Book summary - The First Interview - 4th edition - Morrison (2014)

Chapter 0: What is this book about?

James Morrison is Affiliate Professor of Psychiatry at Oregon Health and Science University in Portland. He has extensive experience and has written several books related to the psychodiagnostics process. 'The First Interview' provides a manual on interviewing mental health patients based on objective research and best-practice principles. In his book, Morrison dives into the topics of interviewing in general (chapter 1), free speech (chapter 2), the development of rapport (chapter 3) and how to manage the patient interview (chapter 4). He discusses how to interview a client about the history of the present illness (chapter 5), how to inquire about the current situation (chapter 6), and how to integrate information about feelings (chapter 7). The personal and social history of the client (chapter 8), encountering sensitive subjects (chapter 9) and controlling the later interview (chapter 10) are also topics that are discussed. Morrison talks about how to perform a mental status exam (chapter 11 and 12), and the signs and symptoms of several clinical diagnoses (chapter 13). The book also integrates the topics of closure (chapter 14), interviewing informants (chapter 15), what to do in case of resistance (chapter 16) and what challenging patient behaviors the interviewer can encounter (chapter 17). The process of diagnosing (chapter 18) and sharing these findings with the patient (chapter 19) and others (chapter 20) are also discussed. Lastly, Morrison talks about how to critically evaluate the interview (chapter 21).

Chapter 1: How do you open an interview?

What is the goal of this book about interviewing?

By the time you have completed an initial interview, you should have obtained information from your patient and established the basis for a good working relationship. The information includes various types of history and a mental status examination.

• The history includes a detailed account that includes current symptoms, previous illnesses, medications, family and social relationships, health risk issues-in short, everything that bears on your patient's life and mental health problems.
• A mental status examination, or MSE, is an evaluation of your patient's current thinking and behavior.

In the course of this book, each section of the history and MSE will be discussed, in more or less the chronological order you would use when talking with a patient. In separate chapters, the content of the information you should expect to obtain and the interview techniques that are most appropriate to that content will be discussed. Where it seems appropriate, issues of rapport will also be discussed.  

What time factors play a role in an interview?

In the first few moments of an initial interview, you will need to accomplish several tasks:

• You should indicate what form your interview will take-how much time it will take, what sort of questions you will ask, and the like.
• You should convey some idea about the sort of information you expect your patient (or other informant) to give you.
• You must create a comfortable and secure environment that will allow your patient as much control as possible, under the circumstances.  

Regardless of your level of experience, your emphasis should be on collecting the most information possible early in the relationship before you can become too committed to a diagnosis. Even a seasoned interviewer occasionally requires more than one session for an initial evaluation, and anyone needs more time for a patient who is unusually talkative, vague, hostile, suspicious, or hard to understand, or for one who has a complicated story to tell. Some patients simply cannot tolerate a lengthy interview, and even those who are hospitalized may have other appointments to keep. Multiple interviews also give a patient time to reflect and to recall material that might have been initially omitted. Of course, if you interview relatives or other informants, you will need additional sessions, plus time to integrate the information from all of your sources. With the rush of modern health care, time available is constantly shrinking.

How should you divide the time within the interview process?

Morrison expresses percentages the amounts of time you should plan to devote to the various portions of an average initial interview:

• In 15% of the time, determine the chief complaint and encourage free speech.
• For 30% of the time, pursue specific diagnoses.
• 15% of the time should be allocated to obtaining the medical history.
• In 25% of the time, obtain rest of personal and social history; evaluate character pathology.
• In 10% of the time, conduct a MSE.
• Allocate 5% of the time to discussing the diagnosis and treatment with patient; and plan the next meeting.

How can the proposed time allocation become a bit different?

Your own professional needs may change the focus somewhat. For example, social workers may spend additional time on the personal and social history. Regardless of your profession, Morrison recommends that you try to get the whole story early in the relationship with your patient. After the first few sessions, even experienced clinicians sometimes assume that they know a patient well and ignore certain vital information. Of course, just as no one has unlimited time, no evaluation can ever be considered complete. But if you have done your job well in the beginning, these will largely be matters of corroborative detail that won't substantially affect diagnosis or may have escaped Many patients seek help for serious problems that they find frightening or overwhelming. You should elicit their stories in such a way that they feel they have received a complete, fair, professional evaluation. If your patient is unusually dramatic, slow, or discursive, try to understand this behavior in the light of the stresses and anxi- eties anyone might face, and allow additional time.

How do you start an interview?

The first moments any professional person spends with a new patient set the tone for all subsequent interactions. Careful attention to such simple matters as introductions and the patient's comfort and sense of control helps establish a relationship grounded in respect and cooperation. Fortunately, the effectiveness of the interview is not related to the elegance of the surroundings. Though a measure of privacy will yield the most information. What is paramount is your concern for the patient's comfort and privacy. It does not allow leeway to give more space to the suspicious patient or to draw nearer someone whose depression requires the close comfort of another human being. Try instead to arrange your chairs so you can face the patient across the corner of a desk or table.

How do you begin the relationship with your client?

At the start of the interview, it is important to introduce yourself and indicate the seating arrangement you prefer. Often, you will already know something about the patient from case notes of previous workers, a hospital chart or a referral. You can save time and increase the accuracy of your assessment by reviewing this material before you begin. Some interviewing try to ease into a relationship with small talk, but Morrison advices against it. Small talk may come across as a distraction or an expression of unconcern on your part, and it is better to go right into the heart of the matter. 

Can you take notes during an interview?

Few of us can remember even briefly all the material we hear, and you may not have the opportunity to write up your interview right away. Point out to your patients that you will be taking notes and make sure this is okay with them. Nonetheless, you should try to keep note taking to a minimum. This allows you to spend more time observing your patient's behavior and facial expressions for clues to feelings. A tip is to only write down key words. 

Chapter 2: How does the topic of free speech play a role in a clinical interview?

What is the difference between directive and non-directive questions?

By asking many specific questions, a directive interviewer explicitly provides the structure that tells the patient what sort of information is wanted. The non-directive interviewer more passively absorbs whatever information the aptient chooses to present. A non-directe style usually yields strong rapport and reliable facts. However, an exclusively non-directive style also produces less information. A maximally effective initial interview uses both non-directive and directive questions. Most of the early portion of the interview should be non-directive. This helps establishing a working relationship and learn what sorts of problems and feelings are uppermost in your patient's mind.

What is a good opening question for an interview?

When you ask your first question, you should be specific. The patient must know exactly what you want to hear about. A good opening question for a clinical interview is: "Please tell me what problems made you come for treatment". For most patients, this will serve very well. Open-ended requests can broaden the scope of information that you obtain; with more freedom to respond, patients tell you what's important to them. Open-ended questions let patients know that their stories matter to you. They also allow you to spend less time talking and more time observing. Closed-ended questions more narrowly direct the sort of answer desired and can be answer din a few words. They are also useful as they are necessary to obtain the most information in the least time. But in early parts of the interview, you should use open-ended questions that will encourage your patient to tell a story that touches on as many aspects of the case history as are relevant.

What is the chief complaint and how can an interviewer unravel it?

The chief complaint is the patient's stated reason for seeking help. It is usually the first full sentence or two of the reply to your opening question; "Tell me about the problem that brought you here". The chief complaint is important for either of two reasons:

• It is usually the problem uppermost in the patient's mind, it suggests an area to explore first. Most patients have some sort of specific problem or request. It expresses some discomfort, life problem, or fear that the patient wants help with.
• By contrast, sometimes the chief complaint is a flat denial that anything is wrong. When this is the case, it tips you off about your patient's insight, intelligence or cooperation. 

Some chief complaints suggest that your patients does not quite understand the purpose of the interview. You will sometimes encounter this sort of vague or slightly quarrelsome chief complaint. A patient's first words also do not always express the real reason for seeking help. Some patients do not recognise the real reason, others may feel ashamed or fearful of what they will be told. In either case, the stated chief complaint may be only a 'ticket of admission' to the help a clinician can provide. Often, as an interviewer, you can ferret out the real problem later in the interview by asking: "Is anything else bothering you?" Sometimes you might determine your patient's underlying motivation only after you think you have completed your initial evaluation. Regardless of what chief complaint is presented, you should write it down in your patient's exact words. Later, you will want to contrast it with what you believe prompted the patient to seek help.

What is the role of free speech in an initial clinical interview?

During the few minutes following the chief complaint, your patient should have the chance to discuss freely the reasons for seeking treatment. To encourage the widest possible range of information, allow the story to emerge with little detailed probing or other interruption from you. We call this non-directed flow of information free speech, to distinguish it from the relatively constrained question-and-answer format of the later clinical interview. Free speech, simply put, is just an opportunity for patients to express their thoughts without constraint or direction. Some clinicians also refer to it as 'speech with a minimum of structuring'. Experienced interviewers recommend this period of free speech for several reasons:

• It establishes you as someone who cares enough to listen to your patient's concerns.
• It provides the patient an opportunity to organise and explore the reasons for seeking treatment.
• You have the opportunity to learn what is uppermost in your patient's mind. 
• It gives you the flavour of the patient's personality. 
• Unhampered by any need to direct the conversation, you can start making observations about mood, behavior, and thought processes.
• Character traits may be more likely to emerge in a person who is speaking spontaneously than in one who is answering a stream of questions.

Most patients will respond quickly and appropriately to your request that they talk about their problems. The opposite may be true of others. Allowing patients time to speak freely is very important.

What are areas of clinical interest?

During free speech, your patient will probably mention one or more problems. These concerns can be emotional, physical, or social. Most will fall into one of several major areas of clinical interest: difficulty thinking, substance use, psychosis, mood disturbance, excessive anxiety, physical complaints or social/personality problems. Each area of clinical interest comprises a number of diagnoses that have symptoms in common. A number of symptoms and items of historical information specific to each area of clinical interest signal the need for further exploration. When you encounter one in your interview, consider an intensive review of that area. 

How much time should be devoted to the chief complaint and free speech?

Unless your patient's speech is unusually vague or rambling, the chief complaint usually takes only a few seconds. However, the time you devote to free speech can vary tremendously. As a rule, you should allow your patient to speak freely as long as the information you obtain seems important and relevant. 

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 proceeding to the next section of your interview, you should ask whether there are problems other than those already mentioned. This decreases the risk that you will overlook vital problem areas. This is also a good time to check on your understanding of all problems. Briefly summarise each, and invite your patient's assessment of your analysis.

Chapter 3: How do you develop rapport during a clinical interview?

What is rapport?

Rapport is the feeling of harmony and confidence that should exist between patient and clinician. As one of the goal of a good interview, good rapport has practical consequences. This point is especially relevant if you will be treating this patient in the future. The trust and confidence you begin to develop even in the opening minutes of the first session can greatly enhance your ability to manage a course of therapy. In fact, how well you convey your interest is the factor most likely to keep your patient in treatment. The foundation for rapport is usually ready-made. Most patients come looking for help and expect that they will get if from a clinician. You can build on this expectation with your words and body language, which should express real interest in the patient. 

What is the basis for rapport?

