PSYCHIATRIC INTERVIEWINGResident Lecture SeriesJerome Lee and Jen Wide

Outline

Therapeutic alliance Interview Process Application of Questions Screening Questions MSE Questions

Therapeutic Alliance

Establish Therapeutic Alliance = collaborative nature of the partnership

between clinician and client Is a partnership that incorporates client

preferences and goals into treatment outlines methods for accomplishing those goals

based on listening to w/o being judgmental or giving unwarranted advice

Gain cooperation and allow the patient to develop a connection/relationship with treating team/physician

Importance of Therapeutic Alliance Accounts for more variance in treatment

outcomes than any single patient characteristic

For positive txn outcomes, establishing a strong, helping alliance is better than: professional training type of therapy or intervention how long you spend with a patient

Importance of Therapeutic Alliance In substance use

Reductions in substance consumption Increased abstinence rates Better social adjustment More successful referrals to treatment

Components of Good Alliance Non-possessive warmth Friendliness Genuineness Respect Affirmation Empathy

The 6 People in the Room

With every conversation between two people there are at least 6 people present:

1. What each person said = 2 people2. What each person meant to say = 2

people3. What each person understood the other

to say are = 2 people

Be a Good Listener

essential to listen and clarify the issue with the pt

Be a vigilant inward listener Pay attention to nonverbal cues such as body

language. Ask yourself “Is there something the client is

trying to say that I’m not getting?” pursue what you don’t understand

“reflective listening” repeat back to the client what you hear them

saying to you rephrase or paraphrase what they’ve said

Be Non-Judgmental

Be receptive to the unknown When there is judgment about what is

revealed, the speaker is sealed off from the listener no longer an exchange

Offer understanding and unconditional acceptance of the client

Self-Awareness

Time to get to know yourself!

must actively listen to the client and monitor your own responses to the patient

But don’t get too overly focused on yourself

Be Weary of Unwelcomed Adviced Don’t tell them what you think should be

done Be careful not to give advice to the client

unless asked directly for it especially during the pre-engagement and

engagement stages Giving advice that the client is not yet ready

to hear or deal with weakens therapeutic alliance makes the client feel as though you are not

really listening to what the client wants.

Empathy

Don’t fake it! Patients can sense a dislike of them

Be as genuine as possible E.g. “I can see that it’s causing you a lot of

distress” “You seem angry, I imagine that must be

frustrating” “It seems a lot for you”

Patients appreciate a genuine attempt by the counselor to see things from their point of view

Respect

No one wants to feel like an idiot Respect = Golden Rule

explaining things to patients Acknowledging unfairness/poor

txn/mistakes Use simply language

Grade 6 edu Don’t use medical jargon, e.g.

“hypertension”

Final Suggestions

Recognize and praise patient when they have made progress toward attaining their goals. can include showing up for the counseling

session, being coop, etc. Offer a hopeful, but realistic attitude that

goals can be met Help pt make realistic goals

Acknowledge and directly address rifts in the therapeutic relationship

The Interview Process

How to Start an Interview

Be warm, courteous and emotionally sensitive Actively diffuse the strangeness of the clinical

situation Educate the patient about the nature of the

interview Gain your patient’s trust by projecting

competence, but be real about your abilities Be yourself Give the patient the opening word

“tell me about yourself”, “what brought you here” Alternatively may begin with background info

Techniques

Open ended verbalizations

Variable verbalizations

Close ended verbalizations

Spontaneous Natural Referred Phantom Implied

Questions types Gates/Transitions

Open Ended Verbalization

These questions invite the patient to share personal experiences

Two forms:1. Open ended questions

What are your plans for the marriage?

2. Gentle commands Tell me about your mother?

Close ended Verbalizations

Answers potentially can be answered with 1-2 words.

Two Types:1. Close ended questions

Are you feeling happy, angry or sad?

2. Close ended statements-Anxieties can be helped by behavioral therapies. Closed ended statements are used for

educational slants or explanations.

Variable Verbalizations

Middle ground questions They tend to vary in

the response they create.

A good blend causes a production of large amount of spontaneous speech = A GOOD THING.

1. Swing type Can you describe your

marriage?2. Qualitative

How is your appetite3. Statements of Inquiry

So you left marriage after three years?

4. Empathetic statements

Its sounds like a troubling time for you

5. Facilitatory type I see, Go on.

“Gates”

Spontaneous Gate simple follow up question following the

interviewee at “pivot points.” clinician can decide to pursue or not

Natural Gate clinician enters a new region cueing directly

off the patient’s preceding statement Referred Gate

refers back to simple statements by the patient.

Good technique to return to a poorly understood/expanded area

“Gates Cont’d”

Implied gates allows one to join similar regions and can

also provide parallel expansions to related regions

E.g. connecting energy and sleep during mood screen

Phantom gate The physician’s derailment appears out of nowhere! Generally avoided.

Shifting Topics with Style

Use smooth transition to cue off something the patient just said

Use referred transition to cue off something said earlier in the interview

Use introduction transitions to pull off a new topic from thin air

Remind yourself/patient this is a clinical interview – not a chat

Never apologize for the questions you are or are about to ask

How to Approach Threatening Topics Use normalizing questions to decrease a

patients sense of embarrassment about a feeling or behavior

Use reduction of guilt to defuse admission of embarrassing behavior

Use symptom exaggeration to determine the actual frequency of a sensitive, shameful behavior

Use familiar language when asking about behaviors

Examples: Normalization

With all the stress you’ve been under I wonder if you’ve been drinking more lately?

Sometime when people are very depressed they think of hurting themselves. Has this been true for you?

