Practical Matters
Laboratory Testing
Psychiatrists must increasingly rely on laboratory testing to confirm their diagnostic impressions, to detect medical or neurologic illness that may underlie or coexist with neuropsychiatric symptoms, and to ensure the safe and maximally effective use of certain psychotropic medications. Clinicians should understand the relevance of any laboratory test to the clinical problem presented by the patient and be ready to use the information obtained to enhance the findings of the psychiatric history and MSE.
Table 8-11 summarizes the common laboratory tests the interviewer considers ordering in certain classes of psychiatric disorders, although it is by no means an exhaustive listing. It can be used as a guideline for determining which test might be germane to a patient when considering a particular psychiatric diagnosis.
Facilitating the Interview
If an interview is to achieve its purpose (ie, to gather information), the interviewer must develop an atmosphere favoring the expression of ideas, feelings, and attitudes. The patient must develop a sense of trust and confidence in the interviewer, in order to be as spontaneous as possible. He or she will thereby see the interview as encouraging participation and collaboration toward a therapeutic end, through free expression and self-exploration.
What can the interviewer do to promote trust, spontaneity, and free expression? The interviewer must accept the patient, without moral judgment. If he or she cannot do so, it is better to be honest about it and refer the patient to another physician. Anybody can help somebody, but nobody can help everybody. If a patient angers, repels, or frightens the interviewer, and the feeling persists, the interviewer should seek help from a colleague.
The interview is facilitated if the interviewer understands the patient and conveys this understanding by facial expression, intonation, and well-timed reflections of the content and emotion behind the patient’s story. The deepest affective understanding is empathy, that is, feeling with, or sharing the feelings of, the patient. It contrasts with sympathy, which is a feeling for the patient.
The open-ended style of questioning we described earlier in this chapter as being most appropriate to reconnaissance and detailed inquiry helps to convey the spirit of collaboration, free expression, and self-exploration. An atmosphere of trust is fostered if the interviewer is relaxed and receptive, not preoccupied, rushed, abrupt, or irritable. Interviewers will likely adapt to their own purposes the techniques of others that have impressed them.
Interview Setting
A skilled interviewer can be effective walking along a corridor, playing catch, or sitting by the side of a bed. Nevertheless, offices are preferable to closets, and chairs are an improvement over packing boxes. If the interviewer has the opportunity, he or she should arrange the interview room to take advantage of its size, proportions, furnishings, and design.
The fundamental principles are simple. The room should be large enough to fit the patient, a desk, chairs, and other equipment, without crowding the interviewer. It is desirable, though not always possible, to have enough room and seating to accommodate the patient and four others, particularly if the interviewer plans to see families as well as individuals. The arrangement of the desk and chairs should allow entry and egress, but the interviewer should not sit between the patient and the door. He or she should try not to interview people from across a desk. Harsh lighting should be avoided. The patient should not be blinded by glare shining directly from a window or a lamp. The chairs should be comfortable, and the interviewer should not tower over the patient. The interviewer should not leave the patient stranded in the middle of the room; people feel less exposed with something solid behind them. The interviewer should not sit too close (ie, knee to knee) or too far away. He or she should be near enough to make arm contact by leaning forward.
Interview Techniques
The interviewer should encourage free expression during the reconnaissance and detailed inquiry stages of the psychiatric interview. He or she does so by the setting provided, the atmosphere created, and the interview techniques used. The interviewer should be at ease with these techniques, and they should be used naturally, without flamboyance or stiltedness. If a particular technique does not suit the interviewer, he or she should not use it; an alternative should be found that conveys the same spirit and has a similar purpose.
The following are examples of useful techniques: attentive listening, subtle vocal and nonvocal encouragement, support and reassurance, the reflection of feeling, gentle indication, and judicious paraphrasing.
Having invited the patient to tell his or her story, the interviewer waits and listens. He or she does not stare but meets the patient’s gaze from time to time to indicate he or she is following. The interviewer’s intent but relaxed posture indicates involvement. If the interviewer takes notes, they are brief and unobtrusive.