Right from the start, most patients will expect to like you. But rel rapport between two individuals does not usually spring up overnight. It develops gradually, with long acquaintance and the cooperation of both parties. Your demeaned is key. Remember that professionalism dos not demand stiff formality. In fact, you should take care to avoid the image of the stone-faced therapist that was once popular in movies and fiction. As an interviewer, you should appear relaxed, interested and sympathetic. 

At first, using praise as a reinforcer can powerfully shape behavior, but early in any relationship, you do not know enough to be sure what behavior you will be reinforcing. For instance, you do not want to praise apparent openness if your patient has not told you the whole truth. The patient's own demeaned shapes your interaction with him or her more than any other factor. Body language often clearly indicates how your patient feels. You should carefully maintain a certain neutrality toward what you are told. A safe response is an empathic comment that does not take sides. Your attitude as an interviewer should be sympathetic, nonjudgmental, and respectful of the patient and relatives. These things are likely to foster a good working relationship.

How do you assess feelings as an interviewer?

How you feel about the patient can have important consequences. If your feelings are positive, you will probably come across as warm and caring. Your attitude may serve as an encouragement to reveal additional sensitive information. Heavily influenced by your won background and upbringing, your feeling could in turn affect your ability to make an accurate evaluation. Therefore, you need to be aware of the nature and the sources of your feelings. Your goal is to express empathy, which means that on some level you can feel as your patient feels. Having empathy means understanding the motivation driving a patient's behavior, even if it still does not seem like the right thing to do. Showing your empathy sparks confidence in the process and encourages the patient to give you the diagnostic information you need. 

All professionals have feelings, attitudes and experiences that can affect the image they project. We must all be constantly alert to prevent these personal issues from impairing our effectiveness with patients. Many beginning interviewers have learned that they can alleviate pressure if they introduce themselves to patients as students. But regardless of your stage of training or practice, your temperament and experience wil determine how you deal with your personal Achilles' heel. Whatever it is, your effectiveness with patients will increase if ou remain aware of you own limitations. 

How should interviewers consider their manner of speaking?

For good rapport, the patient must know that you understand. You can suggest your compassion and interest by making comments like "you must have felt terribly unhappy", "I have never been in that position, so I can only imagine how you felt", or "that was a terrible experience. I can see that it upset you a great deal". Sometimes you may find that you need to overemphasize your feelings a little. This suggestion might sound deceitful, but it is about amplifying your own emotional output to impress upon some patients how deeply to sympathise with them. You can accomplish this with your facial expressions, or with your voice by varying its volume, pitch and emphasis. However, it is far too easy to go overboard, so be careful not to portray your patient as a victim, for example. You should avoid psychological jargon. 

How can humor play a role in your interaction with a patient?

Humor can be a great facilitator of communication: It helps people to relax and to feel that they are among friendly people. As a clinician, you should take care to judge your use of humor carefully. With any recent acquaintance, it is easy to misjudge and say something in jest that can be taken amiss. In general, it is safe to laugh with, but of course never at, the patient. That means that you should generally let the patient start it. 

How do interviewers professionally maintain boundaries?

How clinicians relate eto their patients has been a moving target over the years. Clinicians should maintain boundaries in their interaction with their client. In general, it is a good idea not to reveal too much about yourself to your patients. However, if you are having difficulty getting information, you might be able to encourage greater cooperation by identifying something that you and the patient share. Some requests for personal information from the client may be prompted by a largely unconscious desire to achieve a sense of equality between interviewer and patient. Others may be an attempt to avoid discussing sensitive material and these should be handled firmly but with tact. 

How should interviewers show their expertise to their client?

You can pave another pathway to rapport by informing the patient that you know something about the presenting symptoms and what they could mean. A natural consequence of empathy is respect,t which implies that you should take pains to avoid sounding authoritarian. Inevitably, you will encounter an occasional patient you just cannot work with. Such patients will probably be few, but you have a duty to face them honestly. Of course, to be sure your first impressions are correct, you should complete the evaluation before deciding. 

Chapter 4: How do you manage the early patient interview?

What are nonverbal encouragements that you can use as an interviewer?

A few minutes into a typical interview session, the patient should be relaxed and giving you the information you need. To keep speech flowing freely, intrude as little as possible. A long as you are finding out why your patient came for treatment, you should keep out of the way. In practical terms, you will usually just listen for only the first couple of minutes or so. Then the flow of information will slow down or take a wrong turn, and you will have to intervene.

Your most frequent challenge as an interviewer is to deal with silence. Especially beginners often find silence hard to tolerate and feel that every hole in the conversation must be filled up with words. However, brief pauses often mean only that your patient is trying to organise some thoughts for further discussion. As an interviewer, you must learn to walk the line between allowing brief pauses to let your patient think and long gaps that make you seem unfeeling of uninterested. A glance should tell you whether the narrative is still underway. You can encourage further speech by using nonverbal cues of your own. You can lean in a bit closer, be aware of maintaining eye contact, or slightly nod.

What are verbal encouragements that you can use as an interviewer?

Body language helps, but you will also have to do some talking. Your choice of words is important: You want to facilitate, not distract. A syllable or two is usually all it takes. "Yes" or "Mm-hmmm" clearly indicates that the material is registering with you. One such encouragement every minute or two should keep your patient talking. There are several other verbal techniques you can use to request additional information. These are more intrusive than those just mentioned, so you should use them sparingly:

• Repeat your patient's own last word or two with a rising inflection in your voice to make a question of it.
• Elaborate on a word the patient used earlier. This technique allows you to reach baked to an idea that was not the last thought spoken. 
• You can also directly ask for more information on a specific topic.
• Re-request information when the patient seems to have misinterpreted your original question.
• Sometimes, you can also offer brief summaries. Summaries do not only help with transitions; they also offer concrete evidence that the patient has been understood. 

How can you offer reassurance as an interviewer?

Reassurance is anything you do to increase a patient's sense of confidence or well-being. Because it shows that you like or are interested int he other person, it can also foster rapport. Used sparingly during the initial interview, supportive statements say "I'm on your side. We'll get this job done". Any interview can be therapeutic. The purpose to the initial interview is to obtain the information you need to plan treatment. On the other hand, you should not pass up an opportunity to provide reassurance, as long as it does not interfere with the main gaol of your interview. You might even raise the confidence of some patients enough that they wil reveal especially sensitive material you would not otherwise have obtained.

Body language can be reassuring, but mostly you will reassure with your speech. Supportive reassurance must be factual, sincere and specific to the situation. Avoid false generalisations that come too early in the interview or are based on too little factual information. Occasionally a patient wil express concern based on a misconception about mental or physical phenomena. Then, you can use your expertise to set the record straight without interfering with the history taking. Mostly, your efforts at reassurance and encouragement will meet with success. Nevertheless, any of these techniques can sometimes backfire. 

Chapter 5: How do we inquire about the history of the present illness?

How should the interviewer inquire about the present episode?

Once you feel that there are no additional major problem areas to discover, close the period of free speech and move smoothly into the history of the present illness. Now you will explore more throughly the problems that have brought the patient into treatment. To aid this process, you might consider the areas of clinical interest that you identified during free speech. Although you wil eventually want to learn about any and all episodes, first focus on the current episode of illness. Your patient will be most concerned about it, and its details will be freshest in the minds of all your informants. 

How do you describe symptoms?

As an interviewer, you should learn as much as you can about each symptom your patient reports. Characterise each symptom as fully as you can. Find out whether the symptom is episodic, how intense it is, if it varies in intensity and how often the symptom occurs. It is important to observe how the patient describes the symptom. Has the intensity or frequency of the symptom been increasing, staying the same, or decreasing? It is also important to ask in which context the symptoms occur. 

What are vegetative symptoms?

Many patients with serious problems such as anxiety attacks, depression and psychosis have experienced vegetative symptoms. This term refers to body functions that are concerned with maintaining health and vigorous. Vegetative symptoms include problems with sleep, appetite, weight change, energy level and sexual interest.

• The patient may complain of either excessive sleepiness, called hypersomnia, or the inability to sleep, which is called insomnia. 
• The appetite and weight of the patient may increase or decrease during episodes of illness.
• Sometimes the patient can also complain of feeling constantly tired.
• A diurnal variation of mood can also occur, which refers to the tendency of some patients to feel better during a certain part of the day. For example, patients with depression often feel worse upon arising and better as the day goes on.
• Sexual functioning usually depends strongly upon the individual's sense of well-being. Therefore, loss of interest in sex is often an early casualty of mental distress. 

How do you ask about the consequences of illness?

Mental disorder can interfere with the entire range of human interaction. For several reasons, it is important to learn how your patient's illness has affected functioning and relationships across all areas of functioning, including social, educational/occupational, and family life.

• It may provide your most reliable index of severity. 
• The definition of many disorders in the DSM-5 depends heavily on social consequences.
• You may also learn that relatives blame the patient for being fired, getting divorced, et cetera. Yet these and various other ruptured human relationships are really effects of the person's mental disorder. To learn what social problems your patient's illness has caused, start with an open-ended question; one that does not limit the information you might obtain. 

How do you inquire about the onset and sequence of symptoms?

In addition to a complete and accurate description of the symptoms, you should establish their timing and sequence. Frist, when did these problems begin? Try to encourage precision about the onset of especially noticeable symptoms. You might be able to relate the onset to noteworthy dates or events. No matter how much you prompt, some patients simply can not give a date or even an approximation. Then, try to learn which of your patient's several problems started first. It is often important for diagnosis and treatment to know, for example, whether an episode of depression or a bout of drinking began earlier.

In what way are stressors important as well?

Of course, having mental symptoms is enormously stressful itself, but we should also consider stress in a different sense. A stressor is any condition or event that seems to cause, precipitate, or worsen a patient's mental health problems. Sometimes they are referred to as precipitants. The variety of possible stressors is vast, and what one person might find mildly stressful could seem catastrophic to someone else. For years, the diagnostic manuals listed nine groups of potential psychosocial and environmental problems, comprising many individual stressors: (1) Stressors related to access to health care services, (2) economic stressors, (3) educational stressors, (4) stressors related to housing, (5) legal system or crime stressors, (6) occupational stressors, (7) stressors in the social environment, (8) support group stressors, or (9) other stressors. Patients often mention stressors during free speech, or even when stating the chief complaint.

For some episodes of illness, you will find no stressors at all, but to a patient almost anything can seem a possible cause of emotional disorder. Therefore, events reported as stressors may include births, deaths, marriages, divorces, job loss, health problems, et cetera. Your patient's identification of something as a stressor does not mean that it actually caused the disorder to happen. Another patient's stressor may seem an unlikely case of illness. Whether or not the stressor seems related to the disorder, note it down during the interview. You can evaluate it later in the light of everything else you learn about your patient. 

Why should interviewers also ask about previous episodes?

Knowing about previous episodes of the same or a similar mental condition can help you determine diagnosis and prognosis. Therefore, you should also ask about any prior episodes. Since that first episode, has there even been complete recovery, or not? How has your patient reacted to previous symptoms or prior episodes of illness?

