The first interview
Morrison, J.

Chapter 5 History of the present illness

You can move to the history of the present illness if there are no major problem areas to discover. Throughout the balance of history taking, listen for other clues that might point the way for further explorations.

Explore the problems that have brought the client into treatment. You might consider the areas of clinical interest you covered during free speech.

It is a convention to label as ‘illness’, whatever brings anyone in for evaluation. All problems have precipitants, symptoms, course, and other features that allow you to suggest an effective plan of action.

The present episode

Concentrate first on the current episode of illness. You need a fund of basic information as to exactly what symptoms you can expect to find in an episode of illness. For this, you need to refer to textbooks and other resources.

Describing symptoms

Learn as much as you can about each symptom your client reports. A symptom is any subjective sensation that makes the client think that something is wrong. Clarify any descriptive terms that are used.

Characterize each symptom as fully as you can. Symptoms can wax and wane with time or changes in the environment. Does the client notice such factors?

Vegetative symptoms

Vegetative symptoms are body functions that are concerned with maintaining health and vigour. Vegetative symptoms include problems with:

Sleep

Either excessive (hypersomnia) or inability to sleep (insomnia). If the client has insomnia, find out what portion of the sleep is affected; 1) early (initial insomnia), this is common 2) middle (interval insomnia), this can be found in PTSD or substance abuse 3) late (terminal insomnia), this is usually associated with more severe mental problems.

Appetite and weight change

You should learn how significant the change has been and whether this was intentional.

Energy level

Diurnal variation of mood

Clients with severe depression often feel worse upon arising and better as the day goes on. Those who are less depressed are more likely to report feeling better early in the day, but depressed by nightfall.

Sexual interest and performance

Sexual functioning usually depends upon the individual’s sense of wellbeing.

These symptoms are found in so many of the serious mental disorders that they serve as a screening tool. Look especially for change from previous normal functioning.

Consequences of illness

Mental disorder can interfere with the entire range of human interaction.

It is important to learn how you client’s illness has affected functioning and relationships because: 1) It may provide your most reliable index of severity 2) The diagnosis of some disorders depends heavily on social consequences 3) You may learn that relatives blame the client for various things, while these can be the effects of mental disorders.

Start with an open-ended question that doesn’t limit information that you might obtain. Be sure to obtain details about any positive answers. Area to explore include: marital/couple, interpersonal,legal, occupational/educational, disability payments, interests and symptoms.

Onset and sequence of symptoms

Establish the timing and sequence of the symptoms. Try to encourage precision about the onset of especially noticeable symptoms. Some clients can’t give a date or an approximation. In this case, try focusing on something the client may have thought about many times. At least try to learn which of your client’s several problems started first.

Stressors

A stressor is any condition or event that seems to cause, precipitate, or worsen a client’s mental health problems. What might be mildly stressful for one person could seem catastrophic to another.

Stressors should have occurred within the year prior to your evaluation. If they took place earlier, they must be a focus of treatment or have contributed to the development of the mental health disorder to count as a current stressor.

Clients often mention stressors during free speech. If they don’t, you will have to ask. A good time for this is right after you have pinned down the onset of the episode of illness. If you find a stressor, try to learn how if affected the course of the illness.

If the client can’t think of any possible stressor, you should run through a list of possibilities, pausing briefly to allow thinking time.

For some episodes of illness you’ll find no stressors at all. To  a client almost anything can seem a possible cause of emotional disorder.

Just because your client identifies something as a stressor, this doesn’t mean that it actually caused the disorder to happen. Often two events simply occur by coincidence.

Try to answer the question: Why does your client appear for evaluation now?

Previous episodes

Knowing about previous episodes of the same or similar mental condition can help you determine diagnosis and prognosis for the future. Ask whether there were previous episodes and how they went.

This information may help you evaluate the severity of the present episode by comparing it with earlier episodes.

Previous treatment

Try to learn everything about previous treatment.

Chapter 6: Getting the facts about present illness

Of all portions of the initial mental health interview, the history of the present illness is probably most important. This is where you develop most of the information and test the hypotheses that provide the basis for your diagnosis. This process requires highly valid information.

Be clear about the goals of your interview

Ideally, your client will understand your expectations for accuracy form the very beginning of the interview.

Your client may appear to be holding back information. Your first task in this case is to try to understand this behaviour.

It sometimes helps to repeat your reassurances about confidentiality.

Track your distractions

When new material interrupts the flow of your interview, you can either pursue it immediately or make a note to come back to it later. If you choose the later, you should acknowledge that your client has said something.

In clinical interviewing, you try to get all the necessary information and avoid the bog of excessive detail.

Use open-ended questions

Above all else, you want information that is valid. Clients 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.

Talk the client’s language

Guard against using technical words that clients might not understand.

Some clients think they understand something when they don’t. If they answer the question they thought you asked, the information you get might not be accurate. Others are reluctant to admit their ignorance and so say nothing.

