Addressing And Confronting Bias And Prejudice

rior to beginning work on this discussion, please read Chapters 8, 12, and 13 in DSM 5 Made Easy: The Clinician’s Guide to Diagnosis; Chapter 2 in Turning Points in Dynamic Psychotherapy: Initial Assessment, Boundaries, Money, Disruptions and Suicidal Crises; Chapter 5 in The Psychiatric Interview: Evaluation and Diagnosis; all required articles; and review the PSY645 Fictional Sociocultural Case Studies (Links to an external site.)Links to an external site. document.

One of the most important aspects of developing competence in psychopathology is to be as honestly and completely aware as possible of your personal attitudes toward people who have mental health conditions. Through this awareness, we are better able to challenge our own biases and prejudicial views in order to be more open to the findings within scholarly research.

For your initial post in this discussion, choose one of the three case studies from the PSY645 Fictional Sociocultural Case Studies (Links to an external site.)Links to an external site. document, and write a detailed description of your uncensored personal observation of the patient depicted. Describe at least one theoretical orientation you would use to conceptualize your view of the patient’s problem and how it may have developed. Identify the issues you might focus on in treatment with this patient. Be sure to identify within your post which of the three case studies you have chosen.

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Tasman, A., Kay, J., & Ursano, R. J. (2013). The psychiatric interview: Evaluation and diagnosis.Chichester, England: John Wiley & Sons. Retrieved from http://www.ebrary.com

The Psychiatric Interview: Evaluation and Diagnosis, First Edition. Allan Tasman, Jerald Kay and Robert J. Ursano.

Psychiatric Interviews:

Special Populations

Randon Welton and Jerald Kay

There is a popular image of the psychiatric interview where the patient and clinician sit

comfortably in soft leather chairs in the psychiatrist’s office surrounded by objets d’art

and built-in bookshelves. The patient speaks clearly, honestly, and succinctly about his or

her problem. The psychiatrist listens intently and understands thoroughly what is being

said. This mutual understanding allows the therapy to begin effectively and proceed

quickly to its successful conclusion. All too often, the reality of psychiatric practice

reflects more challenging situations.

In this chapter, we shall be examining a number of special, but nonetheless common,

clinical circumstances and patient populations that tend to bend the frame of the traditional

psychiatric interview. There are an infinite number of special circumstances of

course, and this chapter could hardly list, much less discuss, them all. Instead we will be

looking at examples within two major themes. Sometimes the interview is extraordinary

because of the circumstances surrounding the interview. At other times, psychiatrists will

be interacting with a distinct population of patients; patients that inherently require an

alteration of our approach. These situations require extra thoughtfulness and adaptation

on the part of the clinician.

Included under the heading of Special Circumstances are patients located on

Inpatient Units, on Medical Wards, or in the Emergency Department (ED). The acuity of

these patients and the lack of privacy in these locations contribute to the difficulty of the

interview. Another set of special circumstances occurs in Mass Casualty or Disaster scenarios.

In those calamities, the psychiatrist may be responsible to assess large numbers of

patients in orthodox settings.

Even when the interview takes place in a more traditional setting, there are Special

Populations that may challenge the psychiatrist. These include patients with severe

Psychotic Symptoms or significant Suicidality. Interviewing Children and Adolescents

can pose a challenge for the non-subspecialist. Also included in these special populations

are those where there is a difference in language between the patient and the psychiatrist.

This creates the need to incorporate Interpreters into the psychiatric interview. Cultural

chapter

Tasman, A., Kay, J., & Ursano, R. J. (2013). The psychiatric interview : evaluation and diagnosis. Retrieved from http://ebookcentral.proquest.com

104 The Psychiatric Interview

Barriers are invariably present with patients from different ethnic and racial backgrounds

even when they are fluent in English. These differences add difficulty to the psychiatric

interview. In these days of increasing demands and falling recruitment within psychiatry,

Telepsychiatry is becoming an increasingly common solution to providing access to

psychiatry. This new technology, however, often is accompanied by some unique issues

that, if not addressed, add complexity to the clinical interview.

Psychiatric Interview in Special Circumstances

Special Circumstances — Inpatient Units

Interviewing hospitalized psychiatric patients is a routine responsibility that may lead to

an insensitivity to the uniqueness of this environment. Because of the ubiquitous legal and

financial demands inherent in inpatient treatment, modifications to interview style are

necessary. Since a thorough history and physical examination must be documented within

the first 24 hours of admission, this first encounter is likely to be the longest one-on-one

interaction between the patient and psychiatrist.

This documentation of the history and physical examination must meet the standard

required by regulatory agencies such as the Joint Commission for the Accreditation of

Hospitals and includes, but is not limited to, assessments of the patient’s preferred method

of learning, patient strengths, risk to self, comprehensive psychiatric and medical history,

and risk to others. Diagnoses and treatment plans are required as well. In addition, the

psychiatrist will need enough information to satisfy utilization management and thirdparty

standards for hospitalization. The time pressure to get the necessary information as

quickly as possible shapes the psychiatrist’s interview. In the rush to obtain the requisite

information, clinicians often resort to simplified information-gathering tools such as

checklists and “Yes/No” questions, which must be carefully balanced with the development

of a doctor–patient relationship based on empathy and understanding.

Many inpatient units have adopted a team interview model where the psychiatrist is

the collator of information rather than the collector of that information. These units see it

as more cost-effective for nonphysicians to gather much of the background information.

So rather than asking traditional open-ended questions about the patient’s past experiences,

the psychiatrist simply “signs off” on the history obtained by other mental healthcare

providers. This may limit the engagement in the therapeutic relationship between the

patient and the psychiatrist.

The accuracy of a traditional psychiatric inpatient interview has been questioned.

Researchers looked for inter-rater reliability among providers assessing 56 patients using

three different methods. The methods included a traditional, unstructured diagnostic

assessment (TDA), the Structured Clinical Interview for the DSM – Clinical version

(SCID), and a Computer-Assisted Diagnostic Interview (CADI), which utilized questions

based on DSM-IV algorithms. Following the individual interviews, the interviewers met

to come up with a consensus diagnosis. Compared to the consensus diagnosis, the unstructured

TDA was in agreement 53.8% of the time, considerably less than the structured

approaches (SCID – 85.7%, CADI – 85.7%) (Miller et al., 2001). The same facility then

looked at agreement between the diagnosis in the ED and the ultimate diagnosis on the

Tasman, A., Kay, J., & Ursano, R. J. (2013). The psychiatric interview : evaluation and diagnosis. Retrieved from http://ebookcentral.proquest.com

Chapter 5 • Psychiatric Interviews: Special Populations 105

inpatient unit. It used the same CADI to evaluate 39 patients in the ED and then reevaluated

them on the inpatient unit with another provider using the CADI. This was compared

to two groups who received TDAs in both the ED and the inpatient unit. The two TDA

arms combined had 66 patients. Looking at inter-rater reliability found “poor” to “fair”

agreement (45.5–54.5%) with the TDA, while using the CADI resulted in “excellent”

agreement (79.5%) (Miller, 2001).

A final study by this group looked at the impact the assessment had on patient care.

The use of the CADI ensured that the interview would cover all of the key criteria

necessary to screen for the major DSM-IV criteria. Because it was preloaded with the

DSM-IV algorithms, it would also cover all of the criteria when there had been a positive

screening. The interviewer using a traditional diagnostic assessment on average asked

only half of the key criteria screening questions and asked slightly less than half of the

DSM criteria for the likely diagnoses. In these patients, who had been randomly assigned

to the interviews based on their arrival at the hospital, the length of stay for those receiving

the CADI was an average of 4.8 days less than those receiving the TDA (Miller, 2002).

These studies did not address differences in long-term outcome nor the patients’ experiences

in the various approaches.

The challenge for the inpatient psychiatrist then is to obtain the diagnostic accuracy of

a structured or algorithmic interview while preserving the open-ended questions and empathic

connection of the traditional approaches. Working on an inpatient unit requires the psychiatrist

to perform a difficult balancing act. The pace, external accountability requirements, and

diagnostic precision required for the inpatient admission will challenge a slower-paced traditional

interview. Often relying on information provided by others and the use of more structured

and less engaging interviewing techniques is attractive. The cost of this accommodation

may be a decrease in the quality and significance of the relationships between the inpatient

provider and his or her patients. Although no simple solution exists to this tension, the inpatient

psychiatrist can utilize a few techniques to balance these positions:

• When possible, interview the patient after the other providers have collected their

information. The psychiatrist can then refer to the information that others have

obtained and ask the patient to expand on it. This demonstrates that the psychiatrist

has some basic understanding of the patient but wants additional information.

SS Example – The previous interviewer recorded: Academic history – “Graduated High

School in 13 years; a few classes at community college”. The psychiatrist asks: “I

see that you needed an additional year to graduate high school and then went to

college for a while. Tell me about that”.

• Continue to ask open-ended questions, especially at the beginning of the interview.

Ignoring the patient’s perspective on why he or she was brought into the hospital can

damage the development of a therapeutic alliance and limit the clinician’s

understanding.

• Continue to make empathic statements rather than exclusively elicit symptoms.

SS Example – The patient has a chronic history of highly critical auditory

hallucinations. “I see that you have heard voices for a long time and they say some

pretty bad things about you. That must be horrible. How have you managed to deal

with that for all of these years?”

• Aid in the development of a positive “institutional transference” by helping the patient

build trust in the entire team and not just the psychiatrist. Utilizing and praising the

Tasman, A., Kay, J., & Ursano, R. J. (2013). The psychiatric interview : evaluation and diagnosis. Retrieved from http://ebookcentral.proquest.com

106 The Psychiatric Interview

work done by the other team members can aid in this. Stress the ongoing communication

among the team about the patient’s particular situation and treatment plan. If possible,

have them interact with multiple team members at a time along with the psychiatrist.

Summary of Recommendations

• Structured evaluations may be helpful.

• Do not neglect displays of empathy and opportunities to build rapport.

