CLINICAL INTERVIEW

MADE EASY
DR NADER KORHANI PhD
 Goals, Purposes, and Types of Assessment
 Interviewing
 Types of Interviews
 Potential Threats to Effective Interviewing
 Behavioral Observations
 Checklists and Inventories
 Physiological Testing

Lecture Preview
Since the foundation of psychology, assessment
and testing have been important activities.

Psychological assessment is the process to

collect and evaluate information to
 make diagnoses,
 plan treatment, and
 predict behavior.
 Assessment could include
 clinical interviews with a patient or significant other (family member,
friend, colleague);
 behavioral observations (classroom observation);
 the use of checklists, inventories, and psychological tests (IQ and
personality tests);
 the review of previous records (medical charts, school records); and
 discussions with other professionals familiar with the person (physician,
school teacher, school counselor).
 Assessment could include
 clinical interviews with a patient or significant other (family member,
friend, colleague);
 behavioral observations (classroom observation);
 the use of checklists, inventories, and psychological tests (IQ and
personality tests);
 the review of previous records (medical charts, school records); and
 discussions with other professionals familiar with the person (physician,
school teacher, school counselor).
 Assessment may include
 interviewing the patient,
 reviewing past records (such as medical or school records),
 observing behavior, and
 administering psychological tests to measure various
cognitive,
behavioral,
personality,
family, and
even biological factors.
 The choice of assessment tools

depends on

 the nature of the problem(s),

 the skills and perspective of the psychologist,

 the objectives and willingness of the patient, and

 practical matters such as cost and time.

 Goals, Purposes, and Types of Assessment

People ask questions such as:

 «Am I crazy?»
 «Is my child mentally retarded?» or «Is my child
gifted?»
 «Why do I feel so depressed when things in life
appear to be going fine?»
 «How can I overcome my intense fear and panic
whenever I drive over a bridge?»
 Interviewing
We use interviewing as a standard approach to
1) assess problems
2) formulate hypotheses and conclusions.

The purposes of clinical interviews include

1) gathering information about the patient’s
difficulties and process-related variables
2) providing clinical exposure to patients
3) initiating and developing a good therapeutic
alliance
Before helping the patient, an initial
assessment is necessary. The goal of
assessment is fully understanding of the
factors that contribute to the problem(s).

Sometimes the presenting problem or

symptom is not the real problem. Someone
may seek help for headaches. After a session
or two, the patient reports that her marriage
is in trouble. The headaches were a “ticket”
into psychotherapy.
AN EFFECTIVE CLINICAL INTERVIEW

1. To obtain historical perspective of patient’s life,

2. To establish rapport and therapeutic alliance,
3. To develop mutual trust and confidence,
4. To understand present functioning,
5. To make diagnosis,
6. To establish treatment plan.
PRIMARY ELEMENTS OF CLINICAL INTERVIEW
COLLABORATIVE APPROACH
INTERVIEW SETTING & STRUCTURE
 Arrange a comfortable setting with privacy & Confidentiality, Try to avoid
interruptions, arrange Safety- Seating.

 Introduce yourself, and anyone accompanying you; greet pt. by name, and tell
reason of i/v.

 Carefully observe pt.’s nonverbal behavior, posture, mannerisms, and physical

appearance. - Avoid excessive note-making.

 Questions: Open-ended Q?- for neurotic, verbal, intelligent pt. “tell me more
about that.”

 Closed-ended Q?- (yes or no) for psychotic, delirium, dementia, limited-time i/v.
avoid suggesting answers (you feel depressed, don’t - you?).
 Five type of interview questions

1. Open-ended : gives patient responsibility and latitude for responding. Ex

: "would you tell me about your experiences in the army"
2. Facilitative : encourage patient's flow of conversation. Ex: "Can you tell
me a little more about that"?
3. Clarifying : encourages clarity of amplification. Ex: "i guess this means
you felt like"?....
4. Confronting : challenges inconsistencies or contradiction. Ex : "before,
when you said"?....
5. Direct : once rapport has been established and the patient is taking
responsibility. Ex : "what did you say to your father when he criticized
your choice "?
 Attending skills
 Listening skills
 Attend carefully to what is being said and also observes nonverbal
behavior
 Use nonverbal behavior such as nods, eye contact, and vocalizations such
as ‘‘Mmm . . .’’ and ‘‘Uh huh’’ to communicate that he or she is tracking
the conversation without interrupting the flow of what is being said
 Emotional reflections
◦ ‘‘it sounds as though that was very painful for you’’
 focus exclusively on the client
 not take turns in describing similar experiences that he or she has had!
◦ therapeutic self-disclosure is different than reciprocal sharing
 Effective Listening Skills
To fully listen to another without being
distracted by your thoughts and concerns is
challenging work.

Careful listening includes the content of what is

being said and the feelings behind what is being
said.

Listening also includes paying attention to what

is not being said.
 Defining problems & goals

• have a clear sense of the patterns within the problem area

• problem must be defined in specific & concrete terms

• the psychologist must have a good understanding of normative behavior

• Goal must be important to the client

• Goal must be expressed in terms of the ways people behave

• Goals must be small, simple, and achievable

 Observations

• the psychologist is a keen observer of the client

• included comments on the client’s appearance and

grooming

• notice the client’s activity level, attention span, and

impulsivity

• Pay attention to the client’s speech, noting any difficulties

or abnormalities
 Purposes of interview
 whenever a psychologist begins psychotherapy with a new patient.

 whether someone is in a crisis and might be at risk for self-injury or injury

to others.

 to determine the current mental status.

