Essential Concepts
Interviewing a patient’s informants—that is, their family members, friends, coworkers, etc.—is such a crucial part of many psychiatric evaluations that some clinicians will not see patients unless they agree to an informant meeting at some point during the treatment. In my experience, it is not always necessary, but when I have bothered to make it happen, it has always added something of value to my understanding of patients.
Before getting into specific suggestions, I have found it useful to think about the following three goals for interacting with family members and other informants:
1. Let the family know they are not alone.
2. Provide support and allow informants to vent.
3. Instill hope for change (adapted from Mueser and Glynn 1999).
I usually ask something like:
“As part of my evaluation of patients, I find it helpful to talk to someone else involved in your life. Would that be okay with you?”
Most patients will agree to this and will typically be impressed that you care enough to go that extra mile in conducting your evaluation. Assuming they agree, you should figure out who would be the best person to talk to—a parent, a significant other, a roommate, a friend, etc.
Sometimes patients will decline having an informant become part of the treatment, which is certainly their right. But it’s helpful to find out the root of their discomfort. At times, it may be that there is something they want to hide from you, such as drug use or other behaviors at odds with their recovery. But other times, the reasons are understandable.
CLINICAL VIGNETTE
I had seen a man in his 30s for a couple of years for depression, which had gradually improved with treatment, but he continued to complain of not feeling very fulfilled with his life, and he qualified for the diagnosis of dysthymia. He acknowledged that one of the major issues in his life was the fact that his wife wanted to have more children but he didn’t. Several times, I had encouraged him to bring his wife into a meeting—not for couples therapy, but in order to better understand the nature of their relationship so that I could help him in therapy. He eventually said that she would be able to attend our next session. But he came alone.
“Where’s your wife?” I asked, surprised.
“I thought a lot about it, and I agreed that it might be helpful for her to come in to the session. But then I realized that this is my time with you.”
Ultimately, my ready acceptance of his decision strengthened our alliance and improved the quality of our therapy.
Your patient has shown up with his mother as you requested. What kinds of questions are you going to ask? You may feel that the pressure is on, since this may be the only time you will have to interview the informant. Therefore, it’s best to be ready with a list of questions.
As with interviewing patients, when interviewing families, you’ll want to start with an open-ended approach and then drill down to specific questions.
I’ll often start by asking, “How do you think Nancy has been doing?” Some informants will arrive brimming with a wealth of specific and useful information, but others might answer more sparsely, with something like, “She’s been okay. Sometimes she gets nerved up, but then she takes her happy pills and seems better.”
In this case, the informant is not speaking your clinical language and needs education about the specific kind of information you are looking for.
Murray-Swank et al. recommend the following series of questions for informant interviews:
1. “What do you think has caused [name] to have these problems?”
2. “Has anybody ever given you a diagnosis for his/her problems?” (If they have been told of a diagnosis, it is useful to follow up with a question such as “What is your understanding of what that diagnosis means?”)
3. “Are there things that make things better for [name]?”
4. “Are there things that make things worse?”
These kinds of questions allow you to teach the informant the kind of vocabulary that you will find most useful in tracking your patient’s progress.
Going back to our case of nerved-up Nancy, you might say, “I think when you said that Nancy gets ‘nerved up,’ she is having what we think of as a panic attack, and that the ‘happy pill’ is Ativan, an anxiety medicine that helps her get over her panic problem.” This type of psychoeducation may ultimately help your patient understand when to use her medication appropriately because it puts her and her informant on the same page.
Specific pieces of information that you might want to obtain (depending on the specific problem) include the following:
Another way to help you organize your questioning is to try to ascertain the typical day in the life of your patient.
“Mrs. Smith, when I see your husband, it is only for about a half hour every month or so—I see only a tiny slice of his life. I’d like to know more. Beginning with when he wakes up in the morning, what is a typical day like in your husband’s life?”
Sometimes, when a family member pops in, they are doing so because they are not particularly happy with how the patient is doing and they may be wondering if you are competent. If I sense this is true, I will meet the issue head-on.
“How do you think I’ve been doing with Nancy? Do you think I’ve been helping her at all? Am I the best doctor for her? Do you have any ideas for how I might be able to help her more?”