• Ask open-ended questions whenever possible.

• Purposefully develop a therapeutic alliance among the patient, the psychiatrist, and

the rest of the team.

Special Circumstance – Medical Wards

Although the consulting psychiatrist first and foremost has the patient’s best interest at

heart, the principle reason for the consultation, nevertheless, is to assist the medical or

surgical provider who initiated the consult. Depending on the culture of the hospital, these

providers may be asking for the psychiatrist to take over the management of the patient’s

psychiatric issues while on the medical ward. In other facilities, the consulting psychiatrist

is merely asked for advice on how to manage the patient and does not take an active

treatment role.

The patient must understand the role of the consulting psychiatrist and that

information obtained by the psychiatrist during an interview may be conveyed to the

treating team. If this is not clarified from the outset, the psychiatrist can be placed in an

awkward position of either knowing key elements of the patient’s history that he or she

does not relate to the treatment team request or of betraying the patient’s confidence.

There are often concerns about privacy. Although some patients will have single rooms

and can be assessed in privacy, the consult on the medical ward often takes place in a

room that is shared with at least one other patient. The patient’s medical condition may

make it impossible to move the consultation to a more private setting. These factors

necessitate significant changes in the initial interview. Both the patient and psychiatrist

must acknowledge and accept the lack of privacy and confidentiality as well as the dual

agency of the consulting psychiatrist.

The medically ill patient presents some other significant challenges. These include

gathering and understanding comprehensive details of the medical or surgical condition

that necessitated hospitalization. The consultant psychiatrist often returns to reading textbooks

or review articles. Drug–drug interactions in these patients may also be daunting.

The psychiatrist must appreciate the psychiatric manifestations of unfamiliar medications

and their interactions. Again, there must be a willingness to research these issues.

As part of the consult, the psychiatrist must routinely address behavioral medicine

issues in addition to elucidating specific psychiatric diagnoses. Assessing the patient’s

psychosocial adjustment and how it impacts on the patient’s health and response to

treatment falls squarely into the consulting psychiatrist’s purview.

• Example – A 55-year-old man was admitted to a medical ward on numerous occasions

for uncontrolled hypertension. While on the unit his blood pressure was well controlled

Tasman, A., Kay, J., & Ursano, R. J. (2013). The psychiatric interview : evaluation and diagnosis. Retrieved from http://ebookcentral.proquest.com

Chapter 5 • Psychiatric Interviews: Special Populations 107

with medications, within days of discharge his blood pressure rose dangerously. When

asked, he insisted that he was taking his medication as prescribed and was following

the other behavioral suggestions of the treatment regimen. The frustrated treatment

team had asked for a consult to evaluate for malingering or factitious illness. The

psychiatrist took an empathic, nonjudgmental approach with the patient, openly

assuming that the patient was doing what he could to keep himself healthy. As the

patient became more comfortable with the psychiatrist, this proud man disclosed that

he did not have the financial resources to take his medication as prescribed and was in

fact only able to afford to take the prescription “every three or four days”. The

psychiatrist could then assume a liaison role to the team to help them negotiate the

financial aspects of his care.

The lack of comfort with managing psychiatric illnesses on the medical ward goes both

ways. Often the treatment team will be uncomfortable with the patient’s mental illness

and have only a vague idea of what he or she would like the psychiatrist to do for him or

her. This lack of clarity can be confusing for the patient and treatment team as well as for

the psychiatrist. The treatment team may even consult mental health without informing

the patients that they are doing so. When the psychiatrist shows up in the room, these

patients can be surprised and sometimes offended that their providers have consulted

mental health care without their knowledge.

There are some basic steps that the psychiatrist can take to improve the quality and

value of the interview on a medical or surgical ward.

• Specify the question to be answered – As a consultant, the psychiatrist assists the medical

team. The treatment team must, therefore, play a role in defining the focus of the

psychiatrist’s interview. No matter how brilliant the information obtained and relayed by

the psychiatrist is, if it does not answer the team’s question, then the consultation is not

successful. Often the team does not fully understand what they want and will send a

consult request that says in essence “See this patient”. In those situations, the consultant

should talk first with the team to clarify what information would be the most helpful. Are

they looking for help with diagnosis? Are they concerned about the patient’s current or

proposed medication regimen? Do they have questions about the patient’s capacity to

make informed decisions? Some authors have referred to this as the “center of gravity”

for the consult. The psychiatrist assists the patient by helping the medical team

understand what questions they have about the patient (Philbrick et al., 2012).

Frequently, the initial psychiatric consult may be inappropriate or impossible.

SS Example – “35-year-old recently diagnosed with cancer. Patient is crying. Please

evaluate”.

SS Example – “54-year-old chronic alcoholic. He has failed numerous rehabs. He

needs to stop drinking. Please assess and treat”.

One of the most important aspects of the consultation is helping the medical team

understand and accept the limits of what psychiatric consultation can provide them

and their patient (Nichita and Buckley, 2007; Perry and Viederman, 1981a).

• Dealing with Skeptical Staff Members – Unfortunately, the psychiatrist must

occasionally deal with medical and surgical staff that neither understand the impact

and importance of mental illness nor value the input of the psychiatrist. Often a

psychiatry consult appears to team members as the most expedient way to relieve

Tasman, A., Kay, J., & Ursano, R. J. (2013). The psychiatric interview : evaluation and diagnosis. Retrieved from http://ebookcentral.proquest.com

108 The Psychiatric Interview

themselves of a difficult patient. Explaining the limitations and value of a psychiatric

interview and consultation can again be extremely helpful for the patient and the

consulting team. The psychiatrist does not want to remove a patient’s sadness over

tragic events (e.g., the diagnosis of metastatic cancer). A brief consultation will not

change chronic behavioral problems and cannot take the place of ongoing outpatient

therapy. The consultant can, however, point the team in the right direction while

recognizing that the bulk of the work must be completed elsewhere.

• Lack of Confidentiality – As the consulting team is the primary recipient of

information, the psychiatrist must explain the limits of confidentiality to the patient at

the beginning of the interview. The psychiatrist is there to help the medical team

provide care. The information obtained may be conveyed to the team if it is important

in the patient’s medical care. The consult will be included in the general medical

record and can be accessed by a host of personnel (Wise and Rundell, 2005). Of

course, the consulting psychiatrist still has some discretion. Issues that might unduly

embarrass the patient and will not directly impact patient care can usually be

expressed in a tactful fashion.

SS Example – A 45-year-old female with metastatic breast cancer is being seen for

depression. She discloses that her marriage recently ended when her husband

announced that he was homosexual and left her for another man. The psychiatrist

records: “Discussed the painful ending of her marriage”.

• Lack of Privacy – When the interview takes place in a multi-bed room, the

psychiatrist may pull the curtain shut for the illusion of privacy but his or her voice

will easily carry to the other beds. If no private interview room is available or feasible,

the patient can be positioned so that he or she is turned away from his or her

roommate. The psychiatrist should speak softly but must ensure that the patient can

hear and understand him or her. The lack of privacy should not prevent the

psychiatrist from broaching potentially uncomfortable topics such as substance abuse

and suicidality. Euphemisms and generalities can be used to start the conversation, but

at some point the clinician will need to ask about them directly.

• Distractions – Although there is no way to prevent other medical personnel from

interrupting the interview, nursing staff can be asked if there is anything they need

from the patient before starting the interview. This should help minimize distractions.

Politely insist that the television and other entertainment be turned off during the

course of the interview.

• Visitors – Since some wards have restricted visiting hours and some visitors come

from long distances, it often seems uncaring to simply ask them to leave. Working

around the visitor’s schedule is a kind and compassionate thing to do if possible.

Those gestures can help create an instant therapeutic rapport with the patient. If,

however, the psychiatrist lacks such flexibility, he or she can apologize to the patient

and visitors and explain the need to interview the patient in private. Direct them to a

nearby waiting room and be sure to notify them when the interview is finished.

• Monitor Your Attitude – Because the medical/surgical ward is often unfamiliar and

uncomfortable to the psychiatrist, he or she can unconsciously adopt attitudes that are

not therapeutic. Being surrounded by a “medical” environment, the psychiatrist might

tend to function with a strictly biological focus. The psychiatrist adopting this

unempathic stance directs his or her attention only to pertinent positive and negative

Tasman, A., Kay, J., & Ursano, R. J. (2013). The psychiatric interview : evaluation and diagnosis. Retrieved from http://ebookcentral.proquest.com

Chapter 5 • Psychiatric Interviews: Special Populations 109

signs and symptoms, gathering much of the information from the medical records and

staff members. This psychiatrist may stand by the bedside, simply confirming

information already obtained from the record and adopt an attitude of the detached,

benevolent authority. His or her recommendations would focus solely on laboratory

studies and medication changes, ignoring psychological or social interventions. On the

other hand, the psychiatrist, surrounded by poorly understood medical terminology,

can overly identify with the patient. He or she can become enraged by perceived

slights the patient has received from the staff and criticize the direction and pace of

treatment even when he or she does not have a good understanding of the medical

issues. The goal of the psychiatrist is to maintain a middle ground where he or she is

more medically focused and interactive than in a traditional interview but still takes

the time to let the patient explain his or her views (Perry and Viederman, 1981b).

• Mental Status – A significant number of psychiatry consultations center on the

cognitive functioning of the patient. Up to 25% of consultations may be for some

form of competency or capacity evaluation (Wise and Rundell, 2005). In addition, the

psychiatrist is often asked to evaluate for confusion and/or delirium. Although the

assessment of a patient’s mental status may not always require the formal

administration of a mental status examination, in these particular situations, the

formal cognitive exam plays a pivotal role. Moreover, cognitive impairment may go

undetected by nonpsychiatric medical personnel as well as by psychiatrists if there is

not a deliberate exploration of those issues. The patient’s social skills and polite

conversation can compensate for cognitive impairment unless attention, concentration,

memory, and executive functioning are specifically addressed. In order to assess

cognitive functioning in a systematic way, it is advised that the psychiatrist utilize a

standardized instrument such as the Folstein Mini-Mental Status Examination or the

Montreal Cognitive Assessment (Wise and Rundell, 2005).