 Certain techniques and skills

are necessary for all types of interviews:

developing rapport,
effective listening skills,
effective communication,
observation of behavior, and
asking the right questions.
 Rapport
To talk about special problems with a stranger is a very uncomfortable.

To develop an effective interview, the psychologist must develop rapport

with the person. Rapport is the comfortable working relationship that
develops between the professional and the interviewee.

The atmosphere of therapy room is positive, trusting, accepting, respectful,

and helpful.
 For rapport
The professional must focus complete attention on the patient without any
telephone calls or personal concerns.
The professional must maintain eye contact and facing the patient with an
open posture without barrier such as a table.
The psychologist actively and carefully listens.
The psychologist is nonjudgmental and noncritical.
Genuine respect, empathy, sincerity, and acceptance
Principals of psychiatric interview:
1. Time
 Psychiatric assessment and psychological treatments take time.
 Spending time listening to and clarifying patients' problems, and making
an attempt to understand how they feel and why they feel that way, is
therapeutic in itself.
 Unfortunately, the pressure of work in general practice makes it difficult
to find this time. Moreover, the financial incentives of Medicare are
towards shorter, not longer, consultations. One solution is to spread the
assessment out over several sessions.
Principals of psychiatric interview:
2. Reassurance
 As a rule, it is better to try to understand a person's experience more
clearly than to give bland reassurance.
 Although you may mean well, he or she may perceive a reassuring
comment as presumptuous or rejecting. However, reassurance does have a
place when it is true and does not dismiss the person's experience.
Helpful comment:
(To a depressed man) 'When people are depressed, they often feel that
nothing can be done to help. There are effective treatments for depression
and I know that I can help you.‘
.
Principals of psychiatric interview:
 3. Interview technique
 The following characteristics of interview style improve the likelihood of
detecting mental illness:
 listening, clarifying and asking for an example .
 Not interrupting, especially at the beginning of the interview .
 Asking open-ended questions, especially at the beginning of the interview.
 Asking directive psychological questions .
 An empathic style - This involves putting yourself in the other person's position
so as to understand how he or she feels, thinks and behaves, and why he or she
feels that way. However, empathy is not simply an uncritical acceptance of a
person's ideas and impulses ( pseudoempathy ).
 Picking up and responding to verbal and non-verbal cues .
 Maintaining control of the interview.
Principals of psychiatric interview:
Examples of effective interview techniques:

 Clarification
You ask a man to give you an example of what he means when he says he has suffered a panic attack.
You summarize the person's complaints, their time course and the events happening at the time.
 Asking open-ended questions
At the beginning of the interview, you ask, 'How are you feeling?
 Directive psychological questions
You ask a man who presents with fatigue and insomnia if he has been feeling down or depressed. Later, you
ask him about anhedonia, vegetative function change and suicidality.
 Response to a verbal cue
A 47-year-old man complains of a number of vague physical symptoms including fatigue, abdominal
discomfort and headaches. He says that he cannot even be bothered playing football any more. You ask,
'When did you last do something that you really did enjoy? He takes some time responding, and then says,
'It seems ages. I suppose I enjoyed the trip to sharm last winter. Then you ask if he has been feeling
depressed. You pick up the man's cue about anhedonia and follow it up with direct questions about
depression.
Principals of psychiatric interview:
Examples of effective interview techniques:
 Response to a non-verbal cue
A woman who has been attending your practice over the past five years is not herself. She looks tired and
depressed and sits slumped in the chair. Usually well groomed, today her hair is untidy and her clothes
rumpled. Her affect is flat and she speaks in a soft voice giving unelaborated responses to your questions.
You say, 'You look tired today. How are you feeling?' Later you ask if she has been feeling depressed.
 Empathic style
A middle-aged man becomes depressed after being overlooked for a promotion at work. You ask about his
prospects for promotion in the future. This uncovers his fear that, at 52, he is unlikely ever to be promoted.
The question that you ask leads the man to elaborate his concerns. Further questions may address the other
developmental challenges of middle age that he is presently facing.
 Maintaining control
An elderly man speaks at length about how unjustly he is treated by his neighbours. You say, 'I am sorry to
hear that you are so upset by your neighbours, but could I take you back to what you were saying about
feeling depressed'.
 Types of Interviews
different types of interviews

 to admission to a clinic or hospital,

 to determine if a patient is in danger of injuring herself or someone else,
 to determine a diagnosis.

highly structured X unstructured and spontaneous.

 Types of Clinical Interviews
 Initial Intake or Admissions Interview
 Mental Status Interview
 Crisis Interview
 Diagnostic Interview
 Structured Interviews
 Computer-Assisted Interviews
 Termination Interview

Copyright ©Allyn & Bacon 2005

 Initial Intake or
Admissions Interview
to develop an understanding of the patient’s symptoms or to recommend
the treatment or intervention plan.
The initial interview attempts
 to evaluate the patient’s situation before admission to the hospital,
 to determine whether the services provided by the hospital can meet the
patient’s needs,
 to instill trust, rapport, and hope.
 Crisis Interview
is conducted when a patient is in a significant and traumatic or life-
threatening crisis. We might encounter such a situation in an emergency
room, a clinic, or a student health service on campus.

It is critical to determine whether the person is at significant risk of hurting

him- or herself or others. It is important to determine whether the alcohol,
drugs, and/or medication the person taken is a lethal dose.
 Crisis Interview

 Primary Goal: resolve the immediate problem

 Secondary Goal: refer to appropriate resources

 In the case of crisis
The interviewer may need to
 be more directive (encouraging the person to phone the police);
 break confidentiality if the person is in serious and immediate danger;
 or enlist the help of others (e.g., police department, ambulance).
INTERVIEW STRUCTURE CONT.
HOW TO START:

• Identifying data:- name, age, sex, marital

status, education, address, occupation.