You will improve validity if you pitch your questions at a level the client can understand, but be careful not to talk down the client.

You should work hard to be sure that you understand what your client is trying to say. To find out, you can do two things: 1) state your understanding of the expression 2) ask what was meant.

Be careful not to judge other people’s behaviour by your own.

Choose the right probing questions

When you want to know about something, just ask. If you use an open-ended question, you’ll probably get the details.

When it comes time to delve more deeply into your client’s presenting problems, choose probing questions with two principles in mind: 1) select probes that will resolve unanswered questions 2) if your questions show that you know a lot about the illness, you will be perceived as knowledgeable. The resulting dividend of rapport and trust should lead to increased sharing of information.

Questions beginning with ‘Why’ can prove frustrating to a clients who lacks insight. These 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 the client’s symptoms or problems. Each symptom has its unique set of details that must be explored. For a full, rich exploration of any behaviour or event, certain items of information are always necessary. These include details about the symptoms’: type, severity, frequency, duration and context.

Because you will be looking for specific details, you will be using more close-ended questions. You should still include some open-ended questions which will stimulate your client to relate additional material you may not have thought to ask about.

It is important to: 1) don’t phrase questions in the negative 2) don’t ask double questions 3) avoid leading questions 4) encourage precisions 5) keep questions brief 6) keep on the lookout for new leads.

Confrontations

Confrontation means pointing out something that requires clarification. The purpose of this is to help you and the client communicate better.

In the usual initial interview, you should try to avoid any confrontation more than a mild one because you don’t know another well at all. If you seem to be getting contradictory information on an important point, try to enhance validity by asking for clarification. When you ask, be gentle.

Whatever the issue, try to restrict your confrontations to one or two essential issues.

To be sure that you reserve this treatment for only the most important issues, it is better to save confrontation until close to the end of the interview 1) The relationship should be better 2) you have obtained most of your information.

Chapter 7: Interviewing about feelings

Feelings about the illness will be among the most important information you obtain during the entire interview.

Negative and positive feelings

You can obtain information about feelings from most normally expressive people just be watching and listening. In some clients you will have to go prospecting to elicit feelings.

Eliciting feelings

Most clients will express their feelings adequately if you just ask. Two techniques are especially good at eliciting emotions: 1) direct request 2) open-ended questions.

Direct request for feelings

Watch for the opportunity to ask about the feelings associated with any of the facts you have been discussing. Asking is the most effective method of eliciting emotions, but be careful to use the word feelings or a synonym.

Open-ended questions

Open-ended questions encourage the free expression of emotions. Its relative freedom encourages clients to speak at length. The more people talk, the more likely they are to reveal emotion-laded information.

This technique suggest that you care about how the client perceives the situation as a whole.

Open-ended questions can help  clients who have trouble sorting out conflicting feelings.

Other techniques

Several situations can make it hard to elicit emotions from clients: 1) from childhood, some people are discouraged from revealing their feelings or displaying emotions 2) some clients don’t recognize their own feeling or have difficulty connecting their feelings to their experiences 3) some may be reluctant to express themselves because it makes them feel vulnerable.

To elicit feelings in some of these situations may require to use such techniques as: 1) expressions of concern of sympathy, this is especially likely to work if the client has already begun to share some feelings. This can be either verbal or behavioural 2) reflection of feelings, explicitly stating the emotion you thing the client might have felt in a given situation 3) picking up on emotional cues, being constantly alert for indications of high emotional concern. Often these will be nonverbal 4) interpretation, drawing parallels between the emotional content of current and past situations. Ideally, the client should be the one who suggests the connection, if not, offer it tentatively.

Analogy

For the client who absolutely cannot identify the feeling that accompany a given situation, you could ask about times when similar feelings might have been experienced.

Following 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.

Defence mechanisms

You should learn what your client does to cope with feelings. These strategies hare called defence mechanisms. They can be harmful and helpful.

Handling excessively emotional clients

Some clients are so emotional that it impedes their communication. This can be due to a variety of reasons: 1) people why are angry 2) some people have learned that high-volume emotions help them get their way 3) some use high emotional output to control their families or friends 4) some have been rewarded for using emotions 5) anxiety 6) some cannot stand the loneliness of silence 7) a fear for disinterest.

In such a situation, try to adopt a brisk, controlling manner in which you firmly direct the course of the interview: 1) acknowledge the emotion 2) talk quietly. It will be hard for most people to maintain high-volume output when you are speaking so softly you can barely be heard 3) explain again what information you are trying to get 4) redirect any of the clients questions or comments that change the topic 5) switch to a closed-ended style 6) check to be sure that the client understands what you want.

The aim of these techniques is to reduce the client’s scope for excessive verbal and behavioural output.

It these techniques are insufficient, you make have to break off the interview long enough for the client to get a better grip.