• Collateral Information – Especially when there is a component of cognitive

impairment, patients may not be the best source of information about their current and

recent life experiences and mental functioning. Even the most impaired patient

deserves the psychiatrist’s best effort at establishing rapport and utilizing the patient

as the “expert on themselves”, but the consultant must be prepared to contact family

members or friends at times to clarify the patient’s situation (Wise and Rundell,

2005). Although Health Information Portability and Accountability Act concerns are

not raised when a sole psychiatrist gathers information, it is always best to gain the

patient’s consent before contacting outsiders. During these conversations with

collateral sources, the psychiatrist needs to be aware that the thrust of questions may

inadvertently convey personal health information to the other person. It is best

therefore to stick to general questions: “What changes have you noticed in the

patient?” “What other medical or mental health issues does he or she have?” “What

medications does he or she take regularly” Once the informant has brought up more

focused problems such as depression, confusion, or hallucination, the psychiatrist

should pursue those directly.

• The Surprised Patient – The psychiatrist should not be surprised that some patients will

be unaware that the medical team has consulted mental health. This surprised patient can

become resistant to the clinician. Hostility toward the consultant can arise through the

misconception that the psychiatrist believes that the patient’s problems are “all in his or

Tasman, A., Kay, J., & Ursano, R. J. (2013). The psychiatric interview : evaluation and diagnosis. Retrieved from http://ebookcentral.proquest.com

110 The Psychiatric Interview

her head”. For this reason, many psychiatrists insist that the team’s consultation request

be explained to the patient before the first visit. The psychiatrist can sometimes assuage

the patient’s hostility by emphasizing that understanding and addressing the psychosocial

aspects of illness is an important aspect of the patient’s overall medical care.

SS Example – A 43-year-old female has been admitted for unexplained abdominal pain.

The extensive workup has been negative. The consult request reads simply “43 y/o

with abdominal pain without medical cause. Evaluate and treat”. She is upset with her

team’s giving up on her and “calling in the shrink”. “That’s what they do when they

can’t find a cause. Rather than admit they are not that smart, they blame the patient”.

The psychiatrist explains that he or she has been invited to provide help to the team

beyond the extensive workup that has been done. “Obviously your team believes you

have pain or they would not have done those tests. Sometimes, though, the stress of

chronic unexplained pain or persisting illness might make the person sicker than they

were before. I’m wondering if you have noticed that your pain fluctuates with stress.

Is it worse when things are going poorly and better when things go well?”

• Complicated Medical/Surgical or Medication Issues – Do not be afraid to

acknowledge your ignorance. The psychiatrist can admit to the consulting team or

even the patient that additional research must be conducted to better appreciate the

clinical presentation. In addition to being honest, this interaction has other advantages.

It models an active style of learning to the patient that he or she can use. Asking the

consulting team for an explanation of the medical issues also sets a precedent for the

psychiatrist explaining some of the behavioral health or mental health aspects of the

case later on. Encouraging this type of interdisciplinary communication is an

important aspect of the liaison function.

Summary of Recommendations

• Clarify the question.

• Clarify the roles and responsibilities.

• Engage with the consulting team.

• Address behavioral medicine issues.

• Strive for a private, uninterrupted interview.

• Complete the mental status examination.

• Maintain an empathic relationship.

Special Circumstance – Emergency Department

Interviewing patients in the ED combines many of the difficulties found on the inpatient

unit and the medical ward. A significant number of patients presenting to the ED arrive

with complex and severe psychiatric issues such as psychosis, suicidality, dangerousness

to others, and/or aggressive behaviors. These issues are often compounded by medical

illnesses and the misuse of psychoactive substances. The psychiatrist may be called to

interview patients who are intoxicated or delirious. Many of these patients will be

uninterested in receiving help and can be openly confrontational. There are also patients

who present to the ED for what has been termed social reasons. They are homeless and

know that reporting severe psychiatric symptoms is a path to shelter and meals.

Tasman, A., Kay, J., & Ursano, R. J. (2013). The psychiatric interview : evaluation and diagnosis. Retrieved from http://ebookcentral.proquest.com

Chapter 5 • Psychiatric Interviews: Special Populations 111

The setting of the ED interview complicates a patient evaluation. The ED often

lacks private, calming locations for the interview. The patient may be separated from

other patients by only a sheet that does not reach the floor. Without accompanying

records, the psychiatrist has nothing more than laboratory data, the physical examination,

and his or her psychiatric interview on which to base his or her assessment. The

evaluation may be further complicated by the ED’s attitudes toward many psychiatric

patients, especially when they are repeat visitors or so-called frequent flyers. These individuals

are very familiar to the ED staff, and often “getting the patient up to the ward” is

their sole priority.

As in the case of the Consult-Liaison psychiatry, an important aspect of treating this

patient is determining the concerns of the ED staff. Often these concerns involve issues of

dangerousness or the need for hospitalization. It is important that the psychiatrist knows

not only what questions the ED staff have but also what prompted those concerns.

The psychiatrist should always look for past medical records. In addition to providing

past diagnoses, these can also describe previous medication trials and offer a baseline of

behavior and symptoms. If no such records are available, then the psychiatrist may need

further discussion with ED staff members who likely have been observing the patient’s

affect, thinking, and behavior for several hours. Another potentially valuable and often

overlooked resource are laboratory studies. The psychiatrist will want to know which

have been ordered and which results have returned. Laboratory results may point to nonpsychiatric

issues that need to be addressed or provide reasons to delay the interview. For

example, when patients are intoxicated, the psychiatrist will want to wait until the blood

alcohol levels approach legal limits as information obtained while the patient is intoxicated

is suspect at best.

Once again, the complexity of the situation, the acuity of the patient, and the inevitable

time crunch will test the psychiatrist’s ability to utilize an unstructured interview

with open-ended questions. A more directed examination of the most pressing symptoms,

pertinent risk factors, and criteria for admission may be indicated. Nevertheless, the

patient’s past psychiatric history, social history, substance use, and recent stresses must be

elucidated. When suicide is a concern, in-depth exploration and documentation of current

thoughts of death and suicide, recent violent or self-destructive behavior, a past history of

violence or suicide attempts, current support systems, and substance abuse must be

obtained (Feinstein and Plutchik, 1990).

Reliance on checklists of psychiatric symptoms is to be avoided since this practice

does not permit the patient the freedom to tell his or her story in his or her own words and

to express his or her understanding of his or her current predicament. While the interview

will predominately focus on the presenting problem and acute issues, the psychiatrist

should try to not immediately plunge into the heart of the crisis at the outset of the interview.

A few questions about the patient’s background and life circumstances demonstrate

a thorough interest in the patient. This can also provide valuable insight into the patient’s

functional level as well as sources of social support.

In the rush to gather the information required for admission or medical/legal

purposes, an opportunity for crisis intervention should not be squandered. Patients are

exquisitely sensitive to perceived criticism and rejection by the ED staff, and a psychiatrist

who is willing to make a concerted effort and take the time necessary to understand

the situation can obtain valuable insights into the patient and can provide much needed

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112 The Psychiatric Interview

support for the patient. The psychiatrist in the ED will want to deliberately and rapidly

develop a therapeutic alliance. An appreciation for the patient’s past efforts at solving

problems reassures the patient and helps to establish this rapport.

• Example – An unemployed 52-year-old man is brought into the Emergency

Department by family concerned for his safety. He recounts numerous attempts to

find work and his profound sense that he is failing his family. Being brought into the

Emergency Department is humiliating proof of his failure. “Not only am I not helping

them, but now they are having to watch over me like I am a child.” The psychiatrist

praises his devotion to his family and his persistent efforts to find work. “Many people

would have quit a long time ago, but I am getting the sense that quitting is not in your

personality.” The psychiatrist then proposes that the patient work “just as diligently”

with an outpatient therapist to get control of this depression. “The first, best step to

get you back on your feet is to get this depression under control.”

Supporting patients and minimizing their distress while they are in the ED is not only

practicing good medicine but can also facilitate the interview process. This could be

something as simple as arranging for them to receive a blanket, glass of water, or medication

to decrease acute anxiety. An attitude of reasonable optimism about the efficacy of

medications and psychotherapy can help set the stage for future providers. All of these

can elevate the ED experience from one where the psychiatrist is simply the gatekeeper to

the inpatient wards to a critical therapeutic experience for the patient (Rosenberg, 1994).

Because interviewing patients in the ED is significantly different from what most

psychiatrists do day to day, there are some steps that can increase the clinician’s comfort

during the interview and ultimately result in the provision of better care.

• Feel safe and secure.

SS If patients represent an imminent risk to themselves or others, arrange for support

that is close at hand during the interview.

■ If the patient is acutely agitated, maintain a reasonable distance so that you are out

of arm’s reach, yet without being so distant as to make conversation difficult.

SS Maximize Privacy – Some EDs will have relatively quiet rooms that can be used for

more difficult or sensitive interviews such as in the case of rape. If it is safe, ask for

one of these rooms to increase the patient’s sense of privacy and decrease

distractions and interruptions.

SS Speak to the Patient Alone – The patient may have friends or family members with

him or her. If the patient can speak for himself or herself, visitors should leave

during the interview. This will decrease their opportunities to speak for the patient,

and may help the patient speak more freely and accurately.

SS After the interview is complete, family or friends can be brought into the room or

can be spoken to separately to confirm details of the patient’s account or to gain

outside perspectives. Unless the patient has expressly given permission, the

psychiatrist should not provide information about the patient’s condition.

SS Even with agitated and disorganized patients, it is worthwhile to start with openended

questions. These will help the patient feel that he or she has been heard and

understood. It also allows the psychiatrist to observe the patient’s mental functioning

in a naturalistic setting (MacKinnon et al., 2006; Meyers and Stein, 2000).