• Chief complaint (cc):- brief statement in “ pt.’s

own words” of why he is in hospital or seen in
consultation. “ what seems to be the
problem?”.
 Typical Information Requested
during a Standard Clinical Interview
 Identifying information (e.g., name, age, gender, address, date, marital
status, education level) sociodemographic information
 Referral Source (who referred the person and why)
 Chief Complaint or problems (list of symptoms)
 Family background
 Health background
 Educational background
 Employment background
 (Cont) Typical Information Requested
during a Standard Clinical Interview
 Interpersonal relationships
 Developmental history (birth and early child development history)
 Sexual history (sexual experiences, orientation, concerns)
 Previous medical problems and treatment
 Previous psychiatric problems and treatment
 History of Traumas (e.g., physical or sexual abuse, major losses, major
accidents)
 Current treatment goals
 My favourite questions:
 What do you think about contributing factors associated with the
development and maintenance of the problem?

 How have you tried to cope with the problems up to now?

 Why do you want to get professional service now?

 The Referral

• The assessment process begin with a referral

• Someone (parent, teacher, psychiatrist, judge, psychologist)
poses a question about the patient

what influences how the clinician addresses the referral question ?

answer : influenced by the clinician's theoretical commitments

(pychodynamic, behavioral, cognitive-behavior. etc )
 Active listening skills
include paraphrasing, reflection, summarization, and
clarification techniques.

Paraphrasing involves rephrasing (rewording) the content of what is being

said. A brief summary

Reflection involves rephrasing the feelings of what is being said in order to

encourage the person to express feeling
 Active listening skills

Summarization involves both paraphrasing and reflection in attempting to

pull together several points into a coherent brief review of the message.

Clarification includes asking questions to ensure that the message is being

fully understood.
 Effective Communication
The professional must use language appropriate to the patient and avoids
the use of professional jargon. The interviewer tries to fully understand
what the patient is trying to communicate and asks for clarification when he
or she is unsure.

Psychologists must be sensitive to different communication styles and learn

more about how race, culture, and gender impact these styles.
 Observation of Behavior

The psychologist pays attention to how it is being said. Observation of

nonverbal communication (e.g., body posture or body language, eye
contact, voice tone, appearence) provides useful information.
 Asking the Right Questions

Typical questions include issues such as the frequency, duration, severity,

and patient’s perception of the etiology of the presenting problem.
Open versus closed questions:
Closed questions Opened questions
A closed question can be answered with either a single An open question is likely to receive a long
word (yes/no) or a short phrase. answer.
 Thus 'How old are you?' and 'Where do you live?'
are closed questions.
 Although any question can receive a long
answer, open questions deliberately seek
 Thus 'Are you happy?' and 'Is that a book I see
before me?' are closed questions, whilst 'How are
longer answers, and are the opposite of
you? Is not. closed questions.
Using closed questions: Using open questions:
 They give you facts.  Open questions have the following
 They are easy to answer. characteristics:
 They are quick to answer.  They ask the respondent to think and
 They keep control of the conversation with the reflect.
questioner.  They will give you opinions and feelings.
 They hand control of the conversation to
the respondent.
Open versus closed questions in psychiatric interview:
Closed questions
 closed questions are more useful in patients
with marked loosening of associations.
 Closed questions are also useful in patients
with organic brain conditions (learning
difficulties, delirium or dementia) who can
loose track of longer answers.
 Closed questions have a lot of disadvantages:
they don’t build rapport or allow the patient
to open up, who can feel grilled. From the
point of view of the doctor, you can collect
the facts but miss the person. It’s also easy to
fall in to the trap of asking another question
when you don’t know what to do.
Opened questions
 Are often more useful in therapeutic
work with patients than closed
questions.
 Pros: Open-ended questions develop
trust, are perceived as less threatening,
allow an unrestrained or free response.
 Cons: Can be time-consuming, may
result in unnecessary information, and
may require more effort on the part of
the user.
Asking better questions:
 Good questions often begin who, what, when, how much, how many.

 Questions that begin with why are less useful as they tend to provoke defensiveness. How
can also be problematic in that it provokes analysis rather than awareness/autonomy
(compare how are you going to give up drinking? with what steps might you take to give
up drinking?).

 They also encourage the use of descriptive rather than judgemental terminology
(preventing defensiveness and unhelpful self criticism that may distort perception).

 It follows that good questions follow the line of interest of the patient, not the doctor:
the aim is to raise his or her awareness, so questions must follow this lead.

