The Psychiatric Interview

Overview

The purpose of the initial psychiatric interview is to build a relationship and a therapeutic alliance with an individual or a family, and to collect, organize, and synthesize information about present and past thoughts, feelings, and behaviors. The relevant data derive from several sources: observing the patient's behavior with the examiner and with others present (including medical staff); attending to the emotional responses of the examiner; obtaining pertinent medical, psychiatric, developmental, educational, occupational, social, cultural, and spiritual history (using collateral resources if possible); and performing a mental status examination. The initial evaluation should enable the practitioner to develop a clinical formulation that integrates biological, social, and psychological dimensions of a patient's life and establish provisional clinical hypotheses and questions—the differential diagnosis—that need to be tested empirically in future clinical work.

A collaborative review of the formulation and differential diagnosis can provide a platform for developing (with the patient) options and recommendations for treatment, taking into account the patient's amenability for therapeutic intervention. Finally, the interview must generate a relationship both with the patient and with the primary medical or surgical team as the basis of future collaboration for treatment.

Few medical encounters are more intimate and potentially frightening and shameful than the psychiatric examination. As such, it is critical that the examiner create a safe space for the kind of deeply personal self-revelation required.

Several methods of the psychiatric interview are examined in this chapter. These methods include the following: promoting a healthy and secure attachment between doctor and patient that promotes self-disclosure and reflection and lends itself to the creation of a coherent narrative of the patient's life; appreciating the context of the interview that influences the interviewer's clinical technique; establishing an alliance around the task at hand and fostering effective communication; considering awareness of one's personal implicit biases that may influence history gathering, establishing a relationship, and offering options for treatment; collecting data necessary for creating a formulation of the patient's strengths and weaknesses, a differential diagnosis, and recommendations for treatment, if necessary; educating the patient about the nature of emotional, behavioral, and interpersonal problems, and psychiatric illnesses (while preparing the patient for a psychiatric intervention, if indicated and agreed upon, and setting up arrangements for follow-up); using special techniques with children, adolescents, and families; understanding difficulties and errors in the psychiatric interview; and documenting the clinical findings for the medical record and communicating with other clinicians involved in the patient's care.

Case 1

Mr. C, a 96-year-old man presented to the emergency department (ED) the day after he fell the previous night in his assisted-living facility; while on the way to the bathroom he tripped and fell. There was no pain, no head injury, and no loss of consciousness. He had called his 65-year-old son (a physician) and they agreed that Mr. C could probably return to bed and that they would talk the next day.

The day after the fall, Mr. C called his primary care provider (PCP) and reported that he had not urinated that day. He was told to go to the ED. His son, who was notified, met him at the hospital. His medications included a diuretic for hypertension, metoprolol for an arrhythmia, and escitalopram for anxiety. He had been treated for prostate cancer 6 years earlier, with excellent results.

In the ED he was alert and articulate, and able to describe his medical, social, and psychiatric history. His son corroborated the history. The consultant frequently turned to the son to obtain parts of the history. Mr. C also had a 60-year-old daughter. His wife had died 10 years previously from cancer. He said that he was dizzy and short of breath. His work-up revealed that his hematocrit had dropped from a baseline of 35.3 to 29, and he had a large hematoma in his left chest, with six fractured ribs. There was no pneumothorax. Mr. C received a blood transfusion.

In the ED, he became disoriented and agitated, and began talking to his wife. His son informed the nurse and a psychiatric consultation was ordered. About 2 hours later, the psychiatric consultant arrived and noted that Mr. C was oriented (times three), that his recent and remote memory was intact, and his speech was normal in flow and form. His mood and affect were normal and he did not recall having spoken with his deceased wife. He denied hallucinations, paranoia, or suicidal ideation. The psychiatrist's interview included a lengthy discussion of his passion for fishing, boating, and gourmet cooking. They talked about his life-long work as an entrepreneur, and the loving relationship he had with his late wife. They also talked about their mutual love for sushi. He made frequent jokes about the long wait for a bed, and the frantic pace in the ED. Given Mr. C's long wait in the ED, he thought it might be a good idea for the hospital to have room service and this might help in the financial problems in the healthcare system, and he suggested that the hospital leadership might consult him for advice. He noted that serving fish would be wonderful for raising everyone's omega-3 fatty acids.

