Creating a Safe Environment

The goal of the interviewer during the introduction remains relatively simple: engage the patient by decreasing the patient’s anxiety. Employing one of Sullivan’s terms mentioned earlier, we can state the goal as follows: the clinician attempts to decrease the patient’s need for an overactive self-system. In a similar vein, the goal of the patient is also relatively easy: “to find out what is going on here,” because many patients are encountering a mental health professional for the first time.

The patient’s need to understand the immediate interview process itself tends to be rather intense, for it is stoked by some of the fears described in Chapter 2. It is worth reviewing these concerns in more detail here, for it is in the introduction phase that we have our first opportunity to address them, before they can create a lasting problem with engagement:

Not all patients are dealing with all these fears, but most patients are probably coping with a good number of them, either consciously or unconsciously. The goal of the clinician and the goal of the patient are really the same at this moment in the interview: in short, to help the patient to feel more at ease. To achieve this more comfortable state of affairs, after some friendly chit-chat the clinician can address some of these questions in the introduction either directly or indirectly. If done sensitively, the patient’s initial anxiety should begin to decrease and the interview should begin to gracefully move forward.

There exists no correct method for handling these fears. Consequently, each clinician needs to determine a comfortable style of addressing these issues in his or her own fashion. I shall give two examples. The first example is the work of an inexperienced clinician. The second dialogue demonstrates one method that addresses the issues more smoothly.

[The clinician enters brusquely, shaking the patient’s hand very firmly. The clinician does not smile.]

It is hard not to chuckle at this exchange, for the interviewer has successfully aroused almost all of the anxieties mentioned earlier. Even such word choices as “I’ll be conducting the interview” suggest that the patient should expect no control here, although the clinician’s overpowering handshake may have already served as a premonition of this fact.

The following dialogue represents a more satisfying solution to the demands of the situation.

[The patient enters the room (or if there is a waiting room the clinician will have greeted the patient there). The clinician smiles warmly and spontaneously. He walks over to the patient at a normal pace and shakes the patient’s hand with a gentle firmness.]

[After confidentiality is explained and discussed, the interview might proceed as follows:]

In this introduction, which has imperceptibly moved into the opening phase, the clinician has smoothly addressed many of the potential concerns mentioned earlier. In particular, a large element of respect has been conveyed to the patient by the simple gesture of offering to hang up his coat and by addressing the information his wife communicated during the appointment call. The clinician also clearly appears to be on no one’s side, emphasizing the desire to hear the patient’s opinions, and even stating that the issue of a problem with the patient has not been determined yet by the comment “and getting your perspectives on what, if anything, has been going on.”

Storr² points out that the situation may be slightly different if the patient has been referred by a fellow mental health professional or from an inpatient unit. In these cases, Storr adds a nice touch, as follows:

In this example, Storr conveys respect and concern, essentially acknowledging that the patient might find repeating the story again somewhat irksome. The last statement also indicates, from the perspective of person-centered interviewing, the clinician’s desire to understand the patient as a unique individual, not just a case. Some clinicians also prefer to end the introduction by asking, “Before we go on, do you have any questions?” Such a question once again conveys a sense of respect, while checking for possible patient concerns.

Going back to our own example of an effective introduction, we find that the clinician has also managed to give a sense of control to the patient with phrases such as, “Perhaps we could start with your telling me a little about how you see things at this point. I know from Sally that she feels you’re depressed, but what is more important is what you think.”

The clinician also asked the patient how he would like to be addressed. One will encounter many vehemently held opinions both for and against using a patient’s first name. I shall not add many pages to this debate, because I think the intensity of the debate has led to overstated arguments on both sides. I, personally, feel that one should not assume a first name basis without asking first. Some patients may find a first name threatening or a “put down,” especially if the patient is a young adult or is much older than the clinician. Consequently, when first greeting a patient, I always use his or her last name.

