The psychiatric interview carlat pdf download

In psychiatry, this process is multiplied, as indicated in Figure 1. It was widely assumed that development, and problems related to development, effect the inner experiences of various affects. This perspective underlies the principle articulated in text after text on interviewing that emphasizes the importance of establish- ing rapport in the process of history taking. It is incredibly easy for the psychiatrist to attribute to the patient what she or he would have meant and what most people might have meant in using a particular word or phrase.

The sense in the narrator that the listener is truly present, connected, and with the patient enormously enhances the accuracy of the story reported. Words that have been used to describe this process of constant attention to and infer- ence of inner experience by the listener include interest, empathy, attentiveness, and noncontingent positive regard.

However, these are words that may say less than they seem to. This quality of listening produces what we call rapport, without which psychiatric histories become spotty, superficial, and even suspect.

There are no bad historians, only patients who have not yet found the right listener. It is well established that two powerful predictors of outcome in any form of psychotherapy are empathy and the therapeutic alliance. This has been shown again and again in study after study for dynamic therapy, cognitive therapy, behavior therapy, and even medication management.

Helpful psychiatric listening requires a complicated attitude toward control and power in the interview see Table 1. He or she is invited, too, to question and observe him- self or herself. This method of history taking remains the principal tool of general clinical medicine.

However, as Freud pointed out, these methods of active uncovering are more complex in the psychic realm. The use of the patient as a voluntary reporter requires that the investigator keep in mind the unconscious and its power over the patient and listener. Can the patient be a reliable objective witness of himself or herself or his or her symp- toms?

Can the listener hold in mind his or her own set of filters, meanings, and distortions as he or she hears? Objective—descriptive examiners are like detectives closing in on disease. The psy- chiatric detective enters the inquiry with an attitude of unknowing and suspends prior opinion. The techniques of listening invoke a wondering and a wandering with the patient. It is embarking on the history taking journey together — free of judgments, opinions, criticism, or preconceived notions — that underpins rapport.

Good listening requires a complex understanding of what objective truth is and how it may be found. The psychiatrist constantly asks: What is being said? Why is it being said at this moment? What is the meaning of what is being said? In what context is all this emerging?

What does that tell me about the meaning of and what does it reflect about the doctor—patient relationship? The ear of the empathic listener is the organ of receptivity — gratifying and, at times, indulging the patient. Every human being has a preferred interpersonal stance, a set of relationships and transactions with which she or he is most comfortable and feels most gratified.

The problem is that for most psychiatric patients, they do not work well, but the psychiatrist, through listening and observing, must understand the patient. Beyond attitudes that enable or prevent listening, there is a role for specific knowledge. In striving to grasp the inner experience of any other human being, one must know what it is to be human; one must have an idea of what is inside any person.

This provides a framework for understanding what the patient — who would not be a patient if he fully understood what was inside of him — is struggling to communicate. Personality theory is absolutely crucial to this process. Whether we acknowledge it or not, every one of us has a theory of human person- ality in this day and age of porous boundaries between psychology and biology, we should really speak of a psychobiological theory of human experience , which we apply in various situations, social or clinical.

These theories become part of the template alluded to earlier, which allows certain words, stories, actions, and cues from the patient to jump out with profound meaning to the psychiatrist. There is no substitute for a thorough knowledge of many theories of human functioning and a well-disciplined synthesis and internal set of rules to decide which theories to use in which situations. Different theoretical positions offer slightly different and often complementary perspectives on listening Table 1.

Each of the great schools of psychotherapy places the psychiatrist in a somewhat different relationship to the patient. This may even be reflected in the physical placement of the therapist in relation to the patient. In a classical psychoanalytic stance, the therapist, traditionally unseen behind the patient, assumes an active, hovering attention. The interpersonal psychiatrist stresses a collaborative dialogue with shared control. One can almost imagine the two side by side as the clinician strives to sense what the storyteller is doing to and with the listener.

Interpersonal theory stresses the need for each participant to act within that interpersonal social field. In connecting with the patient, the listener is also tuned in to the fact that parts and fragments of him or her are being internalized by the patient. Chapter 1 r Listening to the Patient 15 Table 1. Cognitive and behavioral psychiatrists are kindly experts, listening attentively and subtly for hidden assumptions, distortions, and connections.

