PSYCHIATRIC INTERVIEWING

1. PSYCHIATRIC INTERVIEWING Resident Lecture Series Jerome Lee and Jen Wide

2. Outline • Therapeutic alliance • Interview Process • Application of Questions • Screening Questions • MSE Questions

3. Therapeutic Alliance

4. 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

5. 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

6. Importance of Therapeutic Alliance • In substance use • Reductions in substance consumption • Increased abstinence rates • Better social adjustment • More successful referrals to treatment

7. Components of Good Alliance • Non-possessive warmth • Friendliness • Genuineness • Respect • Affirmation • Empathy

8. The 6 People in the Room • 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

9. 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

10. 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

11. 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

12. 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.

13. 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

14. 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”

15. 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

16. The Interview Process

17. 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

18. Techniques Questions types Gates/Transitions • Open ended verbalizations • Variable verbalizations • Close ended verbalizations • Spontaneous • Natural • Referred • Phantom • Implied

19. Open Ended Verbalization • These questions invite the patient to share personal experiences • Two forms: • Open ended questions • What are your plans for the marriage? • Gentle commands • Tell me about your mother?

20. 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.

21. Variable Verbalizations • Middle ground questions • They 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 • Can you describe your marriage? • Qualitative • How is your appetite • Statements of Inquiry • So you left marriage after three years? • Empathetic statements • Its sounds like a troubling time for you • Facilitatory type • I see, Go on.

22. “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

23. “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.

24. 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

25. 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

26. 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….

27. 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?

28. 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

29. The Power of Silences • Be ok with uncomfortable silences • Let the patient be the first to break and talk, and they will

30. APPLICATION OF QUESTIONS AND GATES TO DIFFICULT PATIENTS

31. 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

32. The Shut Down Interview • use more Open ended verbalizations • “What are some of your thoughts about the marriage?” • 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 • “Describe your initial reaction?” • Increase eye contact • Avoid long pauses before asking the next question. • Avoid sensitive topics to start. (lethality, substances sexual history)

33. 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.

34. 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.

35. SCREENING QUESTIONS

36. 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

37. 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.

38. Schizophrenia • Requires two symptoms for 1 month, plus 6 months of prodromal or residual symptoms • Delusions • Hallucinations • Speech disorganization • Behaviour disorganization • Negative Symptoms

39. 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

40. 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

41. 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)

42. Asking About MSE

43. 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?”

44. 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?

45. 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?

46. 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?

47. 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?”

48. 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?

49. Cognition • Attention: • World backwards • Days of week or Months of year backwards

50. References • Daniel Carlat – The Psychiatric Interview • Shawn Shea – Psychiatric Interviewing: The Art of Understanding