You should also ask whether the patient received treatment before? If so, to guide your plans for future therapy, you will want to obtain details about what was offered and what was tried. You should ask about previous psychotherapy as well as previous pharmacotherapy. Ask what the effects of previous treatment has been.

Chapter 6: How should interviewers inquire about the present illness?

In what way can interviewers be clear about the goal of the interview? 

Of all portion of the initial mental health interview, the history of the present illness is probably the most important. As an interviewer, you try to require highly valid information that reflects as closely as possible the true facts of your patient's history. Ideally, the patient will understand your expectations for accuracy from the very beginning. Still, in the middle of the interview, your apparently truthful patient may seem to be holding back on you. For minor evasions and omissions, it may be enough simply to restate the goal of the interview. In clinical interviewing, you must constantly reconcile two opposing principles: harvesting all the necessary information while avoiding the bog of excessive detail. Resolving this dilemma often means putting off until later questions that, however much you would like their answers, must take a back seat to other, more burning issues. 

Why should interviewers stick to asking open-ended questions?

Above all else, you want information that is valid. Studies have shown that patients give the most valid information when they are allowed to answer freely, in their own words, and as completely as they wish. Whenever possible, phrase your question in an open-ended way that allows the widest possible scope of response.

Even the most experienced interviewers must guards against using technical words that patients might not understand. If you use an unfamiliar word and are asked to define it, you will not lose anything but little time. You will improve validity if you pitch your questions at a level the patient can understand. Even then, you may find that your patient has a different understanding of a word whose meaning you thought was pretty well standardised. As an interviewer, you should work hard to be sure that you understand what your patient is trying to say. Ensuring good communication requires your constant vigilance. It is all to easy to assume that you know what your patient means, when in fact the two of you are speaking gin different idioms.

In what way should interviewers choose probing questions?

When you want to know about something, just ask your patient. A simple request for information will often produce what you need for a minimum effort. Your patient might appreciate your directness. If you use open-ended questions, you will probably get all the needed details. When it comes time to delve more deeply into your patient's presenting problems, choose your probing questions with two principles in mind:

• Select probes that will resolve unanswered questions. It is more efficient to concentrate your efforts on areas you have not already covered.
• If your questions show familiarity with the illness, you will be perceived as knowledgeable. The resulting rapport and trust should lead to increased sharing of information. 

Why should interviewers avoid questions started with "why"?

At this point in your interview, you are interested in the facts, so questions that begin with "why" are often better avoided. This is especially true if the questions refer to the patient's opinions or to other people's behavior. Besides, "why"-questions can prove frustrating to a patient who lacks insight, and this frustration can inhibit the formation of rapport. "Why"-questions invite speculation rather than facts. Getting a good history depends in part on knowing what questions will help you better understand the facts about your patient's symptoms or problems. Each symptom has its unique set of details that must be explored, but for a full, rich exploration of any behavior or events, certain items of information are always necessary.

Because you will now be looking for specific details, you will be using more closed-ended questions; those that can be answered in a few words and do not invite further comment from your patient. Even when pursuing details, you should still sprinkle in some open-ended questions, which will stimulate your patient to relate additional material that you may not have thought to ask about. 

What are some important rules for interviewing?

Morrison distinguishes several important rules for interviewing:

• Do not phase questions in the negative.
• Do not ask double questions.
• Avoid obvious pejorative questions. Here, for no gain, you risk raising your patient's defences. 
• Avoid leading questions that hints at the answer expected.
• Encourage precision. Where appropriate, ask for dates, times and numbers.
• Keep your questions brief. Long questions with much explanatory detail can confuse the patient; they also occupy time you could be using to obtain information.
• Also watch for new leads. Even when you are hot on the trail of vital information, be alert for hints of other directions to explore later. 

What should interviewers do in the case of confrontations?

Confrontation does not mean showing anger, much less coming to blows. In the context of a mental health interview, it simply means pointing out something that requires clarification. It could be an inconsistency between two points of the history, or between the story and how the patient appears to feel about it. The purpose of the confrontation is to help you and the patient communicate better. When you confront your interviewee, be gentle. the experience of being interrogated is an unpleasant one. Choosing your phrases carefully is of crucial importance. Whatever the issue, try to restrict your confrontations to one or two essential issues. Otherwise , you do put rapport with your new patient at risk. To be sure that you reserve this treatment for only the most important issues, it might be better to save any confrontation until near the end of the interview. 

Chapter 7: How do you interview about feelings?

What forms the distinction between negative and positive feelings?

Whatever the nature of the presenting problems, feelings about the illness and indeed about the interview itself, will probably rank among the most important data you obtain during the entire interview. People can experience an impressive range of feelings. Some are major moods or affects; others are variants or combinations. All are resented by commonly used words. As an interviewer, you can obtain information about feelings from most normally expressive people just by careful watching and listening. But some patients are reluctant to share their feelings, even when they are willing to talk, they can bury their emotions deeply. Then you will have to go prospecting to uncover feelings. 

How do you uncover the feelings of a patient?

Many patients will express their feelings adequately if you just ask. Patients do not seem to mind this method. In fact, studies show that this direct approach is preferred by most patients and informants, as long as the interviewer has a warm and caring manner and is attentive, courteous and responsive to cues. Successful examiners effectively use two techniques that are especially good at eliciting emotions. These are direct requests and open-ended questions.

• Watch for the opportunity to ask about the feelings associated with nay of the facts you have been discussing. Simply asking is probably the most effective method of eliciting emotions, but be careful to use the word feelings or a synonym, instead of a cognitive term. 
• Without specifically asking how the patient feels, open-ended questions encourage the free expression of emotions. This method works because its relative freedom encourages patients to speak at length. The more people talk, the more likely they are to reveal emotion-laden information. This technique, which is really just an extension of free speech, works in part by suggesting that you care about how the patient perceives the situation as a whole. Open-ended questions can also help patients who have trouble sorting out or accepting emotions that conflict with one another. To describe conflicting emotions, we often use the term ambivalence. 

Other techniques to elicit emotions in patients are expressing concern of sympathy, reflecting on the feeling you would yourself experience, picking up on emotional cues, interpreting and drawing parallels between the emotional content of current and past situations, and lastly, naming the feeling and checking whether this matches the patient's experience. For the patient who absolutely cannot identify the feelings that accompany a given situation, you should ask about times when similar feelings might have been experienced. 

How do you then follow up for details?

Once you have uncovered some feelings, increase the depth of the interview by asking for more. Probe to elicit examples and to evaluate details. Be sure to ask follow-up probing questions whenever the patient gives you the opportunity. Beginners sometimes uncover evidence of significant events or pathology, only to ignore it in the subsequent dialogue. 

How do you uncover the ineffective defence mechanisms of your patient?

When following up, you should also learn what your patient does to cope with feelings. These strategies for dealing with emotions and behaviors are called defensive mechanisms. They may seem almost endless in their number and variety. Potentially harmful defense mechanisms are the following:

• Acting out: The politician smashes the camera of a news photographer who is trying to take a picture.
• Denial: "The recount will show that I actually won". 
• Devaluation: "It's a lousy job anyway-the hours are murder, and you get nothing but complaints from the taxpayers."
• Displacement: The politician goes home and kicks the cat.
• Dissociation: The politician awakens one morning in strange surroundings, unable to recall any events of the past 3 days.
• Fantasy: "Next year I'll run for Congress-and win!"
• Intellectualization: "I view this experience only as an example of 'democracy in action.""
• Projection: Unconscious thought: "I'd like to kill him.", "He's plotting to kill me."
• Reaction formation: Thought: "He's a miserable low-life.", “I'm proud to support the honorable council member."
• Repression: The politician "forgets" to attend a banquet in honor of the victor. 
• Somatization: The politician develops persistent chest pain of unexplained origin: "...so I couldn't have served anyway."
• Splitting: "Some politicians are good, some bad; my opponent's one of the bad ones."

How do you uncover the effective defence mechanisms of your patient?

Better-integrated adults rely principally on some of the more mature defense mechanisms.

• Altruism: "I'll support him; he has better qualifications than I do."
• Anticipation: Before voting begins: "Of course, I could lose. But I've got other irons in the fire."
• Humor: "In the campaign I said he was honorable; he said I was a jerk. Perhaps we were both wrong."
• Sublimation: "I'll write a book about the campaign."
• Suppression: "I'll put it to the back of my mind, and concentrate on the business at hand." Note the difference-conscious intent-from repression, above.

How should you deal with excessively emotional patients?

Although you will usually want to encourage the expression of emotions, some patients are so emotional that it impedes their communication with other people, including therapists. People can experience excessive emotionality for a variety of reasons. Whatever the cause, excessive emotionality can focus too much of your attention on feelings, leaving insufficient time for gathering facts. In such a situation, try to adopt a brisk, controlling manner in which you firmly direct the course of the interview. 

• Acknowledge the emotion.
• Talk quietly.
• Explain again what information you are trying to get.
• Redirect any of the patient's questions or comments that change the topic.
• Switch to a closed-ended style. This style will indicate what sort of specific answer you would like to hear, as well as discourage further comment by the patient.
• If you are still having trouble, check to be sure that the patient understands what you want. 

The aim of all these techniques is to reduce the patients scope for excessive verbal and behavioral output. They should help you obtain the diagnostic information you need without sacrificing rapport.

Chapter 8: How do you inquire about the personal and social history of your client?

What memories are most fallible?

Health care professionals do not treat illnesses; they treat people. You therefore need to know the context in which your patient's complaints have occurred. While you are gathering biographical information, maintain a healthy skepticism about its validity. Human memory is fallible, especially when the human has an intense personal interest in what is being remembered. Accurate recall is more likely for major historical events such as births, deaths and marriages, and for recent events that constitute the history of the present illness. On the other hand, some material is especially subject to distortion: early childhood events, interpersonal disputes, everything reported secondhand, and any other item that requires interpretation.

How do you inquire about childhood and adolescence?

A logical starting place in with your patient's birth. In what city did it occur? Was the patient an only child? If there were brothers and sisters, how many of each? What was your patient's position in the sibship? How well did your patient get along with siblings? Et cetera. Whatever the exact nature of your patient's family of origin, you should try to learn something about how the parents related to one another. How was the communication in the family? You inquire about the age of the parents when the patient was born, the socioeconomic status of the family, and the general childhood environment and your patient's place in it.

During the interview, you should also ask about abuse and neglect. You should make an effort to learn whether your patient's childhood involved such experiences. You can lead into these sensitive topics gradually. For adult patients, early developmental milestones are usually not worth pursuing. Most of what your patient knows about milestones has probably been passed along as family mythology, which is highly subject to distortion. Try to learn something about overall childhood health. Also inquire about the patient's temperament and activity level during childhood. Then, you should also inquire about the equation of the patient.

How do you inquire about the life as an adult?

Employment history can help you judge both your patient's underlying potential and the effect of recent illness on performance. This information is relatively objective. Ask about any legal problems as well, which might include lawsuits, evictions and feuds with neighbours. Then, also inquire to what religion, if any, your patient belongs and if this is different from any religious affiliation of childhood. Thereafter, inquire about the current living situation and social network of your patient. Also ask about the marital status of him or her. Finally, you want to know something about how your patient spends his leisure time.