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Chapter 5 • Psychiatric Interviews: Special Populations 113

Summary of Recommendations

• Clarify the question.

• Engage with the ED staff.

• Strive for a private, uninterrupted interview.

• Ask open-ended questions whenever possible.

• Build rapport.

• Maintain an empathic relationship.

Special Circumstance – Mass Casualty/Disaster Situations

One thumbnail definition of a medical disaster is when the available medical resources

are overwhelmed by the demand. By definition then, there are more patients than can be

dealt with using traditional care models. Strategies to evaluate large numbers of victims

quickly have included the use of prognostic indicators such as elevated heart rate have had

limited success (Ritchie et al., 2006). Observation of current level of function and the

psychiatric interview remain our most effective tools.

The psychiatrist in the mass casualty situation will quickly become overwhelmed

if wedded to a rigid traditional psychiatric interview style. There are simply too many

people who have been affected, too few providers, and too little time. Generally, in

mass casualty settings, the psychiatrist is asked to do more than assess current symptoms.

The clinician is also asked to predict risk for compromised future functioning. A

further challenge is that the distress displayed by the patient in the immediate aftermath

of the trauma may not correspond well with his or her previous and ultimate level

of functioning.

The majority of people experiencing a trauma will exhibit only mild or transitory

symptoms. The rate of posttraumatic stress disorder (PTSD) following a traumatic event

is highly variable. Rates as low as 10% can be found in the victims of accidents, while

46% of women and 65% of men who have been raped will meet criteria for PTSD (Kessler

et al., 1995). Although PTSD is intimately associated with disasters, it is not the only

psychiatric disorder seen after a trauma. A significant number of people will develop

depressive or anxiety symptoms, but most people will ultimately do well following the

trauma (Ursano et al., 1995).

A complicating factor during the posttrauma interview is that it may occur in a

variety of nontraditional settings such as homes, shelters, and temporary facilities. One

common strategy among military mental health providers is to triage by walking around,

the idea being that it is more helpful to interview victims in their own environment than

to wait until they venture into the mental health services area. This walking triage may be

especially important as at-risk populations include more than just the identified victims of

trauma. The psychiatrist in a mass casualty situation should also attend to the distress and

functioning of coworkers. They are often the victims of secondary traumatization and

provider fatigue. Depending on the size and location of the disaster, the psychiatrist too

might have been personally affected. If the clinician has missing friends or relatives or has

potentially lost his or her home, his or her ability to evaluate patients might be impacted

(Ritchie and Hamilton, 2004).

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114 The Psychiatric Interview

The interview will be further complicated by the patient’s complex and shifting

response to the recent trauma. He or she may have intense and mixed emotions regarding

the event. There will of course be grief and loss. He or she may also be afraid to remember

details of the event. Often there is tremendous anger directed toward people whom he or

she holds responsible for the trauma or for a lack of a prompt effective response to the

trauma. Guilt about behavior during or after the event is common. He or she may feel that

his or her response was inadequate. There also might be guilt about having survived when

others did not. All of these make it difficult for casualty survivors to openly discuss the

event with the psychiatrist (Connor et al., 2006).

Cultural considerations are always important during the assessment following

trauma. Allowing mental health providers of different cultural backgrounds to assist in

the aftermath of a trauma may be met with resistance. Since culture may alter how patients

express their symptoms, overreliance on DSM phenomenology may be unhelpful. For

example, it has been noted following traumas in Japan that the Japanese may be reluctant

to acknowledge “depression” even when they meet criteria for it (Connor et al., 2006). In

many rural settings, personal identity is bound inextricably to religious identity. Also, a

deep attachment to a village may intensify the sense of loss even when personal, household

loss has not occurred. All of these cultural factors may impact how the trauma is experienced

by the individual (Bryant and Njenga, 2006).

Guidelines for interviewing the victims of mass casualty situations include:

• Look for life-threatening physical conditions. These must be addressed immediately.

• Assess mental status and level of consciousness as these may be indicators of physical

injuries or worsening medical conditions.

• Be aware of your appearance and presentation. The psychiatrist will inevitably be

seen as an outsider but needs to dress in a fashion that will promote acceptance as a

benevolent authority figure by the injured population (Ritchie and Hamilton, 2004).

• Educate survivors regarding normal cognitive, emotional, behavioral, and physical

changes following trauma. Highlight that these are common responses to abnormal

situations and will likely resolve without specific interventions. Emphasize that these

symptoms are not inherently dangerous or an indication of moral or mental weakness.

SS Common impairment includes:

■ Cognitive – Memory loss, anomia, impaired decision-making, poor concentration

■ Emotional – Anxiety, grief, irritability, feeling overwhelmed, fear of future loss

■ Behavioral – Insomnia, hypervigilance, crying, ritualistic behaviors

■ Physical – Fatigue, nausea, tremor, motor tics, dizziness, gastrointestinal distress

(Flynn and Norwood, 2004; Ritchie et al., 2006; Ursano et al., 2003)

• Watch for symptoms of extreme avoidance, numbing, or dissociations. The presence

of dissociations in particular has been associated with an increased risk of PTSD

(Ursano et al., 2003).

• Ask the Victims about the Meaning of the Disaster – The trauma frequently threatens

more than the individual’s life, family, or livelihood. Often these events will challenge

the victims’ understanding of how the world functions. Individuals living with a “just

world hypothesis”, where good things happen to good people and bad things happen

to bad people may find that point of view inadequate to explain what they have just

experienced. Others will have their core religious and spiritual beliefs challenged in a

way that it had not been challenged before.

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Chapter 5 • Psychiatric Interviews: Special Populations 115

• The Use of Screening Tools – There is some controversy as to the utility of screening

tools, with some authors finding it a useful means to getting information on people

quickly and others doubting the reliability of the information obtained (Connor et al.,

2006; Ritchie and Hamilton, 2004).

• Emphasize Strength, Resilience, and Growth – While the psychiatrist should not

minimize the destruction and distress caused by the disaster, it is also important to

recognize that these traumatic events are often a time for growth. Individuals will

demonstrate strength and coping abilities that they may not have realized that they

had. Communities will often pull together and support each other. This growth may

not be evident during the initial interview, but the psychiatrist can lay the

groundwork for recognizing it by inquiring about it even in the early stages of the

post-disaster period.

Summary of Recommendations

• Be prepared to leave the clinic and interview victims where they are.

• Discuss common emotional, physical, and behavioral responses to trauma.

• Watch for cultural differences in responding to trauma.

• Emphasize strength and resilience.

Psychiatric Interview in Special Patient Populations

Even when the psychiatric interview takes place in the comfort of the psychiatrist’s office,

there can be groups of people who raise special challenges. In general, these are patients

whose baseline functioning or illness inherently complicate the interview process. Often

adopting a different style or using different questions to elicit data is vital.

Special Populations – Patients with Psychosis

Psychotic symptoms can be divided into those which affect the content of thought and

those which alter the flow or form of thought processes. Although routine for psychiatrists,

each of these categories presents separate problems for the interviewer. Problems

with thought content include delusions, thought blocking, thought insertion, and perceptual

abnormalities such as hallucinations. These experiences, which diverge greatly from

common experience, make it difficult for these patients to express what is going on in

their lives. They may have difficulty putting their fears or belief systems into words. They

may have difficulty differentiating events in their lives from internal experiences, which

appear to be just as real. Formal thought disorders result in communication that is difficult

to follow. Because of loosened associations or incomplete ideas, the interviewer may

have trouble getting a coherent story. The interviewer’s challenge is to overcome these

obstacles and get as much useful information as can be obtained within a reasonable

period of time.

Often seriously impaired patients have a long history of psychiatric illness. The psychiatrist

during the initial interview should inquire about past interactions with mental

health providers. “What should I know about your illness?” “How can I help you?” “What

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116 The Psychiatric Interview

has worked in the past?” “What have other providers tried that did not work?” These past

experiences can shape the current interaction (MacKinnon et al., 2006). Positive interactions

should be highlighted as evidence of the help that psychiatry can offer. Negative

experiences can be acknowledged, followed closely by a description of how this encounter

can be different.

There are some strategies that apply to patients with both types of psychotic symptoms.

These patients have often been brought for evaluation by someone else and therefore

might get frustrated because they are in the hospital. The psychiatrist can sympathize

with their resentment during the interview but also note their desire to help the patient.

Psychotic symptoms often create a gap between the experience of the patient and of

anyone trying to communicate with him or her. This makes it harder to generate empathy

for the patient and leaves the provider more likely to do a perfunctory assessment

(MacKinnon et al., 2006). To help bridge the gap, the psychiatrist should ask about the

symptoms that bother the patient. Perhaps he or she is not bothered by the voices that he

or she hears but is upset at feeling constantly tired. Other common complaints might

include anxiety, pain, nausea, or problems with sadness. By focusing initially on these

symptoms, the provider might be able to bridge some of the gap separating the patient’s

world from his or her own (Shea, 1988).

• Example – A 28-year-old man with a history of schizophrenia is brought into the ED

after he was found wandering in a city park by the police. He perseverates on

comments such as “I shouldn’t be here. I need to go”. The psychiatrist perceiving this

agitation says: “Some people were pretty concerned that you were getting confused.

They have asked me to see if I can help figure out what is going on. You look pretty

worried. Is there anything I can help with?”

• Psychotic Thought Content – Often the patient is terrified and confused by what he

or she is experiencing and might have no reason to believe that the psychiatrist can

be of any help. Although the psychiatrist’s ability to empathically enter the patient’s

world can be limited, a therapeutic alliance must be forged (e.g., “Can you help me

understand what is upsetting you?”). As is true in any patient encounter, the

psychiatrist uses his or her emotional response to what the patient is describing as

an important vehicle to enhance communication. Attentiveness to a patient’s

emotional state can help focus the patient and develop rapport (MacKinnon et al.,

2006). There is a need to look for any topic that appears to carry a significant

emotional valence since this displays interest in the patient and facilitates

clarification of his or her inner experience. With expressions of fear comes the

opportunity to offer realistic but consistent hopefulness while emphasizing the

current level of safety (Shea, 1988).

