2.

5
Kaplan + Old Trans 
“Your task is not to seek for love, but merely to seek and find all the barriers within
yourself that you have built against it.” ― Rumi
OUTLINE PAGE
I. Patient-Doctor Relationship
A. Establishing Rapport
B. Empathy
C. Transference and Countertransference 1-2
II. Models of Interaction between doctor and patient
III. Biopsychosocial Model
IV. Interviewing Effectively
V. Specific Issues in Psychiatry
VI. Character and Qualities of the Physician
VII. Interviewing Techniques for Special Patient Populations
VIII. Empathic Listening 10
PATIENT-DOCTOR RELATIONSHIP
 Is at the core of the practice of medicine.
 Medicine = intensely a human and interpersonal endeavour
wherein the doctor-patient relationship becomes part
of the therapeutic process.
 Effective relationship = characterized by good rapport.
 Patient:
o expects a good relationship as much as a cure.
o are most tolerant of the limitations of the therapeutic
limitations of medicine when there is mutual respect
between the two parties.
 It is therefore incumbent that clinicians consider the ff:
o nature of the relationship
o the factors in themselves and their patients that
influence the relationship
o the manner in which good rapport can be achieved.
 TO DIAGNOSE, MANAGE, AND TREAT AN ILL PERSON,
doctors must learn to listen.
 ACTIVE LISTENING
o listening both to what they and the patient are saying
and to the undercurrents of the unspoken feelings
between them.
 LEVELS OF COMMUNICATION: (occurs at once)
o What the person believes about himself or herself
o What he or she wants others to believe about them
o Finally who the person really is
 Francis Peabody, M.D. (1881-1927)
o Good physician knows his patients through and through
o Time, sympathy, and understanding must be lavishly
dispensed
o Personal bond forms the greatest satisfaction of the
practice of medicine
o Interest in humanity- one of the essential qualities
of the clinician
 Patients’ satisfaction is influenced by interpersonal factors
such as the perception that the doctor is concerned,
caring and understanding.
 SELF-REFLECTION AND UNDERSTANDING
o necessary to keep the MD-Px relationship a positive
force.
 FLEXIBILITY
o necessary to respond to the subtle interplay between
doctor and patient, and allows for tolerance for the
uncertain.
 Doctors/ Physicians/clinicians:
o must be able to emphasize with patients, yet also able
to leave behind their problems when away from the
hospital.
o should not use patients as substitutes for intimacy or
relationships missing in their personal lives.
o must learn to accept that they cannot control
everything in a patient’s care.
o must also avoid side-stepping issues that they find
difficult to deal with.
September 2013
Patient-Doctor Relationship &
Interviewing Techniques for
Special Patient Populations
pOPULATION Populations
“The secret in the care of the patient is in caring for the
1 patient”- Francis Peabody
1
1
ESTABLISHING RAPPORT
2  RAPPORT
3 o spontaneous, conscious feeling of harmonious
4
responsiveness
6
7
o promotes the development of a constructive
7 therapeutic alliance
o implies an understanding and trust between the doctor
and the patient, wherein patients feel accepted for both
their assets and liabilities.
 6 strategies in the development of rapport (Ekkehard
Othmer and Sieglinde Othmer)
 Putting patients and interviewers at ease
 Finding the patient’s pain and expressing compassion
 Evaluating patient’s insight and becoming an ally
 Showing expertise
 Establishing authority as a physician and therapists
 Balancing the roles of empathic listener, expert, and
authority
 Evaluating the pressures in patients' early lives helps
psychiatrists better understand patients
 Emotional reactions- result of a constant interplay of
biological, sociological, and psychological forces
 Each stress influence and continues to manifest itself
throughout life in proportion to the intensity of its effects
and the susceptibility of the human being involved
EMPATHY
 Empathy is a way of increasing rapport.
 Cannot be created
 Can be focused and deepened through training,
observation, and self-reflection.
