Interviewing for Acuity and the Acute Precipitant
Jon S. Berlin
Jon Gudeman
Significant strides have been made in recent years in the assessment of psychiatric acuity, particularly with respect to appreciating the role that empirically validated risk factors play in determining an individual’s potential for harming self or others (1). However, as the importance of compiling and weighing the various conditions, characteristics, and behaviors that increase the likelihood of a bad outcome has increased, the place of the clinical assessment in determining acuity has become an enigma: Studies have not demonstrated its independent value for estimating degrees of dangerousness, yet no one is willing to dispense with it.
Undoubtedly, this unwillingness stems partly from the multitude of other diagnostic and therapeutic purposes that a clinical assessment interview serves, and partly from the understanding that the concept of acuity includes incapacity and subjective distress and is a much broader domain than that of risk alone. However, in our view, another reason is the awareness that the clinical dialogue, conducted skillfully, does seem to produce reliable subjective and objective findings to use in the assessment of acuity and risk. We, along with many others, believe that the science and art of clinical interviewing is worth preserving and may be essential (2,3,4).
This chapter discusses the role of the initial interview in assessing acuity in the emergency setting. The guiding principle is the value of drawing out the patient to elucidate the underlying acute precipitant for the current visit, sometimes referred to as asking the “Why now and how come?” questions (5). Using multiple case vig-nettes, we illustrate how, if one appreciates the protective roles of resistance and defense, a sensitive probing interview produces a clearer chief complaint, more valid mental status findings, more pertinent history of the present illness, and ultimately a more accurate diagnostic formulation and treatment plan. In helping to estimate acuity, a good interview therefore holds the promise of reducing false positives (i.e., unnecessary admissions) and false negatives (inappropriate discharges). This approach to interviewing may help mitigate the adversarial aspect of some patient–clinician interactions that are endemic in the emergency setting, thereby increasing patient satisfaction and adherence. It may also set the stage for crisis resolution (6), thereby potentially reducing both risk and return visits to the emergency service for a problem that was not adequately addressed the first time.
When the presenting acuity is obvious and vivid, as it is, for example, with cases of psychotic agitation, rage, mania, intense despair, or acute catatonia, actively pursuing the acute precipitant should be deferred until emergency measures have been implemented. Later, however, clinical assessment helps to ascertain the underlying nature of the problem, to engage the patient, and thus to resolve the problem more rapidly at the most therapeutic level of care (7). This can sometimes mean handling the problem in the crisis situation instead of utilizing scarce hospital resources.
Acute presentations demonstrate the importance of preliminary stabilization and securing the foundation or “frame” before attempting to delve into the underlying problem. We address the important contraindications of an uncovering approach, as in acute traumatic stress conditions. In all cases, regardless of presenting acuity, the importance of appreciating the type and current state of an individual’s defense mechanisms remains unaltered.
Our discussion also assumes that the individual has been carefully assessed medically for
delirium, dementia, substance-induced disorders, mental disorders secondary to medical conditions (organic disorders), and emergency medical conditions in general. To the extent possible, these states must be ruled out or stabilized before undertaking the type of examination described.
delirium, dementia, substance-induced disorders, mental disorders secondary to medical conditions (organic disorders), and emergency medical conditions in general. To the extent possible, these states must be ruled out or stabilized before undertaking the type of examination described.
ACUITY AND CHIEF COMPLAINT
The emergency practitioner places emphasis on two tasks: (a) determining and managing acuity, and (b) determining and addressing the real chief complaint. Both are integral to good practice. One can be wrong, for example, about whether an individual being discharged from a psychiatric emergency service (PES) has a bipolar manic psychosis versus a schizoaffective disorder–bipolar type, but one really does not want to be wrong about his or her suicide risk or appropriateness for outpatient follow-up. We also do not want to misunderstand the patient’s view of the problem and his or her specific treatment request.
