The first interview
Chapter 2
Chief complaint and free speech

The chief complaint states the patient’s reasons for seeking care. The free speech encourages the patient to talk about all these reasons.

Directive versus nondirective questions

A directive interviewer explicitly provides the structure that tells the patient what sort of information is wanted. A nondirective interviewer absorbs whatever information the patient chooses to present. This usually yields strong rapport and reliable facts. An exclusively nondirective style produces less information.

A maximally effective initial interview will use both nondirective and directive questions.

Most of the early portion of your interview should be nondirective. This helps to establish a working relationship and to learn what sort of problems and feeling are uppermost in your patient’s mind.

Your opening request for information should clearly state what you expect of your patient.

The opening question

When you ask your first question, be specific. Let your patient know exactly what you want to hear about. The request can have two qualities that affect the type of information you will obtain: it tells the patient what sort of information you seek and it is open-ended. Broaden the scope of information that you might obtain, with more freedom to respond.

Open-ended questions and statements can serve two functions: 1) some request more information about a point 2) Move the story toward the present.

Close questions more narrowly direct the sort of answer desired in a few words. They are sometimes necessary to obtain the most information in the least time.

Early in the interview, open-ended questions are better to encourage patients to tell a story that touches on as many aspects of the case history as are relevant.

The chief complaint

The chief complaint is the patient’s stated reason for seeking help.

Importance

The chief complaint is important for either of two reasons: 1) It is usually the problem uppermost in the patient’s mind, it tells you what area you should explore first. 2) by contrast, sometimes the chief complaint is a flat denial that anything is wrong. If this is the case, it tips you off about your patient’s insight, intelligence, or cooperation.

Responding

Some chief complaints suggest that your patient doesn’t understand the purpose of the interview. If you encounter this, you should be prepared with some good responses.

Try to learn the real reason for coming

A patient’s first words don’t always express the real reason for seeking help. Some patients don’t recognize the real reason, others may feel ashamed or fearful. In either case, the stated chief complaint may be only a ‘ticked of admission’ to help a clinician can provide.

Some complaints mask a deeper, les obvious reasons for seeking help.

Regardless of what chief complaint is presented, you should write it down in the patient’s exact words. Later, you will want to contrast it with what you believe prompted the patient to seek help.

Free speech

During the few minutes following the chief complaint, you patient should have the chance to discuss freely the reasons for seeking treatment. To encourage the widest range of information, allow the story to emerge with little detailed probing or other interruption.

What is free speech?

Reasons for free speech are: 1) it establishes you as someone who cares enough to listen to your patient’s concerns 2)  it provides the patient an opportunity to organize and explore the reasons for seeking treatment 3) you have the opportunity to learn what is uppermost in your patient’s mind 4) it gives you the flavour of the patient’s personality 5) unhampered by any need to direct the conversation, you can start making observations about mood, behaviour and thought processes 6) character traits may be more likely to emerge in a person who is speaking spontaneously 7) when you share control, you establish early the expectation that your patient will be an active partner throughout therapy 8) you can devote close attention to the content of your patient’s speech 9) it provides your patient an opportunity to bring up other concerns that weren’t mentioned in the chief complaint.

Most patients will respond quickly and appropriately to your request that they talk about their problems. For others, this might not be the case. You may have to teach them to give you an expanded version of their feelings and experiences. If the patient persistently makes brief statements, you should explicitly state what you expect.

Areas of clinical interest

During free speech, the patient will probably mention one or more problems.

When people become mental health patients, it is usually because of problems covered by seven areas: 1) cognitive disorders (difficulty thinking) 2) substance use 3) psychosis 4) mood disturbance 5) anxiety, avoidance behaviour and arousal 6) physical complaints 7) social and personality problems.

During free speech, make a note about any subject that seems worth exploring later.

Signalling areas of clinical interest

A number of symptoms and items of historical information specific to each area signal the need for further exploration.

How much time?

The chief complaint usually takes only a few seconds. The time you devote to free speech can vary tremendously. Your allotment to free speech will depend on the total time you can spend interviewing and on what you already know about the history. You should allow the patient to speak freely as long as the information you obtain seems important.

Moving on

The free-speech portion of the interview will draw to a close as you sense that you have obtained a broad outline of the problems that are uppermost in your patient’s mind. Before moving on, you should ask whether there are problems other than those already mentioned. You can also check your understanding of all problems.