SS Example – A disheveled 34-year-old woman, Alice, is brought into the ED by the

police. She had been arrested running down the street striking cars with a rock. She

appears terrified in the ED and is curled into a near fetal position without

acknowledging the psychiatrist when he enters. “Alice, you look very upset. Can

you tell me what is going on”. Alice responds: “I can’t take it anymore”. She is no

longer sure who is harassing her. She figured that by striking the cars she would

draw out the assassins who were following her. “Alice, it must be terrible to feel

that frightened all of the time. Do you feel safe in here?”

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Chapter 5 • Psychiatric Interviews: Special Populations 117

With these few simple sentences, the psychiatrist has made an effort to establish an

empathic connection. Demonstrating sympathy for her troubles, the clinician has also

addressed her with respect and dignity. These can be the first steps toward developing a

meaningful therapeutic rapport.

With a patient who focuses on a single issue, such as a systematic delusion, the psychiatrist

will emphasize the need to gain understanding into other aspects of the patient’s

life. This type of patient will often lose the point of open-ended questions and shift the

topic back to the thought that consumes him or her. To get useful information in this case,

the psychiatrist will have to shift from open-ended questions to more direct questions.

Sometimes these will have to be questions that can be answered by a “yes” or “no”.

As in any patient encounter, honesty is vital. Attempts to enhance the therapeutic

relationship through misinformation (pretending to see or hear his or her hallucinations or

acknowledging conspiracies) are prone to failure. Once the patient realizes that the psychiatrist

has not been truthful, the therapeutic alliance is almost certainly damaged, sometimes

beyond repair. It is usually possible to accept the patient’s response to his or her

experiences without agreeing to his or her perception. “I know that you are hearing an evil

threatening voice, but I do not hear it and no one else here is hearing it. I think that voice

is coming from within your mind”.

Other specific advice includes:

• Delusions – Realize that you will not be able to convince the patient to abandon his or

her delusions, and that he or she will refuse to accept facts that you hold to be

incontrovertible. Acknowledge that he or she believes what he or she is telling you

and that he or she believes there is abundant evidence supporting him or her. Do not

hesitate, however, to wonder with him or her if there might be some other way to

explain the facts. The psychiatrist can acknowledge the anxiety and frustration the

patient experiences in trying to convince others to believe something that they know

to be true (MacKinnon et al., 2006).

• Paranoia – Interviewing the paranoid patient is one of the most difficult challenges for

the psychiatrist. This patient will mistrust motives from the start. He or she will

present himself or herself in a guarded fashion based on his or her fear that what he or

she says will be used to hurt him or her. Tactful telling of the truth in these situations

may not win the patient over but is still the psychiatrist’s best option. Acknowledge

that he or she is not free to leave when he or she wants and that your evaluation will

play a role in what happens to him or her. “You might disagree, but I think the people

who brought you here are truly concerned for your safety. They want me to help

determine if you are safe”. Avoid humor with these patients. They are unlikely to

enjoy it and can easily assume that you are making fun of them, thereby increasing

their agitation. The psychiatrist will often agree with the facts that the patient presents

without agreeing with his or her interpretation of those facts. “I believe that you saw

five black cars pass by your house. I am just not sure that means that the CIA has you

under surveillance”. Resist the patient’s attempt to pull you into a power struggle. The

goal is to assess his or her functioning and safety, not to debate with him or her.

Regardless of good intentions and efforts, the patient may be suspicious of the

psychiatrist or even contemptuous. Accept his or her need for emotional distance and

psychological defenses while proceeding with the interview (MacKinnon et al., 2006).

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118 The Psychiatric Interview

• Hallucinations – The voices that the patient hears and the things that he or she sees

are just as real to him or her as you are. Therefore, attempts to dismiss them or

minimize their importance will rarely succeed. Instead, ask about them as you would

about any other experience (Shea, 1988). You can ask for details such as:

SS How many voices are you hearing?

SS What are they saying?

SS What can you tell me about them?

SS Do they remind you of anyone you know?

SS Are they talking with you now?

SS How difficult is it for you to pay attention to me with them talking?

• Formal Thought Disorder – These patients are attempting to express themselves but

are unable to do so in a fashion that can be followed by the psychiatrist. The

psychiatrist will usually pick up on this within the first few minutes of

conversation. Readily, but tactfully, admit to difficulty understanding what the

patient is trying to say. This can usually be done without humiliating or blaming

the patient. The psychiatrist might find open-ended questioning as being

unproductive. Attempts to gain information through direct questioning should

nevertheless include reflections on the patient’s spontaneous speech and topics of

conversation. This presents the best opportunity for making an empathic connection

with the patient.

• Example – A 45-year-old man with psychotic mania has extremely loosened

associations. His rambling digressions include his involvement with both the president

and the governor and their plans for him to assist them personally on special projects.

As he is completing the interview, the psychiatrist comments: “I know I have not

heard about everything that is going on in your life, but listening to you for these few

minutes I am struck by the sense that you have a lot of potential and opportunities, but

are not quite sure what you want from your life”.

Summary of Recommendations

• Ask about past interactions with mental health.

• Show empathy for their distress.

• Acknowledge their perceptions without necessarily agreeing with their conclusions.

• Do not debate with them.

Special Populations – Suicidal Patients

Patients with a significant risk of suicide are an extremely common cause of emergent

psychiatric consultations. The psychiatrist often enters the situation with little to no

previous alliance with the patient. In order to obtain useful and truthful information, the

psychiatrist must quickly establish a working rapport. Since suicidality is the reason for

the consult, there is a temptation to jump immediately into a discussion of that issue. The

patient, however, has little motivation to be honest with a provider he or she is just meeting.

If he or she is truly suicidal, he or she will see it in his or her best interest to be

deceptive. If he or she is not suicidal, he or she will either tell the truth, which might

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Chapter 5 • Psychiatric Interviews: Special Populations 119

make it difficult to distinguish him or her from the deceitful suicidal patient, or he or she

might try to deceive the provider for other reasons such as an attempt to gain admission

to the hospital.

The best strategy for the psychiatrist is to spend some time getting to know the

patient broadly before broaching the topic of suicidality. This discussion will help build

rapport but will also start filling in the suicide risk factors that are central to the assessment.

• What has brought them into the hospital?

• What do they think can be done to help them?

• Ask about their recent stresses: What has changed in your life recently?

• Ask about recent neurovegetative symptoms.

• Ask about their past psychiatric history: Have they ever been admitted for psychiatric

reasons? Have they ever been treated as an outpatient?

• Are they currently under the care of a mental health professional?

• Ask about their social support.

After gathering this background information, the psychiatrist can move onto more direct

questions. Normalizing thoughts of death and suicide is often an effective means of

starting the exploration of those issues, e.g., “Many people in your situation would have

thoughts of death. They might wish they were dead or have thoughts about killing themselves.

Have you had thoughts like those?”

The psychiatrist will need to ask about suicidality directly.

• Suicidal Ideation – How frequent are the thoughts of killing themselves? How long

have they been present? Are they changing in intensity or frequency?

• Suicidal Plan – Do they have a specific plan to end their life? Is it realistic? Is it

lethal? Are they likely to be rescued in the attempt?

• Suicidal Intent – Do they want to die? Do they feel it is inevitable that they will die?

• Preparation and Rehearsal for Suicide – Have they obtained lethal means? Have they

practiced the suicide attempt?

• Suicide Attempts – Have they ever tried to kill themselves in the past? Do they have

family or friends who have committed suicide?

• Protective Factors – We should also ask about what has kept them alive to this point.

The risk assessment, however, includes more than just questions asked to the patient. The

interviewer’s observational skills are also necessary. What is the patient’s affect? Does he

or she maintain good eye contact? Does he or she display psychomotor retardation? Is

there significant anxiety or agitation?

Gathering this information is only the first part of the suicide risk assessment. Once

the information has been gathered, the clinician should consider the patient’s acute and

chronic risk of suicide. It might be helpful to divide these risk factors into several categories:

static risk factors, dynamic risk factors, and warning signs.

• Static risk factors for suicide are often demographic information that cannot be

quickly altered.

SS Male Sex – Men are three to four times more likely to commit suicide.

SS Age – Although there are legitimate concerns about suicide in young adults, in

general the rate of population is highest among the oldest individuals.

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120 The Psychiatric Interview

SS Race – Elevated rates of suicide are found in White and Native Americans than in

Black and Hispanic Americans.

SS Family history of suicide.

SS Prior Suicide Attempts – This is perhaps the most robust risk factor. Approximately

10–15% of those who have attempted suicide will ultimately kill themselves.

SS Being Single – Although it is not found in every study, being divorced, widowed, or

never married seems to increase the risk of suicide.

• Dynamic risk factors for suicide are ones that can be changed through intervention.

SS Untreated mental illness.

SS Emotional Turmoil – This can be brought on by recent financial or legal problems,

acute and chronic medical conditions, or relationship issues.

SS Expressed suicidality.

SS Access to weapons and other lethal means.

• Warning signs are indicators that suicide may be imminent and are further divided

into two tiers. Both of these groups still indicate marked elevation of risk but the

second is more concerning.

SS Warning signs include hopelessness, rage, anger, acting recklessly, feeling trapped,

increasing alcohol or drug use, withdrawal from friends, anxiety, agitation, altered

sleep, dramatic changes in mood, and seeing no reason for living.

SS Imminent warning signs include direct threats to harm themselves, searching for

means to kill themselves, and writing or talking about death and dying.

The key for thorough suicide risk assessment and management is to incorporate all of the

elicited information and then generate a comprehensive plan based on it. The plan should

minimize as many dynamic factors and warning signs as possible while enhancing the

protective factors. This should be done in a biopsychosocial manner. Biologic interventions

can include starting antidepressants, realizing that these may take several weeks to

take effect and might even increase agitation in the short term. If insomnia has been a

significant factor, then the psychiatrist can consider safe methods for assisting sleep.