How do you inquire about the medical history of your patient?

Even if you are not a physician, don't bypass the medical history of your patient. It is vital for every practitioner to know about this topic and the next one, the review of systems, both of which have practical implications for diagnosis, treatment and prognosis. Ask about disease, medications and possible side effects. Extrapyramidal side effects are neurological symptoms that can be caused by taking antipsychotic medications. The four types of these symptoms are common enough that every mental health professional can expect to encounter each of them from time to time. 

• Acute dystonia develops within a few hours of the first dose of some antipsychotic drugs. It is characterized by a sharp, cramping pain of the neck that may cause the head to turn to the side. Sometimes the eyeballs roll upward. This side effect can be painful and frightening, and can constitute a real emergency.
• Akathisia usually begins within a few days of starting one of the older antipsychotics. Patients experience it as a profound restlessness, often with an inability to sit still that results in pacing.
• Pseudoparkinsonism also occurs soon after starting medication. The patient experiences a decreased mobility of facial expression (masked facies); a tendency to walk with short, shuffling steps; and a back-and- forth tremor of the hands when they are relaxed, as when resting in the patient's lap. This tremor resembles the motion that old-time druggists would use to form drugs into pills; hence the term pill-rolling tremor.
• Tardive dyskinesia usually does not begin until the patient has been using one of the older antipsychotics for months or years. Some- one with tardive dyskinesia typically has uncontrollable motions of the tongue, jaw, and lips that result in persistent pursing, chewing, or licking movements. Patients themselves are often almost entirely unaware that they are doing this; it is not a debilitating disorder, but it is unsightly. Tardive dyskinesia is all the more important because it has no specific treatment. Unless the antipsychotic drug is discontinued quickly, this side effect can become permanent, persisting even after the medication is eventually stopped.

What does a review of systems entail?

In the review of systems, you ask your patient to identify any symptoms they have had from a list that you recite. This list comprises symptoms from all the different organ systems of the body. The rationale for using it is that patients will recognise more symptoms by passive identification than they will report if you depend upon their spontaneous active recall. This list include disturbance of appetite, habits, head injury, history of unconsciousness, convulsions (or seizures), and symptoms of premenstrual dysphoric disorder. In addition to these general-purpose questions, mental health clinicians can use a specialised review of systems to diagnose what DSM-5 now calls somatic symptom and related disorders, which are encountered fairly frequently in mental health populations.

How do you inquire about the family history of your patient?

With the family history, you have the opportunity to accomplish three tasks:

• You develop a brief biographical sketch of parents, siblings, spouse and children.
• You learn about the relationships between patient and relatives, both current and during childhood.
• You learn whether any mental disorders occur in your patient's family, including distant relatives.

How do you inquire about the personal traits and disorders of your patient?

We can define personality as the combination of all the mental, emotional, behavioral and social aspects that make us individual human beings. The term character is often used synonymously. The way individuals perceive, think about, and relate to the environment and to themselves form patterns of behavior called personality traits, that persist for long periods of time, often throughout life. Personality traits can be detected as early as the first few months of life; they shape behaviour forever after and often become even more pronounced with advancing age. These patterns govern relationships with friends, lovers, bosses and colleagues as well as with more causal social contacts. 

In your interview, try to learn what characterised your patient's personality prior to the first episode of mental disorder. This is sometimes referred to as the premorbid personality. In the initial mental health interview, you will often encounter lifelong patterns of maladjustment or interpersonal conflicts. Aside of this, you also inquire about the relationships with others.

In what way do you observe the behavior of your patient during the interview?

Some of the behaviors you observe during the interview may reveal important character traits. Watch for actions or comments that seem to go beyond what you would expect during an interview situation. You focus on any yawns, gazes about the room, invasions of your personal space, repeated questions about your credentials, criticism, strong language, bragging, et cetera. 

When do you diagnose someone with a personality disorder?

By itself, none of the behaviors that were mentioned can be definitive for actual character pathology. In aggregate, however, or combined with your historical information, behaviors such as these may suggest a personality disorder. This diagnosis is made only when character traits are so inflexible and poorly adapted to the requirements of life that they cause considerable distress or impair the person's functioning in the realms of social life, work, or other areas. A personality disorder isn't so much an illness as a way of life, in which long-standing behavior causes problems for the patient and for others. If often has its roots in childhood and may stem either from environmental influences or from the patient's inherited genetic material, or both. The diagnosis of a personality disorder hinges on problems of functioning with the self and with other people. 

What personality disorders do we distinguish?

We distinguish several different personality disorders:

• Antisocial personality disorder: The irresponsible, often criminal behavior of these people begins in childhood or early adolescence. Pathological childhood behavior includes truancy, running away, cruelty, fighting, destructiveness, lying, stealing, and robbery. As adults, they may also default on debts, fail to care for dependents, fail to maintain monogamous relationships, and show no remorse for their behavior.
• Avoidant personality disorder: These timid people are so easily wounded by criticism that they hesitate to become involved with others. They may fear the embarrassment of showing emotion or of saying things that seem foolish. They may have no close friends, and they exaggerate the risks of undertaking pursuits outside their usual routines.
• Borderline personality disorder: These impulsive people make recurrent suicide threats or attempts. Affectively unstable, they often show intense, inappropriate anger. They feel empty or bored, and they frantically try to avoid abandonment. They are uncertain about who they are and unable to maintain stable interpersonal relationships.
• Dependent personality disorder: These people have trouble starting projects or making independent decisions, even to the extent of agreeing with others who may be wrong. Often preoccupied with fears of abandonment, they feel helpless when alone and miserable when relationships end. They are easily hurt by criticism and will volunteer for unpleasant tasks to gain people's favor.
• Histrionic personality disorder: Overly emotional, vague, and attention-seeking, these patients need constant reassurance about their attractiveness. They may be self-centered and sexually seductive.
• Narcissistic personality disorder. These people are self-important and often preoccupied with envy, fantasies of success, or ruminations about the uniqueness of their own problems. Their sense of entitlement and lack of empathy may cause them to take advantage of others. They vigorously reject criticism, and need constant attention and admiration.
• Obsessive-compulsive personality disorder. Perfectionism and rigidity characterize these people. Often workaholics, they tend to be indecisive, excessively scrupulous, and preoccupied with detail. They insist that others do things their way. They have trouble expressing affection, tend to lack generosity, and may even resist throwing away worthless objects they no longer need.
• Paranoid personality disorder: These people expect to be threatened or humiliated; other people's behavior seems to confirm these expectations. They can be quick to take offense and slow to forgive; often they have few confidants, question the loyalty of others, and read hidden meaning into innocent remarks.
• Schizoid personality disorder: These patients care little for social relationships, have a restricted emotional range, and seem indifferent to criticism or praise. Tending to be solitary, they avoid close (including sexual) relationships.
• Schizotypal personality disorder:  Such patients have so much difficulty with interpersonal relationships that they appear peculiar or strange to others. Lacking close friends, they are uncomfortable in social situations. They may show suspiciousness, unusual perceptions or thinking, an eccentric manner of speaking, and inappropriate affect.

Chapter 9: How do you deal with sensitive subjects?

In what way do we redefine what is acceptable in human interaction during a clinical interview?

Summoning the courage to cover certain subjects can be a challenge. Though the material itself is pretty straightforward, our society largely regards these sensitive areas; sex, substance use, violence and suicidal behaviour, as deeply personal. It helps to realise that in the clinical interview, we essentially redefine what's acceptable in human interaction. In the role of patient, people expect to be queried on topics that are ordinarily private, and will freely disclose to an unfamiliar clinician information they'd withhold even from close friends. In turn, we clinicians must steel ourselves to the task of broaching topics that we might prefer not to explore in other situations. Because these topics are, however, critically important, if your patient.does not mention them spontaneously, you must introduce them yourself. You may delay until the latter portions of the interview after you know the patient a little better. But do not wait until the very end: You could run out of time and still have important material yet to cover.

How do you inquire about suicidal behavior?

Delving into suicidal behavior is an absolute must. This rule holds even if there has been no hint of death wishes or suicidal ideas at any time during the interview. To violate the rule risks ignoring potentially life-threatening ideas and behiavors in a patient who may be too ashamed or too embarrassed to mention them spontaneously. Although the vast majority of mental health patients do no skill themselves, nearly every mental health diagnosis confers some degree of suicide risk beyond that found in the general population. When asking about suicidal behavior, you may feel discomfort. However, the real risk lies in not asking soon enough. You can simply ask: "Have you ever had any thoughts of hurting, or killing yourself?"

How do you assess suicide risk?

We can judge the seriousness of a suicide attempt in each of two ways:

• How physically harmful was the attempt?
• And how strong was the patient's intent to die?

When you are assessing a new patient for suicide potential, you should have these guidelines in mind. A suicide attempt is physically serious when it results in significant bodily harm. You must also correlate whatever you learn about previous suicide ideas and attempts with your patient's current thinking on the subject. 

How do you inquire about violence and substance use?

Violence toward others is relatively uncommon, but because of its serous implications for patients and for intended victims, it's at least as important to learn about as is suicidal behaviour. If your patient admits to legal difficulties such as arrests or time in confinement, you will have natural lead-in to questions about violence. If no natural lead-in occurs, you will have to raise the subject. As with self-harm, you can work up to it gradually.

Substance use must be covered in the initial interview of every mental health patient, regardless of sex, age or presenting complaint, as the effects upon patient and environment can be far-reaching. 

How do you inquire about the sexual life of your patient?

To learn about this important life area, you must be able to discuss it openly, without showing disapproval or censure. Clinicians in training often have difficulty questioning patients about their sex lives. During the present illness or the personal and social history, you may have already learned something about the relationship between your patient and his or her partner, that you may be provided with a natural introduction to this subject. You should inquire about sexual practices, sexual preference, and common sexual issues. Also ask about paraphiliac, which are behaviors in which the patient is aroused by a stimulus other than a commenting adult human. Finally, also inquire about sexually transmitted sieges, and possible childhood sexual abuse or current abuse.

Chapter 10: How do you control the later interview?

Why do you need to take more control in the later interview?

During most of the early interview, you have encourages your patient to discuss problems freely. By the time you move on to the personal and social history, you will need to exercise ore control over the form of your interview. This will enable you to use your time efficiently to cover all the material and probe the important remaining areas. A number of verbal and nonverbal techniques can help direct the patient's responses and maximise the amount of material you obtain.

How do you take charge?

Some patients take direction so well that you can exercise control just by gently interjecting an occasional guiding question. Patients who are circumstantial or perhaps just plain talkative will need more active measures of control. With the need to cover so much ground, you may not be able to respond as completely as you would like to issues your patient raises. You should try to avoid abrupt transitions, which can impair rapport. We distinguish some techniques that provide other options:

• You can change the subject with more grace if you first make an empathic comment.
• Stop taking notes and put down your pen. If you continue to write, your patient may feel encouraged to continue talking about the same subject.
• If you must interrupt, try raising your forefinger and taking a breath to signal that you need a turn to speak.
• Try moving quickly to get in a word between two of your patient's sentence. 
• If your patient brings up something that you already have covered sufficiently, indicate the need for a change of direction.
• Nod or smile when you do get the sort of brief answer you want. This reinforcement will encourage further brevity.