Obviously, you are not necessarily asking for a medication consultation from a layperson, but you’d be surprised what comes out. In one situation, I had treated a woman with a series of antidepressants. She was currently on Celexa, and I thought she was doing reasonably well on it. When her husband came to a session, it was clear that he was dissatisfied with her treatment.
“I don’t think she’s doing very well on this medicine,” he said. “My sister is taking Paxil and she’s doing great.”
I had no problem with Paxil—to me, it was just one of a dozen or so equally effective antidepressants, but psychologically, it appeared to be what both the husband and my patient wanted, so I prescribed it, and the patient did well—no doubt with a large placebo component at play.
Occasionally, a patient will tell me that a family member disapproves of medication treatment. If I believe that the medication is effective and necessary, I will strongly encourage an informant meeting. Sometimes, I will simply pick up the phone then and there, with the patient’s permission.
At times, the informant is responding to sensationalized media reports of the dangers of psychiatric drugs, and a short meeting will help set his or her mind at ease. Other times, the informant is adamant that medications are the wrong approach, and if I feel that the patient is stable and might do well with a trial off meds, I’ll readily agree to a gradual taper. In my experience, in the majority of such cases, both the patient and the informant return to my office within several months to request a medication resumption—but that is not always the case.
Sometimes, it may seem that an informant is “antimed,” when in fact he or she is anti-ineffective med.
For example, one patient with bipolar disorder had literally been on every psychiatric medication that I knew of over the course of his life—I was the latest in a long line of psychiatrists. The mother, supposedly antimedication, came in and said, “I’m tired of Jack being a guinea pig. You doctors keep putting him on all these medications, and I think they make him really tired.”
I asked her if any medication had worked for him. “The only medication that really works for him is lithium.” Paradoxically, I had discontinued lithium several months earlier. So the informant who was billed as “antimed” ended up convincing me to put the patient back on a medication with a pretty hefty side effect burden, but it ended up being relatively effective.
In my experience, informants frequently come into a meeting with one or more of the following underlying thoughts and worries.
There’s no specific answer to each of these concerns, but it’s helpful to review this list before you meet with an informant. During your conversation, you may well pick up on one of these possible concerns and then you can address it.
The Health Insurance Portability and Accountability Act (HIPAA) actually gives you more, not less, latitude in sharing patient information with other health care providers. Once your patient signs a HIPAA form, you are allowed to talk to therapists or other doctors without getting specific permission each time. However, HIPAA does not allow you to talk to family members without consent. The exception is when the patient’s life is in danger.
What happens when a family member calls you? Can you talk to them? Yes, you can, as long as you are a recipient of information only. But they often have the misconception that they can’t talk to you at all without a signed release. When an informant calls, I say, “I can listen to anything you have to say, but I won’t be able to share anything your wife has told me without her consent.”
I try to get the informant’s agreement that I can tell the patient about the phone call and about the information I received. Sometimes, the informant is scared of the patient’s possible reactions. A typical scenario is a wife calling about a husband who I am treating individually. The wife tells me that her husband had been drinking more and becoming verbally abusive. She may be terrified that if I share this phone call with the husband, he will become more abusive toward her. Obviously, if you believe that the informant is in imminent danger from your patient, you are duty bound to intervene, regardless of consent forms. But in most cases, these are judgment calls. If I feel that the information is so crucial that it will affect treatment (such as the revelation that a patient is a drug abuser), I may sometimes insist that the informant agrees to be named, because in my experience the patient figures out where I got the information pretty quickly.
Dealing with informants when you are doing inpatient work carries its own challenges and therefore merits a separate section of this chapter. Here is a typical inpatient informant scenario:
It’s 10 a.m., and you have been scurrying around the unit trying to get your work done quickly, because you have to be at the outpatient clinic by 1 p.m. You look at your index card, and there are eight patients on your list. You have to talk with each one, meet with nurses and social workers, and write a note.
Robert Jones is next. A 23-year-old, he was admitted to the hospital 3 days ago after an apparent suicide attempt by overdose. But after having evaluated him, you feel certain that he is not truly suicidal. You found out that his “overdose” was on fifteen 1-mg pills of Klonopin—hardly enough to do much damage, especially considering that his normal prescription was 3 mg per day. The “overdose” came immediately after a telephone call with his ex-girlfriend during which she refused to consider renewing their relationship. Distraught, he took the pills and then immediately called both his father and 911. Within 10 minutes, he was in the local emergency room, from where he was admitted to the psychiatric unit. Over the course of the past 3 days, you and the rest of your team have determined that he was not suicidal and developed an outpatient treatment plan involving a referral to a local clinic that better integrates psychotherapy and psychopharmacological treatment.
