General Features of Psychiatric Interviews

General Features of Psychiatric Interviews

Setting

The ideal interview setting is one which provides a pleasant at-mosphere and is reasonably comfortable, private and free from outside distractions. Such a setting not only provides the physical necessities for an interview but conveys to the patient that he/she will be well cared for and safe. Providing such a setting may pose special problems in certain interviewing situations. For example, it may be necessary to interview highly agitated patients in the presence of security personnel; interviewers on medical–surgical units must pay special attention to the patient’s comfort and privacy.

Verbal Communication

Verbal communication may be straightforward imparting of in-formation: “Every year around November, I begin to lose interest in everything and my energy gets very low”. However, patients may convey information indirectly through metaphor, or use words for noninformational purposes such as to express or con-tain emotions or to create an impact on the interviewer.

In metaphorical language, one idea is represented by an-other with which it shares some features. For example, when asked how she gets along with her daughter-in-law, a woman replies, “I can never visit their house because she always likes to keep the thermostat down. It’s never as warm as I need”. Such a reply suggests that the woman may not feel “warmly” accepted and welcomed by her son’s wife. Metaphor may also use the body to represent ideas or feelings. A man who proved to meet the diagnostic criteria for major depressive disorder described his mood as “OK” but complained that his life was being ruined by constant aching in his chest for which the doc-tors could find no cause. In this instance, the pain of depression was experienced and described metaphorically as a somatic symptom.

Language may be used to express emotions directly (“I’m afraid of you and I don’t want to talk to you”), but more often is used indirectly by influencing the process of the interview (Bernstein and Bernstein, 1985). Patients may shift topics, make off-hand remarks or jokes, ask questions, and compliment or be-little the interviewer as a way of expressing feelings. The process of the interview frequently expresses the patient’s feelings about his/her immediate situation or interaction with the interviewer (Malan, 1979). For example, a woman being evaluated for depres-sion and anxiety suddenly said, “I was just wondering doctor, do you have any children?” The further course of the interview re-vealed that she was terrified of being committed to a hospital and abandoned. The question was an attempt to establish whether the interviewer was a good parent and therefore safe as a caretaker for her.

Language may also be used in the service of psychologi-cal defense mechanisms to contain rather than express emotions (Freud, 1946). For example, a young man with generalized anxi-ety was asked whether he was sexually active. He replied by talk-ing at length about how all the women he knew at college were either unappealing or attached to other men. Further discussion revealed that he developed severe symptoms of anxiety when-ever he was with a woman to whom he felt sexually attracted. His initial reply represented an automatic, verbal mechanism (in this case, a rationalization) for keeping the anxiety out of awareness.

Another form of process communication is the use of lan-guage to make an impact on the interviewer (Casement, 1985). A statement such as “If you can’t help me I’m going to kill my-self”, might convey suicidal intent, but may also serve to stir up feelings of concern and involvement in the interviewer. Simi-larly, the patient who says, “Dr X really understood me, but he was much older and more experienced than you are”, may be feeling vulnerable and ashamed, and unconsciously trying to induce similar feelings in the interviewer. When language is used in this way, the interviewer’s subjective reaction may be the best clue to the underlying feelings and motivations of the patient.

Nonverbal Communication

Emotions and attitudes are communicated nonverbally through facial expressions, gestures, body position, movements of the hands, arms, legs, and feet, interpersonal distance, dress and grooming, and speech prosody (Knapp, 1978). Some nonverbal communications such as gestures are almost always conscious and deliberate, while others often occur automatically outside one’s awareness. The latter type are particularly important to observe during an interview because they may convey messages entirely separate from or even contradictory to what is being said.

        Facial expression, body position, tone of voice, and speech emphasis are universal in the way they convey mean-ing (Ekman et al., 1972). The interviewer will automatically decode these signals but may ignore the message due to coun- tertransference or social pressure from the patient. For exam-ple, a patient may say, “I feel very comfortable with you, doc-tor”, but sit stiffly upright and maintain a rigidly fixed smile, conveying a strong nonverbal message of tension and mistrust. The nonverbal message may be missed if, for example, the in-terviewer has a strong need to be liked by the patient. An-other patient denies angry feelings while sitting with a tightly clenched fist. The interviewer may unconsciously collude with the patient’s need to avoid his anger by ignoring the body language.

As with any medical examination, observation of non-verbal behavior may provide important diagnostic information. For example, a leaden body posture may indicate depression, movements of the foot may arise from anxiety or tardive dys-kinesia, and sudden turning of the head and eyes may suggest hallucinations.

Nonverbal communication proceeds in both directions, and the nonverbal messages of the interviewer are likely to have a considerable effect on the patient. Thus, the interviewer who sits back in his chair and looks down at his notes communicates less interest and involvement than one who sits upright and makes eye contact. Similarly, an interviewer who gives a weak handshake and sits behind a desk or far across the room from the patient will communicate a sense of distance which may interfere with establishing rapport. It is important that the interviewer be aware of his/her own nonverbal messages and adapt them to the needs of the patient.

Listening and Observation

The complexity of communication in the psychiatric interview is mirrored by the complexity of listening (Luborsky, 1984). The interviewer must remain open to literal and metaphorical messages from the patient, to the impact the patient is trying to make, and to the degree to which nonverbal communication complements or contradicts what is being said. Doing this opti-mally requires that the interviewer also be able to listen to his/her own mental processes throughout the interview, including both thoughts and emotional reactions. Listening of this kind depends upon having a certain level of comfort, confidence and space to reflect, and may be very difficult when the patient is hostile, agi-tated, demanding, or putting pressure on the interviewer in any other way. With such patients, it may take many interviews to do enough good listening to gain an adequate understanding of the case.

