Abstract
Interviewing patients is one of the most rewarding aspects of clinical psychiatry. It offers an opportunity to get to know someone, to find clues to diagnosis, and to relieve suffering. The psychiatric interview thus functions as an alliance-building process, diagnostic procedure, and therapeutic intervention. While this may sound complex, the interview process can be simplified by learning to approach it with the proper attitude. This can be considered analogous to helping a young musician learn how to have proper posture at the piano or to hold a violin and bow correctly. Without a good feel for the instrument, and without the appropriate perspective for learning what the music is about, the simple drilling of scales and fingerings will be misguided. Similarly, in the psychiatric interview, one must have a proper attitude toward the patient to be of the most help. The key qualities of this approach are curiosity, respect, and caring. If you notice obstacles to feeling interested in or caring about the patient, do not despair – such attitudes can be cultivated (see the section on empathy and compassion later in this chapter).
Introduction
Interviewing patients is one of the most rewarding aspects of clinical psychiatry. It offers an opportunity to get to know someone, to find clues to diagnosis, and to relieve suffering. The psychiatric interview thus functions as an alliance-building process, diagnostic procedure, and therapeutic intervention. While this may sound complex, the interview process can be simplified by learning to approach it with the proper attitude. This can be considered analogous to helping a young musician learn how to have proper posture at the piano or to hold a violin and bow correctly. Without a good feel for the instrument, and without the appropriate perspective for learning what the music is about, the simple drilling of scales and fingerings will be misguided. Similarly, in the psychiatric interview, one must have a proper attitude toward the patient to be of the most help. The key qualities of this approach are curiosity, respect, and caring. If you notice obstacles to feeling interested in or caring about the patient, do not despair – such attitudes can be cultivated (see the section on empathy and compassion later in this chapter).
Effective psychiatric interviewing involves eliciting feelings as well as data, and in this way, it differs from the more typical “medical” interview. Data collection alone is often not as helpful with psychiatric patients, who suffer in highly personal ways that often involve feeling some combination of shame, fear, despair, or anger. People naturally want to protect themselves from such painful feelings, and of course, it takes time and tact for the clinician to approach sensitive matters. Furthermore, psychiatric symptoms can interfere with the cognitive functions required to answer questions in a straightforward manner. Disorganized thinking, inattention, suspiciousness, and cultural difference are just a few of the factors that can complicate the process of getting to know someone. Such challenges may be overcome not by asking more probing questions but instead by building rapport through respectful curiosity and conversational flexibility.
Trainees often mistakenly feel an inherent conflict between eliciting history and building rapport. In fact, rapport facilitates gathering history, and understanding history facilitates rapport. The quality of information one gathers is a direct function of the quality of connection the clinician establishes with the patient. The best and most meaningful interviews typically resemble a conversation more than an ordinary interview.
Context and Purpose of the Interview
The approach to a psychiatric interview, and the content covered, depend in large part on the clinical context – the setting and situation – and the purpose of the interview. An initial evaluation in a high-acuity setting – such as an emergency department or inpatient unit – will often prioritize eliciting symptoms and history to determine a provisional diagnosis and assess risk. Once rapport is established, more probing questions can easily follow. An initial evaluation in a low-acuity outpatient setting – particularly if the clinical risk is low and the patient will be seen again in ongoing treatment – may emphasize developing the alliance and facilitating an open-ended exploration of the patient’s story. A teaching interview is unique in that its goal is educational as well as therapeutic. In this instance, patients must have the capacity to consent to such an interview, which generally avoids probing distressing issues unless the patient wishes to discuss them.
Therapeutic Alliance
Developing a therapeutic alliance is the first goal of an initial psychiatric interview. Establishing the alliance means joining with the patient in such a way that the two of you can work together toward the goals of understanding and relieving suffering. While there is no one correct way to establish an alliance, one should keep in mind the principle of “get the story first and the symptoms next.”
Numerous studies of psychotherapy efficacy have identified the therapeutic alliance as the most robust predictor of treatment efficacy, regardless of the type of psychotherapy. A therapeutic alliance generally involves an emotional connection between the patient and the clinician, involving caring and trust. A clinician’s benevolence and goodwill are not guaranteed to elicit a patient’s trust. Many patients, perhaps especially psychiatric patients, have little reason to accept the assumed social contract of a cooperative suffering patient seeking help from a kind, more knowledgeable physician; trust must be earned rather than assumed.