Why should you use closed-ended questions in the later interview?

Later in the interview, when you know what sort of specific information may be relevant to diagnosis and therapy, closes-ended questions are recommended. They allow you to pin down diagnostic criteria and clarify previous responses, so you obtain the specifics of you patient's problems. A closed-ended technique is to substitute a multiple-choice request when your patient cannot answer a question that is less well defined. You should, however, be aware of the potential drawbacks of closed-ended questions. Patients who are more verbal may resent closed=ended questions if they think you care more about the process of getting the information than you do about the person who is supplying it. 

Closed-ended questions can be valuable, but you should avoid suggesting how you would like your patient to answer. Such leading questions broadly hint that there are certain standards or behaviours you approve of. This type of question severely limits the scope and validity of the information you will obtain. No one likes to be given the third degree; patients are no exception. So you should therefore try to make your interview feel like a conversation, not an interrogation. Smooth transitions help to create that feeling. But when you have to make an abrupt transition, flag it so the patient realises that you are changing gears intentionally.

Chapter 11: How do you inquire about behavioral aspects during a Mental Status Exam?

What is a mental status exam?

The mental status exam (MSE) is simply your assessment of the patient's current mental functioning. Originally a part of the traditional neurological exam, now it is a staple of the initial mental health evaluation. The MSE is usually divided into several parts. To obtain the behavioral material, you do not have to ask special questions or perform tests. Mostly you just observe speech and behavior while you are talking with your patient. The behavioral aspects include the following:

• General appearance and behaviour
• Mood
• Flow of thought

The cognitive portions of the MSE are concerned with what your patient is thinking or talking about. Their evaluation demands more activity on your part. They include the following:

• Content of thought
• Perception
• Cognition
• Insight and judgment

What do you look for in general appearance and behavior?

You can learn a great deal about a patient by just watching. Most of the following are characteristics that you should begin to notice first thing in your interview, even before anyone says a word.

• The physical characteristics of your patient are important.
• Your patient's alertness can be graded along a continuum, from full or normal alertness, to drowsiness and clouding of consciousness, to eventually coma. 
• Another important aspect is the clothing and hygiene of your client. 
• Also try to assess dominant body attitude, the presence of excessive motion, gestures, inappropriate motor behavior and other types of motor activity.
• The facial expression of your client is also an important aspect. 
• Also focus on the voice, the volume, pitch and clarity.
• Finally, the attitude towards the examiner ranges from cooperative, friendly, open and involved to obstructionistic, hostile, secretive and apathetic.

What do you look for in your patient's mood?

The terms mood and affect have been variously defined. Mood is often used to describe the way a person claims to be feeling, and affect to describe how the person appears to be feeling. Mood is described in several dimensions: type, lability, appropriateness and intensity. 

What do you look for in your patient's flow of thought?

The term flow of thought is a slight misnomer. What we are interested in is the thought, but what we actually perceive is the flow of speech. We assume that the speech we hear reflects the patient's thoughts. 

• Notice whether speech is spontaneous or occurs only in response to questions. Focus on signs of derailment )(a breakdown of thought association in which one idea seems to run into another), flight of ideas (when a word or phrase from one thought stimulates the patient to take off in another direction), tangentiality (irrelevant answers to the question that was asked), poverty of speech, thought blocking, alliteration, clang associations (when speech is governed by rhyming or other similarity of sound), echolalia (unnecessary repeats of the words of the interviewer), verbigeration (continuously repeating a word), incoherence, neologisms, and perseveration. Lastly, also notice stilted speech.
• Then, also focus on the rate and rhythm of speech. 

Chapter 12: How do you inquire about cognitive aspects during a Mental Status Exam?

Why is it important to inquire about cognitive aspects during a MSE?

Some clinicians still fail to assess the cognitive aspects of the MSE, despite the critical importance of this information to the overall evaluation of any patient. Others feel it is insulting to ask a well-functioning adult obvious routine questions. They choose not to do formal testing without a positive indication, such as a complaint by relatives that the patient has seemed forgetful. When you are starting out in the field, it is recommended to perform a formal MSE on all patients. 

Start by explaining what you are about to do. Stress the fact that these questions are the norm and are not occasioned by something the patient has said or done. Use whatever degree of positive feedback seems warranted, as long as you speak no more than the truth. Respond attentively to any distress these questions seem to cause. If necessary, take a break an return later to any aspect that is troublesome. In any case, it is a good idea to get this portion of your evaluation out of the way during the first interview. The MSE properly concerns only current behaviours, experiences, and emotions. However, it is often convenient to cover related historical data at the same time. 

What does content of thought entail?

Whatever the speaker is focused on at the moment constitutes the content of thought. During the history of the present illness, this wil usually concern the problems that caused the patient to seek treatment. Whenever you are investigating abnormalities of thought, probe gently enough that the patient continues to view you as someone who is friendly.

What are delusions?

A delusion is a fixed, false belief that the patient's culture and education cannot account for. You can name some idea a delusion only when the patient maintains an obviously false explanation despite clear evidence to the contrary. It is important to investigate whether the delusion is mood-congruent, meaning whether the content of the delusion is in in line with the patient's mood. 

What types of delusions do we distinguish?

In the course of interviewing many patients, you will probably encounter a wide variety of delusions. We distinguish the following delusions:

• Nihilistic delusions refer to delusions about death and delusions of ill health.
• Grandeur refers to the false belief that the patient is someone of exalted station or has powers of gifts not possessed by other people.
• Patient with delusions of guilt believe that they have committed some grave error or sin, for which they may claim to deserve punishment.
• Ill health or bodily change: These patients believe they are afflicted by some terrible disease.
• Jealousy.
• Misidentification: The patient believes that someone, usually a close relative, has been replaced by an exact double.
• Passivity or influence: Such patients believe that they are being controlled in unusual ways by outside influences, such as television or microwaves.
• Persecution: Patients believe that they are being threatened, ridiculed, discriminated against, or otherwise interfered with. These delusions sometimes occur in schizophrenia. 
• Poverty: Despite evidence to the contrary, these patients believe that destitution will force them to sell the house and auction their property. These delusions sometimes occur in severe depression.

How do you inquire about hallucinations?

Hallucinations are false sensory perceptions that occur in the absence of a related sensory stimulus. Among mental health patients, auditory hallucinations are by far the most common. Hallucinations should be characterised as to severity. Audible thoughts constitute a special form of auditory hallucination, in which patients hear their own thoughts spoken so loudly that others can hear them. Visual hallucinations, on the other hand, are especially characteristic of psychoses that occur with substance use or general medical conditions. Tactile, olfactory and gustatory hallucinations are uncommon in mental health patients. 

How do you inquire about anxiety symptoms?

Anxiety is fear that is neither directed at nor caused by anything specific the patient can identify. It is usually accompanied by various unpleasant bodily sensations. Other mental symptoms may include irritability, poor concentration, mental tension, worrying and an exaggerated startle response. A panic attack is a discrete episode during which a patient suddenly experiences intense anxiety with bodily sensations such as rapid heartbeat, shortness of breath, tremor, and sweating.

What are phobias?

A phobia is an unreasonable and intense fear associated with some object of situation. Common specific phobias are fears of various animals, air travels, heights and being closed in. In your interview, you should also screen for phobias.

What are obsessions and compulsions?

An obsession is a blief, idea or thought that dominates the patient's thought content and persists, despite the fact that the patient recognises its unreality and may try to resist it. Compulsions are acts performed repeatedly in a way that the patient realises is neither useful nor appropriate. A minor degree of obsessional thinking is quite common, so it is important to judge severity.

What are thoughts of violence?

Whether or not there have been previous suicide attempts or violence directed at others, you must learn what the patient is thinking now. Screen for suicidal ideas by asking: "Have you any ideas or thoughts of harming yourself in any way or of killing yourself?" Review all the material you have already obtained about past suicide attempts. Learn whether the patient has current plans and the means to carry them out. 

How do you inquire about consciousness and cognition?

In the next section of the MSE, you evaluate your patient's ability to absorb, process and communicate information. The clinical tests we commonly use are only approximate, but they can serve as a useful guide. To introduce these tasks, you might want again to offer reassurance that you often ask these routine questions of new patients. You inquire about the patient's attention, concentration, and orientation. You also inquire about language use, comprehension, fluency, reading, writing, and memory. Cultural information also forms a traditional part of the MSE, which is why caution about interpretation is important. You also focus on the patient's ability to abstract principle from a specific example; referred to as abstract thinking.  Lastly, you also perform the Mini-Mental State Exam (MMSE); which is a test of cognitive ability. 

How do insight and judgment relate to the mental health evaluation?

In the context of the mental health evaluation, insight refers to the validity or your patient's ideas about whatever problem you are evaluating. The insightful patient recognizes that (1) something is amiss, (2) it can have implications for future well-being, (3) the cause could be biological, psychological or social and (4) some form of treatment is needed. The capacity to participate in psychotherapy or to understand psychodynamics does not usually figure into this assessment. Poor insight is typical or neurocognitive disorders, severe depression and any of the psychoses. Patient's assessment of their own strengths can be important for recommending treatment and estimating prognosis. 

Aside from its role in the acceptance of recommended treatment, we may think of judgment as the ability to decide upon an appropriate course of action in the pursuit of realistic goals. 

Chapter 13: How do you inquire about signs and symptoms in areas of clinical interest?

What are areas of clinical interest?

The areas of clinical interest are simply a way of thinking about historical and mental status information. We distinguish eight areas of clinical interest: (1) psychosis, (2) mood disturbance in the form of depression, (3) mood disturbance in the form of mania, (4) substance use, (5) social and personality problems, (6) difficulty thinking (cognitive problems), (7) anxiety, avoidance and arousal, and (8) physical complaints.

In discussing each are of clinical interest, focus on the following aspects:

• Tip-offs, or the 'red flag' symptoms that should alert you to explore further.
• The main diagnoses. This section covers the most important disorders covered by that are of clinical interest, plus the principal differential diagnoses.
• Historical information. 
• Typical features from the MSE. The current mental status is usually not as helpful as history in sorting out the differential diagnoses, yet still important.  

What does psychosis entail?

Psychosis means simply that the patient is out of touch with reality, as judged by the presence of hallucinations, delusions, or markedly loosened thought associations. Tis condition may be either transient or chronic, although with today's treatment methods it is unusual for a person to remain psychotic for extended periods. Symptoms that should make you consider psychosis as an are of clinical interest: affect that is flat or inappropriate, bizarre behaviour, confusion and delusions, social withdrawal, muteness, hallucinations, and speech that is incoherent or hard to follow. 

A patient who presents with psychosis is likely to have one of three principal diagnoses: an organic psychosis, schizophrenia, or some sort of mood episode. Schizophrenia tends to begin early in life; during adolescence or early adulthood.

What does mood disturbance in the form of depression entail?