On the other hand, the ability to use the patient’s first name can be a powerful asset in engagement. When used sparingly, and with good timing, it can effectively help patients to share difficult material. In a cultural sense, first names are generally used by people who care about us and are privy to our private thoughts. Consequently, I have found it both satisfying and rewarding to simply ask the patient how he or she would like to be addressed. This question accomplishes several tasks:

For instance, very strong opinions voiced by the patient may represent the presence of personality pathology or defensive posturing, thus offering the clinician immediate grist for the mill. A patient developing grandiose thinking as part of a manic episode may adamantly insist on being called “Dr. Jones.” At the other extreme, patients with regressive tendencies may sheepishly smile while stating, “Please just call me Jim.” With experience one can begin to discern the sense of self-identity implied by the patient’s response to this simple question. Indeed, one wonders what psychodynamic issues, if any, may lie beneath ambivalent responses such as, “It doesn’t really matter, you can call me Jim, Jack, or Jimmy.” One can see that even in the introduction phase, the data-gathering process has begun.

There are some exceptions to the above guidelines. If the clinician knows beforehand that the patient has a history of paranoia, it may be advisable to use the last name throughout the interview, because such “distance” may be more comfortable for a patient with a paranoid interpersonal stance, as we saw in our exploration of empathic valence. Patients who are much older than the clinician may prefer to be addressed by last name. In the opposite direction, children and adolescents generally should be addressed on a first name basis from the start. In these cases, though, it is often useful to ask the patient which first name to use. For instance, the family may call an adolescent “Sue,” yet the adolescent would prefer being called “Susan.” Such a simple show of respect can go a long way towards ensuring a powerful engagement.

I should add that with regard to addressing the patient, I have yet to find any problem arising in either the initial interview or subsequent psychotherapy using the above approach. In the end, the reader must decide, from his or her own experience, what feels most comfortable.

In familiarizing the patient with the ensuing interview process, some clinicians go one step further than illustrated above. They specifically describe for the patient what to expect, depending on the goals of the interview, an approach that directly addresses the patient’s underlying question of “What is going on here?” After the clinician and patient have introduced themselves, the dialogue may proceed as follows:

The purpose of a more extended description of the process is twofold. First, it is hoped that the patient’s fear of the unknown will be decreased. Second, the description of the process serves as an educational strategy, subtly alerting the patient to the fact that large amounts of data will be covered in 50 minutes. This may allow the clinician to collaboratively structure the ensuing interview more effectively. It also provides one method for smoothly switching gears later with transitions such as, “As I mentioned earlier, I’d like to learn a little more about your family. How many children do you have besides Jenny?” At the end of this interaction, the clinician also demonstrated the use of well-timed humor to break the anxiety of the first meeting.

Before moving on, one final point may be of value. As with all the other aspects of interviewing we have discussed so far, the format of the introduction varies from one patient to another. In some instances in which the patient is extremely psychotic, the patient may quickly cut short the introduction. In such cases, it is wise to follow the patient’s lead, because clearly such patients have a need to tell their story quickly. It would be inappropriate to adhere rigidly to the typical format of the introduction with such patients. The format is a guide, not a rule.

Addressing Confidentiality

At some point near the end of the introduction, or as one is transitioning to the opening phase of the interview, it is typical to address confidentiality. It is important to be clear about confidentiality, for it has critical ramifications for building trust. A dialogue might evolve as follows:

The Sommers-Flanagans make several excellent points about confidentiality.³ If patients ask further questions about it, then they often are metacommunicating that they might be especially conscious of trust issues, indicating that further open discussion about confidentiality is probably warranted. They also remind us that the confidentiality issues related to written records is important to address with statements such as, “I’ll be keeping records of our meetings, but only my office manager and I have access to these files. And the office manager will also keep your records confidential.”³ I also add, “And, of course, in order for you and I to get your insurance company to reimburse us, they may request information about your diagnoses and care.”

As electronic health record (EHR) implementation evolves, confidentiality issues will also evolve. Various institutes may handle accessibility to the patient’s EHR differently. In a private practice, the confidentiality may be exactly as stated above. In contrast, some hospitals and clinics may allow wider access to records from various clinicians and personnel (for instance every clinician on a given team or all nursing staff may have immediate access to a patient’s EHR as well as administrative personnel). Moreover, as confidentiality evolves, we may see some patients allowing records to be proactively transferable to other institutes and clinics. Whatever evolves, it is important for the interviewer to know the exact confidentiality rules within his or her employ, and these rules must be conveyed to the patient explicitly when discussing confidentiality.

