Conduct of the Interview: Factors Which Affect the Interview
A skillful interview will not necessarily yield all the relevant in-formation but will make the most of the opportunities in a clini-cal situation, given the limitations which both the patient and interviewer bring. Factors which influence the development of an alliance and the amount which can be learned in the interview include the following:
Patients who are in acute distress either from physical dis-comfort or from emotional factors such as severe depression or anxiety will be limited in their motivation and ability to interact with the interviewer. The interviewer may be able to enhance communication by addressing the patient’s discomfort in a supportive manner. However, he/she must also recognize times when the patient’s discomfort necessitates a more limited interview.
Patients who are demented, retarded, disorganized, thought-disordered, amnesic, aphasic, or otherwise impaired in intellec-tual or cognitive capacity have biologically based deficits which limit the amount of information they can convey
Patients bring to the interview a wide variety of preconceptions, expectations and tendencies toward distortion, which influence how they view and relate to the interviewer. Such biases are commonly referred to as transference because they frequently can be understood as arising from interactions with important figures in childhood, such as parents, which then color percep-tions of others during adult life (Nemiah, 1961b). Transferential biases may be positive or negative. Thus, even before the start of the interview, one patient may be primed to view the doctor as a wise and kindly healer, while another will be predisposed to see him/her as an exploitative charlatan. Clearly, such bi-ases affect the amount of openness and trust which the patient brings to the interview and the quality of information he/she provides.
The interviewer, like the patient, may have feelings stirred up by the interaction. The interviewer’s emotional reactions to the patient can be an invaluable asset in assessment if he/she can be conscious of them and reflect on their causes. For example, an interviewer finds himself becoming increasingly annoyed at a highly polite patient. On reflection, he realizes that the polite-ness serves to rebuff his attempts to establish a warmer, more spontaneous relationship and is a manifestation of the patient’s underlying hostile attitude.
When the interviewer is unable to monitor and exam-ine his/her emotional reactions, they are more likely to impede rather than enhance understanding of the patient. This is most likely to happen when emotional reactions are driven more by the interviewer’s own biases than by the patient’s behavior. Such reactions are referred to as the interviewer’s countertransfer-ence (Mackinnon and Michels, 1971). In the example cited in the previous paragraph, the interviewer might inaccurately perceive a polite patient as rigid and hostile due to unconscious biases (countertransference) based on his relationship with his own rig-idly polite parent. The entire range of countertransferential inter-viewer attitudes toward the patient, from aversion to infatuation, might similarly bias judgment.
Patients’ attitudes toward the interview will be strongly influ-enced by the situation in which the consultation arises. Some patients decide for themselves that they need treatment, while others come reluctantly, under pressure from others. Patients who are being evaluated for disability or in connection with a lawsuit may feel a need to prove that they are ill, while those being evaluated for civil commitment or at the insistence of fam-ily members may need to prove that they are well. Similarly, a patient’s past history of relationships with psychiatrists or with health professionals in general is likely to color his/her attitude toward the interviewer.
The interviewer may also be affected by situational fac-tors. For example, pressure of time in a busy emergency service may influence the interviewer to omit important areas of inquiry and reach premature closure; the experience of a recent patient suicide may bias the interviewer toward overestimation of risk in someone with suicidal thoughts. As with countertransference reactions, it is important for the interviewer to minimize dis-tortions due to situational factors by being as aware of them as possible.
The degree of racial, ethnic, cultural, and socioeconomic simi-larity between the patient and interviewer can influence the course and outcome of the interview in many ways. It may affect the level of rapport between patient and interviewer, the way both view the demands of the situation, the way they interpret each other’s verbal and non-verbal communications, and the meaning the interviewer as-signs to the patient’s statements and behaviors (Gaw, 1993). Not only racial or cultural prejudice but also well-intentioned ignorance can interfere with communication and accurate assessment.
Some cultures, for example, place a higher value on po-liteness and respect for authority than does western culture. A patient from such a background might be reluctant to correct or disagree with the interviewer’s statements even when they are er-roneous. The interviewer might not suspect that he/she was hear-ing distorted information, or conversely, might see the patient as pathologically inhibited or unemotional. Many nonwestern cultures place a higher value on family solidarity than on indi-viduality. Pressing a patient from such a culture to report angry feelings toward family members might raise his/her anxiety, de-crease rapport with the interviewer and produce defensive distor-tions in the material.