Depression means a mood that is variously described as 'blue' or 'low'. This low mood must be persistent, usually lasting at least a week or two. You should investigate depression if your patient presents with any of these symptoms: activity level that is either markedly decreased or increased, anxiety, appetite changes, concentration problems, death wishes, depressed mood, interest decreased for usual activities, sleeplessness or excessive sleepiness, suicidal ideas, tearfulness, weight loss or gain, worthlessness, and use of drugs or alcohol. Many of the same physical diseases that produce psychosis can also lead to depression. 

What does mood disturbance in the form of mania entail?

Manic patients describe their moods as high, hyper, exalted or euphoric. Sometimes they are mainly irritable. Although the condition of mania has been recognised for more than 100 years, these patients are often misdiagnosed as having schizophrenia.

You should consider mania when you are confronted with any of the following symptoms: activity level increased, distractibility, grandiose sense of self-worth, judgment deteriorating, mood euphoric or irritable, planning many activities, sleep decreased, speech rapid, substance use, or thoughts moving rapidly from one idea to another. Most manic patients also have episodes of depression. 

What do substance use disorders entail?

Substance misuse is defined by the culture in which it occurs. In most segments of our culture, the majority of adults use substances. Whether we consider a person to be misusing a substance depends not simply on the amount or frequency of use, but also on the consequences of this behavior. These consequences may be behavioral, cognitive, legal, financial and physical. 

The following symptoms should lead you to consider a diagnosis of a substance use disorder: alcohol use greater than one or two drinks per day, arrests or other legal problems, financial problems, health problems, illegal substance use, job loss, memory impairment and social problems. 

What are social and personality problems?

Personality traits are patterns of behavior or thought that persist throughout adult life. To be diagnosable as personality disorders, traits must be pronounced enough to cause the patient functional impairment or personal distress. You should consider social and personality problems whenever your patient has any of the following characteristics: anxiety, behaviors that seem odd or bizarre, dramatic presentation, drug or alcohol misuse, interpersonal conflict, job problems, legal difficulties or marital conflicts. 

What does difficulty thinking entail?

A wide variety of physical and chemical insults can interfere with thinking. These causes include the following: brain tumors, head trauma, hypertension, infections, metabolic disorders, postoperative complications, seizure disorders, toxic substances, vitamin deficiency. Any of the following should stimulate further investigation of cognitive problems: bizarre behaviour, confusion, decreased judgment, delusions, hallucinations, memory defects, mood fluctuations, and history of ingesting toxins. Physical or chemical brain dysfunction produces abnormalities of behavior or thinking that can be either temporary or permanent. 

What do anxiety, avoidance behaviour and arousal entail?

Conditions in this area of clinical interest have in common anxiety symptoms that can result in attempts to avoid the stimulus. Symptoms that would cause you to explore this area include any expression of anxiety or fear, as well as somatic symptoms that suggest breathing or heartbeat problems when there is no known basis for concern. Be aware of anxiety, chest complaints, compulsive behavior, fear of objects, situations, et cetera, nervousness, obsessional ideas, panic, trauma and worries. The principal disorders covered by this area of clinical interest include panic disorder, generalised anxiety disorder, specific phobia, agoraphobia, obsessive-compulsive disorder, post traumatic stress disorder (PTSD).

What do physical complaints entail?

Physical illness must always be a prime concern of any clinician whose patient voices somatic complaints. But many patients come to mental health care complaining of physical symptoms for which inadequate basis in physiology, chemistry, or anatomy can be found. Such symptoms have historically been called hypochondriacal or psychosomatic. Often, by the time such a patient finally seeks help from a mental health clinician, there has already been a full range of medical tests and evaluations. Consider this area of clinical interest if your patient presents any of the following problems: appetite disturbance, depression that is chronic, history that is complicated, multiple complaints, physical symptoms unexplained by known illness, sexual or physical abuse in childhood, substance misuse in a woman, treatment failures that are repeated, vague history, weakness that is chronic, or weight changes.

Chapter 14: How do you close an interview?

Why is closing important?

An hour usually provides enough time to explore the reasons for seeking treatment and to obtain a great deal of personal background information about your patient. During this time, you should also have conducted a formal MSE. Even though there is still much you would like to know, you probably should not push the interview too much further. If necessary, you can also take a break and then continue. 

Closing an initial interview is a minor art form that requires some care. A good closing does not just summarise the interview; it also prepares the patient for the sessions that lie ahead. Your patient, who has just invested considerable hope and confidence in the time you have spent together, quite reasonably expects some information to carry away from the encounter. The content of that message will depend in part upon the nature of your relationship.

What are the important elements in closing an interview?

If you are a practicing clinician responsible for this patient's care, you will probably follow three steps:

1. Summarize your findings.
2. With the patient's collaboration, develop a plan for future management.
3. Set a time for your next meeting.

Whenever it is justified you should also include a message of hope for the future. You may find that something you have left out needs action now. Try to respond factually to any substantive issues. If last-minute information is of life-threatening proportions, you have no choice but to run overtime. If this happens habitually to you, you should resolve to raise these sensitive topics earlier in your interview.

What should you do when a patient wants to leave early?

A rare patient may try to break off the interview before you have finished. Usually this will be someone who is exhibiting a personality disorder or extreme stress. Whatever the cause, you suddenly find yourself trying to get information from someone who is putting on a coat to leave. If it is close to the end of the session, point out that you will need just a few more minutes to finish. Then try to accommodate your patient's agitation by sleecitn only the most important remaining questions to ask. If it is early in the interview, especially right at the beginning, the patient may not fully understand the reasons for the interview. Try explaining again, and at the same time, offer some empathy by stating: "I can see that you have been pretty upset. I'm sorry to be adding to your discomfort, but we do need to talk. It is the only way I can get the information I need to help you." Your appeal to reason may succeed about half the time. If it doesn't, try switching gears to a discussion of the feelings that have blocked cooperation. You may learn quite a lot about your patient's fear, anger or discomfort. By pursuing what you have just heard, you may be able to ease back into the interview.

What if these techniques don't help?

If all your best efforts fail, respect the comfort and privacy of your patient. Specifically, do not plead, threaten or imply shame or guilt. If your patient gets up to leave the room, avoid physical restraint. Instead, acknowledge your patient's right to make this decision and your intention to respect it. Promise to have another try soon at this important task of gathering of information.

When do you decide as an interviewer to quit early?

Occasionally, you may decide to quit early, well short of an hour. This alternative will seem especially attractive when:

• It is late at night, your patient has just been admitted to the hospital, and both of you are exhausted.
• Because of severe psychosis or depression, your patient cannot focus on the interview situation for longer than a few minutes at a time.
• Anger renders your patient unwilling to cooperate.
• You have squeezed a brief interview into an already hectic day.

Chapter 15: How do you interview informants?

Why would you interview informants?

Most patients can tell you nearly everything you need to know, but you can often enrich your database with third-party information. Some situations even demand that you seek additional information or verification. For example, children, adolescents, people with intellectual disability or psychosis, and patients with cognitive disorders or personality disorders often lack adequate perspective on their own behavior. Whenever possible, try to obtain information about a patient's present illness from other sources, such as relatives, friends, previous clinical records and other clinicians. By verifying existing information and providing new facts, you can obtain a clear, comprehensive, balanced view of both patient and milieu.

You will almost always interview the patient first. The only significant exceptions, besides children and younger adolescents who are brought in by their parents, are adults who lack the capacity to speak for themselves. These include regressed patients with schizophrenia, patients with dementia, some individuals with intellectual disability, and persons with whom you do not share a common language. Sometimes an insecure patient needs the support of a relative while telling you the raisins for the appointment.

Why should you obtain permission first?

Before you talk to friends or relatives, yo must usually ask permission from the patient. Most wil consent readily. The few who demur may worry that you will let slip something they have been trying to keep secret. You can often quit these fears by pointing out that your main job is to seek information, not to disperse it, and that to help the most you need another person's perspective. Once you have reached an agreement, be scrupulously careful not to divulge additional information. Revealed secrets have an uncanny way of identifying their source. As a rule, you should try to interview the informant when the patient is not present. The privacy will improve your chances for obtaining complete, accurate information and both you and the informant will feel more comfortable. 

There are a few significant exceptions to the requirement to obtain the patient's consent first: When it entails minors, people on conservatorship or unable to give consent, people who are violent, mute, acutely suicidal, or experiencing any other acute medical or mental health emergency. When it is clear that a patient does not have the judgment to exercise autonomy, it is your duty to step in and make a decision as to the best course of action.

How do you choose and informant?

Because your goal is to obtain as much pertinent material as you can, you will naturally choose an informant who knows your patient well. A spouse or partner usually has the most up-to-date information, so if the patient is married or has an intimate relationship of long standing, this is the person you will probably speak with first. But the sort of information you need may dictate a different choice, for example for a teacher.

What do you ask informants?

You should start by briefly explaining the purpose of the interview. Relatives will readily accept that you need to verify history or to give them information. But they may worry that as a clinician you have another agenda. Your earlier interview with the patient should have netted a rich knowledge base, so your discussion with informants can usually be comparatively brief. Determine that the patient and informant identify the same set of problems. Then you can get down to the business of obtaining the additional specific information you need. It will consist of questions the patient was unable to answer and items about which there is some fonsuion in your mind, often due to inconsistency in the patient's story. If the information from an informant conflicts with what you have obtained from your patient, you must decide which story to believe. You are by no means safe if you automatically accept the informant's version. Rather, when you evaluate conflicting stories, weigh some factors for each information, including the patient him or herself; such as the amount of contact between them, possible distortion by wishful thinking, possible cases of protection of some person. 

Afterwards, it is a good idea to discuss the session with your patient. You should relate some idea of what was said, so as to provide reassurance that you have broken no confidences, but how specific or general you will be depends on your patient's needs and your own taste. 

In what cases can you conduct a group interview?

If the patient's family is large and many members live nearby, you may find yourself interviewing the whole clan. Some clinicians find this difficult, especially when the family members are unhappy and express themselves forcefully. Although it can be difficult to manage a large group of relatives, there are advantages to conducting a group interview instead. When you are meeting with more than one informant at a time, be sure to encourage all relatives to have their say. Your goal should be to facilitate the discussion so that all family members can understand the patient and their common problems.

When do you conduct a telephone interview?

Several studies have shown that you can obtain good-quality information from telephone interviews as well. Perhaps not quite as robust as data from interview conducted face-to-face, but far better than written questionnaires. Especially if there's no other way to speak with a relative, it is certainly better than nothing. But it can be a challenge to interview someone for the first time without face-to-face contact.

Chapter 16: What should you do when you meet resistance?

What does resistance entail?

In most interviews two individuals work together to achieve a common understanding. The vast majority of patients will be cooperative, knowledgeable and, to one degree or other, insightful. But all patients have personal agendas, and sometimes these conflict with the usual goals of the initial interview. That is why many patients will in some manner resits giving complete information. The result can be behavior that frustrates your attempts to obtain a complete database while building rapport. Resistance is any conscious or unconscious attempt to avoid a topic of discussion. Because nearly everyone feels uncomfortable with certain topics, resistance is perhaps the most frequent problem behavior clinicians must learn to deal with. For a number of reasons, then, it is important to address resistance when it appears rather than simply moving on without trying to determine and remedy its causes.