Three actions help develop the therapeutic alliance:
1. Listen authentically, with curiosity and without judgment.
2. Protect the patient’s self-esteem.
3. Show respect and compassion.
When seeking to accomplish these three tasks, it is helpful to remember Harry Stack Sullivan’s observation that “we are all much more simply human than otherwise.” Do not hesitate to consider responding in a more naturally human way. One can remain professional while still being authentic. Patients are remarkable, and their lives are astonishing – allow yourself to experience this. Clinicians can help protect patients’ self-esteem by being aware of their own potential to judge or shame patients, even inadvertently. Patients coming to seek psychiatric care are vulnerable, often having been mistreated or abused by others, and so are acutely sensitive to words or behavior that convey disrespect or disdain. Authentically acknowledging a patient’s strengths is useful as well. Certain patients are fearful of being coerced, so an authoritative stance may need to be softened. Finally, while some patients with severe psychiatric illness may appear confusing to inexperienced clinicians, it is important to recognize that they have the same feelings we all have – loneliness, fear, anger, sadness, and the wish to be cared for.
A sound therapeutic alliance facilitates more accurate reporting by patients, which fosters a clearer understanding of the problem. It engenders trust, which allows the patient to more openly consider whether to accept any treatment recommendations. Most importantly, the connection itself can relieve suffering. By listening respectfully and expressing compassion for a patient in pain, a clinician can benefit patients immensely. As an old saying posits, “A burden shared is a burden halved.” This is often hard for medical students to believe early in their training.
Confidentiality
Maintaining confidentiality is of the utmost importance in psychiatric care, given the sensitivity of topics discussed, the importance of establishing trust, and the stigma attached to psychiatric illness. Explicit exceptions to maintaining confidentiality include the so-called emergency exception and mandated reporting statutes. The “emergency exception” primarily means that clinicians can disclose confidential information if the patient is in imminent danger of harming themselves or others. Clinicians should familiarize themselves with state-specific statutes regarding mandated reporting of suspected neglect or abuse of children, elders, and disabled persons. Finally, it is important to know that a typical signed “consent for treatment” will include the authorization to disclose some information to insurers, including diagnoses and types of treatment. These data, generally entered into the electronic medical record, are often submitted by insurance companies to a national insurance exchange, which then shares this information among insurers.
Empathy and Compassion
Empathy has increasingly been the subject of research, and it now has multiple and sometimes confusing definitions. Put simply, empathy means being attuned to what another person is feeling, and being able to see and feel a situation from another’s perspective. Empathy involves affectively sharing some felt sense of the patient’s emotion and also cognitively understanding the patient’s feelings and perspective (Halpern, 2003). In this way, empathy is a part of deep understanding.
Compassion is related to empathy and involves recognizing that someone is suffering and feeling emotionally moved to want to relieve their suffering. If empathy helps build a “being with” connection, compassion develops the “caring for” response to suffering. Patients feel supported and less alone when they feel truly understood, and they are soothed or even uplifted when they feel their clinician’s compassionate care for them. Skills for heightening empathy and compassion can be taught and cultivated.
Empathic connection can be facilitated in several ways. Just prior to an interview, clinicians may wish to take a moment to remind themselves that, as the ancient Roman playwright Terence put it, “nothing human is alien to me.” More prosaically, one should assume a receptive, friendly demeanor and posture without an excessive focus on note-taking or an electronic device such as a computer or tablet. When a patient describes distress and difficulty, empathic validating comments can strengthen the connection. Tried-and-true responses such as “That sounds really difficult” or “I am so sorry that happened” can sound like clichés or genuine concern, depending on one’s attitude.
Sometimes clinicians will find it hard to feel empathic, particularly if the interviewer perceives the patient as significantly different or upsetting. It may help to imagine how one has felt in an emotionally similar situation, aiming to connect with the common humanity of suffering. But it is also important to recognize the particularity of one’s own emotional responses as well as the patient’s. Regardless of how different or upsetting a patient may seem, the clinician can be certain that the patient would not be coming into contact with psychiatric treatment unless they were deeply struggling and suffering in some way. Caution must be used when considering whether one’s own emotional responses accurately indicate something specific about the patient’s psychopathology. “This patient makes me feel so angry she must be borderline” is the kind of formulation that should be questioned and ideally reviewed with a peer or supervisor before being assumed to be true.