Another important issue in listening is maintaining a proper balance between forming judgments and remaining open to new information and new hypotheses. On the one hand, one approaches the interview with knowledge of diag-nostic classifications, psychological mechanisms, behavioral patterns, social forces and other factors which shape one’s understanding of the patient. The interviewer hears the mate-rial with an ear to fitting the information into these preformed patterns and categories. On the other hand, the interviewer must remain open to hearing and seeing things which extend or modify his/her judgments about the patient. At times the interviewer may listen narrowly to confirm a hypothesis, while at others he/she may listen more openly, with relatively little preconception. Thus, listening must be structured enough to generate a formulation but open enough to avoid premature judgments.

Attitude and Behavior of the Interviewer

The optimal attitude of the interviewer is one of interest, con-cern and intention to help the patient. While the interviewer must be tactful and thoughtful about what he/she says, this should not preclude behaving with natural warmth and spon-taneity. Indeed, these qualities may be needed to support pa-tients through a stressful interview process. Similarly, the interviewer must try to use natural, commonly understood language and avoid jargon or technical terms. The interviewer must communicate his/her intention to keep the patient as safe as possible, whatever the circumstances. Thus, while one must at times set limits on the behavior of an agitated, threat-ening, or abusive patient, one should never be attacking or rejecting.

Empathy is an important quality in psychiatric inter-viewing. While sympathy is an expression of agreement or sup-port for another, empathy entails putting oneself in another’s place and experiencing his/her state of mind. Empathy com-prises both one’s experiencing of another person’s mental state and the expression of that understanding to the other person (Barrett-Lennard, 1981). For example, in listening to a man talk about the death of his wife, the interviewer may allow him-self to resonate empathetically with the patient’s feelings of loneliness and desolation. Based on this resonance, he might respond, “After a loss like that, it feels as if the world is com-pletely empty”.

As a mode of listening, empathy is an important way of understanding the patient; as a mode of response, it is impor-tant in building rapport and alliance. Patients who feel great emotional distance from the interviewer may make empathic understanding difficult or impossible. Thus, the interviewer’s inability to empathize may itself be a clue to the patient’s state of mind.

Structure of the Interview

The overall structure of the psychiatric interview is generally one of reconnaissance and detailed inquiry (Sullivan, 1970). In re-connaissance phases, the interviewer inquires about broad areas of symptomatology, functioning, or life course: “Have you ever had long periods when you felt very low in mood?” “How have you been getting along at work?” “Tell me what you did between high school and when you got married”. In responding to such questions, patients give the interviewer leads which then must be pursued with more detailed questioning. Leads may include references to symptoms, difficulty in functioning, interpersonal problems, ideas, states of feeling, or stressful life events. Each such lead raises questions about the nature of the underlying problem, and the interviewer must attempt to gather enough de-tailed information to answer these questions. Reliance on yes or no “gate questions” to rule out areas of pathology has been shown to increase the risk of missing important information. This risk may be minimized by asking about important areas in several ways (Barber et al., 2001).

In general, the initial reconnaissance consists of asking how the patient comes to treatment at this particular time. This is done by asking an open-ended question such as “What brings you to see me today?” or “How did you come to be in the hos-pital right now?” A well-organized and cooperative patient may spontaneously provide most of the needed information, with lit-tle intervention from the interviewer. However, the patient may reveal deficits in thought process, memory, or ability to com-municate, which dictate more structured and narrowly focused questioning.

The patient’s emotional state and attitude may also im-pede a smooth flow of information. For example, if the patient shows evidence of anxiety, hostility, suspiciousness, or indif-ference, the interviewer must first build a working alliance before trying to collect information. This usually requires ac-knowledging the emotions which the patient presents, helping the patient to express his/her feelings and related thoughts, and discussing these concerns in an accepting and empathic manner (Strean, 1985). As new areas of content open up, the interviewer must continue to attend to the patient’s reactions, both verbal and nonverbal, and to identify and address resistance to open communication.

Setting an appropriate level of structure is an important aspect of psychiatric interviewing. Psychiatric patients may spontaneously report a low number of symptoms, and initial di-agnostic impressions may be misleading (Herran et al., 2001). Over the past two decades, a variety of structured interview for-mats have been developed for psychiatric assessment (Wiens, 1990; Spitzer et al., 1978). In these interviews, the organization, content areas, and, to varying degrees, wording of the questions are standardized; vague, overly complex, leading or biased, and judgmental questions are eliminated, as is variability in the at-tention given to different areas of content. The major benefits of such interviews are that they ensure complete coverage of the specified areas and greatly increase the reliability of informa-tion gathered and diagnostic judgments. In addition, formats which completely specify the wording of questions can be ad-ministered by less highly trained interviewers or even as patient self-reports.

The disadvantages of highly structured interviews are that they diminish the ability to respond flexibly to the patient and preclude exploration of any areas not specified in the for-mat (Groth-Marnat, 1990). They are therefore used to best ad-vantage for interviews with focused goals. For example, such interviews may aim to survey certain DSM IV Axis I disor-ders, to assess the type and degree of substance abuse, or to delineate the psychological and behavioral consequences of a traumatic event. They are less useful in a general psychiatric assessment where the scope and focus of the interview cannot be preordained.

In the usual clinical situation, while the interviewer may have a standardized general plan of approach, he/she must adapt the degree of structure to the individual patient. Open-ended, nondirective questions derive from the psychoanalytic tradition. They are most useful for eliciting and following emotionally salient themes in the patient’s lifestory and interpersonal his-tory. Focused, highly structured questioning derives from the medical/descriptive tradition and is most useful for delineating the scope and evolution of pathological signs and symptoms. In general, one uses the least amount of structure needed to main-tain a good flow of communication and cover the necessary topic areas.