The family systems psychiatrist sits midway among the pressures and forces emanating from each individual, seeking to affect the system so that all must adapt differently. Object relations theorists would note that the clinician had discovered a previously unidentified, powerful introject within the therapeutic dyad.

That is, the patient was attempting to induce the clinician to share the experience of imagining and fantasizing about having Andy Griffith as a father. The therapist could never see the patient in quite the same way again, and the patient sensed it immediately. The family systems psychiatrist would help the patient see that he had manipulated the forces at work on him and actually changed the definition of his family.

The ways and tools of listening also change, according to the purpose, the nature of the therapeutic dyad. The ways of listening also change depending upon whether or not the psychiatrist is preoccupied or inattentive. The medical model psychiatrist lis- tens for signs and symptoms. The analyst listens for the truth often clothed in fantasy and metaphor.

The existentialist listens for feeling, and the interpersonal theorist lis- tens for the shared experiences engendered by the interaction. The listener is asked to clarify and classify the inner world of the storyteller at the same time he or she is experiencing it — no small feat! Using Oneself in Listening Understanding transference and countertransference is crucial to effective listening. Tomkins, LeDoux, Damasio, and Brothers have given us a basic biological perspective on this process.

To know ourselves is to begin to know our patients more deeply. There are many ways to achieve this. Personal therapy is one. Ongoing life experience is another. Once we have started on the road to achieving this understanding by therapy, supervision, or life experience, continued listening to our patients, who teach us about ourselves and others, becomes a lifelong method of growth. To know oneself is to be aware that there are certain common human needs, wishes, fears, feelings, and reactions.

Every person must deal in some way with attachment, dependence, authority, autonomy, selfhood, values and ideals, remembered others, work, love, hate, and loss. It is unlikely that the psychiatrist can comprehend the patient without his or her own self-awareness. Thus, Figure 1. The most psychotic patient in the world is still struggling with these universal human functions Clinical Vignette That is the goal of listening. There are no rules about this, and at any given point in a clinical encounter, there are many ways to accomplish it.

There are also many ways to respond that are unhelpful and even retraumatizing. Clinical Vignette 10 A young man with paranoid schizophrenia had been admitted in to the hospital following a near lethal attack on his father.

When asked about this incident, he became frankly delusional, speaking of the Arab—Israeli conflict, the preciousness of Jerusalem, how the Israelis must defend it at all costs. Unspoken was his conviction that he was like the Israelis, with the entire world attacking and threatening him. He believed his father had threatened and attacked him when, in fact, his father had done little more than seek to be closer, more comforting, and advising with the patient.

The psychiatrist understood the patient to be speaking of that core of selfhood that we all possess, which, when threatened, creates a sense of vulnerability and panic, a disintegrating anxiety unlike any other.

The patient, although still delusional, visibly relaxed and began to speak much more directly about his own sense of vulnerability and uncertainty over his personal integrity and its ability to withstand any closeness.

He still required neuroleptic medication for his illness; however, his violent thoughts and behaviors reduced dramatically. He was able to begin interacting with his father, and his behavior on the ward changed as well. This issue has been addressed by writers who have pointed out how little understood are the concepts of support and empathy Peteet, Being human is also to be a creature of habit and pattern in linguistic, interper- sonal, and emotional realms.

The skilled psychiatrist listens with this ever in mind. What we see in the interview, what we hear in interactions may be presumed to be rep- etitions of many other events. The content may vary, but the form, motive, process, and evolution are generally universal for any given individual. This, too, is part of listening. To Be Found: The Psychological Product of Being Heard Psychiatric patients may be lonely, isolated, demoralized, and desperate, regardless of the specific diagnosis.

They have lost themselves and their primary relationships, if they ever had any. Many therapists believe that before anything else can happen, they must be found, and feel found. They can only be found within the context of their own specific histories, cultures, religions, genders, social contexts, and so on. There is nothing more healing than the experience of being found by another.

The earliest expression of this need is in infancy and we refer to it as the need for attachment. Referring to middle childhood, Harry Stack Sullivan spoke of the importance of the pal or buddy. Kohut spoke of the lifelong need for self-objects. In lay terms, it is often subsumed under the need for love, security, and acceptance. Psychiatric patients have lost or never had this experience. That is the purpose of listening. He had always known he was different in some indefinable ways from his family.

That difference had been both a source of pride and pain to him at various developmental stages. However, the recognition of the specific source, its meaning, and its constant presence in his life created a whole new sense of himself.