How do you recognise resistance?

To counter resistance, you must first recognise it. Sometimes it is easy, especially if it takes the form of such an obvious statement as "I would rather not talk about it". But many patients feel uncomfortable with open defiance; they may resist you in ways so subtle that you will be hard-pressed to detect them. Watch for any of these behaviors that could indicate that your interview may be in trouble:

• Tardiness: Being late for the interview is a classic sign of resistance.
• Voluntary behaviors: Poor eye contact, glancing at the clock, answering a cell phone or shifting uneasily while seated suggests that your patient may feel uncomfortable with the topic currently under discussion.
• Involuntary behaviours: Flushing, yawning or swallowing can imply discomfort.
• Forgetfulness: Some patients develop a 'convenient' poor memory and respond to certain questions with "I don't know".
• Omissions: The patient leaves out certain information. Unless reliable informants are consulted, even experienced clinicians have trouble detecting this sort of resistance.
• Contradictions: Information that contradicts what you thought you learned earlier is relatively easy to spot but may be difficult to reconcile.
• Changing the subject: Shifting to another topic of conversation may be an attempt to draw you away from a subject the patient would like to avoid.
• Exaggerations: Puffing up their own accomplishments is one way some people avoid facing the truth about themselves. 
• Diversionary tactics: These include telling jokes and asking to get a drink or to use the bathroom. 
• Silence: This can be a major indicator of resistance. It should not be confused with the time some patients need to think before responding to a complicated question.
• A slight hesitation: Most sublet of all may be just a slight hesitation before answering certain questions.

What are the possible explanations for resistance?

Patients may resist telling the whole story to a clinician for a variety of reasons. Understanding these reasons can provide the key to breaking up the resistance. 

• One of the most common reasons is preventing embarrassment, which may operate especially during an initial interview.
• Some patients fear criticism or worry that you may be shocked by their stories.
• Some patients withhold information because they are too afraid of its implications for diagnosis, prognosis or treatment.
• Your new patient might not yet feel enough trust to communicate fully with you.
• Altruism may motivate a patient to protect a friend or loved one from any of the consequences mentioned previously.
• Some incidents or thoughts may seem to trivial to relate.
• The patient could be testing you to see whether you are smart enough or persistent enough to dig out the information that is being withheld.
• Patients may withhold information out of conscious or unconscious anger.

Whatever the cause, you must not allow resistance to persist unexplored and unchallenged. You must try to determine the cause and to remedy it. It can be a serious error to skip important topics or just passively to follow the patient's lead.

How do you cope with resistance?

Above all else, it is most important that you try to understand the reasons behind the behavior. The first step should be to consider whether you have one anything to provoke resistance. There may be something obvious that you can deal with directly. In your behavior, make sure that it comes across that you understand your patient and that he or she has the right to these feelings. Your best first response to managing silence may be a little silence of your own. However, a prolonged lack of response may establish a precedent for withholding further information later in the interview, and that is not in the patient's best interest. During the brief silence, your patient's thoughts may have wandered so your next step should be to refocus the question by asking it again in a slightly different form. Another approach is to try to name the emotions your patient might be having. If you do so correctly, you will enhance your image and empathetic, perceptive and trustworthy. You can also delay the discussion of difficult material. This technique sacrifices information for the sake of rapport and the integrity of the interview, so you should use it sparingly. 

How do you prevent resistance?

As with any other problem, no remedy for resistance is as satisfactory as preventing it in the first place. The following strategies should help you avoid having to use other techniques.

• If before the interview begins you can obtain information about your patient's character or style of interacting, you may be better able to modify your approach to difficult topics.
• Sometimes you can tell right away that your patient is reluctant to alk. 
• Carefully monitor your reactions to the information you obtain. If your speech or facial expression hints of surprise or disapproval, you may seriously damage rapport and limit both the quantity and quality of your information. 
• Answer questions as completely and honestly as you can. 
• Individualize your history-taking technique. 
• Preface your MSE questions about delusions, hallucination and orientation with the remark that these are routine questions. 
• If you encounter psychotic material such as delusions or hallucinations, do not argue. 

What should your attitude be like?

A patient who is uncooperative or difficult creates a challenge to you as an interviewer. As a clinician, you must not let passive-aggressive behaviour, sarcasm or anger precipitate an outburst from you. Such negative affect, especially when it comes early in the relationship, can imperil an interview and seriously damage further rapport. You should ask yourself the questions: Why am I feeling upset? What message am I missing? And whom does this patient remind me of? The answers to these questions should help you determine what corrective action to take.

Chapter 17: What special or challenging patient behaviours and issues can you encounter?

What opportunity do challenging behaviors give us as interviewers?

All patient care special, and each is unique. But the behaviors of some can be especially challenging: They may be vague, hostile, untruthful, confused or even violent. And other than behaviours, certain patient characteristics may also require thoughtful attention. Challenging behaviors and issues offer us the opportunity to hone our skills of accommodation and persuasion, and to practice the virtues of patience and tolerance. 

• Instead of information, a patient may give you only empty words. Vagueness occurs when the client has an unfocused chief complaint, overgeneralises, or only gives approximate answers. In order to deal with vagueness, try first to determine why the patient is being vague. Try to provide structure and indicate clearly what type of answer or degree of precision you expect. 
• A problem related to vagueness is that some patients cannot generalise experiences. You can try to deal with this by redefining what it is you are after. If your patient simply cannot generalise, you may have to make do with several examples form which you distill the generalisation yourself.
• As a part of the therapeutic contract implicit in any clinical relationship, the patient agrees to tell the truth. Unfortunately, for a variety of reasons, it does not always turn out this way and patients may lie when they are frightened, ashamed, worried or angry. A variety of clues could warn you that you patient might not be telling the truth, for example when the history is inconsistent with the known course of the disorder you suspect. As with other problematic behaviors, dealing with suspected lying requires a delicate touch. If you suspect that the patient is being deceitful, be extra careful not to ask leading questions. You can ask for a restatement of what your patient just said.
• Of all the problem bheaivors, hostility may be the easiest to spot. The patient's feelings are clearly shown in a scowl, clenched fist, angry tone of voice, or sarcastic content of speech. The possible causes of hostility are numerous. Any evidence of hostility warns you that before continuing, you must confront your patient's feelings. To advance your interview effectively, you must make the confrontation nonthreatening and nonjudgmental. 

How should you deal with potential violence?

Patients are only infrequently hostile to the point of violence. Although it is uncommon that a mental health worker is severely injured by a patient, many of us have been shaken up or struck at least once during our careers. At best, this is an unsettling experience. Unfortunately, predicting who will become violent is pretty hard. Regardless of the client's diagnoses, an actuarial approach uses the presence or absence of several factors to help predict who will become violent. The factors include relative youths, previous history of violence, a history of being physically abused in childhood and common hallucinations that order the person to commit violent acts. When any of these factors obtains fro a given patient, you should be extra vigilant. During an interview, keep in mind several safety principles:

• Review any documentation before your interview with the new patient. Be especially wary of someone who has history of past violence or seems to have a condition suggesting poor impulse control.
• Ideally, an interview room in a mental health emergency facility will have two doors.
• When you are meeting a new patient fro the first time, try to have a security guard available when it is late a night and there are few other people around. 
• Many clinics have panic buttons installed under the desks in their offices. 
• In doubtful circumstances, leaving the door to the interview room open will also provide you a sense of security and give the patient an added reason for restraint.
• Watch carefully for signs of heightened tension: clinched fists, loud or quavering voice, angry words, narrowed gaze or sudden bursts of activity.
• If your patient becomes agitated or otherwise intimidating, remain calm. 

You must be prepared to cope with potential harm to person or property. It is vital to have a three-part plan: With the principles listed above and the strength of a backup force, ensure your own safety and that of those around you. Maintain your composure as you inform the patient about the consequences of further threats or actual acting-out behavior. Also be fully prepared to follow through with the limits you have set. 

How should you deal with confused patients?

Patients with confusion resulting from dementia or delirium present an unusually vexing challenge to the interviewer. They may think and speak slowly, mix up the chronology of events, forgot important facts, and have difficulty following your instructions. Frustration with their own poor performance sometimes precipitates hostility. Because the data you obtain form them are unreliable and sparse, it is hard to make a valid diagnosis. Sometimes you will conclude your interview with little to show for your efforts. The best solution to this frustrating experience is prevention. Before the interview,w obtain all the information you can from collateral sources. 

How should you approach older patients?

Being old does not by itself constitute a disability. Too often, interviewers forget this and assume that patients who are older are also confused, deaf or feeble. Although you should always try to show appropriate concern, older patients justifiably resent being patronised, physically moved around or shouted at. There are a number of special considerations that you should however keep in mind when you interview older patients:

• You will probably need more interview time just to get through the sheer volume of material. During a lifetime that spans many decades, the average older patient has accumulated more experiences, both good and bad.
• A stylistic change seems to take place somewhere during the seventh or eighth decade of life: Personality traits become accentuated. Older people also tend to reminisce a lot. Speak distinctly, allow more response time, and suggest additional interview sessions if you need them to finish gathering data.
• Older patients have some unique problems that young interviewers may have difficulty relating to. 
• Watch out for instances of elder abuse. This problem, which can include neglect, exploitation and rights violations, as well as physical and psychological abuse, affects a great portion of elderly people. 
• Older patients have suffered a variety of losses, which multiply with the passing years. 

How should you approach younger patients?

Interviewing young people is a pretty big subject. Whereas most adults and a few older adolescents will be seen because they think it is a good idea, children and the majority of adolescents rarely present themselves voluntarily for evaluation. You must therefore place even more than your usual emphasis on establishing great rapport.

What other issues and behaviors can occur?

A variety of situations, attitudes and behaviors can affect the success of your initial interview. Although you probably won't often encounter these characteristics, the response you make can modulate the effect of those that do occur. It is good to regard any issue or behavior that threatens to come between you and the patient as something you should face together. 

• Some patients feel they deserve special treatment. 
• Patients with blindness or marked visual impairment can communicate their thoughts, feeling and experiences just as well as people who can see normally. What they cannot do is read the body language all people normally use to help convey concern and requests. Describe your movements, especially use your tone of voice to indicate that you care and take extra care with the words you use to say what you want them to do.
• Most patients with deafness or seriously impaired hearing will communicate quite well if you speak distinctly and slowly, while looking right at them to facilitate lip reading. 
• Although our training and interests as mental health professionals help us value the variety of life's conditions, we must constantly remain alert for modes of living other than our own. Aside from obvious features such as age, gender, ethnicity and language, the search for defining attributes can also apply to a wide variety of other factors. To bridge a cultural divide, you can exploit your patient's history. 
• Sometimes, a professional interpreter is needed. Be sure to speak to and maintain eye contact with the patient, and not with the interpreter. 
• Like deafness, blindness and other physical attributes, muteness can exist to varying degrees and can have a number of potential causes. To assess muteness, ask any friends or relatives present to leave before you continue your  interview. 
• Seductive behavior is less likely to be a problem during the initial interview than during subsequent therapy sessions. However, the potential fro seduction his ways there, especially when the interviewer is male and the patient is female. The best preventive approach is to maintain appropriate distance at all times. 
• Even without formal testing, you can often pick out the patient who is operating on the lower fringes of what is often called general intelligence. 

