Communication Skills for Psychiatry Lucie Bankovská Motlová

Basic Skills

• Observe

• Listen

• Inquire

• Judge

Generall Skills in Inteviewing

• eye contact

• relaxed posture

• not appear hurried

• picking-up verbal and non-verbal cues of distress

• dealing with over-talkativeness

• dealing with reslessness and agression

Establishing Rapport• welcome the patient• state purpose of the meeting• privacy• basic human comforts• calming and respectful demeanor• encourage open communication• acknowledge and validate patient´s

distress/concerns

Phases of the Interview

• Warm-up

• Screening of the problem

• Follow-up of preliminary impressions

• Completion of data base

• Feedback

• Treatment contract

Interviewing Techniques

• Establish rapport as early in the interview as possible.

• Determine the patient’s chief complaint.

• Use the chief complaint to develop a provisional differential diagnosis.

• Rule the various diagnostic possibilities out or in by using focused and detailed questions.

• Follow up on vague or obscure replies with enough persistence to accurately determine the answer to the question.

Interviewing Techniques

• Let the patient talk freely enough to observe how tightly the thoughts are connected.

• Use a mixture of open-ended and closed-ended questions.

• Ask about suicidal thoughts.

• Give the patient a chance to ask questions at the end of the interview.

• Conclude the initial interview by conveying a sense of confidence and, if possible, of hope.

Supportive Interventions

• Encouragement. Patient: I am not very good at putting things into words.

• Doctor: I think you have described the situation very well.

• Reassurance. Doctor: I can understand how those experiences must have frightened you, but I think it is very likely they'll respond to treatment.

• Acknowledging emotion. Doctor: Even now it brings tears to your eyes when you talk about your mother.

• Nonverbal communication. Body posture and facial expression that convey interest, concern, and attentiveness.

Obstructive Interventions

• Closed-ended „double“ questions Doctor: Have you experienced any change in your appetite and sleeping?• Judgmental questions.

Doctor: How do you think your wife felt when she found out about your affair?• Not following the patient's lead.

Patient: I have trouble sleeping through the night.Doctor: Any change in appetite?Patient: I keep waking up out of nightmares about my daughter.Doctor: Do you have less energy than usual?

• Minimization or dismissal. Patient: I'm not able to keep my checkbook balanced the way I need to.Doctor: Oh, I wouldn't worry about it. Lots of people don't even try.

• Premature advice. Patient: Work is almost unbearable. My supervisor watches me like a hawk and criticizes the

tiniest little mistake I make.Doctor: Why not write her a memo and outline your grievances?"

• Nonverbal communication. Yawning, checking one's watch. Patients can often detect an interviewer's inattention by the

absence of facial expression or body movement.

Special Clinical Skills

• Acute psychosis

• Acute psychosis with agression

• Dementia

• Mania

• Depression

• Suicidal patient

• Stupor

Acute Psychosis

Video: „Nemesis“

Psychotic patient: Rules for Communication

how whyUse short sentences Short attention span

One sentence, one information Information processing disorder

Use models, draw, write and repeat frequently

Memory and attention problems

Do not speak out delusions, pay attention to emotional problems connected to delusion

Delusion cannot be corrected by reasoning, but usually is distressing

Dealing with Acute Psychosis with Agression

Video: Management and treatment of acute psychosis

Dementia: Rules for Communication

Dementia screening: • „What is your birthday?“ • „How old are you?“

Close-ended short questions

Useful tests:• Clock Test• MMSE (Mini Mental State Examination)

Video:Mr B with Bartoš

Clock Test: 2:45

Normal

Moderate Cognitive Disorder

Mild Cognitive Disorder

Severe Cognitive Disorder

VideoClock test: 0 point

Mania

Video: Renata

Mania: Rules for Communication

• Keep calm, low voice

• Do not argue with the patient

• If patient uses vulgar expressions, ask him not to do so

• If patient does not cooperate, do not continue with the interview

Depression: Rules for Communication

• Structured communication, short sentences• Do not regret the patient and do not try to tell

him jokes to make him laugh• Ask about apetite, loss of weight and

sleeping pattern• Ask about hopelessness feelings• Ask about suicidal thougts, ideas and plans

Suicide: Questions

• Have you ever felt that life was not worth living?• Did you ever wish you could go to sleep and just

not wake up?• Have things ever reached the point where you

´ve thought about harming yourself?• When did you first notice such thoughts?• Have you made a specific plan to harm or kill

yourself? • If so, what does the plan include?

Source: APA Practice Guidelines for Assessment of Patients with Suicidal behaviors

Risk of Suicide AssessmentS sex: maleA age: >45, <19D depression

P previous attemptsE ethanol abuseR rational thinking loss (psychosis?)S social suppot lackingO organized planN no spouseS sickness (somatic illness with pain)

Management

Each positive answer = 1 point

• 0-2: low risk• 3-4: medium risk; outpatient treatment,

observation• 5-6: high risk; hospitalization, especially in

cases without social support• 7-10: very high risk; hospitalization

Write it to the medical record!

Stupor

• Somatic condition

• Dehydration, bedsores, embolia