He had been found by his psychiatrist, who echoed the discovery, and he had found an entire piece of himself that he had enacted for years, yet which had been disconnected from any integrated sense of himself.

One of the most challenging patients to hear and experience is the acting out, self-destructive, demanding person with borderline personality disorder. Even as the prior sentence conveys, psychiatrists often experience the diagnosis as who the patient is rather than what he or she suffers. The following case conveys how one third-year resident was able to hear such a patient, and in his listening to her introduce the idea that the symptoms were not her but her disorder Clinical Vignette Chapter 1 r Listening to the Patient 19 Clinical Vignette 11 The psychiatrist was working the midnight Friday to 11 a.

Saturday shift in a Psychiatric Emergency Room. The patient was a year-old woman brought in by ambulance after overdosing on sertraline following an argument with her boyfriend. She had been partying with him and became enraged at the attention he was paying to the date of a friend who was accompanying them.

After being cleared medically, the patient was transferred to psychiatry for crisis intervention. It was about 4 a. She was crying and screaming for the psychiatric staff to release her. In the emergency department, she had grabbed a suture scissors attached to the uniform of the charge nurse. The psychiatrist sat wearily and listened to the patient tell her story with tears, shouts, and expletives sputtered through clenched teeth.

She stated that she did not remember ever being happy, that she frequently had thoughts of suicide, and that she had overdosed twice before, following a divorce from her first husband at the age of 19 and then 8 months prior to this episode when she had been fired from a job for arguing with her supervisor.

Her parents had kept her 6-year-old and 7-year-old sons since her divorce. She was currently working as a file clerk and living with her boyfriend of 2 months. She stated that she felt like there was a cold ice cube stuck in her chest as she watched her boyfriend flirting with the other woman. She acknowledged that she felt empty and utterly alone even in the crowded bar.

She created an unpleasant scene and they continued to argue until they got home. Then he had laughed at her and left, stating that he would come back when she had cooled down. The resident sat quietly and listened. He looked dreary. The night had been a busy one. With that statement, he pulled out the DSM-IV and read with her the description of the symptoms and signs of borderline personality disorder. She had been in therapy off and on since she was 16 years old.

No one had ever shared with her the name of the diagnosis but instead had responded to her as if the disorder was the definition of who she was. In his listening, he was able to hear her symptoms as a disorder and not the person. And in his ability to separate the two, he was able to allow her to distance herself from the symptoms, too, and see herself in a new light with her first inkling of her own personhood.

Gender can play a significant role in the experience of feeling found. Some individuals feel that it is easier to connect with a person of the same sex; others, with someone of the opposite sex. Clinical Vignette 6 is an excellent example of this. In these days of significant change in and sensitivity to sex roles, a misinterpretation such as that early in treatment could result in a permanent rupture in the alliance.

Some may do better with those who have chosen more traditional roles; others may be more sensitive to those who have adopted more modern roles. We now know that just as there is a neurobiological basis for empathy and countertrans- ference, there is a similar biological basis for the power of listening to heal, to lift psychological burdens, to remoralize, and to provide emotional regulation to patients who feel out of control in their rage, despair, terror, or other feelings Table 1.

Attachment and social support are psychobiological processes that provide the necessary physiological regulation to human beings. His research in basic human emotions sets forth the idea of their understanding across cultures and ages. It further supports the provocative idea that facial expressions of the listener may generate autonomic and central nervous system changes not only within the listener but within the one being heard, and vice versa. Indeed, the evidence is growing that new experiences in clinical interactions create learning and new memories, which are associ- ated with changes in both brain structure and function.

When we listen in this way, we are intervening not only in a psychological manner to connect, heal, and share burdens but also in a neurobiological fashion to regulate, modulate, and restore functioning. When patients feel found, they are responding to this psychobiological process. Listening to Oneself to Listen Better To hold in mind what has been said and heard after a session and between sessions is the most powerful and active tool of listening.

It is a crucial step often overlooked by students and those new at listening. It is necessary to hear our patients in our thoughts during the in-between times in order to pull together repetitive patterns of thinking, behaving, and feeling, giving us the closest idea of how patients experience themselves and their world. In addition, many of our traumatized patients have not had the experience of being held in mind, of being remembered, and their needs being thought of by significant others.