After Mr. C was admitted to the medical floor, he again became disoriented, agitated, and needed restraint (as he was attempting to pull out his intravenous lines and to leave his bed). The psychiatrist returned to his bedside, noted the changes in his mental status, and suggested low-dose haloperidol and lorazepam for what appeared to be an episode of delirium.

Later that evening, the consultant returned to find the man much improved. Upon greeting him, the psychiatrist was asked how he was doing with establishing room service, particularly now that he was in his room. They talked about the terrible quality of the hospital food, and the need for changes to the healthcare system, as well as a sushi bar in the hospital.

Unfortunately, delirium recurred despite moderately increased doses of haloperidol. The consultant discussed the case with the psychiatric resident covering the consultation service. The resident asked the attending consultant if the recurrent delirium might be complicated by alcohol withdrawal. The resident, who spent considerable time alone with Mr. C inquired about his daily use of alcohol and noted that he tended to drink up to a fifth of vodka nightly to aid a chronic sleep problem. The senior consultant realized that his history was deficient, largely because he did not ask about alcohol or substance use, and reflected that his history was influenced by the presence of the patient's son, who was a physician. He appreciated that he inadvertently omitted sensitive but essential parts of the interview in an effort to avoid shaming the patient and his son. This appreciation resulted in ordering lorazepam and having a more detailed discussion of substance use and his sleep disturbance.

Lessons From Attachment Theory, Narrative Medicine, and Mindful Practice

I'm the spirit's janitor. All I do is wipe the windows a little bit so you can see for yourself. — G odfrey C hips , L akota M edicine M an

Healthy interactions with “attachment figures” in early life (e.g., parents) promote robust biological, emotional, and social development in childhood and throughout the life cycle. The foundations for attachment theory are based on research findings in cognitive neuroscience, genetics, and brain development, and they indicate an ongoing and life-long dance between an individual's neural circuitry, genetic predisposition, brain plasticity, and environmental influences. Secure attachments in childhood foster emotional resilience and generate skills and habits of seeking out selected attachment figures for comfort, protection, advice, and strength. Relationships based on secure attachments lead to effective use of cognitive functions, emotional flexibility, enhancement of security, assignment of meaning to experiences, and effective self-regulation. In emotional relationships of many sorts, including the student–teacher and doctor–patient relationships, there may be many features of attachment present (such as seeking proximity, or using an individual as a “safe haven” for soothing and as a secure base).

What promotes secure attachment in early childhood, and how may we draw from this in understanding a therapeutic doctor–patient relationship and an effective psychiatric interview? The foundations for secure attachment for children (according to Siegel) include several attributes ascribed to parents ( Table 4-1 ).

Table 4-1

Elements That Contribute to Secure Attachments

Communication that is collaborative, resonant, mutual, and attuned to the cognitive and emotional state of the child.
Dialogue that is reflective and responsive to the state of the child. This creates a sense that subjective experience can be shared, and allows for the child “being seen.” It requires use of empathy, “mindsight,” and an ability to “see,” or be in touch with, the child's state of mind.
Identification and repair of miscommunications and misunderstandings. When the parent corrects problems in communication, the child can make sense of painful disconnections. Repair of communication failures requires consistent, predictable, reflective, intentional, and mindful caregiving. The emphasis here is on mindfulness and reflection. Mindfulness in this instance is an example of a parent's ability for self-awareness, particularly of his or her emotional reactions to the child and the impact of his or her words and actions on the child.
Emotional communication that involves sharing feelings that amplify the positive and mitigate the negative.
Assistance in the child's development of coherent narratives that connect experiences in the past and present, creating an autobiographical sense of self-awareness (using language to weave together thoughts, feelings, sensations, and actions as a means of organizing and making sense of internal and external worlds).