 EMPHATIC PSYCHIATRIST
o may anticipate what is felt before it is spoken and can
help patients articulate what they are feeling.
o Non verbal cues, such as body posture and facial
expression are noted.
 Incapacity for normal understanding of what other people
feel = central to certain personality disturbances, (such as
Antisocial And Narcissistic Personality Disorders)
TRANSFERENCE
 The set of expectations, beliefs, and emotional
responses that a patient brings to the patient-doctor
relationship.
 Describes the process of patients unconsciously
attributing to their doctors aspects of important past
relationships, especially those of parents
TRANSFERENTIAL ATTITUDES:
 Patient's attitude toward the physician
o is apt to be a repetition of the attitude he or she
has had toward authority figures.
o may come to see the doctor as cold, harsh, critical etc.,
not because of anything the doctor has done but
because of the patient’s past experience.
o The patient unwittingly passes on the feeling from
the past relationship to the doctor.
o Can be positive or negative, and it may swing back
and forth between the two.

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 Patient-Doctor Rel & Interviewing Techniques for Special Px Pop’ns
ROLE OF THE PSYCHIATRIST VS NONPSYCHIATRIC
PHYSICIAN:
 Transferential reactions can be strongest with
psychiatrists
o For example, in Intensive insight -oriented
psychotherapy, encouragement of transference
feelings is an integral part of treatment
o Psychiatrist sometimes is more or less neutral
o The more neutral the psychiatrist, the more
transferential fantasies and concerns are mobilized and
reflected onto the doctor.
o Once these fantasies are mobilized, the doctor can now
thus help the patient gain insight into how these
fantasies affect important relationships in their lives.
 Although, nonpsychiatrist does not use or even need to
understand transference attitudes in that intensive way, a
solid understanding of the power and manifestations of
transference is necessary for optimal treatment
results.
 How a physician behaves and interacts with patients has a
direct bearing on the emotional and physical reactions of a
patient.
COUNTER-TRANSFERENCE
 Physician unconsciously ascribes motives or attributes
to patients.
 May take the form of negative, disruptive feelings, but
may also encompass positive, idealizing or eroticized
reactions.
 A patient is perceived as good:
o when their expressed severity of symptoms
correlates to overtly diagnosable biological
disorders
o if they are compliant with treatment
o generally non-challenging, emotionally controlled
and if they are grateful.
 If these are not met, the physician with his unconscious
unrealistic needs may perceive the patient as difficult.
DISLIKING A PATIENT
 Emotion breeds counteremotion
 Physician can rise above such emotions & handle a difficult
patient with equanimity  interpersonal relationship may
shift to ↑ acceptance and grudging respect
 If the doctor can understand that the PATIENT'S
ANTAGONISM is in some ways defensive or self-
protective and most likely reflects transferential fears
of disrespect, abuse, and disappointment, the doctor
may be LESS ANGRY AND MORE EMPATHIC than otherwise
 Patient’s reactions are not invariably transferential and may
be based on real interactions.
 PATIENTS THAT ARE DIFFICULT TO HANDLE:
 Those who repeatedly appear to defeat attempts to
help themselves.
 Uncooperative
 Those who request second opinion; who fail to recover
in response to treatment
 Those who use physical or somatic complaints to mask
emotional problems
 Chronic cognitive disorders
SEXUALITY AND THE PHYSICIAN
 Countertransference issues relates to asking Px about
sexual issues & obtaining sexual history.
 RELUCTANCE to do so = may reflect physician’s own
anxiety about sexuality or even an unconscious attraction
toward the patient.
Gisela, Jess, Noe 
 OMISSION of those questions generally tells the patient
that the doctor is uncomfortable with the subject, thus
leading to an inhibition about discussing any number
of other sensitive subjects.
SELF-MONITORING OF COUNTERTRANSFERENCE FEELINGS
 If a doctor feels bored and restless when with a particular
patient and has ascertained that the boredom is not
secondary to his or her own preoccupations, the doctor
may surmise that the patient is speaking about trivial
or insignificant concerns to avoid real and potentially
disturbing concerns.