When clinicians resonate deeply with a patient’s painful feelings, it is important for this empathic resonance to be further developed into compassionate caring. Simply feeling a patient’s suffering may lead to empathic distress, a self-related emotional state that is experienced as stressful (Singer & Klimecki, 2014) and can lead to withdrawal from patients and others. Compassion taps into kindness and generosity and has an other-directed focus. Undertaking an active treatment approach helps clinicians move from empathy to compassion, but medical students or other trainees in primarily learner roles may have more difficulty making this transition since they may be less actively involved in caring for the patient. Two ways to help students make this transition are (1) structuring the student role to be more active and (2) effectively conveying to students that listening and bearing witness to distress is in itself a caring intervention and a compassionate act to relieve suffering.
Boundaries
Understanding the nature and function of boundaries helps define the limits of the clinician-patient relationship. Basic boundaries in the psychiatric interview regulate physical contact, the extent of the clinician’s questioning, and the extent of the clinician’s self-disclosure. While many boundary issues are uncontroversial (we do not socialize with patients, use them as confidants, or ask them for financial guidance, for example), other issues are less clear. Should you shake hands with a patient when first meeting them? For many (probably most) patients, this is a powerful signal of acceptance and a wish for connection. For other patients (who usually appear guarded or make poor eye contact), this can pose a threatening intrusion. The clinician usually develops a sense of what he or she is comfortable with and learns to read the patient’s body language. Some clinicians are overly fearful about any physical contact with any patient. The elderly patient who seeks a hug after revealing how vulnerable he or she feels is quite different from a patient who is about the same age as the therapist and asks “if we can end every session with a hug.” A good rule of thumb for analyzing boundary dilemmas is to ask one’s self “What is the meaning of this action, and is it good for the patient?” Asking these questions helps one analyze common boundary issues, such as physical contact, gift giving, and self-disclosure.
Safety and Respect
Fostering an atmosphere of safety is important for the patient and clinician alike. Two specific situations merit particular attention: interviewing a traumatized patient and interviewing an agitated patient.
We follow the “universal precautions” principle in assuming all patients may have experienced significant trauma. Practical approaches include respect for personal space, positioning oneself at eye level with the patient, and allowing the patient choice in the direction of the interview. Some patients will not be comfortable unless their back is to the wall and they can view the door to the room. If the clinician is unsure how far to probe, one can always “ask about asking.” In effect, this is obtaining informed consent from the patient to continue a line of questioning that may lead to reactions (not necessarily unhelpful) such as crying, anger, or anxiety.
When a patient is agitated and angry, it is ideal (but not an absolute requirement) if the interview room can be set up so both the patient and the clinician have unimpeded access to the door. Patients in a state of high stress generally respond more to nonverbal cues than to verbal ones, and the clinician should make sure that body language, tone of voice, and eye contact convey calm reassurance. Even when firm limits need to be set on a patient’s behavior, this can be done in a nonthreatening, nonshaming way.
Structuring and Directing the Interview
Some patients have difficulty organizing their thoughts and therefore struggle to coherently articulate their feelings. Other patients wish to conceal thoughts and feelings, often to guard against shame. Clinicians thus need to develop their clinical toolkit to tailor their approach to the particular style and needs of each patient. Following the “story first, symptoms next” principle, interviews will generally be more open-ended initially and will progress gradually to a closed-ended or structured format. If a patient starts to seem long-winded or disorganized during a diagnostic interview, it is useful to courteously let the patient know at the outset that, reluctantly, you may have to interrupt them and resort to more structured questions. If the clinician imposes structure prematurely or bluntly, the flow of the interview may become deadened and constrained, with the patient passively providing limited answers to a series of questions. Ideally, the clinician guides and structures the interview without sacrificing its conversational quality; the assessment is a conversation augmented with an inquiry. The clinician should take a stepwise approach to guiding the interview, gradually becoming more active in providing structure and monitoring the patient’s response. If an interruption is required (such as with a hypomanic or obsessional patient), the clinician can apologize in a friendly manner and explain the need to interrupt (for example, due to time constraints or the importance of discussing certain topics).