We must always be mindful not to patronize our patients and to steer clear of the paternalistic power dynamics that could be implied in analogizing the doctor–patient relationship to one between parent and child; nonetheless, if we substitute “doctor” for “parent” and similarly substitute “patient” for “child,” we can immediately see the relevance to clinical practice. We can see how important each of these elements is in fostering a doctor–patient relationship that is open, honest, mutual, collaborative, respectful, trustworthy, and secure. Appreciating the dynamics of secure attachment also deepens the meaning of “patient-centered” care. The medical literature clearly indicates that good outcomes and patient satisfaction involve physician relationship techniques that center on reflection, empathy, understanding, legitimization, and support. Patients reveal more about themselves when they trust their doctors, and trust has been found to relate primarily to behavior during clinical interviews rather than to any preconceived notion of competence of the doctor or behavior outside the office.

Particularly important in the psychiatric interview is the facilitation of a patient's narrative. The practice of narrative medicine involves an ability to acknowledge, absorb, interpret, and act on the stories and struggles of others. Charon describes the process of listening to patients' stories as a process of following the biological, familial, cultural, and existential thread of the situation. It encompasses recognizing the multiple meanings and contradictions in words and events; attending to the silences, pauses, gestures, and non-verbal cues; and entering the world of the patient, while simultaneously arousing the doctor's own memories, associations, creativity, and emotional responses—all of which are seen in some way by the patient. Narratives, as with all stories, are co-created by the teller and the listener. Storytelling is an age-old part of social discourse that involves sustained attention, memory, emotional responsiveness, non-verbal responses and cues, collaborative meaning-making, and attunement to the listener's expectations. It is a vehicle for explaining behavior. Stories and storytelling are pervasive in society as a means of conveying symbolic activity, history, communication, and teaching. If a physician can assist the patient in telling his or her story effectively, reliable and valid data will be collected and the relationship solidified. Narratives are facilitated by authentic, compassionate, and genuine engagement.

A differential diagnosis detached from the patient's narrative is arid; even if it is accurate it may not lead to an effective and mutually designed treatment path. By contrast, an accurate and comprehensive differential diagnosis that is supported by an appreciation of the patient's narrative is experienced by both patient and physician as more three-dimensional, more real, and more likely to lead to a mutually created and achievable plan, with which the patient is much more likely to “comply.”

Creating the optimal conditions for a secure attachment and the elaboration of a coherent narrative requires mindful practice. Just as the parent must be careful to differentiate his or her emotional state and needs from the child's and be aware of conflicts and communication failures, so too must the mindful practitioner. Epstein noted that mindful practitioners attend in a non-judgmental way to their own physical and mental states during the interview. Their critical self-reflection allows them to listen carefully to a patient's distress, to recognize their own errors, to make evidence-based decisions, and to stay attuned to their own values so that they may act with compassion, technical competence, and insight.

Self-reflection is critical in psychiatric interviewing. Reflective practice entails observing ourselves (including our emotional reactions to patients, colleagues, and illness); our deficits in knowledge and skill; our personal styles of communicating; our responses to personal vulnerability and failure; our willingness or resistance to acknowledge error, to apologize, and to ask for forgiveness; and our reactions to stress. Self-awareness allows us to be aware of our own thinking, feelings, and action, while we are in the process of practicing. It is important in the elaboration of a patient's narrative to separate it from one's own. We all have life experiences that may house unconscious associations and biases that may inadvertently color or influence our perception of the stories related by our patients. For example, our attitudes toward gender, sexual orientation, race, ethnicity and culture, are often colored by implicit bias, and these may become barriers to an empathic psychiatric interview. The more we are able and willing to confront our hidden judgmental attitudes, the better we are able to foster truly collaborative relationships, gather history impartially, and engage in patient-centered care. By working in this manner, a clinician enhances his or her confidence, competence, sensitivity, openness, and lack of defensiveness—all of which assist in fostering secure attachments with patients, and help them share their innermost fears, concerns, and problems.