 Going through a psychiatric assessment by rote can be profoundly alienating for a

patient who isn’t led to their core worries.
The Socratic technique of questions:
 It is a way of structuring dialogue such that the teacher uses a set of prepared
questions to engage the learner’s experience and knowledge to solve problems
posed by the questions. The teacher leads the learner along a loosely
predetermined path to develop knowledge and understanding in a particular
direction.
 Socrates sees the advantage of this as leading someone to their ignorance: it is
better to admit ignorance than to have a false belief. This (ideally) leads him or
her to actively desire and pursue new learning through curiosity.
 The values of Socratic reasoning are active, reflective learning and the
importance of a lifelong pursuit of wisdom: this start with an admission of our
own ignorance.
6 types of Socratic questions:
1. Questions for clarification:
 Why do you say that?
 How does this relate to our discussion?
2. Questions that probe assumptions: What could we assume instead?
 How can you verify or disapprove that assumption?
3. Questions that probe reasons and evidence:
 What would be an example?
 What is....analogous to?
 What do you think causes to happen...? Why:?
4. Questions about Viewpoints and Perspectives:
 What would be an alternative?
 What is another way to look at it?
5. Questions that probe implications and consequences:
 What are the consequences of that assumption?
 What are you implying?
6. Questions about the question:
 What was the point of this question?
 Why do you think I asked this question?
 What does...mean?
 How does...apply to everyday life?
Use of Socratic Technique in CBT:
 Cognitive therapy use ‘Socratic’ questioning in a process of guided discovery.
 The therapist does not know in advance where the line of questioning is likely to
lead: ‘if you are too confident of where you are going, you only look ahead and
miss detours that can lead you to a better place’.
 The prime motivation of Socratic questioning is ‘to understand the client’s view
of things, not simply to change the client’s mind’
 The questions used should elicit a behavioural, non judgemental description of
the issue at hand.
 Asking a patient to describe their inner thought processes often directs their
attention to aspects of their experience which though relevant have previously
gone unnoticed.
 This can be profoundly therapeutic in itself, besides being grist to the
therapeutic mill.
(Padesky 1993, 3).
HPI History Of Present Illness

R/O:

• Depression
• Mania
• Anxiety/ PTSD/ OCD
• Psychosis
• Substance Abuse
• Suicidal/ Homicidal Ideations
HPI cont.

Depression: SIG E CAPS

• Sleep
• Interest
• Guilt
• Energy
• Concentration
• Appetite
• Psychomotor activity
• Suicidal Ideation
HPI cont.

Mania: DIG FAST

Distractability
Insomnia/ Impulsivity
Grandiosity
Flight of ideas/ Racing thoughts
Activity/ Agitation
Speech (pressured)
Thoughtlessness
HPI cont.

Anxiety/ PTSD/ OCD:

• Anxiety Disorders
• Panic, Specific Phobia, Social Phobia, GAD etc.
• O-C, Stereotypic & Related Disorders
• OCD, Body Dysmorphic, Hoarding, Hair Pulling, Skin
• Picking, etc.
• Trauma- and Stressor-Related Disorders
• PTSD, Reactive Attachment Disorder, etc.
• Dissociative Disorders
 HPI cont.
Psychosis:
Delusion (fixed false beliefs):
• Paranoid Delusion
• Ideas of reference
• Delusion of Control
• Delusion of Grandeur
• Delusion of Guilt

Illusiions (misinterpretation
of the sensory stimulus):
• Auditory/ Visual/ Olfactory/
Tactile
HPI cont.

Substance Abuse:
Nicotine, Alcohol, Amphetamine (Ice, Speed, Crystal, Ecstasy), PCP (Ketamine, K2) Sedatives
(BDZ, Barbiturates), Hallucinogens (Mushrum, LSD), Opiods, Cannabis, Inhalants, Pills, etc.
1. How often you use?
2. How much money you spend on it?
3. When was the last time you were sober?
4. Have you experienced:
 financial or legal problems,
 health consequences of use (cirrhosis, blackouts, vomiting)
 social consequences such as fights,
 marital problems, and loss of friends,
 loss of job or problems at work
HPI cont.

Suicidal/ Homicidal Ideation/ Plan:

• Stress – pressure
• Hopelessness
• Self-Hate

• One or more previous suicide attempts

• A history of aggressiveness and/or impulsivity
• Depression, especially hopelessness
• History of/or evidence of bipolar disorder
• Any drug or alcohol abuse
PAST PSYCHIATRIC HISTORY
Are you being treated by any other
mental health professional?

Previous Admission:

Onset:
Duration:
Medication:
ECT:
PAST PSYCHIATRIC cont.

• Medical History
• Allergies
• Family History
• Social History
• Legal History
• Sexual History
 Mental Status Interview
is conducted to screen the patient’s level of psychological functioning and
the presence or absence of abnormal mental situation such as delusions,
delirium, or dementia.

They include a brief evaluation and observation of the patient’s appearance

and manner, speech characteristics, mood, thought processes, insight,
judgment, attention, concentration, memory, and orientation.
Mental Status Exam
 General information
 Appearance and behavior
 Speech and thought
 Consciousness
 Perception
 Obsessions and compulsions
 Orientation
 Memory
 Attention/concentration
 Intelligence
 Insight and judgment
 Mental Status Interview
include questions
 to determine orientation to time (e.g., “What day is it? What month is it?
What year is it?”),
 place (“What city are you in? Where are you now? Which hospital are you
in?”),
 and person (“Who am I? Who are you? Who is the president of Turkey?”).
It assesses short-term memory (e.g., “I am going to name three objects I’d
like you to try and remember: chair, key, and dress”) and attention-
concentration (e.g., “Count down by 7s starting at 100. For example, 100, 93,
and so forth”).
 Diagnostic Interview
Axis I includes the presence of clinical syndromes (e.g., depr, panic disorder,
SCH).
Axis II = potential personality disorders (e.g., paranoid, antisocial, borderline)
and mental retardation.
Axis III = physical and medical problems (e.g., heart disease, diabetes, cancer).
Axis IV = psychosocial stressors currently experienced by the patient (e.g., fired
from job, marital discord, financial hardship).
Axis V (Global Assessment of Functioning or GAF) = a clinician rating of how
well the patient is coping with his or her problems (1 = poor coping, 100 =
excellent coping).
 Structured Interviews
To increase the reliability and validity of clinical interviews, a number of
structured interviews have been developed (e.g., the Structured Clinical
Interview for DSM-IV [SCID-I and SCID-II], the Positive and Negative Syndrome
Scale [PANSS]). They include very specific questions in a detailed format.