As the verbal interaction with the patient occurs, psychiatrists may find themselves expressing thoughts and feeling in ways that may be quite different from their usual repertoire. The following case is an example. This sort of listening to oneself in order to understand the patient requires a good working knowledge of projective identification.

Projective identification is a phrase Clinical Vignette 12 A second-year resident, rotating through an inpatient unit that serves the psychiatric needs of very severely ill psychotic patients with multiple admissions, dual diagnoses, homelessness, criminal records, significant histories of medical noncompliance, and, in some, unremitting psychosis, was particularly struggling with a year-old white woman admitted for the 11th time since age The patient invariably stopped medications shortly after discharge, never kept follow-up appointments, and ended up on the streets psychotic and high on crack cocaine.

She would then be involuntarily committed for restabilization. And so the cycle would repeat itself. The resident would see the patient on daily rounds. And regularly she refused doses. She began her regular supervision hours either frustrated or feeling hopeless that anything would change with this patient because the patient flatly refused to acknowledge her disorder. Shortly after a particularly difficult encounter with the patient concerning her refusal to take an evening dose of haloperidol, the resident came to supervision with the report that she had awakened terrorized by dreaming the night before that she had been diagnosed with schizophrenia.

She had been intensely affected by overwhelming pain, confusion, and despair as she heard the diagnosis in her dream. How more intensely can one be empathic with her patient than to dream as if she is experiencing the same horrifying reality?

Clinical Vignette 13 A year-old divorced white woman, being followed for bipolar disorder and borderline personality traits and stable for several years on lithium, was in weekly psychotherapy.

During the prior weekend, she had moved into another apartment closer to her work. Owens Jr. Hunter Manasco. Nayan Patel. Amos Clifford. Boyt Schell. Author : Daniel J. Now DSM-5 updated! Using a unique and effective combination of mnemonics, practical techniques, and phrasing examples that illustrate the nuances of the interviewing process, The Psychiatric Interview, 4th Edition helps you establish a rapport with patients and gain valuable clinical insights.

Now updated to incorporate the DSM-5 and current research, this popular manual teaches you how to? Key Features:Offers a practical, concise approach to the psychiatric interview, filled with tips and pearls to develop confidence in interviewing. Uses mnemonics and pocket cards to help you understand and remember key elements of the effective interview. With the new process, recommendations are determined by weighing potential benefits and harms of an intervention in a specific clinical context.

Clear, concise, and actionable recommendation statements help clinicians to incorporate recommendations into clinical practice, with the goal of improving quality of care. The new practice guideline format is also designed to be more user friendly by dividing information into modules on specific clinical questions.

Each module has a consistent organization, which will assist users in finding clinically useful and relevant information quickly and easily. This new edition of the practice guidelines on psychiatric evaluation for adults is the first set of the APA's guidelines developed under the new guideline development process.

These guidelines address the following nine topics, in the context of an initial psychiatric evaluation: review of psychiatric symptoms, trauma history, and treatment history; substance use assessment; assessment of suicide risk; assessment for risk of aggressive behaviors; assessment of cultural factors; assessment of medical health; quantitative assessment; involvement of the patient in treatment decision making; and documentation of the psychiatric evaluation.

Each guideline recommends or suggests topics to include during an initial psychiatric evaluation. Findings from an expert opinion survey have also been taken into consideration in making recommendations or suggestions. In addition to reviewing the available evidence on psychiatry evaluation, each guideline also provides guidance to clinicians on implementing these recommendations to enhance patient care.

Hales, Stuart C. Yudofsky, Laura Weiss Roberts. Sixth edition. Eliciting useful information from young patients and their families is both a skill and an art, and Psychiatric Interview of Children and Adolescents, an exceptionally practical and comprehensive guide, enables mental health clinicians and trainees to first improve their interviewing skills and then organize and integrate the information derived from the interview to construct an effective treatment program.

This book, building on the success of its predecessor, Clinical Manual of Psychiatric Interview of Children and Adolescents, offers updated and revised material, as well as expanded coverage that includes new findings and addresses emerging issues in the field. For example, a new chapter focusing on the psychiatric evaluation of preschoolers and very young children has been added, and the section on bullying in the chapter on abuse has been expanded to include cyber bullying.

Clinical vignettes illustrate important concepts and techniques, providing a real-world component that readers will find both fascinating and instructive, and the key points at the end of each chapter and numerous quick-reference tables facilitate consolidation of learning.