If you are in training and will be discussing the case either in individual or group supervision, the Sommers-Flanagans handle this gracefully as follows, “Because I’m a graduate student I have a supervisor who checks my work. Sometimes we discuss my work with a small group of other graduate students. However, in each of these situations, the purpose is to enable me to provide you with the best services possible. Other than the exceptions I mentioned, no information about you will leave this clinic without your permission.”³

Confidentiality discussions are critical. I seldom encounter problems with them and part of the art is discussing them in a matter of fact tone of voice. But it should be noted that, even when done well, this early introduction of complex and potentially unnerving information, sometimes may disrupt the naturalistic flow of the interview just as it is getting started. Some clinics, hospitals, and emergency rooms alleviate this problem, in a creative fashion, by having a different staff member than the interviewer, such as a well-trained receptionist, review confidentiality issues in detail before the patient sees the clinician. In these situations, the patient has ample time to ask questions and will also sign a written statement of understanding regarding confidentiality.

This process allows the actual interview to unfold very naturally without the need for the discussion of a delicate topic right off the bat. In these instances, I will ask the patient in the introduction if he or she has any questions about confidentiality. And I still review the key points and exceptions of confidentiality with the patient personally, but can now wait to do so during the closing of the interview, where it fits very nicely. Re-addressing confidentiality in the closing phase of the interview also functions to consolidate the patient’s understanding of confidentiality for our future sessions. Moreover, for a new patient who has never experienced therapy before, the experience of the therapy hour may have raised new questions about confidentiality by the end of the hour.

Patient’s Perspective and Conscious Agenda

Each patient brings a unique set of perceptions and opinions to the initial interview. From our person-centered perspective, these views are invaluable for understanding where to collaboratively move in the interview. Two patient perspectives appear to be particularly crucial in determining whether contractual agreement will occur: (1) the patient’s concept of what is wrong, and (2) the patient’s expectations of the interview and the interviewer. To uncover these perspectives, I often use the following two questions, or a variation of them, at some point during the opening phase:

Many roadblocks to the interview process can arise when the answers to these two questions are not known by the clinician.

On the other hand, sometimes it is the patient’s conscious goals that actually get in the way of the interview, as might be seen in malingering or drug seeking. At such moments, it may be even more important that the clinician be able to ferret out what the real agenda of the patient might be. If the interviewer becomes aware of these potentially problematic beliefs or agendas, some roadblocks may be diminished, worked through, or perhaps even nipped in the bud.

To illustrate the usefulness of uncovering a patient’s conscious agenda, it may be useful to look at a short piece of dialogue. We will picture a man in his mid-30s, who has scheduled an appointment at the strong urging of his wife. He nervously looks about the office, as if anticipating the appearance of a Grand Inquisitor. He has a small mustache and a nervous nose. Early in the opening phase the following interaction develops:

The art inherent in the opening phase consists of listening not only to what the patient says his or her goals are, but also to what the patient implies his or her goals might be. A careful examination of this patient’s opening dialogue may yield some pertinent information.

His opening comment, “It is very difficult to say,” suggests a genuine fear of being misunderstood by the interviewer. This phrase is followed by the statement, “I don’t know what Jane thinks is happening, but I’m not nuts.” Paradoxically, the patient relates that he does not know what his wife thinks yet he implies that she has labeled him as “nuts.” The connection with his fear of being misunderstood seems clearer: one of his goals is to make sure the clinician “gets it” – that he is not crazy; a second goal may be the hope that the clinician will make sure that his wife “gets it.” He probably also fears that the clinician will not value his opinions, which he openly shares with the phrase, “It’s all got something to do with my chemistry, of that I’m sure.”

With this last statement, he offers an explanation for his problem on one level but also provides two more important pieces of information: (1) at some plane of awareness, he recognizes a problem, and (2) he has a need not to view the problem as psychological. With the subsequent phrase, “Somehow or other, I’m a little speeded up,” he further describes his perception of the problem.

With the next question, the clinician demonstrates a desire to understand the patient’s world by requesting a more phenomenological description of his stated symptom. The patient’s reply, once again, confirms his immediate need to conceptualize the problem in physical terms, betraying his fear that the “clinician-inquisitor” will not share this perspective (a second goal has clearly emerged – the need to convince the clinician that the problem is physical not mental). Of course, the patient’s insistence on a physical cause may represent an example of a person who “doth protest too much.” Even the patient may subconsciously fear a psychological problem.

From this brief dialogue we can see that, in a generic sense, the conscious goal of this patient is to make sure the clinician hears his side of the story and believes it. This generic goal manifests itself as two more specific goals: (1) make the point he is not crazy, and (2) make the point that the problem is physical not mental.