If a patient answers yes to a question, a list of additional questions might be

asked to obtain details and clarification. If the patient answers no to a question,
the follow-up questions are skipped.
 Structured Interviews
Clinical judgment are minimized or eliminated in structured interviews.

Semistructured interviews offer some degree of flexibility in the questions.

Structured and semistructured interviews tend to be used in research more

than in private practice or clinics.
 Computer-Assisted Interviews
Computers can be used to ask patients questions and record their responses.

Some patients feel more comfortable answering sensitive and embarrassing

questions via computer rather than face-to-face interview. However, some
people are uncomfortable with computers and prefer to talk with a
professional.

Ethical issue: There is a confidentiality concerns when sensitive material is

being requested in a waiting room and when access to computer files is not
controlled.
 Termination Interview
After completion of treatment, a termination interview may be used to evaluate
the effectiveness of treatment.

It might focus on
 how the patient experienced the treatment,
 what the patient found useful or not useful,
 how he or she might best deal with problems in the future.
 Potential Threats to
Effective Interviewing

BIAS: Interviewer’s personality, theoretical orientation, interests, values,

previous experiences, and cultural background may influence how they
conduct an interview. They may consciously or unconsciously distort
information collected during an interview. Bias can lead to distorted
approaches.
 Potential Threats to
Effective Interviewing
Reliability and Validity: Two or more interviewers conduct independent
interviews with a patient, they may or may not make the same diagnosis,
hypotheses, conclusions, or treatment plans. Patients may not report the
same information when questioned by several different interviewers.
Interviewer gender, race, age, and skill level may affect patient response.
Reliability and validity may be enhanced by using structured interviews,
asking similar questions in different ways, and using multiple interviewers.
Principals of psychiatric interview:
 4. Transference and countertransference:

 Transference can be broadly defined as the feelings that the patient has for you. Some of these feelings are
reality-based, for example, respect for your expertise in medicine. Others have unconscious origins and
arise from the transference on to you of feelings that are held towards others who are significant in the
person’s past or present. For example, being perceived by a young man as an authority figure, you may elicit
transference feelings that he has towards his parents, teachers and other authority figures in his life.
Countertransference refers to the feelings that you have towards the patient. Again, these will, in part, be
reality-based. Some will arise in response to the transference. Some will be similar to feelings that are
elicited in other people who deal with that person, while others will reflect aspects of your own past and
present relationships transferred on to the patient. Most will be a combination of all of these. It is normal,
of course, that you should experience these feelings. The important thing is to be aware of them and to
acknowledge them to yourself, even if they seem unacceptable - for example, feeling angry or bored with a
person, feeling overly concerned about or even feeling attracted to him or her. By acknowledging these
feelings to yourself and making them conscious you are much less likely to act inappropriately upon them.
For example, it is quite normal to feel angry with certain people, but it is likely to be damaging and
unprofessional to act out this anger.
Principals of psychiatric interview:
5. Boundary issues:

 Doctors are sanctioned to ask about private and intimate aspects of their patients' lives and to conduct physical examinations. There is a
clear power differential in the relationship between patient and doctor. In particular, people presenting for counseling or any type of
psychological therapy are often at their most vulnerable. The transference of flattering feelings and impulses onto the doctor -
respect for authority, attraction to power and success, desire for approval - may tempt the doctor into abusing his or her
power. To exploit such a position to fulfil ones own needs is unethical and potentially damaging to patients.
 It is essential to be clear about your role as a professional. You are not a friend of the patient. Indeed, it is wise to avoid, if possible,
treating your friends. It is always unethical to have sexual relations with a patient. For professional therapists, it is prohibited to have
intimate relations even after therapy has finished.
 Monitor your countertransference feelings and impulses and take care not to act out in ways that breach professional boundaries.
Transgressions of these boundaries typically occur in a stepwise progression. They may begin with the acceptance of expensive
gifts, financial advice. There may be a temptation to disclose and discuss one's own problems. Appointments may be made that
are longer than usual, or regularly scheduled at the end of the day when other staff members have left the practice. Fees may
be waived. Unnecessary home visits may be made. This may progress to the performance of unnecessary physical
examinations, meeting patients outside the consulting room, and to involvement in social situations and sexual relations.
Doctors who are vulnerable to boundary transgressions:
Include those experiencing life crises,
1. Those with problems in their own marriages or personal relationships.
2. Perfectionists who are excessively self-sacrificing and work unnecessarily long
hours may have difficulty setting limits on the demands of certain patients
and begin taking extraordinary measures in attempt to rescue them.
3. Patients with histories of sexual abuse may be particularly prone to evoke
such countertransference responses, especially when they express recurrent
suicidal ideation.
4. Doctors who deny their dependency needs and give the appearance of being
self-contained may be prone to seeking gratification for their needs for love
and nurturance through their patients: while denying their own dependency
needs, they may perceive others as being dependent on and needy of them.
5. A doctor suffering a psychosis might violate professional boundaries as a
consequence of the illness. Psychopathic doctors who willfully exploit patients
for the gratification of their own needs have no place in the medical
profession.
Dealing with countertransference:
By acknowledging to yourself your countertransference responses, you
lessen the likelihood of acting out upon them.
Monitoring your countertransference responses can provide you with valuable
information about a person. For example, when seeing a young woman who
repeatedly self-harms, you may feel frustrated and angry and you may even
imagine being cruel to her. Recognising these feelings and impulses, you take
care not to act out upon them. Reflecting upon them, you recognise their origin
in the physical and sexual abuse that she suffered at the hands of her step father.
You gain a deeper understanding of her and the way people react towards her. By
containing the impulse to act out, you avoid repeating and reinforcing the
abusive patterns of her previous relationships. At the same time, you take care
not to act upon unrealistic fantasies of 'rescuing' her .
Monitoring the countertransference can improve your understanding of
the patient.
Principals of psychiatric interview:
6. Understanding versus explanation:
 In formulating a person's problems, we seek to answer the question, 'Why
does this individual feel, think and act this way at this time?' The method
of understanding helps us find reasons for his or her experience; the
method of explanation seeks causes.
 We understand a person's experience when, through listening to his or
her story and clarifying the experience, we are able to empathise with him
or her and to imagine how we might feel under similar circumstances. We
can understand experiences in the mind of another. For example, we
understand the grief of the bereaved, the anger of someone who is
frustrated, the guilt of the person who has hurt another and the shame of
someone who has done something foolish. We can also understand the
meaning of an event for that person, and we can look for reasons why he
or she feels that way.
Principals of psychiatric interview:
7.The dialectical principle:
 In the philosophy of Hegel, dialectics is a process in which a proposition is
made (thesis), then negated (antithesis), and finally replaced by a new
proposition that resolves the conflict between the two (synthesis)4.
Although this may seem a little obscure, this way of thinking is common
in making decisions about mental health problems. You will often have to
make choices between apparently contradictory propositions. Always
consider the possibility that the best course of action lies in a synthesis of
the two. There are very few propositions in psychiatry that hold true in
every case.
Some dialectical dilemmas:
 Since she has a terminal illness, it is understandable that she is depressed, so I should not prescribe medication.
Wrong: although her depression is understandable, if her symptoms persist and include feelings of worthlessness and guilt, suicidality or
psychotic symptoms, she should be treated with an antidepressant (and possibly an antipsychotic or ECT) in addition to some form of
psychotherapy to deal with her grief.
Should I make a formulation specific to this woman’s problems or should I make a diagnosis and treat the condition from which she suffers?
Do both.
Is substance abuse or an underlying psychosis causing his psychotic symptoms?
It could be a combination of the two.
Are his cognitive deficits due to dementia or major depression?
A third possibility is that he suffers both conditions.
Her panic attacks are probably just secondary to her depression so if I treat the depression they should also improve.
Isolated panic attacks can occur in major depression, but if they are recurrent and accompanied by persistent concern about having more
attacks, worry about the implications of the attacks, or significant behaviour change, then both diagnoses should be made. In general
practice settings, mixed anxiety/depression is more common that either one alone. Treat both.
I should strive to be decisive and make the final diagnosis in the first session.
Make a working diagnosis in the first session, but be prepared to tolerate some uncertainty about the final diagnosis. The formulation will
continue to evolve and deepen so long as you continue to see the person.
I must never breach a patient's confidentiality.
There are exceptions. For example, if the person makes a direct threat against someone else, you may be obliged to contact the police or to
warn the intended victim. With most mental health treatment now being delivered in the community, a larger responsibility for care now
falls on the family or other carers. Unless expressly forbidden to do so by the individual, carers should, whenever possible, be involved in
treatment. Ask the person if you can meet his or her spouse and family at the next consultation.
Some dialectical dilemmas:
 During an exacerbation of his psychosis, a man with schizophrenia develops obsessive -
compulsive symptoms.
Should I diagnose obsessive–compulsive disorder? Here, the hierarchical principle of
diagnosis applies. The anxiety symptoms are subsumed under the diagnosis of a
psychotic disorder.

 An elderly woman becomes delirious post-operatively and experiences hallucinations and

persecutory delusions. Should an additional diagnosis of schizophrenia be made?
No. Organic disorders stand at the top of the diagnostic hierarchy and may be manifest
by any neurotic or psychotic symptoms.

 A man subjected to severe road accident presents with a number of anxiety and
depressive symptoms in addition to re-experiencing the traumatic accident scene. Should
I diagnose depression, generalized anxiety and agoraphobia?
The most parsimonious explanation is post-traumatic stress disorder, though this
disorder may be complicated by major depression or an anxiety disorder.
Principals of psychiatric interview:
8.Impairment, disability and handicap:

 When assessing people with mental health problems, it is useful to classify their complaints as
impairments, disabilities or handicaps. Mental impairment is any loss or abnormality in
psychological functioning. It includes the signs and symptoms of mental illness. Disability is any
restriction or lack in ability to perform an activity normal for a human being. Handicap is a
disadvantage, resulting from impairment or disability, that limits or prevents the fulfilment of a
social role that is normal for that individual, given his or her age, sex and cultural expectations.
It is helpful to make this distinction when planning management. In general, the alleviation of
impairments is the focus of treatment, while the prevention and minimization of disabilities and
handicaps constitutes disability support and rehabilitation. As a general practitioner, you will
mainly be involved in the delivery of treatment. However, you need to be familiar with the
rehabilitation services in your area, to know the appropriate referral procedures and to be able to
work in partnership with them.
Examples of impairment, disability and handicap:
 A woman with schizophrenia hears her thoughts spoken out loud (thought broadcast, an
impairment). As a consequence, she withdraws, spending much of her time at home, and she no
longer goes shopping (agoraphobia, a disability). She has not managed to work since the onset of
her illness five years before, she has no social contacts outside her immediate family and she
depends on her husband to do all of her shopping (handicap).