Summary
Developing advanced interviewing skills is a long process, measured in years. Yet the beginner, even when feeling uncertain and awkward, can nevertheless be of enormous help to the patient, merely by showing interest and concern. Whenever students wonder “What am I supposed to be doing here?,” it can help to imagine one’s role as that of a “collaborative curious co-investigator.”
Psychiatric Assessment and Write-Up
A careful psychiatric evaluation includes interviewing and data gathering, clinical reasoning, and documentation. This chapter focuses on the content and documentation of the evaluation, not the process of interviewing. There is broad agreement on the fundamental parts of a psychiatric assessment. Clerkships, residency training programs, and clinical services generally use similar templates. The American Psychiatric Association1 has published guidelines for the psychiatric evaluation of adults.
This chapter includes a representative assessment outline. It is not meant to be an outline of the order in which questions should be asked in an interview, but rather the order in which data should be presented. The comments about specific sections do not comprehensively list everything to possibly include, but instead outline major points to help guide clinical thinking.
Goals of a Write-Up
Thoughtful documentation accomplishes many important goals, some of which can be undermined by forms, checklists, and a cumbersome electronic medical record (EMR).
1. Organizing data and clinical reasoning to support diagnosis and treatment
2. Supporting treatment by communicating effectively with others, including current and future clinicians
3. Documenting evaluation and treatment planning for the patient and family
4. Including required regulatory content and demonstrating clinical thinking relevant to medicolegal issues
General Principles
Do not let templates and the EMR diminish your observational skills and clinical thinking.
Balance comprehensiveness with conciseness and clarity.
Avoid objectifying language and personal judgments. Increasingly the medical record is shared by clinicians and patients, and patients may want to read their records.
Choose clear, simple, and specific language over jargon to more accurately convey information.
Visual clarity and organization support good patient care by allowing busy clinicians to quickly find relevant information by scanning for headings, subheadings, bullet points, bolded content, and so forth.
Outline of Representative Assessment
Identifying Data
Capsule summary of current presentation with most relevant identifying details
There is debate about how many descriptors to routinely list regarding – for example, age; sex/gender pronouns and sexual orientation; employment and housing status; self-identified race, ethnicity, or national origin. Some clinicians favor including a broad range of information with the intention of presenting the broadest picture of the patient, while others emphasize that listing identifiers at the start of a case presentation activates implicit and explicit bias. A general rule of thumb is to include a descriptor if it adds appreciably to the understanding of the patient’s current clinical situation.
Chief Complaint
In patient’s words whenever possible
Chief concern is a related term and may be less likely to foster implicit judgmental attitudes, but is not always considered synonymous to chief complaint.
Sources of Information
For example, patient interview, medical records, collateral information from treating clinicians or friends/family
History of the Present Illness
Aim for an understandable narrative. Ask yourself, “Do I really understand what the patient is experiencing and how the patient arrived at this particular circumstance?”
Recent symptoms/problems, impact on functioning, efforts at coping
Recent context and circumstances leading to current evaluation
Pertinent positives and negatives of common disorders for establishing differential diagnosis, including major psychiatric, neurological, and other medical conditions including substance use. One option is to use the mnemonic “follow the MAPS TO diagnosis”:
◦ M: Mood
▪ depressive symptoms
▪ manic symptoms
◦ A: Anxiety
▪ panic symptoms and somatic anxiety symptoms
▪ worry
▪ avoidance
◦ P: Psychosis
▪ hallucinations
▪ paranoia and delusions
▪ thought disorganization
◦ S: Substances (see separate section for more detailed history)
▪ recent use of substances
◦ T: Trauma (see separate section for more detailed history)
▪ recent trauma related to HPI
▪ past trauma affecting current functioning (nightmares, flashbacks, hypervigilance/hyperarousal, dissociation, avoidance)
◦ O: Other medical
▪ current medical illnesses or treatments affecting current functioning, especially pain
Precipitating or exacerbating factors
Recent treatment including adherence or other changes in treatment
Risk issues (i.e., suicidality, aggression, impulsivity)
Past Psychiatric History
Pertinent diagnostic symptoms and diagnoses – for example, mood, anxiety and PTSD, psychosis, personality, somatic symptoms, eating disorder, and so forth
Treatment history including duration, adherence, response (benefits and harms)
◦ First psychiatric treatment
◦ Prior diagnoses
◦ Prior psychiatric medications
◦ Previous psychotherapies, including type of therapy
◦ Psychiatric outpatient treatment
◦ Hospitalizations and/or emergency evaluations
▪ precipitants
▪ voluntary or non-voluntary
▪ benefit/harm
◦ Other treatments such as ECT, partial hospitalization, or residential treatment
◦ Known barriers to treatment
Risk and safety: For risk issues such as suicidality or violence, it is crucial to include details of any instance such as a suicide attempt or episode of aggression. A lack of specificity can lead to underestimation or overestimation of risk and thereby adversely affect clinical care.