Psychological interventions should include the initiation of psychotherapy, which can be

facilitated during the initial interview by delineating some of the major conflicts that are

upsetting the patient. Social interactions can include increasing support as well as helping

to create a safer environment for the patient. Environmental manipulation can include

reducing access to lethal means of self-harm. Often with the patient’s permission, family

and friends can be involved in controlling access to potentially dangerous weapons and

medications. Social manipulation might also involve hospitalization as a means of protecting

the patient while waiting for the other interventions to have an opportunity to work

(Welton, 2007). Providers can never completely prevent suicide in patients who have

committed themselves to dying, but a thorough evaluation and appropriate intervention is

the best method for helping these patients.

Summary of Recommendations

• Work to establish rapport.

• Be aware of and inquire about suicide risk factors.

• Ask about protective factors.

• Biopsychosocial interventions should target dynamic risk factors and warning signs.

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Chapter 5 • Psychiatric Interviews: Special Populations 121

Special Populations – Children/Adolescents

Alterations in interview style and content must be expected when working with children

and adolescents. Even within this group, there is great variation depending on the age and

maturational level of the child and the circumstances leading to the interview. The interview

of a depressed or traumatized 5-year-old will be very different than the interview of

a depressed or traumatized 9-year-old.

Adults will usually enter a psychiatrist’s office with some idea of the role and capabilities

of a psychiatrist. The child may not have this understanding and may find the experience

extremely foreign and threatening. Helping to clarify children’s expectation about the

interview and their perspective on the issues that brought them in to be assessed is a good

starting point. Especially with younger children, it is helpful to clarify that they are not in

trouble and have not been brought in because they are bad (Sadock and Sadock, 2003).

The psychiatrist might want to start the interview with a review of the less charged

aspects of the child’s life such as involvement in hobbies, sports, and favorite leisure time

activities. These topics also provide useful information about the number and quality of

his or her interactions and social, academic, and physical development (Sadock and

Sadock, 2003). Younger, school-age children can be brought into a room with a variety of

toys and observed in unstructured play. As the child plays, the interviewer can ask questions

about the child’s inner life. Having toys that are reminiscent of home situations (e.g.,

adult and child dolls) can also lead to fruitful discussions about relationships with the

child, inevitably conveying information about his or her home life. Another useful technique

is to ask the child to draw. Asking children to draw family members and having

them talk about their families can also establish their views on family dynamics. The

interviewer looks for themes or patterns in the child’s play and drawings. There are still

questions that need to be asked, but the psychiatrist will likely need to modify the questions.

Open-ended questions may be less successful than giving the child several possible

answers. The interviewer can still try an open-ended question but have a list of possible

answers if the child cannot answer (Sadock and Sadock, 2003).

• Example – During an interview the child is asked, “How have you been feeling?” She

answers, “Good I guess”. The interviewer goes on, “Have you been feeling sad or

angry or scared?”

Some of the differences in interview technique are straightforward and require sensitivity

to developmentally appropriate language. The simple question “Are you depressed”

may have no meaning to a bright 8-year-old, or even worse, may mean something completely

different than what the clinician intended. Often simple behavioral or functional

questions can be substituted for more complex or abstract ones. Rather than asking

about lethargy, anhedonia, appetite, and anxiety, the interviewer can ask questions such

as: “Do you get tired easier than your friends?”, “What do you do with your friends that

is really fun?”, “Do you eat everything on your plate at meals?”, or “Is there anything

that is scaring you?” In addition to ascertaining the DSMIV-TR criteria for mental illness,

the interviewer working with small children should also attempt to obtain an

understanding of their level of development. This will help guide future interventions if

deficits are found.

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122 The Psychiatric Interview

One model used to understand the development of younger children is the

Developmental, Individual difference, Relationship (DIR) model. This model seeks to

facilitate a comprehensive understanding of the child through a systematic evaluation of

three major components of his or her mental life. The interviewer examines the functional

emotional development of the child, the sensory reactivity/cognitive processing/executive

functioning of the child, and finally the relationships the child has with significant caregivers

in his or her life.

• Functional Emotional Development – The first category involves the child’s ability to

work toward emotionally meaningful goals. This will be evaluated by looking at a

variety of responses and behaviors:

SS Is the child able to retain a sense of calm while watching and listening to his or her

caregivers?

SS Does the child display apparent pleasure from his or her interactions with his or her

caregiver?

SS Does the child engage in reciprocal communication with the others?

SS Can the child engage in problem-solving communication?

SS Can the child engage in creative and imaginative play?

SS Can the child give meaning to symbols?

SS Can the child display the ability to use logic, reality testing, and judgment in

interactions with others?

• Sensory reactivity, cognitive processing, and executive functioning are also assessed.

This category recognizes the fact that even children who have significant similarities

in their emotional development may have significant differences in their cognitive

function. These variations can be the result of genetic, prenatal, or maturational

factors. The areas to be evaluated include:

SS Reactivity to sensory perception

■ Does the child underreact or overreact to sensory stimuli?

SS Sensory processing

■ Is the child able to register, decode, and comprehend what he or she is hearing and

seeing? SS Ability to process and react to affect with action or communication

■ Does the child understand emotional responses and act accordingly?

SS Ability to plan behavior and predict consequences of behavior

• Assessing the style and quality of relationships

SS Does the child have appropriate interactions with primary caregivers and family

members?

SS How does the child choose to engage with his or her environment? Does he or she

seek out interactions with those around him or her? Does he or she explore his or

her surroundings appropriately?

The DIR model leads to an individualized profile of the child that can serve as a basis for

developing targeted interventions. It considers biological and psychological development

as well as valuing the social interactions as a significant factor in child growth (Greenspan

and Wieder, 2003).

A one-on-one interview of the child is rarely sufficient to develop a complete understanding

of his or her world and mental state. Children often lack the self-observing

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Chapter 5 • Psychiatric Interviews: Special Populations 123

functions necessary to describe themselves in an objective fashion. The younger the child,

the fewer his or her reference points for normal behavior. Because of these factors,

collateral information is vital. Parents or other primary caretakers can provide the best

overview of the child and can provide key insights into the developmental history. In

addition to augmenting the child’s perspective, these caregivers can discuss neurovegetative

symptoms such as eating and sleeping habits as well as describe interactions with

others (family and friends). If possible, both parents should be interviewed. This will

sometimes help provide a more balanced perspective as well as clarifying the differing

expectations, perceptions, and roles that exist within the family.

In addition to family information, with school-age children, information from teachers

and counselors can be extremely important. The classroom represents a ready-made control

group where the child’s performance and behavior can be directly compared to those of

peers. Parents may at times have a very skewed view of their child based on their personal

expectations and what they see at home. Experienced teachers and school counselors often

have a more accurate view of the child’s functioning in structured and controlled settings.

As the interview proceeds, the issue of confidentiality can be introduced.

Confidentiality will depend largely on the age and developmental stage of the child. With

very young children, there will be very little that will be held back from the parents. As

the child ages, he or she will have more right to maintain some information from his or

her parents (Sadock and Sadock, 2003).

Often parents wish to be present when the psychiatrist talks with their child. Children

may also find the doctor’s office an intimidating place and wish strongly that their parents

stay with them. In both of these instances, the interviewer should politely push to be alone

with the child for at least part of the interview. One common strategy is to speak with the

child and parents at first. This gives the parents and child an opportunity to help define the

problem. It is also a helpful time to ask about past treatment, past similar experiences, and

trends in symptoms. Hopefully, by this time, both the child and parents are feeling more

comfortable with the psychiatrist, who can then outline the rest of the interview process.

After speaking to the parents and child, most psychiatrists will prefer to speak privately

with the child. This will be followed by interviewing the parents and then bringing

everyone back into the room.

Interviewing the child without his or her parents provides several advantages. In

addition to increasing disclosure from the child, it allows the interviewer greater freedom

to conduct the interview without having to explain interview techniques or involve the

parents in the conversation. It also keeps the parents from answering for their child and

solidifies the relationship with the child. Speaking to the parents alone similarly helps

them to reveal information about the child and their home life that they may not feel comfortable

expressing in front of the child. Finally, bringing everyone back into the room for

a few minutes will allow the psychiatrist some additional insight into the family’s functioning.

How does the child interact with his or her parents? Does he or she turn to the

parents as a source of support? Is he or she dependent on the parents to speak for him or

her? How does the child’s interaction with the psychiatrist change when his or her parents

come back into the room? Bringing the family back together also allows the psychiatrist

to ensure that all know what the treatment plan includes and what the next step will be.

Adolescent Issues – During the interview of adolescents, the psychiatrist must

remember that their inner world and experiences might be much broader than their parents

Tasman, A., Kay, J., & Ursano, R. J. (2013). The psychiatric interview : evaluation and diagnosis. Retrieved from http://ebookcentral.proquest.com

124 The Psychiatric Interview

realize, and, therefore, nothing can be assumed. The interviewer must ask teenagers about

their sexual experiences, alcohol consumption, and recreational drug use. If these experiences

are normalized, there is a greater chance of getting truthful information from the

adolescent, e.g., “Many teens your age have already had sexual experiences. What experiences

have you had?” As teens may feel uncomfortable answering these issues in front

of their parents, interviewing them separately is crucial. They may still be hesitant to

answer questions if confidentiality has not already been discussed.

The interview of a minor carries with it legal as well as ethical obligations to ensure the

safety of the child. This can include inquiring about abuse or neglect as well as asking questions

about violence at school, in the neighborhood, and at home. Particular interest should

be paid to the issue of punishment for misbehavior. Most states will have a requirement that

a reasonable suspicion of abuse must be reported to state agencies for further evaluation.

Summary of Recommendations

• Clarify interview process with child and parents.

• Inquire about all aspects of child’s life.

• Interview child and parents alone and together.

• Consider developmental issues.

• Discuss confidentiality.

