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PSYCHIATRIC INTERVIEWING Resident Lecture Series Jerome Lee and Jen Wide Outline Therapeutic alliance Interview Process Application of Questions Screening Questions MSE Questions Therapeutic Alliance Establish Therapeutic Alliance = collaborative nature of the partnership between clinician and client Is a partnership that incorporates client preferences and goals into treatment outlines 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 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 In substance use Reductions in substance consumption Increased abstinence rates Better social adjustment More successful referrals to treatment Components of Good Alliance Non-possessive warmth Friendliness Genuineness Respect Affirmation Empathy The 6 People in the Room 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 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 “reflective listening” repeat back to the client what you hear them saying to you rephrase or paraphrase what they’ve said Be Non-Judgmental Be receptive to the unknown When there is judgment about what is revealed, the speaker is sealed off from the listener no longer an exchange Offer understanding and unconditional acceptance of the client Self-Awareness 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 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 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 Don’t fake it! Patients 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” Patients appreciate a genuine attempt by the counselor to see things from their point of view Respect No one wants to feel like an idiot Respect = Golden Rule explaining things to patients Acknowledging unfairness/poor txn/mistakes Use simply language Grade 6 edu Don’t use medical jargon, e.g. “hypertension” Final Suggestions Recognize and praise patient when they have made progress toward attaining their goals. can include showing up for the counseling session, being coop, etc. Offer a hopeful, but realistic attitude that goals can be met Help pt make realistic goals Acknowledge and directly address rifts in the therapeutic relationship The Interview Process How to Start an Interview 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 “tell me about yourself”, “what brought you here” Alternatively may begin with background info Techniques Questions types Open ended verbalizations Variable verbalizations Close ended verbalizations Gates/Transitions Spontaneous Natural Referred Phantom Implied Open Ended Verbalization 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 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 Middle ground questions 1. They 2. tend to vary in the response they create. A good blend causes a production of large amount of spontaneous speech = A GOOD THING. Swing type Qualitative 3. So you left marriage after three years? Empathetic statements 5. How is your appetite Statements of Inquiry 4. Can you describe your marriage? Its sounds like a troubling time for you Facilitatory type I see, Go on. “Gates” Spontaneous Gate simple follow up question following the interviewee at “pivot points.” clinician can decide to pursue or not Natural Gate 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 “Gates Cont’d” 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 Phantom gate The physician’s derailment appears out of nowhere! Generally avoided. Shifting Topics with Style 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 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 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: What sorts of drugs do you use when drinking? Experimented with any drugs? What kinds of ways to hurt yourself have you thought of? Other Examples Symptom exaggeration: How many times do you purge in a day, 5-10? If lower frequency they won’t be perceived as being bad Reduction of guilt Use familiar language – use their language The Power of Silences 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 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: lack of empathy possibly focusing on close ended questions hitting criteria like check marks The Shut Down Interview use more Open ended verbalizations Follow up with topic that patient gives slightest hints that they want to discuss. Supportive comments. “That was must have been difficult for you to deal with.” Gentle commands “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 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 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 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 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) Requires 1 week of 3/6 of the above symptoms. Schizophrenia Requires two symptoms for 1 month, plus 6 months of prodromal or residual symptoms Delusions Hallucinations Speech disorganization Behaviour disorganization Negative Symptoms Panic Disorder 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 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) Asking About MSE Asking about Mood Symptoms? “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 Normalizing When things get really bad, some people start having thoughts of suicide or death. Have you had such thought? Contextualizing I do have to ask, have you had any thoughts of hurting or killing yourself? Others? Thought Content 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 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? “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 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? Judgment What are the txn options? What are the pros/cons of +/- txn? Cognition Attention: World backwards Days of week or Months of year backwards References Daniel Carlat – The Psychiatric Interview Shawn Shea – Psychiatric Interviewing: The Art of Understanding