Today, you walk into his room to say your goodbyes and to make sure that he understands his discharge plan. But you are surprised to see three people in the room, who turn out to be his two parents and his sister. The first question from the father is, “Are you really discharging him? After only 3 days? He just tried to kill himself!”
What do you do? A long meeting will throw your schedule off—but clearly, the family deserves to have some significant contact with their loved one’s psychiatrist. Although from your perspective, this patient is one of a long list of people you must help, for the family there is only one person on their list—their loved one. Empathizing with the family will go a long way toward helping you do the right thing.
The wrong way to respond would be: “I’m sorry, but I don’t have time for a meeting right now—but I can set up a time for you to speak with the social worker or one of the nurses.” To the family, the underlying message is, “I don’t really care,” or “I don’t have time for you,” or “Your loved one’s issues are not important enough to require my time.”
Instead, no matter how hurried you feel, take a deep breath, smile, and say, “I’m really glad we are having a chance to meet.” Make sure to find a place to sit down, because nothing says “rushed” more than a meeting while standing. Next, explain your time constraints apologetically. “I wish we had a good hour to talk about Robert, but today unfortunately, I can only meet for about 10 minutes. I’m really sorry about this, but I also think we can get a lot done to help you understand what’s going on with Robert in those 10 minutes. And if you have any other questions, I’ll arrange for you to meet with our social worker.”
What are you realistically going to be able to accomplish in those measly 10 minutes? Primarily, you are going to be educating the family about the purposes and the limitations of inpatient psychiatric treatment. Families often think that psychiatric hospitalizations are meant to provide a definitive “answer” to a problem that has been going on for years. They may expect that you will come up with the perfect medication and that you will fix a wide range of problems, such as family dynamics issues, work problems, social problems, or school problems. If so, they need you to educate them about the realities of inpatient admissions:
“In the past, hospitalizations went on for a long time, sometimes many months. But these days, they are brief, and our goal is to solve the immediate crisis and to make sure patients are safe before they leave. We also work hard on setting up a good outpatient program, because that is where the work of healing takes place—over the long term, out in the real world.”
Some clinicians will also mention that ever-present big white elephant in the room—the insurance company: “Unfortunately, insurance companies will no longer pay for admissions longer than a few days, unless the patient will be clearly unsafe if discharged.”
This is a card you don’t want to play too much, however, because the family may get the message that you are discharging the patient prematurely because you are not getting paid.
Psychoeducation is a two-way street. What kinds of questions are most crucial for you to ask of family during an inpatient admission? Well, since this is a major crisis, you’ll want to focus on immediate triggers and safety concerns.
“It’s important that I understand the events leading up to Suzie’s admission here. I’d really like to hear your perspective on how things have been going.”
Often, the family will give you a very different account from the impression you may have received from interviewing the patient.
CLINICAL VIGNETTE
A 50-year-old woman was admitted after having walked into the emergency room saying that she wanted to die. She said she believed her husband didn’t love her anymore and suspected he was seeing another woman. The psychiatrist held a meeting with the husband and the patient’s grown daughter the next morning.
Interviewer: Vicki tells me she’s been concerned about your relationship.
Husband: (Looking confused). What do you mean “concerned”?
Interviewer: She told me that you have been distant, spending nights out, and maybe seeing someone else.
The husband and the daughter looked bewildered and shook their heads.
Husband: I haven’t gone out at night without Vicki since last winter, when I went to a work Christmas party that she didn’t want to go to. We’re basically joined at the hip.
Interviewer: So what had been happening in the few days before she came to the ER?
Daughter: Mom has been saying strange things. She’s been worried about everything. We went to the mall together and she wouldn’t go into any of the stores. She said they were dangerous and that there was a “code orange” and there might be terrorists planting bombs in the store.
On further evaluation, it turned out that the patient was suffering a psychotic depression with the paranoid delusion that her husband had been sleeping with a terrorist.
In sum, whether you are evaluating patients in an office setting or in the hospital, do not neglect one of your most valuable resources—the people who know your patients the best.