The patient described is an example of a patient with a thought disorder. Disorders of thought can seriously impair effective communication. The evaluating psychiatrist should note formal thought disorders while minimizing an adverse impact on the interview. When derailment is evident, as in this case, the psychiatrist typically proceeds with questions that call for short answers.

Somatizing patients pose a number of difficulties for consulting and treating psychiatrists because they may be reluctant to engage in self-reflection and psychological exploration. Many somatizing patients live with the fear that their symptoms are not being taken seriously and the parallel fear that something medically serious may be overlooked. Psychiatrists’ main task in dealing with these patients is to acknowledge the suffering conveyed by the symptoms without necessarily accepting the patient’s explanation for the symptoms.

Delusions are fixed, false beliefs not shared by members of one’s culture. Delusional patients often come for a psychiatric evaluation after having had their beliefs dismissed or belittled by friends and family. They are on guard for similar reactions from the examiner. It is possible to ask questions about delusions without revealing belief or disbelief (e.g., “Does it seem that people are intent on hurting you?” rather than “Do you believe there is a plot to hurt you?”). Many psychiatrists have found that patients can speak more freely when asked to talk about the accompanying emotions rather than the belief itself (“It must be frightening to think there are people you do not know who are plotting against you”).

Demanding patients have a difficult time delaying gratification and demand that their discomfort be eliminated immediately. They are easily frustrated and can become petulant or even angry and hostile if they do not get what they want when they want it. Beneath their surface behavior, they may fear that they will never get what they need from others and thus must act in that inappropriately aggressive way. The doctor must be firm with these patients from the outset and must clearly define acceptable and unacceptable behavior. These patients must be treated with respect and care, but they must also be confronted with their behavior.

An agitated patient is emotionally restless and excited. He or she may make physical threats to the physician. When interviewing agitated and potentially violent patients, the tasks are to conduct an assessment, contain behavior, and limit the potential for harm.

Three functions of medical interviews are to assess the nature of the problem, to develop and maintain a therapeutic relationship, and to communicate information and implement a treatment plan. See Table 6.1. Although showing expertise may be a good way to establish rapport, it is not a function of psychiatric interview.

At times, patients will ask questions about the psychiatrist. A good rule of thumb is that questions about the physician’s qualifications and position should generally be answered directly (e.g., board certification, hospital privileges). On occasion, such a question might actually be a sarcastic comment (“Did you really go to medical school?”). In this case, it would be better to address the issue that provoked the comment rather than respond concretely. A major reason for not answering personal questions directly is that the interview may become psychiatrist centered rather than patient centered.

Rapport is the spontaneous, conscious feeling of harmony that promotes the development of a therapeutic alliance. It implies an understanding and trust between the doctor and patient. Frequently, the doctor is the only person to whom a patient can talk about things that he or she cannot tell anyone else. Most patients trust their doctors to keep secrets, and this confidence must not be disobeyed.

Transference describes the process of patients unconsciously projecting feelings from their past relationships to the doctor. When doctors unconsciously project their feelings to the patient, the process is called countertransference; these feelings are not directly related to rapport. For example, a patient may remind the doctor of his father’s narcissism.

A thorough assessment of suicide potential addresses intent, plans, means, and perceived consequences, as well as a history of attempts, and family history of suicide. The examiner must ask clear, straightforward, noneuphemistic questions. Asking about suicide does not increase risk; the psychiatrist is not raising a topic that the patient has not already contemplated. Some patients may report a wish that they were dead but would never intentionally do anything to take their own lives. Others express greater degrees of determination. Either way, any expression of a wish to die should be considered and evaluated seriously. It should never be considered lightly or as a part of a “normal” grief reaction. Normal grief may include sadness and guilt; however, this resolves within 1 year. There are some patients who tell no one of their suicide plans and proceed in a deliberate, systematic manner. The daughter did not overreact because her father experienced a loss, and suicidal statements need to be taken seriously.

Transference describes the process of patients unconsciously projecting feelings from their past relationships to the doctor. A patient may come to see the doctor as cold, harsh, critical, threatening, seductive, caring, or nurturing, not because of anything the physician says or does but because that has been part of the patient’s past. The residue of such experience leads the patient to unwittingly “transfer” the feeling from past relationships to the doctor. The transference can be positive or negative, and it can swing back and forth—sometimes abruptly—between the two. Many a physician has become unsettled when a pleasant, cooperative, and admiring patient suddenly and for no discernible reason becomes enraged and breaks off the relationship or threatens a lawsuit. Physicians are not immune to distorted perceptions of the patient–doctor relationship. When doctors unconsciously project their feelings to the patient, the process is called countertransference.

Although physicians can be sued for anything, transference feelings are not one of the main reasons for lawsuits filed by mistreated patients.

A doctor’s level of expertise does not have any effect on whether transference feelings will occur or not.

The early part of the interview is generally the most open ended in that the physician allows patients to speak as much as possible in their own words by asking open-ended questions and permits them to finish. An open-ended question is one that cannot be answered by a simple “yes” or “no” (e.g., “Can you tell me more about that?”). This type of questioning is important to establish rapport, which is the first step in an interview. In one survey of 700 patients, the patients substantially agreed that physicians do not have the time or the inclination to listen and to consider the patient’s feelings. They also stated that physicians do not have enough knowledge of the emotional problems and socioeconomic background of the patient’s family and that physicians increase patients’ fears by giving explanations in technical language. Psychosocial and economic factors exert a profound influence on human relationships, so the physician should have as much understanding as possible of the patient’s environment and subculture.

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