The Context of the Interview: Factors Influencing the Form and Content of the Interview

All interviews occur in a context. Awareness of the context may require modification of clinical interviewing techniques. There are four elements to consider: the setting, the situation, the subject, and the significance.

The Setting

Patients are exquisitely sensitive to the environment in which they are evaluated. There is a vast difference between being seen in an emergency department (ED), on a medical floor, on an inpatient or partial hospital unit, in a psychiatric outpatient clinic, in a private doctor's office, in a school, or in a court clinic. In the ED or on a medical or surgical floor, space for private, undisturbed interviews is usually inadequate. Such settings are filled with action, drama, and hospital personnel who race around. ED visits may require long waits and contribute to impersonal approaches to patients and negative attitudes towards psychiatric patients. For a patient with borderline traits who is in crisis, this can only create extreme frustration and exacerbate chronic fears of deprivation, betrayal, abandonment, aloneness, and regression. For these and for higher functioning patients, the public nature of the environment and the frantic pace of the emergency service may make it difficult for the patient to present personal, private material calmly. It is always advisable to ask the patient directly how comfortable he or she feels in the examining room, and to try to ensure privacy and a quiet environment with minimal distractions.

The setting must be comfortable for the patient and the physician. If the patient is agitated, aggressive, or threatening, it is important to calmly assert that the examination must require that everyone is safe and that we will only use words and not actions during the interview. Hostile patients should be interviewed in a setting in which the doctor is protected. In some instances, local security may need to be called to ensure safety.

The Situation

Many individuals seek psychiatric help because they are aware that they have a problem. Given the limitations placed on psychiatrists by some managed care panels, access to care may be severely limited. It is not unusual for a patient to present to an ED in crisis after having called multiple psychiatrists, only to find that their practices are all filled. The frustrating process of finding a psychiatrist sets the stage for some patients to either disparage the field and the healthcare system, or to idealize the psychiatrist who has made the time for the patient. In either case, much goes on before the first visit that may significantly affect the initial interview. To complicate matters, the evaluator needs to understand previous experience with psychiatrists and psychiatric treatment. Sometimes a patient has had a negative experience with another psychiatrist—perhaps the result of a mismatch of personalities, a style that was ineffective, a treatment that did not work, or other problems. Many will wonder about a repeat performance. In all cases, in the history and relationship-building, it is propitious to ask about previous treatments (e.g., what worked and what did not, and particularly how the patient felt about the psychiatrist). There should be reassurance that this information is held in confidence, though in a hospital setting, the clinician should discuss that information may be shared with the medical or surgical team.

Other patients may come in reluctantly or even with great resistance. Many arrive in the ED at the request or demand of a loved one, friend, colleague, or employer because of behaviors deemed troublesome. The patient may deny any problem or simply be too terrified to confront a condition that is bizarre, unexplainable, or “mental.” Some conditions are ego-syntonic, such as anorexia nervosa. A patient with this eating disorder typically sees the psychiatrist as the enemy—as a doctor who wants to make her “get fat.” For resistant patients, it is often very useful to address the issue at the outset. With an anorexic patient referred by her internist and brought in by family, one could begin by saying, “Hi, Ms. Jones. I know you really don't want to be here. I understand that your doctor and family are concerned about your weight. I assure you that my job is first and foremost to understand your point of view. Can you tell me why you think they wanted you to see me?” Another common situation with extreme resistance is the individual with alcohol abuse who is brought in by a spouse or friend (and clearly not ready to stop drinking). In this case you might say, “Good morning, Mr. Jones. I heard from your wife that she is really concerned about your drinking, and your safety, especially when driving. First, let me tell you that neither I nor anyone else can stop you from drinking. That is not my mission today. I do want to know what your drinking pattern is, but more than that, I want to get the picture of your entire life to understand your current situation.” Extremely resistant patients may be brought involuntarily to an emergency service, often in restraints, by police or ambulance, because they are considered dangerous to themselves or others. It is typically terrifying, insulting, and humiliating to be physically restrained. Regardless of the reasons for admission, unknown to the psychiatrist, it is often wise to begin the interview as follows: “Hi, Ms. Carter, my name is Dr. Beresin. I am terribly sorry you are strapped down, but the police and your family were very upset when you locked yourself in the car and turned on the ignition. They found a suicide note on the kitchen table. Everyone was really concerned about your safety. I would like to discuss what is going on, and see what we can do together to figure things out.”

