychiatrist. • If the patient is referred by the court, a lawyer, or some other non- treatment-oriented agency such as an insurance company, the goals of the interview may be different from diagnosis and treatment recommendations. • These goals can include determination of disability, questions of competence or capacity, or determining, if possible, the cause or contributors of the psychiatric illness. • In these special circumstances, the patient and clinician are not entering a treatment relationship, and often the usual rules of confidentiality do not apply. • This limited confidentiality must be explicitly established with the patient and must include a discussion of who will be receiving the information gathered during the interview. The Waiting Room • When the patient arrives for the initial appointment, he or she is often given forms to complete. • Many practices also ask for a list of medications, the name and address of the primary care physician, and identification of major medical problems and allergies. • Sometimes the patient is asked what his or her major reason is for coming to the office. • sometimes the choice of the chair or how the chair is chosen can reveal characteristics of the patient. • Many psychiatrists suggest that the interviewer's chair and the patient's chair be of relatively equal height so that the interviewer does not tower over the patient (or vice versa). • It is generally agreed that the patient and the psychiatrist should be seated approximately 4 to 6 feet apart. • The psychiatrist should not be seated behind a desk. • The psychiatrist should dress professionally and be well groomed. • Distractions should be kept to a minimum. Initiation of the Interview • The patient is greeted in the waiting room by the psychiatrist who, with a friendly face, introduces himself or herself, extends a hand, and, if the patient reciprocates, gives a firm handshake. • Upon entering the interview room, if the patient has a coat, the psychiatrist can offer to take the coat and hang it up. • The psychiatrist then indicates where the patient can sit. • A brief pause can be helpful as there may be something the patient wants to say immediately. • If not, the psychiatrist can inquire if the patient prefers to be called Mr. Smith, Thomas, or Tom. • These first few minutes of the encounter, even before the formal interview begins, can be crucial to the success of the interview and the development of a helpful patient-doctor relationship. • Psychiatrists can convey interest and support by exhibiting a warm, friendly face and other nonverbal communications such as leaning forward in their chair. • It is generally useful for the psychiatrist to indicate how much time is available for the interview. • The psychiatrist can then continue with an open-ended inquiry, "Why don't we start by you telling me what has led to your being here," or simply, "What has led to your being here?" • When a referral has been made, it is important to elicit from the patient his or her understanding of why he or she has been referred. Open-Ended Questions • As the patient responds to these initial questions, it is very important that the psychiatrist interacts in a manner that allows the patient to tell his or her story. • This is the primary goal of the data collection part of the interview, to elicit the patient's story of his or her health and illness. • Open-ended questions identify an area but provide minimal structure as to how to respond. • As the patient continues to share his or her story about an aspect of his or her health or illness, the psychiatrist may ask some increasingly closed-ended questions to understand some of the specifics of the history. • Then, when that area is understood, the psychiatrist may make a transition to another area again using open-ended questions and eventually closed-ended questions until that area is well described. • Hence, the interview should not be a single funnel of open-ended questions in the beginning and closed-ended questions at the end of the interview but rather a series of funnels, each of which begins with open-ended questions.