While the flow of associations proceeds, the interviewer need do little but maintain relaxed concentration, signaled by posture, eye contact, and subtle nonvocal or vocal encouragement. A nod or an “uh-huh” or “mm-mm” at strategic points may be all that is needed. Sometimes, when the flow seems to waver or slow, it is very effective to pick up and repeat a significant phrase or the last word the patient has said. But the interviewer should not be mechanical and should not do something unless it feels natural.
The interviewer needs to be alert to the patient’s reactions, particularly to changes in voice intonation and speech tempo, tensing of facial muscles, alterations of skin color, and moistening of conjunctivae, which herald a flush of anxiety or anger or a sudden feeling of sadness.
How does the interviewer handle silences? If the patient is thinking fruitfully, all the interviewer need do is wait. Similarly, if the patient has broken down in tears, it may be better to wait calmly until the patient can continue. If the silence occurs when the patient has lost track of or has confused feelings about the topic, the interviewer can facilitate associations with a subtle oral reflection, picking up a key word, phrase, or idea from the recent conversation and repeating it gently, sometimes with a questioning intonation. Oral reflection is also useful to help circumstantial patients get back on track.
The reflection of feeling is a variant of the technique of oral reflection. The interviewer picks up and echoes feelings explicit or implicit in what has been said but that have been expressed incompletely up to that point.
Transference & Countertransference
Transference refers to the unreasonable displacement of attitudes and feelings that originated in childhood to people in the here and now. This phenomenon is particularly likely to affect the doctor-patient relationship when patients are made vulnerable by fear, anxiety, guilt, despair, and hope.
Note the term “unreasonable” in the definition. The patient who is angered by overt rudeness is not displaying transference. However, if the patient is angered because the interviewer has a mustache or wears pearls, it is apparent that something is being added to an objectively neutral situation.
The patient may unconsciously regard the physician as a parent or a sibling, casting him or her in a caring or antagonistic role. Some examples of the commonest roles are of nurturing mother, demanding mother, protective father, punitive father, and rivalrous sibling. Sometimes older patients will relate to the physician as though they themselves were parents, reversing the roles.
How can the interviewer recognize transference? When the patient is exceptionally deferential, hanging onto the interviewer’s opinions, singing his or her praises to others, or is easily slighted by a brief or delayed appointment, the interviewer may suspect a positive transference. When the patient is unexpectedly hostile, suspicious, or competitive, and there is no reasonable explanation for such antagonism, a negative transference is likely.
It is not difficult to imagine how a positive transference can become eroticized, with the patient falling in love with an idealized parental figure. Most of these infatuations are transitory, like the crushes of adolescence. If the interviewer recognizes them and responds in a professional manner, they will go no further. Occasionally, however, unscheduled visits, notes, telephone calls, or seductive dress indicate that the matter is more serious. The interviewer may need to consult a psychiatric colleague to decide how to proceed. The interviewer should not respond impulsively, out of fear or affront, lest a vulnerable patient be hurt.
Transference has its counterpart in a physician’s countertransference, which occurs when a physician irrationally transfers to a patient his or her attitudes and feelings derived from childhood experiences. Psychiatric interviewers must be alert for countertransference. They should suspect it whenever they have powerful feelings of affection, protectiveness, fear, frustration, irritation, hatred, or erotic excitement toward a patient; when they very much look forward to the next appointment; or when they cannot tolerate a particular patient. If the interviewer recognizes these feelings, they will be much less likely to respond impulsively with rejection, flight, or self-indulgence. Once again, the interviewer should seek the help of a colleague or group of colleagues if he or she is unsure how to proceed in the patient’s best interests.
There is no need to be embarrassed by transference or countertransference. Experienced clinicians know that these emotional displacements are ubiquitous and inescapable. They are most likely to be problematic when the interviewer is overworked, preoccupied, or rendered emotionally vulnerable by the vicissitudes of his or her personal life. The interviewer must look after himself or herself physically and emotionally and should do the best he or she can to ensure a fulfilling life outside of medicine itself.