Chapter 18: How do you make diagnoses and recommendations?

What do you do after the interview is completed?

With all interviews completed, you face the task of evaluating your information. it should be organised in a form that is useful for making recommendations and for communicating with patients and other professionals. 

What is the importance of a correct diagnosis?

The importance of an accurate diagnosis can hardly be overstated. At best, an incorrect diagnosis delays effective treatment, at worst, it may usher in treatment that is ineffective or even dangerous. Inaccurate diagnosis also risks giving a prognosis that is either too gloomy or too optimistic for the individual patient. Once made, diagnostic error can be difficult to reverse. Diagnosis is passed along from one clinician to another, from one chart to the next. 

What does a differential diagnosis entail?

Most health care professionals state their impressions in terms of a differential diagnosis; a list of the possible diagnoses that should be considered for a given patient. In constructing a differential diagnosis, you need to consider two principles:

• The first principle is to list the most likely diagnoses first, and the rest in decreasing order of probability. Sometimes we call the most likely one the best diagnosis.
• The second one is called the safety principle. It means that there are always some possibilities in the differential list with potential consequences so dire that it is just plain unsafe to ignore them. They are the ones that should be placed at the very top of the differential, to be ruled out first, whether or not you think that they actually caused the illness.

How do you choose treatment?

Fortunately, mental health patients and their therapists today can draw upon a variety of effective biological, psychological and social treatments. Most of these are not specific for any diagnostic category, rather they can be applied across a spectrum of diagnoses. In formulating a treatment plan, you should consider a list of questions to consider:

• Is any treatment likely to reverse the course of the disorder? Unhappily, the answer is sometimes no. 
• How certain is the diagnosis? Treatment has the greatest chance for success when it is based on clinical studies of reliably diagnosed patients. 
• How urgent is the treatment? In general, the urgency for treatment will increase when the symptoms are increasing in number, in intensity or in the alarming consequences it leads to.
• How costly is the treatment?
• What are the relative contraindications of the therapy you are considering?
• And lastly, have you considered all feasible treatment modalities?

The fact that most mental disorders probably have multiple causes should encourage all clinicians to consider using more than one therapeutic modality for any given patient.

What does prognosis entail?

The term prognosis has Greek roots meaning "to know in advance", which is of course impossible. But scientific progress over the past few decades has greatly improved our ability to predict likely outcome for individual patients. The term prognosis implies a number of meanings:

• It relates to symptoms: Will they be relieved partly or completely?
• It relates to the course of illness: Will it be chronic or episodic?
• It relates to the response to treatment: How rapidly will it occur, and will it be complete?
• It also relates to the degree of recovery.
• Then, it also relates to the time course of illness: How long will recovery take?
• It relates to the social consequences of the illness. 
• And lastly, it relates to the degree to which other family members are at risk for the illness.

What factors affect prognosis?

A number of factors help us make accurate predictions. Unfortunately, no one knows how strongly any one factor will influence the outcome in any given case. The factors that affect prognosis are the principal diagnosis, the availability of treatment for the primary disorder, the duration and course of illness, previous response to treatment, adherence to treatment, available social support, premorbid personality, the highest recent level of functioning and other factors. 

What if further investigation is needed?

Further study may be necessary to confirm or rule out specific diagnoses. Resources for this information include a review of prior hospital and other records, laboratory tests, formal neuropsychological testing, and interviews with relatives. 

When do you make referrals?

You are likely to recommend mental health therapy that is directed specifically at your patient's complaints. You should also keep in mind the range of other treatments and referrals that may be needed, either to help manage the presenting complaints or to deal with social, psychological, and biological problems that are incidental to the main problems. 

Many organisations and individuals can help you manage nearly nay problem you might encounter. This is fortunate, because no clinician has the training and experience to do it all alone. It is vital that you know the limits of your own capabilities and refer for outside help those aspects of each patient's difficulties that can be better treated by others. How much outside help will be needed depends on the type of problem, the severity of the problem, the strength and extent of the support network, the patient's motivation and cooperation, and the clinician's training, experience and available time. You can refer patients to other therapists, a mental hospital, legal assistance, support groups, shelters, or other resources.

Chapter 19: How do you share your findings with your patients?

What is the importance of conferring with the patient?

Clinical findings and recommendations become far move useful when they are shared with others. The most important instance of this sharing is with the patient, but it often extends to the family as well. Whether or not you see an outward indication of nervousness, your patient will probably be feeling apprehensive about the results of your findings. This is why you should plan to discuss them just as soon as you can. 

If you follow a few simple rules when communicating your findings, your message will stand a better chance of being both heard and accepted:

• Summarize the problems.
• Give a diagnosis.
• Keep it simple.
• Do not use jargon.
• Also, keep asking for feedback.
• Emphasize the positive. 
• And last but not least, show your compassion.

How do you discuss treatment with your patient?

The treatment plan you arrive at should be structured as a collaborative effort between clinician and patient. Although this approach to treatment planning requires more initial effort in the long run everyone will benefit. A plan shared with the patient is an important part of the initial interview. In the negotiated approach to treatment, patient and clinician together formulate the plan. When you are drawing up the treatment plan together, there are several points to consider:

• Discuss the options.
• Mention the drawbacks. 
• You can favour one option.
• Make sure the patient understands the options.
• Avoid making promises, other than that you will do all in your power to help.

How do you motivate your patient?

Of course, without implementation, the best treatment plan in the world will accomplish precisely nothing. And far too often, that's the outcome of a mental health consultation. Despite the best efforts of the clinician, a patient may forget to take medication, neglect behavioral exercises, or go ahead and drink or use drugs anyway. Enter motivational interviewing (MI), a client-entered approach first used for patient with substance use disorders. MI attempts to persuade people to adopt new behaviors they need for health care or other reasons. Instead of confrontation, it emphasises collaboration. According to MI, you should empathise, help the patient recognise how current behavior is frustrating long-term wishes, don't agree with resistance, and provide hope by showing you believe the patient can succeed. 

How do you discuss the plan with the family?

A close-knit family will want to know all that can be done for the patient. Many relatives have had considerable experience in dealing with mental health professionals; for some, this involvement has not always been satisfactory. The quality of their experience this time will usually be in direct proportion to (1) the amount of contact they have with you, (2) the degree to which they feel they have input, (3) how caring you appear to be, and (4) the patient's opinion of you and the treatment plan. Be sure to tell ratline show to get in touch with you, and emphasise that you want all three groups - the patient, the relatives and you - to work together as partners in problem solving. 

What if the plan is rejected?

With the stress of mental illness in the family, it is not uncommon for someone to object to the treatment plan. If it is a relative or friend, and you and the patient agree about how to proceed, move ahead with the plan. If your patient is the one who balks at treatment, proceed with a series of steps that might resolve your impasse:

• Try to discover what about the plan is not acceptable.
• Identify the areas that you do not agree about.
• Learn what therapeutic measure the patient will accept.
• You may agree to an experimental trial, with the proviso that you will monitor the results carefully and stop or change treatment if the patient feels dissatisfied.
• Offer to arrange for a second opinion.
• Finally, it is possible that either the patient or the family may reject treatment you consider to be essential.

Chapter 20: How do you communicate your findings to others?

How do you write a written report?

Even the most expert of clinicians collect their data somewhat haphazardly. It is therefore necessary to organise your findings before reporting them. For written and oral reports, the organisation of material will be about the same. Written reports are usually the more complete. The identifying data section provides the reader with a framework upon which to construct a mental image of the patient whose history you are reporting. You state the basic demographic data and anything else that seems relevant. Then, describe the chief complaint, the names of the informant, the history of the present illness and the personal and social history. Thereafter, you provide information about the mental status examination. 

How do you record your diagnosis?

The standard for psychiatric diagnosis has been each successive edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association. The DSM specifies that each patient be assessed in several areas.

• The first includes the major clinical syndromes; most mental health patients will have at least one of these diagnoses. 
• A statement of nay physical diagnoses that contribute to your understanding of the patient.
• The psychosocial stressors that during the past year may have caused or affected the patient's mental condition, or might materially affect treatment.
• The Global Assessment of Functioning rates the patient's overall functioning. 

How do you formulate your diagnosis?

In the case formulation, you attempt to synthesise all that has been learned about the patient's past, so as to point the way to a better future. There are several reasons for preparing a formulation:

• It focuses your thinking about the patient.
• It summarises the logic behind your diagnosis.
• You identify future need for information and treatment.
• And you present a brief summary of the patient.

A number of formats can be used. One of the methods is to present a brief recapitulation, differential diagnosis, the best diagnosis, contributing factors, further information that is needed, the treatment plan and a prognosis. 

Chapter 21: How do you troubleshoot your interview?

When is an interview troubled?

To some degree, every interview has flaws, and every interviewer has faults. The art of the expert interview lies in compensating for the former and minimising the effects of the later. An initial evaluation can go awry in many ways, but the outcome can be affected in only a couple of ways. Rapport with the patient probably least often falls victim to problematic interviewing. The other effect of an interview that's run aground involves the data we seek. That is, we clinicians sometimes obtain information that we think is accurate and complete, when it is not.

What signals point into the direction of a troubled interview?

Some signals that can tip you off that your interview is troubled are the following:

• During the interview, the patient might become quiet, quarrelsome or critical.
• Although a patient who glances around the room may be attending to hallucinations, it is more likely that this patient has lost interest in the conversation.
• You might get contradictory answers to reparations of essentially the same question. 
• You may find that you cannot think of questions to ask that will pin down an important part of the differential diagnosis.
• You patient may continually ask you the treat your questions.
• You yourself may want to get up and leave the room.
• Once your patient has departed, you may find that you have omitted important data points.
• The patient may decline to make another appointment.
• Information you have just gathered may contradict data from old charts or collateral sources.
• Your information may speak only to one item in the differential diagnosis.
• You may have learned a lot about baseball, but little about the patient's history. 
• You may not have learned enough about the patient's feelings.
• Or lastly, you may not have raised one of these issues critical to every interview: sex, substance use or suicidal ideas. 

How do you determine what is wrong with your interview?

The following diagnostic steps can help you determine what is wrong with your interview. Even if you have not encountered any of the issues mentioned before, it is recommended to take the fearless first step once in a while anyway. After all, the most insidious error of all is the one that isn't called to your attention.

• Make a recording of your interview, and watch it critically.
• Do some witnessed interviews. 

You may learn that the scope of your interview is too limited, you insufficiently follow up on clues, you make inadequately use open-ended questions, there may be inappropriate probing, or inadequate control of the interview, or you observe that there is poor rapport between you and the client. You may observe that you ignore the patient, have no real plan for the interview, you may excessively talk, or there may be negative countertransference. There can be a variety of other factors that you observe when looking back at your own interview. It is important to be critical.