Essential Concepts
Occasionally, you run into the ideal patient. She’s troubled and eager to talk. She briefly outlines the problems that led to her visit and then answers each of your questions in full, stopping in preparation for your next query. You find that you’ve gathered all the vital information in 30 minutes, and you have the luxury of exploring her social and developmental history deeply. You feel like a real therapist. Your mind is whirring, and you can’t wait to dust off that copy of Freud you bought the day you got into your training program but haven’t had time to look at since.
Usually, however, your patient will fall somewhere on either side of a spectrum of information flow. Either he’s not saying enough or he’s saying too much, and it’s not his fault. The average patient has no way of knowing what information is and is not important for a psychiatric diagnosis. It’s up to you to educate the patient and to steer the interview appropriately.
You can use open-ended questions and commands to increase the flow of information. Open-ended questions can’t be answered with a simple “yes” or “no.”
What kinds of symptoms has your depression caused?
What sorts of things have you done when you felt manic?
Open-ended commands are questions altered slightly to sound more directive.
Tell me what kinds of symptoms you’ve had.
Describe for me some of the things you’ve done while you were manic.
CLINICAL VIGNETTE
The patient was a woman in her 30s who had been admitted to the hospital after an overdose. She was unhappy with the involuntary admission and initially resistant to answering questions.
Interviewer: I understand that you took an overdose of your medicine last week.
Patient: Uh huh.
Interviewer: What do you think was going on? (An open-ended question.)
Patient: I don’t know. (Which doesn’t get anywhere.)
Interviewer: Were you feeling depressed?
Patient: Maybe.
Interviewer: Tell me a little about how you were feeling. (An open-ended command.)
Patient: There’s not much to tell. I took the pills, that’s all. (Still no results.)
Interviewer: I really want to help you, but the only way I can do that is to understand what was going through your head when you took the pills. (Some education, combined with another, more specific, command.)
Patient: I guess I thought it would be a good idea to take ’em. My husband was driving me crazy. (Now we’re getting somewhere.)
Continuation techniques can be used to keep the flow coming. These expressions encourage a patient to continue revealing sensitive information:
They are often combined with facilitative body language, such as head nods, persistent eye contact, holding the chin between thumb and index finger, and facial emotional response to the material. Generally, the more spontaneous and genuine your responses to reluctant patients, the more likely you are to disarm them.
Some interviews begin badly and quickly deteriorate. For example, you may have had the experience of interviewing a patient who becomes increasingly alienated as your questions become more “psychiatric.” If this happens, try changing the subject to something nonpsychiatric, with the intention of sidling back into your territory once you’ve gained the patient’s trust.
I interviewed a college student who was referred by his dean for psychological evaluation after having said he would kill himself if he was not given a better grade in a course. He was an unwilling participant and had shown up only because he was threatened with suspension if he did not.
After the first 5 minutes of the interview, it was clear that he was not interested in talking about what was going through his mind, so I shifted to relatively neutral ground.
Interviewer: So how do you like college X?
Patient: It’s fine. There’s a good English department.
Interviewer: Really? Any particularly interesting classes?
Patient: King Lear and the Modern World.
Interviewer: It’s been a while since I read that. How is King Lear related to the modern world?
Patient: It’s all about money and power. Everyone sucks up to King Lear because he has all this land to give away. It’s the same way with lobbyists in Washington. Or professors at a university.
Interviewer: Is that the way it is at your college?
Patient: Of course. Professors sit in their offices, fat and happy, and students mean nothing to them. Unless they can get you to be their slave.
This led to a discussion of his frustrations with school, which in turn led to his revealing the extent of his depressive symptoms.
When all else fails, you may need to schedule a second interview. If you’re not getting anywhere with the patient, no matter how many interviewing tricks you use, you may need to cut the interview short with a comment such as
Why don’t we stop for now and meet again next week [or tomorrow, for inpatient work]. That will give you a chance to think more about the sorts of things that are bothering you, and we can take it from there.
I’ve done this several times, and the patient is usually more forthcoming at the next interview. I’m not sure why this works. Maybe giving the message that I accept their reluctance paradoxically encourages them to open up, or perhaps they feel awkward about not answering questions two interviews in a row.
Of course, before you end the interview, you must feel comfortable that the patient is not at imminent risk of suicide or other dangerous behaviors.