Phases of the Interview

Phases of the Interview

The typical interview comprises an opening, middle and clos-ing phase. In the opening phase, the interviewer and patient are introduced, and the purposes and procedures of the interview are set. It is generally useful for the interviewer to begin by summarizing what he/she already knows about the patient andproceeding to the patient’s own account of the situation. For example, the interviewer may say, “Dr Smith has told me that you have had several episodes of depression in the past, and now you may be going into another one”, or “I understand that you were brought in by the police because you were threaten-ing people on the street. What do you think is happening with you?” or “When we spoke on the phone you said you thought your marriage was in trouble. What has been going wrong?” Such an approach orients the patient and sets a collaborative tone.

The opening phase may also include clarification of what the patient hopes to gain from the consultation. Patients may sometimes state this explicitly, but often do not, and the inter-viewer should not assume that his/her goals are the same as the patient’s (Lazare et al., 1975). A question such as “How were you hoping I could help you with the problem you have told me about?” invites the patient to formulate and express his/her request and avoids situations in which the patient and interviewer work at cross-purposes. The interviewer must also be explicit about his/her own goals and the extent to which they fit with the patient’s expectations. This is especially important when the in-terests of a third party, such as an employer, a family member, or a court of law is involved.

The middle phase of the interview consists of assess-ing the major issues in the case and filling in enough detail to answer the salient questions and construct a working for-mulation. Most of the work of determining the relative im-portance of biological, psychological, environmental and so-ciocultural contributions to the problem is done during this phase. The patient’s attitudes and transferential perceptions are also monitored during this phase so that the interviewer can recognize and address barriers to communication and collaboration.

When appropriate, formal aspects of the Mental Status Examination are performed during the middle phase of the in-terview. While most of the mental status evaluation is accom-plished simply by observing the patient, certain components such as cognitive testing and review of psychotic symptoms may not fit smoothly into the rest of the interview. These are gener-ally best covered toward the end of the interview, after the issues of greatest importance to the patient have been discussed and rapport has been established. A brief explanation that the inter-viewer has a few standard questions he/she needs to cover before the end of the interview serves as a bridge and minimizes the awkwardness of asking questions which may seem incongruous or pejorative.

In general, note-taking during an assessment interview is helpful to the interviewer and not disruptive of rapport with the patient. Notes should be limited to brief recording of fac-tual material such as dates, durations, symptom lists, important events and past treatments, which might be difficult to keep in memory accurately. The interviewer must take care not to be-come so involved in taking notes as to lose touch with the pa-tient. It is especially important to maintain a posture of attentive listening when the patient is talking about emotionally intense or meaningful issues. When done with interpersonal sensitiv-ity, note-taking during an assessment interview may actually enhance rapport by communicating that what the patient says is important and worth remembering. This is to be distinguished from note-taking during psychotherapy sessions, which is more likely to diminish the treater’s ability to listen and respond flexibly.

In the third or closing phase of the interview, the in-terviewer shares his/her conclusions with the patient, makes treatment recommendations and elicits reactions. In situations where the assessment runs longer than one session, the inter-viewer may sum up what has been covered in the interview and what needs to be done in subsequent sessions. Communications of this kind serve several purposes. They allow the patient to cor-rect or add to the salient facts as understood by the interviewer. They contribute to the patient’s feeling of having gained some-thing from the interview. They are also the first step in initiat-ing the treatment process because they present a provisional un-derstanding of the problem and a plan for dealing with it. All treatment plans must be negotiated with the patient, including discussion of mutual goals, expected benefits, liabilities, limita-tions and alternatives, if any. In many cases, such negotiations extend beyond the initial interview and may constitute the first phase of treatment.