The next question arises: What can be done with this information? First, one can easily imagine what not to do, as would be exemplified by the clinician’s proceeding with statements such as, “Perhaps you can start by telling me about some of your stresses with your son, since your wife seems to feel these stresses are at the root of your problem,” or “Physiology may play a part here, but first let’s look at some of the psychological issues that may be playing a part in your problems.” Such blundering inquiries must represent the clinician’s hidden masochistic needs, because the clinician is adamantly refusing to explore the patient’s world through the patient’s eyes. A reciprocal desire by the patient not to accommodate the clinician’s goals and recommendations will most likely follow. Two can play at this game.

In contrast, let us look at a possible line of questioning that attempts to move with the patient’s needs while ultimately joining both the goals of the patient and of the interviewer:

As opposed to a denial of the patient’s overt goals, this interviewer has implicitly acknowledged them. For example, the clinician picks up on the patient’s hint, “… and I think I’ve got some understanding of what the hell is going on here,” by asking, “Oh, what kinds of things have you come up with?” – essentially a variation of our question, “In your opinion, what exactly do you think the main problem is at this time?” The patient is being expressly asked to tell his side of the story.

This particular choice of topics by the interviewer has also reinforced the issue of physiology, which symbolizes an area in which this patient feels safe, a topic in which his self-system is less likely to be activated by discussion. By moving with this patient’s needs, the conversation transforms itself gracefully into an exploration of family relations.

This example stands merely as an illustration. Patient needs and perspectives change with each individual. But certain conscious – although not always stated – patient agenda items are fairly common, and the interviewer may want to listen attentively for their presence. The following list includes some of the more common appropriate conscious needs:

As mentioned earlier, there are some goals that may or may not be compatible with the goals of the clinician. In particular, problems arise when the patient’s agenda may not originate from a sincere motivation for help, as with the following more manipulative needs:

These latter goals can significantly disrupt the development of a sound therapeutic alliance. If a clinician intuitively becomes suspicious that conscious problematic goals might be present, they can be intentionally sought. If the clinician has not already asked, “What are some of the things that you hope we might be able to accomplish today?” such hidden-agenda items may surprisingly surface with a simple variation of this question said in a gentle and non-accusatory way: “At this point in our talk, it might help both of us to clarify what we want to accomplish in this interview. What specifically would you like me to do for you today?”

Assessment of the Patient’s Immediate Mental State

Much can be learned from a single glance if the glance has years of experience behind it. Although the details of the mental status examination will unfold in the body of the interview, during both the introduction and opening phases a simple passive noting of the patient’s immediate mental state can provide invaluable information. In this “scouting period” of the interview, the clinician searches for mental state clues that may suggest a need for changing the strategy of the interview itself.

These clues are of three major types: (1) clues suggesting possible diagnoses and, hence, suggesting future areas for more extensive diagnostic exploration; (2) clues suggesting significant patient concerns about the interview process itself that need to be addressed; and (3) clues indicating that rather radical changes in the interview format may be needed because severe psychopathology may be present. In Chapter 16 we will look at the mental status in more detail, but for now we will briefly survey these three topics as they pertain to the opening phase.

With regard to diagnostic clues, one of the more interesting findings revolves about the issue of psychosis. If a patient presents with a smoldering psychotic process, it is not unusual for subtle signs to be present during the opening phase. Such subtle signs may include processes such as an infrequent loosening of associations, a slightly inappropriate affect, or an overriding intensity to the patient’s feelings and affects. The presence of such clues may suggest that questions dealing with psychosis may yield a rich harvest later in the interview.

In relation to the second area, evidence of patient concerns about the interview process itself, the opening phase is of vital importance. If patient concerns are present and the patient is feeling uncomfortable or angry, it generally becomes necessary to work through these concerns, if possible, before proceeding to the main body of data gathering. Unresolved hesitancies or anger may leave the clinician with an incomplete or erroneous database because invalid data often lie in their wake.

