Download Psychiatric Interviewing

PSYCHIATRIC
INTERVIEWING
Resident Lecture Series
Jerome Lee and Jen Wide
Outline
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Therapeutic alliance
Interview Process
Application of Questions
Screening Questions
MSE Questions
Therapeutic Alliance
Establish Therapeutic Alliance
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= collaborative nature of the partnership between
clinician and client
Is a partnership that incorporates client preferences
and goals into treatment
 outlines
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methods for accomplishing those goals
based on listening to w/o being judgmental or
giving unwarranted advice
Gain cooperation and allow the patient to develop
a connection/relationship with treating
team/physician
Importance of Therapeutic Alliance
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Accounts for more variance in treatment outcomes
than any single patient characteristic
For positive txn outcomes, establishing a strong,
helping alliance is better than:
 professional
training
 type of therapy or intervention
 how long you spend with a patient
Importance of Therapeutic Alliance
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In substance use
 Reductions
in substance consumption
 Increased abstinence rates
 Better social adjustment
 More successful referrals to treatment
Components of Good Alliance
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Non-possessive warmth
Friendliness
Genuineness
Respect
Affirmation
Empathy
The 6 People in the Room
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1.
2.
3.
With every conversation between two people there
are at least 6 people present:
What each person said = 2 people
What each person meant to say = 2 people
What each person understood the other to say are
= 2 people
Be a Good Listener
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essential to listen and clarify the issue with the pt
Be a vigilant inward listener
 Pay
attention to nonverbal cues such as body language.
 Ask yourself “Is there something the client is trying to
say that I’m not getting?”
 pursue what you don’t understand
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“reflective listening”
 repeat
back to the client what you hear them saying to
you
 rephrase or paraphrase what they’ve said
Be Non-Judgmental
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Be receptive to the unknown
When there is judgment about what is revealed, the
speaker is sealed off from the listener
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no longer an exchange
Offer understanding and unconditional acceptance
of the client
Self-Awareness
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Time to get to know yourself!
must actively listen to the client and monitor your
own responses to the patient
But don’t get too overly focused on yourself
Be Weary of Unwelcomed Adviced
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Don’t tell them what you think should be done
Be careful not to give advice to the client unless
asked directly for it
 especially
during the pre-engagement and
engagement stages
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Giving advice that the client is not yet ready to
hear or deal with weakens therapeutic alliance
 makes
the client feel as though you are not really
listening to what the client wants.
Empathy
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Don’t fake it!
 Patients
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can sense a dislike of them
Be as genuine as possible
 E.g.
“I can see that it’s causing you a lot of distress”
 “You seem angry, I imagine that must be frustrating”
 “It seems a lot for you”
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Patients appreciate a genuine attempt by the
counselor to see things from their point of view
Respect
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No one wants to feel like an idiot
Respect = Golden Rule
 explaining
things to patients
 Acknowledging unfairness/poor txn/mistakes
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Use simply language
 Grade
6 edu
 Don’t use medical jargon, e.g. “hypertension”
Final Suggestions
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Recognize and praise patient when they have made
progress toward attaining their goals.
 can
include showing up for the counseling session, being
coop, etc.
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Offer a hopeful, but realistic attitude that goals can
be met
 Help
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pt make realistic goals
Acknowledge and directly address rifts in the
therapeutic relationship
The Interview Process
How to Start an Interview
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Be warm, courteous and emotionally sensitive
Actively diffuse the strangeness of the clinical situation
Educate the patient about the nature of the interview
Gain your patient’s trust by projecting competence, but be
real about your abilities
Be yourself
Give the patient the opening word
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“tell me about yourself”, “what brought you here”
Alternatively may begin with background info
Techniques
Questions types
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Open ended
verbalizations
Variable
verbalizations
Close ended
verbalizations
Gates/Transitions
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Spontaneous
Natural
Referred
Phantom
Implied
Open Ended Verbalization
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1.
These questions invite the patient to share personal
experiences
Two forms:
Open ended questions
 What
2.
are your plans for the marriage?
Gentle commands
 Tell
me about your mother?
