Essential Concepts
The therapeutic alliance is a feeling that you should create over the course of the diagnostic interview, a sense of rapport, trust, and warmth. Most research on the therapeutic alliance has been done in the context of psychotherapy, rather than the diagnostic interview. Jerome Frank, author of Persuasion and Healing (Frank and Frank 1991) and the father of the comparative study of psychotherapy, found that a therapeutic alliance is the most important ingredient in all effective psychotherapies. Creating rapport is truly an art and therefore difficult to teach, but here are some tips that should increase your success.
While there is much to be learned from books and research about how to be a good interviewer, you’ll never enjoy psychiatry very much unless you can find some way to inject your own personality and style into your work. If you can’t do this, you’ll always be working at odds with who you are, and this work will exhaust you.
CLINICAL VIGNETTE
My friend and colleague, Leo Shapiro, does both inpatient and outpatient work. He’s a character, no question about it. As a patient, you either love him or hate him, but either way, what you see is what you get.
Two examples of Dr. Shapiro’s unorthodox style:
1. Walking down the hallway of the inpatient unit, Dr. Shapiro spotted the patient he needed to interview next.
“Hey, what’s wrong, does your face hurt?”
Patient: “No, my face doesn’t hurt.”
Dr. Shapiro: “Well, it’s killing me!”
The patient chuckled, and the rapport was solidified.
2. The Shapiro thumb wrestling ploy
An angry, depressed man was demanding to be discharged, prematurely according to staff reports. Dr. Shapiro agreed that discharge would be risky, partly because the patient had developed little in the way of rapport with anyone.
Dr. Shapiro: “I understand you want to be discharged?”
Patient: “Of course, this place is stupid, no one’s helping me.”
Dr. Shapiro: “If you can beat me at thumb wrestling, I’ll let you leave.”
Patient: “What?!!!”
Dr. Shapiro (putting out his hand): “Seriously. Or are you afraid of the challenge?”
Patient (reluctantly joining hands with Shapiro): “This is crazy.”
Dr. Shapiro: “One, two, three, go”
Dr. Shapiro quickly wins, as he always does. “Well, I guess you have to stay another day. See you tomorrow.”
Patient (smiling, despite himself): “That’s it?”
Dr. Shapiro: “What? You wanna talk, OK, let’s talk.”
A significant exchange ensued, and the patient was in fact discharged that afternoon with appropriate follow-up.
No, I’m not endorsing the Shapiro technique. It works great for him, because that’s his personality, but it would be a disaster for me, a mellow Californian at heart. The key is to be able to adapt your own personality to the task at hand—helping patients feel better.
Are there any specific interviewing techniques that lead to good rapport? Surprisingly, the answer appears to be “no,” and that is good news. A group of researchers from London have studied this question in depth and published their results in seven papers in the British Journal of Psychiatry (Cox et al. 1981a,b; 1988). Their bottom line was that several interviewing styles were equally effective in eliciting emotions. As long as the trainees whom they observed behaved with a basic sense of warmth, courtesy, and sensitivity, it didn’t particularly matter which techniques they used; all techniques worked well.
No book can teach you warmth, courtesy, or sensitivity. These are attributes that you probably already have if you are in one of the helping professions. Just be sure to consciously activate these qualities during your initial interview.
There are, however, some specific rapport-building techniques that you should be aware of:
What do you do if you don’t like your patient? Certainly, some patients immediately seem unlikeable, perhaps because of their anger, passivity, or dependence. If you are bothered by such qualities, it’s often helpful to see them as expressions of psychopathology and awaken your compassion for the patient on that basis. It may also be that your negative feelings are expressions of countertransference, which is discussed in Chapter 13.
It’s easy to lose sight of the fact that an hour-long psychiatric interview is a strange and anxiety-provoking experience. Your patient is expected to reveal his or her deepest and most shameful secrets to a perfect stranger. There are several ways to quickly defuse that strangeness.
Hi, I’m Dr. Carlat. Nice to meet you. I hope you were able to make your way through the maze of the hospital without too much trouble.
Ask the patient what he wants to be called, and make sure to use that name a few times during the interview.
Do you prefer that I call you Mr. Whalen, or Michael, or something else?
Using the patient’s name, especially the first name, is a great way of increasing a sense of familiarity.
Caveat: Some patients (as well as some clinicians) view small talk as unprofessional. I try to size up my patient visually before deciding how to greet him or her. For example, small talk is rarely appropriate for patients who are in obvious emotional pain or for grossly psychotic patients, particularly if they are paranoid.
Before we get into the issues that brought you here, I’d like to know a little bit about you as a person—where you live, what you do, that sort of thing.