 A man has developed agoraphobia (disability) after having a panic attack (impairment) in a
bank three months before. He remains on sickness allowance and sees little of his friends. His
wife is becoming increasingly angry by his dependence on her (handicap).

 A man with early dementia suffers memory deficits, disorientation in place and mild agnosia
(impairments). He has left the gas on twice after heating the kettle, he got lost on the way back
from the shops and his wife has to remind him to attend to his personal hygiene (disabilities).
He had to give up his job as an architect a year ago and is now becoming increasingly dependent
on his wife for care and supervision (handicap).
Interviewing a paranoid patient:
 Don’t try to argue or rationally persuade the patient out of a delusion.
 This may lead to more assertion of delusional ideas.
 Don’t automatically laugh at a patient when something is said that seems
funny. Laughing at a patient can convey disrespect and lack of
understanding of the underlying terror and despair that many patient’s
feel.
Interviewing a paranoid patient:
 Do listen. Listen to how patients experience the world. They may
experience it as dangerous, bizarre , overwhelming and invasive.
 Try to understand what is their image of themselves.
 DO acknowledge these feelings to the patient simply and clearly. For
example if the patient respond that “When I walk into a room people can
see inside my head and read my thoughts”. The clinician might respond to
it as “ What are your feelings then” or “How do you feel then”.
 Be straightforward with a patient. Do not pretend that a delusion is
actually true, but convey that delusion is actually true for the patient. If a
paranoid schizophrenic says that “people are watching me all the time and
they could know what I am thinking and see what I am doing” the doctor
should say that “I can understand what you are feeling but I could not see
anyone here who is keeping an eye on you”.
Interviewing a paranoid patient:
 Do respect a paranoid’s patient’s need for maintaining distance and
control. Sometimes the paranoid patients are more comfortable when
they are aloof as opposed to the expressions of warmth and empathy.
 Allow, the patient to speak. This helps the patient to feel that he is
somebody important and has something important to say.
 Be flexible about interview times. If the patient can tolerate only 10
minutes , tell him that the interview will resume later.
 DO pay attention, how the patient make you feel. Work over and analyze
your feelings. Feel empathetic but do not get carried over by the feelings.
If you feel annoyed find the reason for it.
Interviewing a patient with somatization:
 Encourage the development of trusting relationship.
 Don’t argue about the reality.
 Respectfully and systematically evaluate physical symptoms.
 Establish appropriate therapeutic goals.
 Regular follow-up independent of symptoms.
 Appropriate treatment of psychiatric condition.
 Only appropriate referrals, but maintain involvement.
 Minimize medicalization.
 Focus on positive aspects of patient’s personality and behavior.
Suicide assessment:
Current presentation of suicidality:
 Suicidal or self-harming thoughts, plans, behavior, and intent.
 Specific methods for suicide, including their lethality and whether firearms are accessible.
 Evidence of hopelessness, impulsivity, anhedonia, panic attacks, or anxiety.
 Alcohol or substance abuse.
 Thoughts, plans, or intentions of violence toward others.
Psychiatric illness:
 Current evidence of psychiatric disorder , mood(MDE or mixed episodes), schizophrenia,
substance abuse, anxiety disorders, BPD.
 History: previous suicidal attempts, or other self-harming behavior.
 Family history of suicide.
 Previous and current medical diagnosis ,medications ,surgeries, hospitalizations.
Suicide assessment:
Psychosocial situation:
 Acute and chronic psychosocial crises, interpersonal loss, financial difficulties, or change in
socioeconomic status , family discord, domestic violence, past or current sexual or physical
abuse or neglect.
 Employment, living situation, and presence or absent of external support.
 Family constellation and quality of family relationships.
 Cultural and religious beliefs about death or suicide.
Individual strengths and vulnerabilities:
 coping skills.
 Personality traits.
 Past responses to stress.
 Capacity for reality testing.
 Ability to tolerate psychological pain and satisfy psychological needs.
Risk factors for violence and assessment of dangerousness:
 Must be conducted in a safe environment, safe for patient and psychiatrist.
 Determine substance of abuse, alcohol, amphetamines.
 Severe akathisia (Akathisia is a movement disorder characterized by a feeling of inner restlessness and a
compelling need to be in constant motion, as well as by actions such as rocking while standing or sitting, lifting the feet
as if marching on the spot, and crossing and uncrossing the legs while sitting. People with akathisia are unable to sit or
keep still, complain of restlessness, fidget, rock from foot to foot, and pace.) may contribute to aggressive
behavior.
 Inquire about thoughts of violence and determine the person to whom this is
directed.
 When patient pose serious threat to others (having homicidal ideation with
imminent plans , the psychiatrist must consider hospitalization.
 The psychiatrist must exercise his own best judgment in accord with the legal
requirements and system.
How to deal with a violent patient:
 If the patient is acutely aggressive, the psychiatrist can try to calm the patient
by “ de-escalation” technique.
 If restraint or seclusion is required it should be done with adequate numbers of
well trained professional staff.
 When sedation is indicated and the patient refuse oral medication,
intramuscular injection of antipsychotic (haloperidol 5mg) can be given with or
without 1-2 mg of oral or intramuscular lorazepam.
 After seclusion, restraint or sedation, the mental status and vital signs of the
patient should be monitored regularly.
 Release from seclusion or restraint can proceed in a graded fashion, as risk of
harm to self or others diminishes.
De-escalation technique
 Appear confident
 · Displaying calmness
 · Create some space
 · Speak slowly, gently and clearly
 · Lower your voice
 · Avoid staring
 · Avoid arguing and confrontation
 · Show that they are listening
 · Calm the patient before trying to solve the problem

 Staff should adopt a non-threatening body posture:
 · Use a calm, open posture (sitting or standing)
 · Reduce direct eye contact (as it may be taken as a confrontation)
 · Allow the patient adequate personal space
 · Keep both hands visible
 · Avoid sudden movements that may startle or be perceived as an attack
 · Avoid audiences – as an audience may escalate the situation
Thank You
 Behavioral Observations
are an attempt by the psychologist to watch the problems and behaviors in
the real world.

