The Psychiatric Interview / The Medical Interview


        When interviewing any patient, whether in a psychiatric setting, or a medical setting, the interviewer faces a number of options as to how best to approach the interview, what the goals of the interview should be, how best to maximize the finite and usually limited time available.  There are as many interview styles as there are interviewers and each style captures something unique about the relationship between doctor and patient. 

        At each moment in the interview the interviewer faces a number of opportunities and pitfalls, which can either deepen trust and understanding or create greater difference and defensiveness.  Probably the greatest mistake most interviews make is asking too many too specific questions, turning the interview into an interrogation. 

        In principle it is better to start with open-ended questions and follow up on what the patient chooses to reveal about themselves.  In practice this may be more difficult than it seems.  With practice, it becomes quite natural and spontaneous. 
       
        All patients have a need to be understood and want to tell “their story”.  We might call this the “narrative imperative.”  This is especially manifested when someone comes to a doctor for help.  But we need to appreciate that most people do not know the kind of help they need, nor do doctors know without listening carefully.  There may be some dancing around the issues, or back and forth volleying while the doctor tries to find out how forthcoming the patient is prepared to be and the patient tries to find out how attentive the doctor is prepared to be to their “inner self”.  Even the most guarded paranoiac wants to be understood. 

It is thus tempting for the doctor to launch into a question and answer mode when the patient initially hesitates.  Communications specialists observing doctor-patient interviews that this usually takes place in the first seconds of an interview, not in minutes, and that even if patients start to elaborate their concerns, doctors usually interrupt and direct the interview within the first minute.  Most medical interviewers are like the Joe Friday, the LAPD detective of Dragnet fame:  “Just the facts, Ma'me.”   A more appropriate detective role model might be Columbo, who though a bit rumpled, always listened patiently to the story, then came back with follow-up questions. 

The Minimal Activity Technique

        The Minimal Activity Technique is a way of disciplining ourselves to let the patient tell their story.  It serves as a reminder that patients come to us to talk and we can listen.  We control the interview with a light touch.  We have two ears and one mouth for a reason and should probably use them in that proportion. 

        The open-ended question: Recognizing that there is not one standard way to interview patients, the interviewer should select an opening open-ended question to start the interview.  “Why have you come for help? “  “How can I help you?”  “Can you tell me something about yourself and your concerns?”  “What would you like to talk about today?” are all appropriate opening open-ended questions. 

        Volleying or Dancing or Sparring:  One may expect in the opening moments of the interview the patient to clarify what is expected.  Patients will often ask, “What do you want to know?” which many doctors will take as a cue to abandon the open-ended approach and launch into 40 questions and 40 answers.  This is a mistake.  It reflects the doctors anxiety rather than confidence.  It is better to acknowledge the tension with another open-ended invitation.  “Whatever you feel is important?”  or “Whatever you would feel most comfortable talking about.”  Often interviews will want to “make the patient feel comfortable” by starting with chit-chat.  This is also a mistake.  An interview that starts superficially usually stays superficially.  If the doctor signals that she or he is uncomfortable with feelings, the patient will pick up on that.  No one will feel comfortable talking about the humiliation of their divorce or how hurt their were by childhood trauma right away, but they will be testing the interviewer to see if this might be a place where they can feel safe. 

        Stage One:  Active listening.  One the patient feels comfortable, the interviewer can relax and listen to the patient’s narrative.  Patients will usually talk uninterrupted for many minutes if they feel they are being listened to.  The manic patient may talk forever and need to be interrupted.  The obsessive patient  may give more details than we can initially make sense of, and eventually need to be redirected, but listening precedes redirection. 

        Stage Two:  Non-verbal encouragement.  After the patient has been talking for several minutes, they may stop or pause.  This is not yet an occasion to switch to the Q and A format?  There will be a temptation to clarify what the patient has said, but that is not necessary at this point.  At this point in the interview, it is better to encourage the patient to continue talking and this can usually be done with a gesture like leaning forward, looking at the patient directly and expectantly.  The patient will usually resume talking, and the interviewer can go back to active listening. 

        Stage Three: Verbal encouragement.  After a period of active listening, escalation to non-verbal encouragement perhaps several times, the patient may pause again, uncertain about how to proceed.  It is still not time to ask direct questions.  It may be more appropriate here to give some sort of verbal encouragement:  “Go on”  “Is this difficult to talk about”  “Can you say more about that?”  “What else?”

        Caution:  Stay with feelings.   One of the biggest mistakes a medical Joe Friday can make is to change the subject when patients begin to show feelings, sadness especially but even anger or other feelings.  .  Patients will be inclined to do this themselves.  A supportive gesture, like offering a tissue, is an acknowledgement of the feelings, but may suggest that tears should be wiped away, so we can get on with fact-gathering.  It may be better to ask, “Can you put words on those feelings?”  or at least to acknowlege in words what you are observing:  “This must be difficult to talk about.”  or “You still have feelings about this.” 

        Stage Four:  Indirect question.  After some time, the interviewer begins to get some sense about how the patient is viewing their situation and is also trying to make sense about what is being said.  Indirect questions are extensions of verbal encouragement and transitions to more direct questions.  Indirect questions facilitate the narrative by helping the patient begin to observe what they are reporting.  “You mentioned your mother, but haven’t said anything about your father.”  “How did you feel when you received the news?” 

        Stage Five:  The Direct question.  There are many options the interviewer has before asking direct questions.  By the time it is necessary to ask direct questions, the patient will have told the doctor much of the needed information, and the patient by tell his story in his way has also told the doctor how they understand themselves and their situation.  Although time has been “lost” by letting the patient talk, much important information (and understanding) has been gained.  The direct questions that the doctor then asks will be more meaningful for the patients and for the patience shown. 





        t=0   Establish rapport:  Open –ended questions

                     Expect some volleying

                     Minimal activity technique





    t=10      Think about Differential Diagnosis

               


        t=15     Screening questions   




   t=20      Developmental  history




   t=25   Mental Status Questions pertinent to Diff Diagnosis




   t=30  Feedback about what has been learned  

Building a History:

Building a History:  By medical convention, the presentation of a history is in a certain border, starting with the chief concerns (not the chief complaint, please), progressing through the history of the present illness, the past medical history, the family history, social history, exams (physical exam, mental status exam, laboratory exams) and the Developmental History.  Conceptually the Developmental Life History (or biography or patient narrative)  is the foundation of the history we build with the patient.  See more about the Developmental History and Repetition Compulsion.