Easy to read, yet rigorous in its clinical focus, Psychiatric Interview of Children and Adolescents provides a solid foundation and expert guidance for clinicians evaluating and treating this critically important population.

An engaging and accessible guide to developing interpersonal clinical skills in the interviewing and assessment of psychiatric patients. This trusted practitioner resource and text helps the busy clinician find the right psychiatric diagnosis and avoid the many pitfalls that lead to errors.

Covering every disorder routinely encountered in clinical practice, Allen Frances provides the ICDCM codes and where feasible ICDCM codes required for billing, a useful screening question, a descriptive prototype, diagnostic tips, and other disorders that must be ruled out. Frances was instrumental in the development of past editions of DSM and provides helpful cautions on questionable aspects of DSM An index of common presenting symptoms lists possible diagnoses that must be considered for each.

Psychiatric Clinical Skills is a practical guide to engaging and assessing people who have mental health problems. Written by a team of experienced clinicians, it focuses on "what to ask" and "how to ask" and covers a wide spectrum of clinical problems and settings. When one works in a fast pace like a psych emergency room this book does comes handy.

By Vanessa O Really helped with my interviewing skills as an intern, and loved how he had a section on anxiety and obsessions because those were my weak spots. I also like how it gave tips, and alternative questions if you weren't eliciting any answers from the basic questions. Great for an intern. Posting Komentar. Kamis, 26 Desember [F March - Steven T. Most helpful customer reviews 3 of 3 people found the following review helpful. Ther e ar e two pr i nci pal ways to do thi s:.

Star t the question by implying that the behavior is a nor mal or under standable r esponse to a mood or situation:. With all the str ess you've been under , I wonder if you've been dr inking mor e lately? Sometimes when people ar e ver y depr essed, they think of hur ting themselves. Has this been tr ue for you? Sometimes when people ar e under str ess or ar e feeling lonely, they binge on lar ge amounts of food to make themselves feel better. Is this tr ue for you? Begi n by descr i bi ng another pati ent or pati ents who has engaged i n the behavi or, showi ng your pati ent that she i s not al one:.

I've seen a number of patients who've told me that their anxiety causes them to avoid doing things, like dr iving on the highway or going to the gr ocer y stor e. Has that been tr ue for you? I've talked to sever al patients who've said that their depr ession causes them to have str ange exper iences, like hear ing voices or thinking that str anger s ar e laughing at them.

It's possi bl e to go too far wi th nor mal i z ati on. Some behavi or s ar e i mpossi bl e to consi der nor mal or under standabl e, such as acts of extr eme vi ol ence or sexual abuse, so don't use nor mal i z ati on to ask about these.

Phrase your questi ons to i mpl y that you al r eady assume the pati ent has engaged i n some behavi or and that you wi l l not be offended by a posi ti ve r esponse. Thi s techni que i s most. A few exampl es fol l ow:. Drug use. Your pati ent has r el uctantl y admi tted to excessi ve al cohol use, and you str ongl y suspect abuse of i l l i ci t dr ugs. Symptom expectati on may encourage a strai ghtfor war d, honest r esponse. What sor ts of dr ugs do you usual l y use when you'r e dr i nki ng?

Your pati ent i s pr ofoundl y depr essed and has expr essed feel i ngs of hopel essness. You suspect SI, but you sense that the pati ent may be too ashamed to admi t i t. Rather than gi nger l y aski ng, Have you had any thoughts that you'd be better off dead? What ki nds of ways to hur t your sel f have you thought about?

Remember to use thi s techni que onl y when you suspect that the pati ent has engaged i n the behavi or. For exampl e, the questi on What ki nds of r ecr eati onal dr ugs do you use?

Symptom exaggerati on or ampl i fi cati on Shea , often used wi th symptom expectati on, i s hel pful i n cl ar i fyi ng the sever i ty of symptoms. The techni que i nvol ves suggesti ng a fr equency of a pr obl emati c behavi or that i s hi gher than your expectati on, so that the pati ent feel s that hi s actual , l ower fr equency of the behavi or wi l l not be per cei ved by you as bei ng bad.

How much vodka do you dr ink each day? Two fifths? Thr ee? Mor e? How many times do you binge and pur ge each day?