The clinical interview relies on self-report information that may or may not
be accurate. Information obtained through an interview may be biased.

naturalistic,
self-monitoring, and
controlled
 Behavioral Observations
Functional analysis refers to a behavioral analysis of the antecedents, or what
led up to the behavior, as well as the consequences of the behavior.

Target behaviors are specific behaviors that are examined, evaluated, and
altered by interventions. Many people have vague complaints. To isolate target
behavior is difficult.

Behavioral observations must identify clear target behaviors to observe.

Operational definitions to define target behaviors are necessary for behavioral
observations.
 Naturalistic Observation
Observing patients in their natural environments. It involves entering into the world
of the patient to observe the person interacting with the environment in which
problems occur.

Disadvantages:
 It can be time consuming and expensive.
 Confidentiality can be problem, when teachers, coworkers, peers, and others know
that there is a psychologist.
 Most people behave differently when they know they are being watched. This is
referred to as reactivity.
 The problematic behavior may or may not occur during the observation.
 The observation may be biased. The psychologist may expect to see certain behavior.
 Self-Monitoring
is conducted by the patient. The patient is instructed in how to observe and
record his or her own behavior in an objective manner. Self-monitoring has
become a very commonly used tool not only for assessing problems but also
as an intervention.

Patients are instructed to record the problematic behaviors when they occur
each time as well as other important information such as feelings and
thoughts.

Both patient and psychologist develop a better understanding of the target

behavior as well as the factors that may encourage or reinforce it.
 Self-Monitoring
has been successfully used with a large number of problem behaviors such
as eating problems, smoking, sleeping problems, anxiety symptoms, and
criminal behavior.

If patients know that they must write down everything they eat, they may
think twice before impulsively eating. Thus, self-monitoring is used as both
an intervention and an assessment technique.
 Self-Monitoring
Disadvantages:
Few people are willing to self-monitor for a long period of time.
Some people may not record honestly because of embarrassment and /or
denial.
 Controlled Observations
Rather than waiting for target behaviors in the natural environment or for
the patient to report using self-monitoring, controlled observations force
the behavior to occur in a simulated way.

The most commonly used type of controlled observation is the role play.
Role plays require people to act as if they were in a particular situation that
causes them concern. Role plays can be used both for the assessment of a
problem and for treatment interventions.
 Checklists and Inventories
Interviews and observations can provide a great deal of helpful information,
but both methods take a lot of time to complete and tend to be expensive.
When many people’s assessment are needed at one time, they are
impractical.

Checklists and inventories, brief pencil-and paper questionnaires assess one

or more traits or problem areas. They can be administered to a large number
of people at one time, are inexpensive, and can be quickly scored and
analyzed.
 Checklists and Inventories
Information obtained from checklists and inventories are more reliable and
valid than information obtained from other methods.

Numerous checklists and inventories have been developed to assess and

diagnose a wide variety of problems such as anxiety, depr, eating disorders,
and ADHD. They are very brief, easy to complete, and need little instruction
or supervision from a professional.
 Beck Inventories
A. Beck, father of CBT, has developed a series of inventories to assess depr,
anx, hopelessness, and suicidal ideation.
All the Beck Scales are brief and are used with persons who range in age
from 17 to 80 years. Each scale takes only 5 to 10 minutes to complete and
has a simple scoring system.
 The Beck Depression Inventory (BDI) is the most widely used instrument
to assess the severity of depressive symptoms.
 The Beck Anxiety Scale is a popular instrument for assessing the intensity
of anx symptoms.
 The Beck Hopelessness Scale assesses hopelessness about the future.
 The Symptom Checklist 90-Revised
(SCL-90-R)

is a brief and multidimensional self-report measure for major psychiatric

symptoms. It consists of 90 items, scored on a 5-point scale. The checklist
can be administered to people ages 13 through adulthood and takes 10 to 15
minutes to complete.
 Other Checklists and Inventories
Many instruments have been developed for specific populations or clinical
problems.
Disadvantages:
 Because these instruments rely on self-report information, people may
distort their answers or try to present themselves in a favorable way.
 These instruments do not provide the depth and complexity of
information.
 Physiological Testing
Anxiety and stress can be assessed through noninvasive techniques that
measure physiological activity (e.g., blood pressure, heart rate, and
sweating, respiration, and muscle tension).

Neuroimaging techniques such as Magnetic Resonance Imaging (MRI),

Computerized Axial Tomography (CAT),
and Position Emission Tomography (PET) examine physiological activities
associated with mood.
 Physiological Testing
Polygraphs, or lie detector tests, measure physiological reactions.
Biofeedback equipment is similar to polygraphs. Unlike polygraphs,
biofeedback provides information to patients about their level of
physiological arousal through visual or auditory feedback. High-pitched
tone sounds when heart rate is fast and low-pitched tone sounds when heart
rate is slow. Biofeedback provides information to patients who try to lower
their physiological arousal through the use of relaxation.