Close ended Verbalizations
Answers potentially can be answered with 1-2
words.
 Two Types:
1. Close ended questions
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 Are
you feeling happy, angry or sad?
2. Close ended statements
-Anxieties can be helped by behavioral therapies.
 Closed
ended statements are used for educational
slants or explanations.
Variable Verbalizations
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Middle ground
questions
1.
 They
2.
tend to vary in
the response they
create.
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A good blend causes a
production of large
amount of spontaneous
speech = A GOOD
THING.
Swing type
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Qualitative
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3.
So you left marriage after
three years?
Empathetic statements
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5.
How is your appetite
Statements of Inquiry
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4.
Can you describe your
marriage?
Its sounds like a troubling
time for you
Facilitatory type
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I see, Go on.
“Gates”
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Spontaneous Gate
simple follow up question following the interviewee at
“pivot points.”
 clinician can decide to pursue or not
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Natural Gate
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clinician enters a new region cueing directly off the
patient’s preceding statement
Referred Gate
refers back to simple statements by the patient.
 Good technique to return to a poorly
understood/expanded area
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“Gates Cont’d”
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Implied gates
 allows
one to join similar regions and can also provide
parallel expansions to related regions
 E.g. connecting energy and sleep during mood screen
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Phantom gate
 The
physician’s derailment
 appears out of nowhere! Generally avoided.
Shifting Topics with Style
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Use smooth transition to cue off something the patient
just said
Use referred transition to cue off something said
earlier in the interview
Use introduction transitions to pull off a new topic
from thin air
Remind yourself/patient this is a clinical interview –
not a chat
Never apologize for the questions you are or are
about to ask
How to Approach Threatening
Topics
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Use normalizing questions to decrease a patients
sense of embarrassment about a feeling or
behavior
Use reduction of guilt to defuse admission of
embarrassing behavior
Use symptom exaggeration to determine the actual
frequency of a sensitive, shameful behavior
Use familiar language when asking about behaviors
Examples: Normalization
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With all the stress you’ve been under I wonder if
you’ve been drinking more lately?
Sometime when people are very depressed they
think of hurting themselves. Has this been true for
you?
I’ve seen a number of patients who’ve told me that
their anxiety causes them to avoid things, like
driving….
Examples: Gentle assumption:
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What sorts of drugs do you use when drinking?
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Experimented with any drugs?
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What kinds of ways to hurt yourself have you
thought of?
Other Examples
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Symptom exaggeration:
 How
many times do you purge in a day, 5-10?
 If lower frequency they won’t be perceived as being
bad
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Reduction of guilt
 Use
familiar language – use their language
The Power of Silences
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Be ok with uncomfortable silences
Let the patient be the first to break and talk, and
they will
APPLICATION OF QUESTIONS AND
GATES TO DIFFICULT PATIENTS
The Shut Down Interview
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An interview where the patient displays short
responses, long delay between answering and body
cues that suggest “not interested.”
It is common that the interviewer is “feeling
frustrated” resulting in:
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lack of empathy
possibly focusing on close ended questions
hitting criteria like check marks
The Shut Down Interview
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use more Open ended verbalizations
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Follow up with topic that patient gives slightest hints that
they want to discuss.
Supportive comments.
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“That was must have been difficult for you to deal with.”
Gentle commands
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“What are some of your thoughts about the marriage?”
“Describe your initial reaction?”
Increase eye contact
Avoid long pauses before asking the next question.
Avoid sensitive topics to start. (lethality, substances sexual
history)
Wandering Interview
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Patient speaks with a mild pressure, often talking
for long periods with vary little breaks jumping from
one topic to another.
Hard to interrupt
Sometimes completely off topic ie asking about
current depressive sx and patient talks about her
abuse at the age of 10 years old.
Wandering Interview
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Increase closed ended questions
Avoid reinforcement with head nodding and cues like
“go on”
Gentle structure comments such as “let’s focus on what
your mood was like this week.”
More firm comments, “I’m going to focus on some
important areas you mentioned in an effort to
understand you better.”
