Bullet point summaries with The First Interview - 4th edition - Morrison (2014)

Chapter 1: How do you open an interview?

• 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.
• 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.
• Morrison expresses percentages the amounts of time you should plan to devote to the various portions of an average initial interview. Your own professional needs may change the focus somewhat.
• 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.
• 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.

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

• 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.
• 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. 
• 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'.
• 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.
• As a rule, you should allow your patient to speak freely as long as the information you obtain seems important and relevant. 

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

• Rapport is the feeling of harmony and confidence that should exist between patient and clinician.
• 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
• 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.
• For good rapport, the patient must know that you understand.
• 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. 
• 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.
• A natural consequence of empathy is respect,t which implies that you should take pains to avoid sounding authoritarian.

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

• 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.
• 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.
• 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.
• 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.

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

• 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. 
• 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.
• 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.
• 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.
• Patients often mention stressors during free speech, or even when stating the chief complaint.
• 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.

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

• 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.
• In clinical interviewing, you must constantly reconcile two opposing principles: harvesting all the necessary information while avoiding the bog of excessive detail.
• 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.
• When it comes time to delve more deeply into your patient's presenting problems, choose your probing questions with two principles in mind: (1) Select probes that will resolve unanswered questions. It is more efficient to concentrate your efforts on areas you have not already covered. (2) 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.
• At this point in your interview, you are interested in the facts, so questions that begin with "why" are often better avoided.
• Morrison distinguishes several important rules for interviewing.

Chapter 7: How do you interview about feelings?

• 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. 
• Successful examiners effectively use two techniques that are especially good at eliciting emotions. These are direct requests and open-ended questions.
• 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. 
• 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, and they can be effective or ineffective.

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

• 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.
• During the interview, you inquire about childhood and adolescence, the life as an adult, the medical history, the family history, personal traits and disorders.
• We distinguish several different personality disorders. 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.

Chapter 9: How do you deal with sensitive subjects?

• 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.

Chapter 10: How do you control 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. 
  • 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.
• 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.

Chapter 11: How do you inquire about behavioral aspects during 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 general appearance and behaviour, mood and 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 content of thought, perception, cognition, insight and judgment.
• 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.
• Mood is described in several dimensions: type, lability, appropriateness and intensity. 
• 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. 

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

• 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
• A delusion is a fixed, false belief that the patient's culture and education cannot account for.
• Hallucinations are false sensory perceptions that occur in the absence of a related sensory stimulus.
• Anxiety is fear that is neither directed at nor caused by anything specific the patient can identify.
• 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.
• In the context of the mental health evaluation, insight refers to the validity or your patient's ideas about whatever problem you are evaluating.

Chapter 13: How do you inquire about signs and symptoms in 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 specific tip-offs, or the 'red flag' symptoms that should alert you to explore further. 

Chapter 14: How do you close an interview?

• 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. 
• If you are a practicing clinician responsible for this patient's care, you will probably follow three steps: Summarize your findings, with the patient's collaboration, develop a plan for future management, and set a time for your next meeting.
• Sometimes a patient wants to leave early. If all your best efforts to make him or her stay fail, respect the comfort and privacy of your patient.

Chapter 15: How do 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.
• Because your goal is to obtain as much pertinent material as you can, you will naturally choose an informant who knows your patient well
• 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.

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

• 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.
• To counter resistance, you must first recognise it.
• 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. 
• 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.
• 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?

• 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. 
• 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. 
• 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.
• 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.
• 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.

Chapter 18: How do you make diagnoses and recommendations?

• The importance of an accurate diagnosis can hardly be overstated.
• 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.
• 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.
• The term prognosis implies a number of meanings.

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

• 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, keep asking for feedback, emphasize the positive, and last but not least, show your compassion.
• Motivational interviewing (MI) attempts to persuade people to adopt new behaviors they need for health care or other reasons. Instead of confrontation, it emphasises collaboration.
• With the stress of mental illness in the family, it is not uncommon for someone to object to the treatment plan.

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

• 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. 
• 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.
• One of the methods for formulating a diagnosis 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?

• 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
• There are a variety of signals that can tip you off that your interview is troubled.
• Make a recording of your interview, and watch it critically and do some witnessed interviews. It is important to be critical.