F ive times? Ten times? How many suicide attempts have you had since your last hospitaliz ation? F our? F ive? As i s tr ue for symptom expectati on, you must r eser ve thi s techni que for si tuati ons i n whi ch i t seems appr opr i ate. For exampl e,. REDUCTION OF GUILT Al though i t i s tr ue that al l the techni ques i n thi s chapter boi l down to r educi ng a pati ent's sense of shame and gui l t, the r educti on-of- gui l t techni que seeks to di r ectl y r educe a pati ent's gui l t about a speci fi c behavi or to di scover what he has been doi ng.

Thi s techni que i s especi al l y useful i n obtai ni ng a hi stor y of domesti c vi ol ence and other anti soci al behavi or. When you argue with your wife, Interviewer: does she ever throw things at you or hit you?

She sure does. See this scar? Patient: She threw a vase at me 2 years ago. Well, yes. I've bruised her a few Patient: times.

Nothing compared to what she did to me. Another ver si on of thi s techni que i s to begi n by aski ng about other peopl e:. Do you have any friends who push around their wives or Interviewer: girlfriends when they have an argument? They get pushed back, Patient: too.

Have you done that yourself, Interviewer: pushed or hit your wife? I'm not proud of it, but Patient: I've done it when she's gotten out of hand. Have you ever had any legal Interviewer: problems? Oh, here and there. A little Patient: shoplifting. Normal stuff. What was the best thing Interviewer: you ever stole? The best thing? Well, I was into cars for a while. I spent a week cruising around in a Porsche Patient: , but I returned it. I was just into joyrides. Everyone was doing it back then.

In thi s exampl e, the i nter vi ewer used i nducti on to braggi ng to r educe the pati ent's sense of gui l t and l ead to an admi ssi on of somethi ng mor e si gni fi cant than shopl i fti ng.

In the fi r st method, they used standar d l anguagewor ds and phrases such as i ntoxi cated and sexual i nter cour se. In the second method, they used fami l i ar or poeti c l anguagethe l anguage thei r r espondents used for the same behavi or, l i ke getti ng l oaded and maki ng l ove.

Appar entl y, pati ents feel mor e comfor tabl e admi tti ng to soci al l y undesi rabl e behavi or s i f they feel the i nter vi ewer speaks thei r l anguage. Tabl e 4. Do you have a history of Have you ever shot intravenous drug use?

Do you get high? Do you smoke Do you smoke marijuana? Do you snort coke? Do you use cocaine? Smoke crack? Anchor questi ons to memorabl e events. Tag questi ons wi th speci fi c exampl es. Descr i be syndr omes i n your pati ent's ter ms. Utter i ng a wor d i s l i ke str i ki ng a note on the keyboar d of the i magi nati on.

Thr oughout the di agnosti c i nter vi ew, your pati ent's memor y wi l l be both your al l y and your enemy. Even when the desi r ed i nfor mati on i s not thr eateni ng i n any way, be pr epar ed for major i naccuraci es and fr ustrati on i f the events descr i bed occur r ed mor e than a few months ago.

Nonethel ess, we've al l had the i n-trai ni ng exper i ence of watchi ng an excel l ent teacher el i ci t l ar ge quanti ti es of hi stor i cal i nfor mati on fr om a pati ent for whom we coul d bar el y deter mi ne age and sex. How do they do i t?

Her e ar e some tr i cks of the trade. Si mpson tr i al or Pr i ncess Di ana's death. As an exampl e, suppose you ar e i nter vi ewi ng a young woman wi th depr essi on. You fi nd out over the cour se of the i nter vi ew that she has a heavy dr i nki ng hi stor y, and you want to deter mi ne. You coul d ask, How many year s ago di d you begi n dr i nki ng? Instead, use the anchor i ng techni que:.

Did you drink when you Interviewer: graduated from high school? I was drinking a lot back then, every weekend at least.

Patient: Graduation week was one big party. How about when you first Interviewer: started high school? Were you drinking then? Oh no, I didn't really start drinking until I hooked up with Patient: my best friend toward the end of my freshman year.

Were you depressed when you Interviewer: started school? Oh yeah, I could barely get up in Patient: time to make it to classes, I was so down. You've succeeded i n establ i shi ng that her depr essi on pr edated her al cohol i sm, whi ch may have i mpor tant i mpl i cati ons for tr eatment. Taggi ng wi th exampl es i s si mi l ar to posi ng mul ti pl e-choi ce questi ons, but i t i s used speci fi cal l y for ar eas i n whi ch your pati ent i s havi ng tr oubl e wi th r ecal l.