In the general hospital, a physician is commonly asked to perform a psychiatric evaluation on a patient who is hospitalized on a medical or surgical service with symptoms arising during medical or surgical treatment. These patients may be delirious and have no idea that they are going to be seen by a psychiatrist. This was never part of their agreement when they came into the hospital for surgery, and no one may have explained the risk of delirium. Some may be resistant, others confused. Other delirious patients are quite cognizant of their altered mental status and are extremely frightened. They may wonder whether the condition is going to continue forever. For example, if we know a patient has undergone abdominal surgery for colon cancer, and has been agitated, sleepless, hallucinating, and delusional, a psychiatric consultant might begin, “Good morning, Mr. Harris. My name is Dr. Beresin. I heard about your surgery from Dr. Rand and understand you have been having some experiences that may seem kind of strange or frightening to you. Sometimes after surgery, people have a reaction to the procedure or the medications used that causes difficulties with sleep, agitation, and mental confusion. This is not unusual, and it is generally temporary. I would like to help you and your team figure out what is going on and what we can do about this.” Other requests for psychiatric evaluation may require entirely different skills, such as when the medical team or emergency service seeks help for a family who lost a loved one.

In each of these situations, the psychiatrist needs to understand the nature of the situation and to take this into account when planning the evaluation. In the aforementioned examples, only the introduction was addressed. However, when we see the details (discussed next) about building a relationship and modifying communication styles and questions to meet the needs of each situation, other techniques might have to be employed to make a therapeutic alliance. It is always helpful to find out as much ancillary information as possible before the interview. This may be done by talking with the medical team and primary care physicians, by looking in an electronic medical record or patient chart, and by talking with family, friends, or professionals (such as police or emergency medical technicians).

The Subject

Naturally, the clinical interview needs to take into account features of the subject (including age, developmental level, gender, and cultural background, among others). Moreover, one needs to determine “who” the patient is. In families, there may be an identified patient (e.g., a conduct-disordered child or a child with chronic abdominal pain). However, the examiner must keep in mind that psychiatric and medical syndromes do not occur in a vacuum. Although the family has determined an “identified patient,” the examiner should consider that, when evaluating the child, all members of the environment need to be part of the evaluation. A similar situation occurs when an adult child brings in an elderly demented parent for an evaluation. It is incumbent on the evaluator to consider the home environment and caretaking, in addition to simply evaluating the geriatric patient. In couples, one or both may identify the “other” as the “problem.” An astute clinician remains neutral (i.e., does not “take sides”) and allows each person's perspective to be clarified.

Children and adolescents require special consideration. Though they may, indeed, be the “identified patient,” they are embedded in a home life that requires evaluation; the parent(s) or guardian(s) must help administer any prescribed treatment (e.g., psychotropic or behavioral). Furthermore, the developmental level of the child needs to be considered in the examination. Young children may not be able to articulate what they are experiencing. For example, an 8-year-old boy who has panic attacks may simply throw temper tantrums and display oppositional behavior when asked to go to a restaurant. Although he may be phobic about malls and restaurants, his parents simply see his behavior as defiance. When asked what he is experiencing, he may not be able to describe palpitations, shortness of breath, fears of impending doom, or tremulousness. However, if he is asked to draw a picture of himself at the restaurant, he may draw himself with a scared look on his face and with jagged lines all around his body. Then when specific questions are asked, he is able to acknowledge many classic symptoms of panic disorder.