Clarify or address resistance: “Its seems that you
wander off the subject, what do you think is going on?”
Sometimes you can use PHANTOM gates but may cause
loss of rapport.
SCREENING QUESTIONS
Depression Questions
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Mneumonic for the DSM IV Criteria
“M- SIGECAPS”
Mood, Sleep, Interest, Guilt, Energy, Concentration,
Appetite, Psychomotor agitation/retardation,
Suicide.
Requires decreased mood or interest for two weeks
plus 5/9
Mania Screening Questions
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Mneumonic of the DSM IV Criteria
“DIGFAST” where the mood is “on top of the world”.
Distractible,
 Indiscretion,
 Grandiosity,
 Flight of Ideas,
 Activities increased,
 Sleep Deficit,
 Talkative (pressured speech)
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Requires 1 week of 3/6 of the above symptoms.
Schizophrenia
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Requires two symptoms for 1 month, plus 6 months
of prodromal or residual symptoms
Delusions
Hallucinations
Speech disorganization
Behaviour disorganization
Negative Symptoms
Panic Disorder
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Recurrent Panic Attacks (must have 4 of 13
symptoms)
Mneumonic: Heart, Breathless, Fear
Heart Cluster: Nausea, Palpitations, Pain, Sweat
Breathless Cluster: SOB, Choking, Dizziness
Fear Cluster: Fear of dying, going crazy
One month of fear, worry and change in behaviour
over the idea of having another attack
Generalized Anxiety Disorder
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Excessive anxiety about a number of things for most
days over 6 months; unable to control
Mneumonic: SCRIFT (sleep concentration
restlessness irritability fatigue tension)
Sleep
Concentration
Restlessness
Irritability
Fatigue
Tension
Obsessive Compulsive Disorder
Mneumonic: Washing and Straightening Make Clean
Houses
 Washing
 Straightening
 Mental Rituals
 Checking
 Hoarding
Must have obsessions (thoughts, impulses, images causing
distress) or compulsions (behaviours or mental acts
driven to perform to prevent/reduce stress)
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Asking About MSE
Asking about Mood Symptoms?
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“How have you been feeling lately?”
“How would you describe you mood right now?”
“Have you been feeling sad, blue, down or
depressed?”
“Have you been feeling nervous or anxious much of
the time?”
Thought Content
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Normalizing
 When
things get really bad, some people start having
thoughts of suicide or death. Have you had such
thought?
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Contextualizing
I
do have to ask, have you had any thoughts of hurting
or killing yourself? Others?
Thought Content
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Do you spend a lot of time thinking of something?
Do you have some ideas that you hold very strongly?
Do others frequently disagree with your point of view?
Do you ever feel as if someone or something is out to
get you?
Do you ever feel as if people are judging you?
Do you ever feel as if your thoughts are not your own?
Do you ever feel there are special messages that are
only being directed at you?
Do you ever think you have any special powers?
Have you had any new ideas about religion?
Thought Content
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Do you ever experience thoughts that you can’t stop?
Do your thoughts feel like they are your own?
Are you ever forced to think of something against your
will?
Are there objects or situations that make you intensely
anxious if you cannot avoid them?
Do you have strong fears about being humiliated in
public?
Do you require special arrangements to be made for
you to be comfortable when you are outside your
home?
Asking about Perceptual Disorders?
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“Many people with difficulties like yours have other
symptoms as well. To be thorough, I’d like to ask you
about some of these things so I have a complete
understanding of what’s been happening.”
When depression gets really bad, some people
start seeing or hearing things. Has that happened
to you
“Have you had any unusual experiences?”
“Have things been happening around you that seem
puzzling?”
Insight & Judgment
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Insight
 Is
it you opinion that you have an illness?
 How do you account for the difficulties you are having?
 What does (name of condition) mean to you?
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Judgment
 What
are the txn options?
 What are the pros/cons of +/- txn?
Cognition
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Attention:
 World
backwards
 Days of week or Months of year backwards
References
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Daniel Carlat – The Psychiatric Interview
Shawn Shea – Psychiatric Interviewing: The Art of
Understanding