You si mpl y tag a l i st of exampl es onto the end of your questi on. To ascer tai n what medi cati ons your pati ent has taken i n the past for depr essi on, for exampl e:.

What were the names of the Interviewer: medications you took back then? Who knows? I really don't Patient: remember. Pamelor, I think. It gave me a Patient: really dry mouth. For exampl e, suppose you ar e i nter vi ewi ng a year-ol d man wi th depr essi on, and you want to deter mi ne when he had hi s fi r st epi sode:. How old were you when you first Interviewer: remember feeling depressed? I don't know. I've always been Patient: depressed.

You suspect that you and the pati ent have di ffer ent meani ngs of depr essi on, and you al ter your appr oach:. Just to clarify: I'm not talking about the kind of sadness that we all experience from time to time. I'm trying to understand when you first felt what we call a clinical depression, and by that I mean that you were so down Interviewer: that it seriously affected your functioning, so that, for example, it might have interfered with your sleep, your appetite, and your ability to concentrate.

When do you remember first experiencing something that severe? Oh, that just started a month Patient: ago. Use smooth transitions to cue off somethi ng the pati ent just sai d. Use referred transitions to cue off somethi ng sai d ear l i er i n the i nter vi ew.

Use introduced transitions to pul l a new topi c fr om thi n ai r. Inter vi ewi ng a pati ent for the fi r st ti me r equi r es touchi ng on many di ffer ent topi cs wi thi n a br i ef per i od. You'l l need to constantl y change the subject, whi ch can be jar r i ng and off-putti ng to a pati ent, especi al l y when she i s i nvol ved i n an i mpor tant and emoti onal topi c.

Ski l l ed i nter vi ewer s ar e abl e to change topi cs wi thout al i enati ng thei r pati ents and use var i ous transi ti ons to tur n the i nter vi ew i nto what Har r y Stack Sul l i van cal l ed a col l aborati ve i nqui r y. Speaking of family, has anyone else in your family been through Interviewer: the kind of depression that you've been going through?

For exampl e, at the begi nni ng of an i nter vi ew, a depr essed pati ent had br i efl y menti oned that he di dn't know i f he coul d take thi s si tuati on any mor e. Now, wel l i nto the eval uati on, the i nter vi ewer wants to ful l y assess sui ci dal i ty:. My doctor tried me on some Patient: medication for a while, but it didn't do much good. Earlier, you mentioned that you didn't know how much more of Interviewer: this you could take.

Have you had the thought that you'd be better off dead? Thi s transi ti on i s often begun by a statement such as, Now I'd l i ke to swi tch gear s. For exampl e, you need to qui ckl y r un thr ough the PROS, but you don't want the pati ent to thi nk that you ar e aski ng these questi ons because you expect that he actual l y exper i ences al l of these symptoms:.

Now I'd like to switch gears a little and ask you about a bunch of different psychological symptoms that people Interviewer: sometimes have. Many of these may not apply to you at all, and that is a useful thing to know in itself. Use open-ended questions and commands to i ncr ease the fl ow of i nfor mati on. Use continuation techni ques to keep the fl ow comi ng. Shift to neutral ground when necessar y.

Schedule a second interview when al l el se fai l s. Occasi onal l y, you r un i nto the i deal pati ent. She's tr oubl ed and eager to tal k. She br i efl y outl i nes the pr obl ems that l ed to her vi si t and then answer s each of your questi ons i n ful l , stoppi ng i n pr eparati on for your next quer y. You fi nd that you've gather ed al l the vi tal i nfor mati on i n 30 mi nutes, and you have the l uxur y of expl or i ng her soci al and devel opmental hi stor y deepl y. You feel l i ke a r eal therapi st.

Your mi nd i s whi r r i ng, and you can't wai t to dust off that copy of F r eud you bought the day you got i nto your trai ni ng pr ogram but haven't had ti me to l ook at si nce.

Usual l y, however, your pati ent wi l l fal l somewher e on ei ther si de of a spectr um of i nfor mati on fl ow. Ei ther he's not sayi ng enough or he's sayi ng too much, and i t's not hi s faul t. The average pati ent has no way of knowi ng what i nfor mati on i s and i s not i mpor tant for a psychi atr i c di agnosi s. It's up to you to educate the pati ent and to steer the i nter vi ew appr opr i atel y.