We concur with Allen’s articulation (8) of the difference between the triage model and the treatment model in emergency psychiatric practice and his advocacy for a treatment model based on more concerted efforts to definitively diagnose and treat psychopathology. The number of patients in the community with incompletely characterized, “not otherwise specified” diagnoses receiving nonspecific treatment is a real concern. Unfortunately, ever-increasing volume surges are forcing the triage model in many emergency centers to become the default mode, leaving the nuances of psychopathologic axes I and II diagnosis to other settings. But nuances of acuity cannot be ignored. In DSM-IV terms, it might be said that the approach we are describing is the focus of our attention on not only axis I, but also on the defenses of axis II (9), the acute precipitants of axis IV, and the acuity of axis V.
TIME
The time element in an emergency setting is crucial. Working conditions sometimes require clinicians to see two to three patients per hour. Does an interview focused on the acute precipitant take too long? In our experience, it either shortens the interview or the overall time that the person spends in the emergency department (ED) or PES. Sometimes this more in-depth approach does lead to a longer stay in the crisis service, but less time in the hospital. Of course, sometimes one barely has enough time to identify medical emergencies, keep everyone safe, and rapidly triage to a variety of settings. But if the patient goes to the observation area of the PES or ED, or if no beds are available and the patient ends up remaining in the waiting room, one may pursue the acute precipitant at a slightly later time, but still prior to a final disposition.
Time is also crucial in relation to how long a patient waits to be seen. People seeking mental health services want relief of suffering. The sooner they are seen, the more willing and able they are to open up. After a certain point, they start to wonder if their concerns are of any interest or importance to the ED staff, and they start to shut down or act up.
REVIEW OF THE LITERATURE
The tasks of any initial psychiatric interview include a sequence of establishing rapport, inquiring how the person sees his or her problem, gathering subjective and objective data, collating these data with information from other sources, formulating a biopsychosocial assessment, and collaborating on a biopsychosocial treatment plan. The main adaptations of this schema described in the emergency literature are triage and the necessity at times to act decisively with incomplete information (3,5,10,11,12). The clinician evaluates and treats simultaneously. Although this idea is not new or limited to emergencies (2,13,14,15), its usefulness in this situation is unmistakable. For example, faced with an acutely agitated, unknown patient without identification who is brought in by police, the emergency clinician quickly works through the above sequence of interview tasks not once, but in repetitive cycles, each time with greater precision and depth.
In their chapter “The Emergency Patient,” MacKinnon, Michels, and Buckley (3) identify overwhelming anxiety and urgency as a predominant feature. They emphasize both the importance
of authoritativeness and self-assuredness on the clinician’s part and of helping to instill or restore a personal sense of initiative and effectiveness on the patient’s part. Interestingly, these are both important techniques in the intervention currently referred to as psychological first aid (16).
of authoritativeness and self-assuredness on the clinician’s part and of helping to instill or restore a personal sense of initiative and effectiveness on the patient’s part. Interestingly, these are both important techniques in the intervention currently referred to as psychological first aid (16).
The ultimate goal with any patient is to have a real conversation. In classic chapters on validity techniques and on eliciting suicidal ideation, Shea (4) stresses the importance of the depressed patient inviting the clinician “into the nitty-gritty details” of his or her inner world. Shea explicates how histories and mental status exams become increasingly valid with improving interview technique. He also recognizes the need for interviews to be time-efficient.
In a related vein, Gabbard (2) highlights the need to go beyond the descriptive diagnoses of axes I and II and to consider the psychodynamic importance of the precipitants on axis IV. He also talks about axis V as a summation of a person’s level of functioning, although from an emergency perspective the acuity component of axis V has more immediate relevance. Gabbard and Shea both stress the importance of understanding one’s own feelings that are activated in the assessment process, not only to keep them from interfering but also to use them as potentially useful clues about the patient.
Psychoanalysts, including Langs (17) and Gill (16), have demonstrated that a contemporary psychodynamic approach—far from being passive, slow, or focused on the deep unconscious—capitalizes on the preconscious derivatives of a person’s relevant underlying issues that have made their way in decipherable form into the here-and-now interaction. Langs (19) also emphasizes doing what one can to establish an appropriate “frame” for the clinical interview, including those undertaken in the emergency department. He recommends establishing as much privacy and confidentiality as is practical and safe. He points out the negative effects that seeking out unnecessary collateral history can have on the alliance.