PHYSICIANS AS PATIENTS
 For a physician, being a patient may mean giving up
control, becoming dependent, and appearing
vulnerable and frightened—behaviors that most
physicians are trained to suppress.
MODELS OF INTERACTION BETWEEN DOCTOR AND
PATIENT
 Helpful in thinking about the relationship
 Fluid concepts
 TALENTED and SENSITIVE physician:
o have different approaches with different patients and
indeed may have different approaches with the same
patient as time and medical circumstances vary.
 Only guides for thinking about the MD-Px relationship.
 One is not superior to the other.
 Difficulties: arise from physicians who rigidly practice only
one model and cannot be able to switch strategies.
1. PATERNALISTIC BEHAVIOR/AUTOCRATIC MODEL
 It is assumed that the doctor knows best.
 He will prescribe treatment and the patient is expected to
comply without questioning.
 The doctor may withhold information if it is in the best
interest of the patient.
 Autocratic model - physician asks most of the questions
and generally dominates the interview
 Used in emergency situations, (When potentially life-saving
decisions need to be made, and when some patients feel
overwhelmed by their illnesses.)
 Advantage: some patients feel overwhelmed by their
illness and are comforted by a doctor who can take charge
 Disadvantage: risks a clash of values
2. INFORMATIVE MODEL
 Doctor dispenses information
 All available data are freely given but the choice is up to
the patient.
 May be appropriate for one-time consultations where no
established relationship exists and the patient will be
returning for regular consult to a known physician.
 Places the patient in an unrealistically autonomous role
 Patient may feel that the doctor is cold and uncaring
3. INTERPRETATIVE MODEL
 Doctors who have come to know their patients better
and understand something of the circumstances of their
lives, are better able to make recommendations which take
into account the unique characteristics of the individual
patient.
 Sense of shared decision-making is established.
o as the doctor presents and discusses alternatives with
the patient’s participation.
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 Patient-Doctor Rel & Interviewing Techniques for Special Px Pop’ns

 Doctor does not abrogate responsibility for decision  Physicians must be prepared to conduct multiple brief
making, but is flexible and is willing to consider criticism interactions over time, for as long as the patient is able
and alternative suggestions. to, and then stop and return until the patient is able to
tolerate more.
4. DELIBERATIVE MODEL  POWERS OF OBSERVATION = used when a patient cannot
 The doctor acts as a friend or counselor by actively communicate well verbally, observing the patient’s general
advocating a particular course of action. appearance, behavior and body language.
 This is typically used by doctors who hope to modify  Evaluations based solely on review of records and
injurious behaviors. interviews of persons close to the patient are inherently
 Ex. Trying to get their patients to stop smoking or lose limited.
weight  All physicians must be familiar with the APA guideline
because many non-psychiatric physicians see psychiatric
ILLNESS BEHAVIOR patients.
 Patient’s reaction to being sick.  Non-psychiatric physicians should know the special
 SICK ROLE problems of psychiatric patients and the specific techniques
o aspect ascribed by society to those who are ill. to treat them.
o can include being excused from responsibilities and the
expectation of wanting to get well. BIOPSYCHOSOCIAL MODEL
 Illness behaviors and sick roles are affected by people’s  George Engel (1977)
previous experience with the illness and their cultural  published a paper on the Biopsychosocial model of
beliefs about the disease. disease, which stressed an integrated approach to
 Also important: Relation of illness to family processes, human behaviour and disease.
class status, and ethnic identity
 Some people see illnesses as a loss; some see it as a BIOLOGICAL PSYCHOLOGICAL SOCIAL
challenge they must overcome or a punishment they SYSTEM SYSTEM SYSTEM
deserve  refers to  refers to the  examines
anatomical, effects of cultural,
PSYCHIATRIC vs. MEDICAL-SURGICAL INTERVIEWS structural, and psychodynamic environmental
 Mack Lipkin Jr. described three fundamental functions* molecular factors, and familial
of medical interview: substrates of motivation, and influences on
 To assess the nature of the problem disease and its personality on expression and
 To develop and maintain a therapeutic relationship effect on experience of and experience of
 To communicate information and implement a patients. reaction to illness. illness.
treatment plan.