What ki nds of symptoms has your depr essi on caused? What sor ts of thi ngs have you done when you fel t mani c? Open-ended commands ar e questi ons al ter ed sl i ghtl y to sound mor e di r ecti ve. Tel l me what ki nds of symptoms you've had. Descr i be for me some of the thi ngs you've done whi l e you wer e mani c.

She was unhappy wi th the i nvol untar y admi ssi on and i ni ti al l y r esi stant to answer i ng questi ons. I understand that you took an Interviewer: overdose of your medicine last week.

What do you think was going Interviewer: on? An open-ended question. Which doesn't Patient: get anywhere. Patient: Maybe. Tell me a little about how you Interviewer: were feeling. An open-ended command. There's not much to tell. I took Patient: the pills, that's all. Still no results. I really want to help you, but the only way I can do that is to understand what was going through your head when you Interviewer: took the pills.

Some education, combined with another, more specific, command. I guess I thought it would be a good idea to take 'em. My Patient: husband was driving me crazy. Now we're getting somewhere. These expr essi ons encourage a pati ent to conti nue r eveal i ng sensi ti ve i nfor mati on:.

Uh huh. Conti nue wi th what you wer e sayi ng about Real l y? They ar e often combi ned wi th faci l i tati ve body l anguage, such as head nods, per si stent eye contact, hol di ng the chi n between thumb and i ndex fi nger, and faci al emoti onal r esponse to the mater i al.

G eneral l y, the mor e spontaneous and genui ne your r esponses to r el uctant pati ents, the mor e l i kel y you ar e to di sar m them. For exampl e, you may have had the exper i ence of i nter vi ewi ng a pati ent who becomes i ncr easi ngl y al i enated as your questi ons become mor e psychi atr i c. If thi s happens, tr y changi ng the subject to somethi ng nonpsychi atr i c, wi th the i ntenti on of si dl i ng back i nto your ter r i tor y once you've gai ned the pati ent's tr ust.

I i nter vi ewed a col l ege student who was r efer r ed by hi s dean for psychol ogi cal eval uati on after havi ng sai d he woul d ki l l hi msel f i f he was not gi ven a better grade i n a cour se. He was an unwi l l i ng par ti ci pant and had shown up onl y because he was thr eatened wi th suspensi on i f he di d not.

After the fi r st 5 mi nutes of the i nter vi ew, i t was cl ear that he was not i nter ested i n tal ki ng about what was goi ng thr ough hi s mi nd, so I shi fted to r el ati vel y neutral gr ound. It's fine. There's a good English Patient: department. Any particularly Interviewer: interesting classes?

Patient: King Lear and the Modern World. It's been a while since I read Interviewer: that. How is King Lear related to the modern world? It's all about money and power. Everyone sucks up to King Lear because he has all this land to Patient: give away. It's the same way with lobbyists in Washington. Or professors at a university. Is that the way it is at your Interviewer: college? Of course. Professors sit in their offices, fat and happy, and Patient: students mean nothing to them.

Unless they can get you to be their slave. Thi s l ed to a di scussi on of hi s fr ustrati ons wi th school , whi ch i n tur n l ed to hi s r eveal i ng the extent of hi s depr essi ve symptoms.

If you'r e not getti ng anywher e wi th the pati ent, no matter how many i nter vi ewi ng tr i cks you use, you may need to cut the i nter vi ew shor t wi th a comment such as. Why don't we stop for now and meet again next week [or tomor r ow, for inpatient wor k].

I've done thi s several ti mes, and the pati ent i s usual l y mor e for thcomi ng at the next i nter vi ew. I'm not sur e why thi s wor ks. Maybe gi vi ng the message that I accept thei r r el uctance paradoxi cal l y encourages them to open up, or per haps they feel awkwar d about not answer i ng questi ons two i nter vi ews i n a r ow.

Of cour se, befor e you end the i nter vi ew, you must feel comfor tabl e that the pati ent i s not at i mmi nent r i sk of sui ci de or other danger ous behavi or s. Use closed-ended and multiple-choice questions to l i mi t the fl ow.

Per fect the ar t of the gentle interruption. Educate the pati ent about the need to move al ong i n the i nter vi ew.