In a 1995 critical appraisal of axis IV, Forman et al. (20) sum up its clinical utility as “at once self-evident and uncertain.” They allude to “the significant literature on the effects of stressful life events in psychiatric and general medical conditions,” and they cite the major emphasis of the brief, focused therapies on current problems. On the other hand, they acknowledge that the underlying biology of a mental illness appears to be the dominant etiologic factor at times, and for acute episodes of these conditions caution the clinician not to give psychosocial factors “a false, preeminent position.”
PSYCHODYNAMIC PERSPECTIVE
Psychiatric crises and clinical presentations may be viewed as an amalgam of an acute precipitant; a preexisting biologic, psychological, or interpersonal vulnerability; an unbearable, painful mental state; and a maladaptive response of conduct, thinking, and/or subjective distress. These four elements make up a precipitant complex. Descriptively speaking, the maladaptive response (e.g., a suicide threat) is viewed as the presenting problem, whereas in reality the suicide threat is really the individual’s own misguided attempt to cope with a painful mental state. This state is the result of an acute precipitant that has set off or stimulated a preexisting diathesis.
The individual has a hard time talking about, or even being aware of, the acute precipitant, out of fear that the painful affect connected with it will be intolerable, forcing the clinician to pick up various clues. Quite frequently, there is an associated fear that a helping professional will not understand or react appropriately. Under more normal circumstances, a person who has experienced a painful event, such as a loss or failure, will be able to process it in his or her own way or be able to talk about it with friends, family, or a trusted confidant of some type. When in need, this person is more likely to be seen in an outpatient setting, if at all. Conversely, people who end up needing emergency services often lack the necessary internal and external resources to cope on their own.
Resistance and Defense Mechanisms
From this perspective, a clinician attempting to get at the acute precipitant should expect to be met with some degree of resistance (2,3), for he or she is asking the individual to abandon his or her usual coping skills of guardedness, denial,
minimization, repression, and so on. The clinician will encounter individuals who may expect him or her to be unsympathetic, self-serving, incompetent, or disinterested (21–22). The interviewer must counter these expectations with genuine interest and expertise: the desire to help, the ability to listen, knowledge, and professional self-confidence. His or her handling of patients’ defenses against the attempt to get to know them is key: The evaluator must understand that the presenting problem is the person’s attempt at self-cure and must respect his or her difficulty talking about the issues underlying it. The clinician must also remain determined and not give up prematurely. He or she should expect that the same defensive maneuvers and coping skills that lie behind the presenting problem will pervade the person’s interaction with the evaluator. It will come as no surprise, for example, when a woman minimizing and rationalizing a suicide attempt says she really will become suicidal if the evaluator decides not to discharge her home and instead says she requires hospitalization.
minimization, repression, and so on. The clinician will encounter individuals who may expect him or her to be unsympathetic, self-serving, incompetent, or disinterested (21–22). The interviewer must counter these expectations with genuine interest and expertise: the desire to help, the ability to listen, knowledge, and professional self-confidence. His or her handling of patients’ defenses against the attempt to get to know them is key: The evaluator must understand that the presenting problem is the person’s attempt at self-cure and must respect his or her difficulty talking about the issues underlying it. The clinician must also remain determined and not give up prematurely. He or she should expect that the same defensive maneuvers and coping skills that lie behind the presenting problem will pervade the person’s interaction with the evaluator. It will come as no surprise, for example, when a woman minimizing and rationalizing a suicide attempt says she really will become suicidal if the evaluator decides not to discharge her home and instead says she requires hospitalization.
Patients seen in emergency settings often use primary defense mechanisms to protect themselves. These are denial, distortion, projection, avoidance, acting up (sometimes referred to as “acting out”), and minimization. All of them can be used by both neurotic and psychotic patients, but in psychosis they are used more tenaciously and with a loss of reality testing (23). Denial is an active process of refusing to acknowledge reality. It is a conscious or unconscious warding off of pain. With distortion, the ego fools itself into believing its self-flattering ideas to gratify unobtainable wishes. This defense also serves the purpose of keeping people at a distance. Projection transfers blame to outside people or things: “It is not I who controls the situation; it is others who are controlling me.” Avoidance is the act of looking elsewhere and getting away from where it hurts.
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