Evaluation of adolescents raises additional issues. While some may come willingly, others are dragged in against their will. In this instance, it is very important to identify and to empathize with the teenager: “Hi, Tony. I can see this is the last place you want to be. But now that you've been hauled in here by your folks, we should make the best of it. Look, I have no clue what is going on, and don't even know if you are the problem! Why don't you tell me your story?” Teenagers may indeed feel like hostages. They may have bona fide psychiatric disorders or may be stuck in a terrible home situation. The most important thing the examiner must convey is that the teenager's perspective is important, and that this will be looked at, as well as the parent's point of view. It is also critical to let adolescents, as all patients, know about the rules and limits of confidentiality. Many children think that whatever they say will be directly transmitted to their parents. Surely this is their experience in school. However, there are clear guidelines about adolescent confidentiality, and these should be delineated at the beginning of the clinical encounter. Confidentiality is a core part of the evaluation, and it will be honored for the adolescent; it is essential that this be communicated to them so they may feel safe in divulging very sensitive and private information without fear of repercussion. Issues such as sexuality, sexually transmitted diseases, substance abuse, and mental health are protected by state and federal statutes. There are, however, exceptions; one major exception is that if the patient or another is in danger by virtue of an adolescent's behavior, confidentiality is waived.

The Significance

Psychiatric disorders are commonly stigmatized and subsequently are often accompanied by profound shame, anxiety, denial, fear, and uncertainty. Patients generally have a poor understanding of psychiatric disorders, either from lack of information, myth, or misinformation from the media (e.g., TV, radio, and the internet). Many patients have preconceived notions of what to expect (bad or good), based on the experience of friends or family. Some patients, having talked with others or having searched online, may be certain or very worried that they suffer from a particular condition, and this may color the information presented to an examiner. A specific syndrome or symptom may have idiosyncratic significance to a patient, perhaps because a relative with a mood disorder was hospitalized for life, before the deinstitutionalization of people with mental disorders. Hence, he or she may be extremely wary of divulging any indication of severe symptoms lest life-long hospitalization results. Obsessions or compulsions may be seen as clear evidence of losing one's mind, having a brain tumor, or “becoming like Aunt Jessie with a chronic psychosis.” Some patients (based on cognitive limitations) may not understand their symptoms. These may be normal, such as the developmental stage in a school-age child, whereas others may be a function of mental retardation, autistic spectrum disorder, or cerebral lacunae secondary to multiple infarcts following embolic strokes.

Finally, there are significant cultural differences in the way mental health and mental illness are viewed. Culture may influence health-seeking and mental health-seeking behavior, the understanding of psychiatric symptoms, the course of psychiatric disorders, the efficacy of various treatments, or the kinds of treatments accepted. Psychosis, for example, may be viewed as possession by spirits. Some cultural groups have much higher completion rates for suicide, and thus previous attempts in some individuals should be taken more seriously. Understanding the family structure may be critical to the negotiation of treatment; approval by a family elder could be crucial in the acceptance of professional help.

Establishing an Alliance and Fostering Effective Communication

Studies of physician–patient communication have demonstrated that good outcomes flow from effective communication; developing a good patient-centered relationship is characterized by friendliness, courtesy, empathy, and partnership building, and by the provision of information. Positive outcomes have included benefits to emotional health, symptom resolution, and physiologic measures (e.g., blood pressure, blood glucose level, and pain control).

In 1999, leaders and representatives of major medical schools and professional organizations convened at the Fetzer Institute in Kalamazoo, Michigan, to propose a model for doctor–patient communication that would lend itself to the creation of curricula for medical and graduate medical education, and for the development of standards for the profession. The goals of the Kalamazoo Consensus Statement were to foster a sound doctor–patient relationship and to provide a model for the clinical interview. The key elements of this statement are summarized in Table 4-2 , and are applicable to the psychiatric interview.