I’ve seen a number of patients who’ve told me that their anxiety causes them to avoid things, like driving….

Examples: Gentle assumption: What sorts of drugs do you use when

drinking?

Experimented with any drugs?

What kinds of ways to hurt yourself have you thought of?

Other Examples

Symptom exaggeration: How many times do you purge in a day, 5-

10? If lower frequency they won’t be perceived

as being bad

Reduction of guilt Use familiar language – use their language

The Power of Silences

Be ok with uncomfortable silences Let the patient be the first to break and

talk, and they will

APPLICATION OF QUESTIONS AND GATES TO DIFFICULT PATIENTS

The Shut Down Interview

An interview where the patient displays short responses, long delay between answering and body cues that suggest “not interested.”

It is common that the interviewer is “feeling frustrated” resulting in: lack of empathy possibly focusing on close ended questions hitting criteria like check marks

The Shut Down Interview

use more Open ended verbalizations “What are some of your thoughts about the marriage?”

Follow up with topic that patient gives slightest hints that they want to discuss.

Supportive comments. “That was must have been difficult for you to deal with.”

Gentle commands “Describe your initial reaction?”

Increase eye contact Avoid long pauses before asking the next question. Avoid sensitive topics to start. (lethality,

substances sexual history)

Wandering Interview

Patient speaks with a mild pressure, often talking for long periods with vary little breaks jumping from one topic to another.

Hard to interrupt Sometimes completely off topic ie asking

about current depressive sx and patient talks about her abuse at the age of 10 years old.

Wandering Interview

Increase closed ended questions Avoid reinforcement with head nodding and

cues like “go on” Gentle structure comments such as “let’s focus

on what your mood was like this week.” More firm comments, “I’m going to focus on

some important areas you mentioned in an effort to understand you better.”

Clarify or address resistance: “Its seems that you wander off the subject, what do you think is going on?”

Sometimes you can use PHANTOM gates but may cause loss of rapport.

SCREENING QUESTIONS

Depression Questions

Mneumonic for the DSM IV Criteria “M- SIGECAPS” Mood, Sleep, Interest, Guilt, Energy,

Concentration, Appetite, Psychomotor agitation/retardation, Suicide.

Requires decreased mood or interest for two weeks plus 5/9

Mania Screening Questions

Mneumonic of the DSM IV Criteria “DIGFAST” where the mood is “on top of the

world”. Distractible, Indiscretion, Grandiosity, Flight of Ideas, Activities increased, Sleep Deficit, Talkative (pressured speech)

Requires 1 week of 3/6 of the above symptoms.

Schizophrenia

Requires two symptoms for 1 month, plus 6 months of prodromal or residual symptoms

Delusions Hallucinations Speech disorganization Behaviour disorganization Negative Symptoms

Panic Disorder

Recurrent Panic Attacks (must have 4 of 13 symptoms)

Mneumonic: Heart, Breathless, Fear Heart Cluster: Nausea, Palpitations, Pain,

Sweat Breathless Cluster: SOB, Choking, Dizziness Fear Cluster: Fear of dying, going crazy One month of fear, worry and change in

behaviour over the idea of having another attack

Generalized Anxiety Disorder Excessive anxiety about a number of things

for most days over 6 months; unable to control

Mneumonic: SCRIFT (sleep concentration restlessness irritability fatigue tension)

Sleep Concentration Restlessness Irritability Fatigue Tension

Obsessive Compulsive Disorder

Mneumonic: Washing and Straightening Make Clean Houses

Washing Straightening Mental Rituals Checking HoardingMust have obsessions (thoughts, impulses,

images causing distress) or compulsions (behaviours or mental acts driven to perform to prevent/reduce stress)

Asking About MSE

Asking about Mood Symptoms?

“How have you been feeling lately?” “How would you describe you mood right

now?” “Have you been feeling sad, blue, down

or depressed?” “Have you been feeling nervous or

anxious much of the time?”

Thought Content

Normalizing When things get really bad, some people

start having thoughts of suicide or death. Have you had such thought?

Contextualizing I do have to ask, have you had any

thoughts of hurting or killing yourself? Others?

Thought Content

Do you spend a lot of time thinking of something? Do you have some ideas that you hold very

strongly? Do others frequently disagree with your point of

view? Do you ever feel as if someone or something is out

to get you? Do you ever feel as if people are judging you? Do you ever feel as if your thoughts are not your

own? Do you ever feel there are special messages that

are only being directed at you? Do you ever think you have any special powers? Have you had any new ideas about religion?

Thought Content

Do you ever experience thoughts that you can’t stop?

Do your thoughts feel like they are your own? Are you ever forced to think of something

against your will? Are there objects or situations that make you

intensely anxious if you cannot avoid them? Do you have strong fears about being

humiliated in public? Do you require special arrangements to be

made for you to be comfortable when you are outside your home?

Asking about Perceptual Disorders? “Many people with difficulties like yours

have other symptoms as well. To be thorough, I’d like to ask you about some of these things so I have a complete understanding of what’s been happening.”

When depression gets really bad, some people start seeing or hearing things. Has that happened to you

“Have you had any unusual experiences?” “Have things been happening around you

that seem puzzling?”

Insight & Judgment

Insight Is it you opinion that you have an illness? How do you account for the difficulties you

are having? What does (name of condition) mean to

you? Judgment

What are the txn options? What are the pros/cons of +/- txn?

Cognition

Attention: World backwards Days of week or Months of year backwards

References

Daniel Carlat – The Psychiatric Interview Shawn Shea – Psychiatric Interviewing:

The Art of Understanding