Special Populations – Using Interpreters

An increasingly common situation is when the patient and psychiatrist are separated by

language. Subtleties of speech and nonverbal communication are central in understanding

patients. Differences in language between the patient and interviewer can obfuscate those

vital clues. Even slight problems with fluency can have a significant impact. Studies have

found that psychoanalysis conducted with bilingual people is more successful in their

first language than in their second (Farooq and Fear, 2003). Most facilities have made

some accommodations for dealing with patients who do not speak English, but working

with these interpreters does not eliminate all of the challenges. There are several categories

of interpreters that might be used. These include family members or friends,

bilingual hospital personnel, or outside volunteers/contractors. Each category has potential

risks and benefits.

Family/Friends

One of the primary advantages to using family is availability. Often they will already be

nearby when the psychiatrist arrives. Becoming interpreters provides them an opportunity

to directly help the patient. Their involvement also contributes to the patient’s support of

the treatment plan since very meaningful people have been involved in the discussion.

Another advantage is that family and friends may have a wealth of knowledge about the

patient’s biopsychosocial history. Often they are familiar with the patient’s medical history

and current medications. They can provide instant collateral information. If the

patient is being unclear, evasive, or deceitful, they may share this observation with the

Tasman, A., Kay, J., & Ursano, R. J. (2013). The psychiatric interview : evaluation and diagnosis. Retrieved from http://ebookcentral.proquest.com

Chapter 5 • Psychiatric Interviews: Special Populations 125

clinician. They can also comment on changes that they have seen in the patient over time.

The psychiatrist can ask if the patient is expressing himself or herself as he or she normally

does. “Does he or she sound confused or appear nervous or sad?” Despite the

advantages of using family and friends, however, the disadvantages may be even greater.

If the psychiatrist does not know the patient, then he or she probably does not know

the family either. The interviewer will be unaware of who in the family knows the patient

well and who will be the most truthful. There is a temptation for the family member to

change the story to protect the good name of the family through excluding or minimizing

embarrassing information as he or she translates (Phelan and Parkman, 1995). Family

members may have preconceived ideas about the patient’s condition. They can steer the

psychiatrist in a way to cast blame on who or what they think is responsible for the

patient’s distress. Family members without medical training or background may not

understand the questions that the interviewer is asking, but may be hesitant to ask for clarification.

On the other hand, they may not understand the patient’s response and rather

than report the patient’s distorted information, they may insert their own answer to the

question. They, of course, might be providing accurate information, but at this stage in the

assessment, the interviewer needs to hear the patient’s responses in an unadulterated

form. There is also no control over the quality and nature of the relationship that the

patient has with the family members. Perhaps the family member who is volunteering to

translate is being abusive or neglectful toward the patient, and this may not be clear during

the interview. Ideally, family members should provide a calming experience for the

patient, yet often the closest relationships can be the most provocative. This can lead to

increased agitation during the interview. Family members may be more likely than other

interpreters to insert their own questions and openly disagree with the patient’s answers

to questions (Phelan and Parkman, 1995). Privacy is also a significant concern since the

patient is asked to disclose highly personal information in front of individuals with whom

he or she is likely to interact throughout his or her lifetime.

Bilingual Staff

Many psychiatrists prefer to rely on their bilingual staff members, especially if these are

mental health workers. These individuals will be knowledgeable about their role as

interpreters. Appreciating colloquialisms and common expressions facilitates the interviewer’s

intentions and meanings in ways that are preferable to a literal word-for-word

translation. The patient may be relieved to have a staff member with whom he or she can

talk freely and will often turn to them for support. This supportive presence may encourage

the patient to be more honest and disclosing. Because these interpreters are trained medical

personnel, the interviewer is often more comfortable in inquiring into sensitive issues.

Questions about drug and alcohol use, sexual tendencies, and infidelities may be difficult

to ask when using a family interpreter, but will be significantly easier when the interpreter

is a medical professional.

These trained staff members can describe basic mental functions such as thought

processes and thought content. “Does the patient ramble?”, “Is the patient answering questions

logically?”, and “Is he or she paying attention to the conversation?” are questions that

can be answered with reasonable certainty by these medically knowledgeable interpreters.

Tasman, A., Kay, J., & Ursano, R. J. (2013). The psychiatric interview : evaluation and diagnosis. Retrieved from http://ebookcentral.proquest.com

126 The Psychiatric Interview

Despite these advantages, there are some drawbacks in using bilingual staff members.

Since they might be trained in mental health interviewing, they may change the question

from the one asked to one they think should have been asked. Their judgment may be

accurate, but it adds a complicating factor to the interview as the interviewer will not

know if the patient is being evasive, is uncertain of the answer, or was simply not asked

the intended question. Since these translators are more familiar with mental health

language, they may tend to paraphrase a patient’s answers, thereby complicating the

assessment of the patient’s use of language.

• Example – A psychiatrist is interviewing a patient using a mental health technician as

an interpreter. The psychiatrist asks if the patient is having any trouble sleeping. The

technician speaks for quite a while. The patient gives a brief response and the

technician replies: “She does not have any neurovegetative symptoms”. Unless this

psychiatrist goes back to clarify the exact symptoms, it will be unclear which

symptoms were asked about and which were not.

Another issue with hospital personnel is the assumption that all speakers of a language

can understand each other equally well. The reality is far different. Spanish speakers

taught continental Spanish may have some difficulty understanding a Spanish speaker

from rural Columbia. An American may have a similar problems understanding a Scot

from Glasgow. Not only are the accents sometimes difficult to understand, but local

idioms may be hard to follow.

Remote Interpreters

Many hospitals have turned to the services of paid interpreters who are accessed by phone.

The interviewer is in the room with the patient while both are speaking through an interpreter

in some distant location. Many of these interpreters are extremely fluent in multiple

languages and proficient at their jobs. They have been instructed to ask questions in as

close to a word-to-word translation as possible and to convey the answers in a similar

fashion. Because they are used to consulting to medical facilities, they are adept at employing

medical terms as well as making normal conversation. Since they do not know the

patient, they have little bias and can relate responses in a straightforward fashion. When

asked, these interpreters can give comments about the patient’s use of language and ability

to express themselves. They can be asked simple questions about the patient’s speech such

as “Were they easy to understand?” and “Did they answer the questions appropriately?”

The fact that the interpreter is not in the room, however, adds uncertainty to the

translation. Assessing nonverbal cues may be problematic. The interpreter may have difficulty

understanding tone and inflection over the phone lines. Although the interviewer

has every reason to trust the interpreter, the patient may not choose to do so. If the patient

is suspicious of the interpreter, he or she tends to be less disclosing and more evasive.

When it comes to asking potentially uncomfortable personal questions, the remote trained

professional is generally more comfortable than a family member but less comfortable

than the bilingual coworker.

The push toward brevity is a common problem when utilizing an interpreter. The

use of a translator often places the interviewer and the patient in an unfamiliar and

Tasman, A., Kay, J., & Ursano, R. J. (2013). The psychiatric interview : evaluation and diagnosis. Retrieved from http://ebookcentral.proquest.com

Chapter 5 • Psychiatric Interviews: Special Populations 127

uncomfortable circumstance. In addition, the interview often takes much longer than

usual. Both the patient and psychiatrist may grow weary of the long pauses and delays

in communication. The interviewer may get frustrated with the struggle to get answers

for his or her questions. All of these factors may lead the psychiatrist to prematurely terminate

the assessment, thereby relying on a minimum of information and/or making

unwarranted assumptions. An interpreter may also have a tendency to condense

information in an attempt to be more efficient. The interpreter may take the interview’s

open-ended questions and change them to quicker, close-ended questions, falsely giving

the interviewer the idea of limited spontaneous speech by the patient (Farooq and Fear,

2003). The patient may also try to speed up the process by deliberately shortening his or

her answers so that he or she will be understood more quickly. This deprives the psychiatrist

of an accurate view of the patient’s inner world and experiences. All of these can

lead to subpar interviews and patient care. The psychiatrist can guard against this by

allotting more time than usual for the interview and acknowledging the patient’s frustration

with the process.

The clinician should meet with the interpreter before the interview to explain the

purpose of the interview and to clarify the anticipated questions. If the interpreter has

questions about the medical terms being used, these can be addressed prior to meeting

with the patient. Further, the importance of word-by-word interpretation and the importance

of discerning evidence of a formal thought disorder, neologisms, or hallucinations

can be emphasized. If possible, using the same interpreter on subsequent interviews promotes

continuity and rapport (Phelan and Parkman, 1995).

After introductions, the psychiatrist will review the role of the interpreter and the

mandate of confidentiality. With marginally fluent, English-speaking patients, the interviewer

should suggest that an interpreter be brought in. Patients who have good conversational

English may find themselves stymied by the demands of a psychiatric interview.

Patients may be embarrassed by their limited grasp of the language and might provide

answers to what they think was asked rather than request clarification. The interpreter

standing nearby gives them another alternative for handling this situation (Phelan and

Parkman, 1995).

During the interview, it is important for the interviewer to look at the patient even

while the patient responds directly to the interpreter. In employing a remote interpreter,

there can be a tendency to look at either the loudspeaker or phone while waiting for

answers. This emphasizes the separation between the patient and the interviewer, however,

and should be avoided. Observing the patient while he or she speaks also permits the

psychiatrist to view nonverbal communications such as affect and mannerisms.

The interviewer should speak at a slightly slower than normal rate but still try to

maintain a natural pace and rhythm. The interpreter will sometimes rely on inflection and

rhythm of the interviewer to help set the inflection and rhythm of his or her questions. The

interviewer should not ask multipart, ambiguous, or complex questions as they often confuse

the interpreter and/or the patient.

• Example – “Do you have problems with sleep, and if you do, is that a problem getting

to sleep, staying asleep, or with waking the next morning?” This inquiry should be

broken down into a series of simple, direct questions starting with the open-ended

question “Tell me about your sleeping”.