Table 4-2

Building a Relationship: the Fundamental Tasks of Communication

Elicit the patient's story while guiding the interview by diagnostic reasoning.
Maintain an awareness that feelings, ideas, and values of both the patient and the doctor influence the relationship.
Develop a partnership with the patient and form an alliance in which the patient participates in decision-making.
Work with patients' families and support networks.

Open the Discussion

Allow the patient to express his or her opening statement without interruption.
Encourage the patient to describe a full set of concerns.
Maintain a personal connection during the interview.

Gather Information

Use both open- and closed-ended questions.
Provide structure, clarification, and a summary of the information collected.
Listen actively, using verbal and non-verbal methods (e.g., eye contact).

Understand the Patient's Perspective

Explore contextual issues (e.g., familial, cultural, spiritual, age, gender, and socioeconomic status).
Elicit beliefs, concerns, and expectations about health and illness.
Validate and respond appropriately to the patient's ideas, feelings, and values.

Share Information

Avoid technical language and medical jargon.
Determine if the patient understands your explanations.
Encourage questions.

Reach Agreement on Problems and Plans

Welcome participation in decision-making.
Determine the patient's amenability to following a plan.
Identify and enlist resources and supports.

Provide Closure

Ask if the patient has questions or other concerns.
Summarize and solidify the agreement with a plan of action.
Review the follow-up plans.

Building the Relationship and Therapeutic Alliance

All psychiatric interviews must begin with a personal introduction and establish the purpose of the interview; this helps create an alliance around the initial examination. The interviewer should attempt to greet the person warmly and use words that demonstrate care, attention, and concern. Note-taking and use of computers should be minimized and, if used, should not interfere with ongoing eye contact. The interviewer should indicate that this interaction is collaborative, and that any misunderstandings on the part of patient or physician should be immediately clarified. In addition, the patient should be instructed to ask questions, interrupt, and provide corrections or additions at any time. The time frame for the interview should be announced. In general, the interviewer should acknowledge that some of the issues and questions raised will be highly personal, and that if there are issues that the patient has real trouble with, he or she should let the examiner know. Confidentiality should be assured at the outset of the interview. If the psychiatrist is meeting a hospitalized patient at the request of the primary medical or surgical team, this should be stated at the outset.

These initial guidelines set the tone, quality, and style of the clinical interview. An example of a beginning is, “Hi, Mr. Smith. My name is Dr. Beresin. It is nice to meet you. Your surgeon, Dr. Jones, asked me to meet with you because he is concerned that you haven't eaten or taken any of your medications since you've been in the hospital. I would like to discuss some of the issues or problems you are dealing with so that we can both understand them better, and figure out what kind of assistance may be available. I will need to ask you a number of questions about your life, both your past and present, and if I need some clarification about your descriptions I will ask for your help to be sure I ‘get it.’ If you think I have missed the boat, please chime in and correct my misunderstanding. Some of the topics may be highly personal, and I hope that you will let me know if things get a bit too much. We will have about an hour to go through this, and then we'll try to come up with a reasonable plan together. I do want you to know that everything we say is confidential. Do you have any questions about our job today?” This should be followed with an open-ended question about the reasons for the interview.

One of the most important aspects of building a therapeutic alliance is helping the patient feel safe. Demonstrating warmth and respect is essential. In addition, the psychiatrist should display genuine interest and curiosity in working with a new patient. Preconceived notions about the patient should be eschewed. If there are questions about the patient's cultural background or spiritual beliefs that may have an impact on the information provided, on the emotional response to symptoms, or on the acceptance of a treatment plan, the physician should note at the outset that if any of these areas are of central importance to the patient, he or she should feel free to speak about such beliefs or values. The patient should have the sense that both doctor and patient are exploring the history, life experience, and current symptoms together.