▪ Prior thoughts of suicide or self-harm
▪ Any suicide attempts including intent and estimated lethality
▪ Self-injury/self-harm, such as cutting
◦ Aggression: gathering this history can often be done when asking about symptoms and coping related to anger.
▪ Prior thoughts of aggression or violence
▪ Aggressive behaviors, including assault, use of weapons, destruction of property
▪ Threats to others; stalking
Substance Use History
This important area is sometimes integrated into the PPH, but it often benefits patients and clinicians to document separately. Separate documentation demonstrates the appropriate importance of this information and also supports more thorough evaluation. Substance use history should not be included in social history because substance use disorders are medical/psychiatric disorders – documenting substance use history as social history should be considered an outdated practice reflective of historical ignorance but unfortunately is still widely taught and practiced.
Substance type, including alcohol and tobacco and misuse of prescription medication
◦ First use, mode of ingestion, quantity, frequency, last use
◦ Pattern of use over time
Substance use disorder
◦ Dose escalation, tolerance, withdrawal
◦ Efforts to reduce, control or stop; periods of abstinence
◦ Consequences, including psychiatric, medical, legal, financial, relationships
◦ Relapse
◦ Treatment: medications, peer-support, detoxification, residential
Trauma History
This important area generally merits careful separate documentation, but often trauma history is closely interwoven with HPI or social/developmental history, and in these situations, it may be integrated into those sections. Include direct and indirect exposure to violence such as witnessing violence.
Past Medical History
Any significant medical or surgical conditions
Special attention to neurologic/endocrine: head trauma, seizures, thyroid disorders
Pain symptoms, especially chronic pain
Sexual and reproductive history
Current primary care provider and other medical providers
Current Medications
Prescribed, unprescribed, OTC, supplements and herbal preparations, internet purchases
Lifestyle
Caffeine (not generally included in substance use history because of the relatively low rate of morbidity related to caffeine use)
Exercise and physical activity
Diet/nutrition, access and affordability of fresh groceries
Wellness practices – wellness and stress management approaches, including mind/body practices such as meditation and yoga
Family History
Psychiatric and substance history, especially first-degree relatives: diagnoses, symptoms, hospitalizations, completed suicide, violence
Significant medical conditions
Social and Developmental History
Brief description of early life, including childhood/adolescence, family life and home environment, behavioral problems, losses, adversities such as poverty or experiences of marginalization and oppression
Educational history: learning or attentional problems, attainment
Family relationships: family of origin, current family (including children)
Social supports: friendships, intimate relationships, other supports within the community
Financial: current income, disability income, poverty or difficulty covering expenses, insurance status
Current housing situation and neighborhood/community, including sense of safety
Occupational history: student status or job history; reasons for job changes or loss
Typical daily activities – it can be illuminating to ask a patient to describe a typical day or a typical week
Interests and leisure activities
Legal history: including charges, convictions, time in prison, current status (e.g., probation), restraining orders
Military service: nature of service, current status
Identity and cultural factors (self-identified): emphasizing those that the patient identifies as important to them
◦ Gender identity and use of pronouns, sexual orientation
◦ Race, ethnicity, and/or cultural self-identification
◦ Spirituality and religion
◦ Connection or sense of belonging in a community
◦ Cultural attitudes toward psychiatry and mental illness
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