Tasman, A., Kay, J., & Ursano, R. J. (2013). The psychiatric interview : evaluation and diagnosis. Retrieved from http://ebookcentral.proquest.com

128 The Psychiatric Interview

One other specific issue involves the use of sign language. In those cases, the interpreter

should be situated beside or slightly behind the interviewer so the patient can watch the

interviewer’s lips but then move quickly to the signer’s hands (Phelan and Parkman, 1995).

Summary of Recommendations

• Use trained medical interpreters whenever possible.

• Ask for word-by-word translation.

• Ask the interpreter about the patient’s thought processes.

• Allow for more time than usual.

• Focus on the patient during the interview.

Special Populations – Cross-cultural Issues

Working in a multicultural arena presents a constant challenge for the psychiatrist. Often the

same words may have remarkably different meanings for each of the parties requiring additional

time to explore issues thoughtfully. Stereotyping and personal biases dramatically

alter any clinical relationship. Assumptions about shared experiences are to be avoided.

• Example – Both the therapist and the patient grew up as Latinas in a southwestern

region of the country. As had been the case for the interviewer, there was an

assumption that the church was a central and comforting part of the patient’s life.

Later, it becomes apparent that the church is united in the patient’s mind with her

autocratic demanding and abusive father.

Special Population – Telepsychiatry

In an effort to enhance psychiatric coverage to rural and isolated locations, many health

systems are turning to telepsychiatry, which allows psychiatric evaluation from a distant

location. This is part of an overall increase in the use of information technology to enhance

medical care. According to the American Telemedicine Association, 20 million Americans

get some part of their health care remotely (Ravn, 2012). Patients who would not be able

to see specialists in person can still receive their care through video links to their Primary

Care Provider’s office.

In addition to reaching isolated populations, another potential advantage of telepsychiatry

is cost savings. While purchasing and maintaining the computer and camera equipment

at the base location and distant sites can be a significant upfront cost, this will likely

be offset by the savings that comes from not having to pay the psychiatrist’s travel expenses.

A 6-month study compared in-person treatment of depression with telepsychiatry and

found that the per session cost of telepsychiatry was more than that of in-person sessions

($86.16 vs. $63.25). When travel costs were included, however, the cost became equal

with a drive of 22 miles. If the psychiatrist had to drive more than 22 miles to the distant

site, then telepsychiatry was less expensive (Ruskin et al., 2004). An additional financial

benefit comes from an expected increase in the number of patient contacts. As the provider

does not lose time driving to the distant site, he or she has more time to see patients.

Tasman, A., Kay, J., & Ursano, R. J. (2013). The psychiatric interview : evaluation and diagnosis. Retrieved from http://ebookcentral.proquest.com

Chapter 5 • Psychiatric Interviews: Special Populations 129

There is mounting evidence that in addition to being fiscally beneficial, telepsychiatry

provides good quality care. When adequate equipment is used, telepsychiatry can

accurately assess cognitive functioning, depressive, anxiety, and psychotic symptoms

(O’Reilly et al., 2007). A 2005 meta-analysis of 14 studies with 500 patients found no

difference in accuracy or patient satisfaction using telepsychiatry versus in-person evaluations

(Hyler et al., 2005).

There have been a number of positive trials examining patient outcomes after

receiving telepsychiatry services. One hundred and nineteen veterans with depression

were followed for 6 months by in-person psychiatry or telepsychiatry. This study found

that depressive symptoms, adherence to treatment, drop-out rates, and satisfaction levels

were equivalent. When travel expenses were included, the two treatments were equal in

costs (Ruskin et al., 2004). A Canadian study tracked 495 patients who were followed in

person or by telepsychiatry. After 4 months of treatment, the patients were reassessed, and

both groups had similar improvements in symptoms (O’Reilly et al., 2007).

The United States’ Veterans Administration (VA) has promoted the use of telemedicine

for mental health services since the early 2000s as a means of reaching out to

veterans in rural settings. Between 2003 and early 2012, there had been almost 500,000

tele-mental health encounters with 98,609 veterans. The tele-mental health technology

used during 2006–2010 allowed for greater access to evaluations, psychotherapy, and

psychoeducational programs. The study also examined the use of mental health resources

before and after enrollment and found that the number of admissions and hospital days

decreased by nearly 25% after patients enrolled in a telepsychiatry program (Godleski

et al., 2012). While telepsychiatry undoubtedly presents exciting opportunities to bring

psychiatric services to areas that had been neglected, using telepsychiatry to interview

patients creates new challenges.

There are legal and privileging issues that are pertinent to telepsychiatry. Can interviews

cross state lines? What are the privileging and licensure requirements if they do? What if

patients become agitated during the interview? What if they threaten themselves or someone

else? How can the interviewing psychiatrist respond when hundreds of miles away? These

questions will need to be answered on a case-by-case basis (Monnier et al., 2003).

Some challenges are strictly technical ones. Compatibility of equipment and software

and the adequacy of the available bandwidth need to be addressed. As would be

expected, the broader the bandwidth and the better the quality of the picture, the more

accurate the assessment. Forty-two patients were assessed in person and via telepsychiatry

using a standardized rating scale. The telepsychiatry evaluations were conducted

using either narrowband or broadband technology. The quality of assessments utilizing

broadband technology was similar to face-to-face interviews. Narrowband technology,

however, led to inferior assessments. This decrease in accuracy was likely due to poor

image quality and the inability to assess nonverbal cues (Yoshino et al., 2001).

With less than optimal technology, the provider may have difficulty conducting

numerous parts of the interview. The psychiatrist may have more difficulty assessing tone

of voice. Depending on the camera angle, some important nonverbal cues may go unnoticed.

If the patient is not speaking into a high-quality microphone, the clinician may have

difficulty hearing or understanding the patient. Eye contact is also difficult to establish.

Should the psychiatrist and patient look at the picture on the monitor or into the camera?

With adequate preparation, however, many of these problems can be solved.

Tasman, A., Kay, J., & Ursano, R. J. (2013). The psychiatric interview : evaluation and diagnosis. Retrieved from http://ebookcentral.proquest.com

130 The Psychiatric Interview

Before beginning an interview, the psychiatrist should become thoroughly

acquainted with the functioning and capability of the equipment. He or she can optimize

the experience by having an assistant at the distant site play the role of the

patient sitting where he or she would sit and speaking in a normal, soft, and then loud

tone. This advance work can also include adjusting the camera and the lighting so

that the patient’s features and upper body are plainly visible. The psychiatrist can

also be positioned to look into the camera while still having a good view of the patient

on the monitor.

To minimize the risk of agitation or threatened violence, some locations may choose

to have a mental health technician or other medical personnel sitting in the room with the

patient. Having this third-party in the session may raise issues of confidentiality and may

adversely impact the therapeutic alliance. Another solution to these safety concerns is to

have a second line that the provider can use to instantly notify the distant site if the patient

demonstrates a deteriorating mental state or expresses concerns about harming himself or

herself or others.

The provider should speak in a slightly slow but precise fashion. Early in the interview,

significant procedures should be reviewed with the patient. What should be done

when the connection is lost? What should occur if the image freezes? What would lead

the psychiatrist to contact the distant site for assistance? This is in essence a modified

informed consent. Repeatedly checking in with patients during the interview regarding

their mood and emotional state is critical since appreciation of nonverbal cues is lessened.

Feedback from patients about their ability to see, hear, and understand the psychiatrist is

essential as the psychiatrist’s ability to see, hear, and understand the patient. Since both

the patient and interviewer quickly become aware of the limitations of this modality,

asking them to lean forward or speak more slowly is a reasonable request to make.

The US Army began a telepsychiatry program linking Walter Reed Army Medical

Center in Washington, DC and Carlisle Barracks in Carlisle, Pennsylvania. They

assessed patients’ initial concerns about using telepsychiatry services and then followed

up about the experience. Nearly a third had concerns about privacy issues before starting

telepsychiatry, but, after using the service, that number had been cut in half. Those

expressing concerns about confidentiality decreased from 76% before using the program

to only 4% with some experience. None of the patients thought that the telepsychiatry

experience interfered with their relationship with their psychiatrists. Ninety-six percent

eventually agreed that they were comfortable using telepsychiatry services and 84%

thought that the care they received was as good if not better than if it had been face-to-face

(Schneider, 2006). Although telepsychiatry is still relatively young and the data are

limited, with proper safeguards, telepsychiatry appears to be an appropriate venue for

psychiatric evaluations.

It is as of yet unclear how telepsychiatry impacts the therapeutic alliance. While

patients receiving telepsychiatry often report satisfaction with their interactions with their

tele-provider, this may be due to increased convenience and their getting to see a specialist

than the creation of a positive relationship with the tele-provider (Monnier et al.,

2003). Large-scale studies looking specifically at the therapeutic alliance have yet to be

done. It has been suggested that the issue of therapeutic alliance using telepsychiatry may

be rapidly shifting as younger generations are increasingly comfortable with carrying out

intimate relationships via digital connections (Zur, 2012).

Tasman, A., Kay, J., & Ursano, R. J. (2013). The psychiatric interview : evaluation and diagnosis. Retrieved from http://ebookcentral.proquest.com

Chapter 5 • Psychiatric Interviews: Special Populations 131

Summary of Recommendations

• Use high-quality, broadband equipment.

• Establish procedures for the handling of emergencies and loss of connection.

• Check in with patient frequently about his or her mood and the interview experience.

• Deliberately attempt to enhance the alliance with the patient.

Conclusions

The psychiatric interview is the psychiatrist’s chief means of obtaining information about

the patient. Every interview is unique. The life history of each patient is always different

from every other patient encountered. When the patient and psychiatrist meet, they are at

the juxtaposition of a particular time in the life of the patient and the professional and

personal life of the psychiatrist. If they had met 3 months earlier or later, the interview

might be considerably different. This chapter has looked at some special circumstances,

patient populations, and interactions that frequently create additional challenges for the

psychiatrist. By attending to the characteristics of the interview setting and the patient’s

circumstances, the psychiatrist can adapt strategies and techniques to overcome these

difficulties and provide excellent patient care.

Addressing And Confronting Bias And Prejudice

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