For many patients, the psychiatric interview is probably one of the most confusing examinations in medicine. The psychiatric interview is at once professional and profoundly intimate. We are asking patients to reveal parts of their life they may only have shared with extremely close friends, a spouse, clergy, or family, if anyone. And they are coming into a setting in which they are supposed to do this with a total stranger. Being a doctor may not be sufficient to allay the apprehension that surrounds this situation; being a trustworthy, caring human being may help a great deal. It is vital to make the interview highly personal and to use techniques that come naturally. Beyond affirming and validating the patient's story with extreme sensitivity, some clinicians may use humor and judicious self-revelation. These elements are characteristics of healers.

An example should serve to demonstrate some of these principles. A 65-year-old deeply religious woman was seen to evaluate delirium following cardiac bypass surgery. She told the psychiatric examiner in her opening discussion that she wanted to switch from her primary care physician, whom she had seen for more than 30 years. As part of her postoperative delirium, she developed the delusion that he may have raped her during one of his visits with her. She felt that she could not possibly face him, her priest, or her family, and she was stricken with deep despair. Although the examiner may have recognized this as a biological consequence of her surgery and postoperative course, the patient's personal experience spoke differently. She would not immediately accept an early interpretation or explanation that her brain was not functioning correctly. In such a situation, the examiner must verbally acknowledge her perspective, seeing the problem through her eyes, and helping her see that he or she “gets it.” For the patient, this was a horrible nightmare. The interviewer might have said, “Mrs. Jones, I understand how awful you must feel. Can you tell me how this could have happened, given your long-standing and trusting relationship with your doctor?” She answered that she did not know, but that she was really confused and upset. When the examiner established a trusting relationship, completed the examination, determined delirium was present, and explained the nature of this problem, they agreed on using haloperidol to improve sleep and “nerves.” Additional clarifications could be made in a subsequent session after the delirium cleared.

As noted earlier, reliable mirroring of the patient's cognitive and emotional state and self-reflection of one's affective response to patients are part and parcel of establishing secure attachments. Actively practicing self-reflection and clarifying one's understanding helps to model behavior for the patient, as the doctor and patient co-create the narrative.

Giving frequent summaries to “check in” on what the physician has heard may be very valuable, particularly early on in the interview, when the opening discussion or chief complaints are elicited. For example, consultation was requested after a 22-year-old woman who was hospitalized for emergency surgery refused to go to a rehabilitation facility. During the course of the psychiatric interview, the physician elicited a history of obsessive–compulsive symptoms during the past 2 years that led her to be housebound. The interviewer said, “So, Ms. Thompson, let's see if I get it. You have been stuck at home and cannot get out of the house because you have to walk up and down the stairs for a number of hours. If you did not ‘get it right,’ something terrible would happen to one of your family members. You also noted that you were found walking the stairs in public places, and that even your friends did not understand this behavior, and they made fun of you. You mentioned that you had to ‘check’ on the stove and other appliances being turned off, and could not leave your car, because you were afraid it would not turn off, or that the brake was not fully on, and again, something terrible would happen to someone. And you said to me that you were really upset because you knew this behavior was ‘crazy.’ How awful this must be for you! Did I get it right?” The examiner should be sure to see both verbally and non-verbally that this captured the patient's problem. If positive feedback did not occur, the examiner should attempt to see if there was a misinterpretation, or if the interviewer came across as judgmental or critical. One could “normalize” the situation and reassure the patient to further solidify the alliance by saying, “Ms. Thompson, your tendency to stay home, stuck, in the effort to avoid hurting anyone is totally natural given your perception and concern for others close to you. I do agree, it does not make sense, and appreciate that it feels bizarre and unusual. I can see why it would be upsetting to have to wait any longer to return home. I think we can better understand this behavior, and later I can suggest ways of coping and maybe even overcoming this situation through treatments that have been quite successful with others. However, I do need to get some additional information. Is that OK?” In this way, the clinician helps the patient feel understood—that anyone in that situation would feel the same way, and that there is hope. But more information is needed. This strategy demonstrates respect and understanding and provides support and comfort, while building the alliance.

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