Learning a bit about your patient’s demographics at the outset has the added advantage of helping you start your diagnostic hypothesizing. There’s a reason why the standard opening line of a written or oral case presentation is a description of demographics: “This is a 75-year-old white widower who is a retired police officer and lives alone in a small apartment downtown.” You can already begin to make diagnostic hypotheses: “He’s a widower and thus at high risk for depression. He’s elderly, so at higher risk for dementia. He apparently had a career as a police officer, so probably is not schizophrenic,” and so on. Knowing basic demographics at the outset doesn’t excuse you from asking all the questions required for a diagnostic evaluation, but it certainly helps set priorities in the direction of inquiry.
It may be embarrassing for you to reveal all these things to a stranger. Who knows how I’d react? In fact, I’m here to understand you and to help you.
CLINICAL VIGNETTE
Paranoid patients often project malevolent intentions onto the interviewer. In this example, the interviewer addresses these projections directly:
I: Are you concerned about why I’m asking all these questions?
P: Sure. You’ve got to wonder—What’s in it for you? How are you going to use all this information?
I:I’m going to use it to understand you better and to help you. It won’t go any further than this room.
P: (Smirking) I’ve heard that before.
I:Did someone turn it against you?
P: You bet.
I:Then I can understand that you’d be careful about talking to me—you probably think I’d do the same thing.
P: You never know.
With the distrust issue brought out into the open, the patient was more forthcoming throughout the rest of the interview.
In one study of physicians, patients were allowed to complete their opening statements of concern in only 23% of cases (Beckman and Franckel 1984). An average of 18 seconds elapsed before these patients were interrupted. The consequence of this highly controlling interviewing style is that important clinical information may never make it out of the patient’s mouth (Platt and McMath 1979).
You should allow your patients about 5 minutes of “free speech” (Morrison 2014) before you ask specific questions. This accomplishes two goals: First, it gives your patient the sense that you are interested in listening, thereby establishing rapport, and second, it increases the likelihood that you will understand the issues that are most troubling to the patient and thereby make a correct diagnosis. Shea (1998) has called this initial listening phase the “scouting period,” because you can use it to scout for clues to psychopathology that you will want to follow up on later in the interview. It has also been called the “warm-up” period by Othmer and Othmer (2001), because one of its purposes is to create a comfort level between you and the patient so that the patient is not put off by the large number of diagnostic questions to come.
Of course, you have to be flexible. Some patients begin in such a vague or disorganized fashion that you will have to ask your questions right away, whereas others are so articulate that if you let them talk for 10 or 20 minutes, they will tell you almost everything you need to know.
Each clinician develops his or her own first question, but all first questions should be open-ended and should invite the patient’s story. Here are several examples of first questions:
A somewhat different way of approaching the first question is to view it as a way of immediately exploring what that patient’s goals are for the interview. Called “solution-focused interviewing,” this approach is recommended by Chang and Nylund (2013).
Rather than asking “What brings you in?” or “What troubles you?” he recommends “What would make this a helpful visit?” “What would you like to see different from coming here?” This approach may work out particularly well with reluctant patients, who may not believe they have any problems in the first place.
A related question type is “the Miracle question,” which goes like this: “Imagine that tonight you go to bed, like you normally do. Then, imagine that while you’re asleep…. [pause)] …a miracle happens. Imagine that because of this miracle, your depression [or whatever the patient’s problem is] goes away. What will your day be like tomorrow?”
Patient: “Well, I guess I would wake up, and rather than sleep in, I’d wake up on time and get ready instead of procrastinating. Then I’d eat breakfast rather than skipping it, and at breakfast, we’d all get along better without fighting. Then I’d go to work, and I’d have more confidence, so I would say ‘no’ to people if they ask me to do too much….”
This is always a tricky issue for novice interviewers, who often feel anything but competent. In fact, your patient usually gives you the benefit of the doubt here, because of something called “ascribed” competence. This is the competence your patient attributes to you purely because of your institutional ties. You work for Hospital X or University Y, so you must be competent. Ascribed confidence will get you through the first several minutes of the interview, but after that, you have to earn your patient’s respect.
Gaining a patient’s trust is easier than you might think. Even as a novice, you know much more about mental illness than your patient, and this knowledge is communicated by the kinds of questions you ask. For example, your patient tells you she is depressed. You immediately ask questions about sleep and appetite. Most patients will be impressed by your ability to elicit relevant data in this way.
Other, more prosaic ways of projecting competence include dressing professionally and adopting a general attitude of confidence. At the end of the interview, your ability to provide meaningful feedback will further cement your patient’s respect.