To this end, the clinician keeps an attentive eye out for behavioral evidence suggesting unspoken roadblocks to the development of a therapeutic alliance. As discussed earlier, interpersonal anxiety is to be expected, but unusually high anxiety states may indicate intense fears of rejection, embarrassment, or ridicule. If the clinician suspects the presence of these fears, the following, said gently, may bring them to the surface where they can be dealt with more effectively: “It can be somewhat anxiety provoking to talk with a therapist like myself, especially the first time we are meeting. I’m wondering what, if any, types of things might be concerning you as we are talking here today?” Some interviewers prefer a slightly different wording, which is less assumptive of a problem: “It can be somewhat anxiety provoking to talk with a therapist like myself, especially the first time we are meeting. I’m wondering what you are feeling as we are talking today?”

James Morrison, in his informative book, The First Interview: A Guide for Clinicians, takes this one step further in a technique that he refers to as “naming emotions.” If a patient appears to be stalled, secondary to such hesitancies, Morrison suggests addressing this process by naming several emotions that could be behind the patient’s concerns. His gentle, yet direct, approach is as follows:

“I can see that you are having a real problem with that question. Sometimes people have trouble with questions when they feel ashamed. Or sometimes it’s anxiety or fear. Are you having any of those feelings now?”⁵

This technique can open the gate to transform a potentially damaging communication impasse. It should also be kept in mind that patient concerns may be quite direct, as evidenced by purposefully vague answers, an irritated or hostile affect, or no answer at all.

With regard to the third area, the discovery of a need to significantly change the structure of the interview, the issue of disruptive psychopathology rears its head. The question becomes whether a given patient can tolerate a standard initial interview. This question, frequently relevant to the emergency room setting, focuses directly upon the patient’s immediate impulse control. A good clinician becomes facile at recognizing the situation in which the best interview may be a short one.

For instance, the clinician may happen upon a patient whose thinking has become laced with delusional ideation. The patient may be furiously pacing about the waiting room, shaking a fist at voices heard only in the private world of a psychotic nightmare. When questioning begins, this type of patient may rapidly escalate towards violence. As such a rapid escalation begins to unfold, the clinician may decide to alter the strategy of the interview drastically, including its length. This type of agitated behavior may also suggest the wisdom of interrupting the interview briefly in order to alert the charge nurse to the possibility of impending violence.

Clinician’s Perspective of the Patient’s Problems and the Patient’s Unconscious Goals

A significant chasm may separate the patient’s perspective from the clinician’s perspective. For example, a patient may feel that the central problem consists of a vicious harassment devised by the FBI. The clinician may view this patient’s problem as the development of a paranoid delusion. In other instances, the clinician and the patient may share similar views concerning the nature of the problem but differ on the issue of its etiology. Fortunately, much of the time, both the clinician and the patient share similar conceptualizations.

It is useful for a clinician to be aware of possible diagnostic issues early in the interview, because this tentative formulation may help determine the basic strategy of the interview itself. By way of illustration, the clinician may be interviewing an elderly man brought by his family because “he can’t take care of himself anymore.” During the opening phase, the clinician may notice thought disorganization, thought blocking, and a striking memory deficit. Normally, the cognitive mental status examination is brief and generally appears late in the body of the interview. But in this instance, the clinician may decide that a determination should be made of the severity of this patient’s cognitive deficit earlier in the interviewing process. Moreover, with this type of patient, the cognitive examination may be lengthened in an effort to explore the degree of cognitive deficit while uncovering the possible presence of a delirium or dementia.

If severe memory deficits are recognized, then little can be gained by a lengthy interview, which would be both tiring and frustrating for the patient suffering with a moderate or severe dementia. Instead, this time may be more profitably spent with members of the patient’s family, because they may provide a more reliable history. Once again, the clinician moves flexibly, adjusting to the unique needs of the patient and the clinical situation.

Of equal importance is the determination made by the clinician of the patient’s unconscious goals. It is worth emphasizing repeatedly that much of the art of interviewing consists not of analyzing what the patient says but of speculating on what is not said and why it is not said. In a similar vein, patients often “half mention” issues, and the clinician needs to uncover what has been left partially clad. In particular, the issue of unconscious goals remains one of the major tasks of the opening phase.

The unconscious goals include those psychodynamic drives of which the patient may be partially or totally unaware. These needs, frequently arising from core psychological pains, may represent the most telling reasons why the patient has come for help or may also present significant roadblocks to the task of the initial assessment. An example will help to clarify this concept.

In this illustration the patient is a man about 30 years of age. His speech has a pressured quality, as if his words need to escape his mouth. He has been brought by his father, who threatened to commit him after the patient squirted his father with tear gas during a family squabble.

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