(*same for psychiatric and surgical interviews.)  Example:
 Between sudden death and psychological factors. After
 Universal coping mechanisms, such as anxiety, investigating 170 sudden deaths over 6 years, he
depression, anger, must be recognized by the physician and observed sudden death may be associated with
properly addressed if any treatment and intervention is to psychological stress or trauma.
happen.  Potential triggers: death of a close friend, grief,
anniversary reactions, loss of self-esteem, personal
 PSYCHIATRIC INTERVIEWS 2 major technical goals*: danger or threat, the letdown after the threat has
o Recognition of the psychological determinants of passed and reunions or triumphs.
behavior  PATIENT-DOCTOR RELATIONSHIP IS A CRITICAL
o Symptom classification COMPONENT OF THE BIOPSYCHOSOCIAL MODEL.
(*These goals are reflected in two styles of interview)
 2 STYLES OF INTERVIEWING: BEYOND THE PSYCHOSOCIAL MODEL
o INSIGHT-ORIENTED OR PSYCHODYNAMIC STYLE  Importance of the Biopsychosocial model has been repeated
 Attempts to elicit unconscious conflicts, anxieties, to the point of catechism in medicine.
and defenses  The proportional importance of social and psychological
o SYMPTOM-ORIENTED, OR DESCRIPTIVE STYLE factors depends on the medical circumstance of the
 Emphasizes the classification of patients' person.
complaints and dysfunctions as defined by specific
diagnostic categories  Chronic conditions are affected by multiple aspects of
 Approaches are not mutually exclusive and can be personality and social environment.
compatible  Acute conditions may not be affected by such.
 Psychiatric patients often contend with stresses and
pressures such as:  Because the Biopsychosocial model offers no guidance on
o Stigma attached to being a psychiatric patient which factors are important, some physicians feel they
o Communication difficulty because of disorders of must know everything about their patient, which is
thinking; oddities of behavior; and impairments of obviously impossible.
insight and judgment that might make compliance with
treatment difficult  Provides a conceptual framework for dealing with
 Family members, friends, and spouses can provide critical disparate information and serves as a reminder of other
data important issues besides the purely biological.
 Psychiatric patients may not be able to tolerate a traditional  Not a template for treating individuals, nor can it substitute
interview format, especially in the acute stages of a for warmth, genuine concern and mutual trust.
disorder.

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 Patient-Doctor Rel & Interviewing Techniques for Special Px Pop’ns

SOME TABLES FROM THE BOOK: INTERVIEWING EFFECTIVELY

TABLE 1. THREE FUNCTIONS OF THE MEDICAL INTERVIEW  An important tool of any physician. (ABILITY TO
FUNCTIONS OBJECTIVES SKILLS INTERVIEW EFFECTIVELY)
I. To enable the clinician 1. Knowledge base of diseases,
Determining to: disorders, problems, and clinical
 A skilled interview can allow a physician to gather data
the nature  establish a diagnosis hypotheses from multiple necessary to treat and understand patients and in the
of the or recommend conceptual domains: biomedical, process, increase their understanding and compliance
problem further diagnostic sociocultural, psychodynamic, and
procedures behavioral
with the physician’s advice.
 suggest a course of 2. Ability to elicit data for the  Factors that influence both the content and the process of
treatment conceptual domains (encouraging interviews:
 predict the nature of the px to tell his story: organizing
the illness the flow of the interview, the form
o Patient’s personality, character style and
of questions, the characterization emotional context
of symptoms, the MSE) o CLINICAL SITUATIONS (shape the questions asked
3. Ability to perceive data from
multiple sources (history, MSE, and recommendations offered)
physician's subjective response to o TECHNICAL FACTORS (such as phone interruptions,
the px, nonverbal cues, listening interpreters, note taking and the patient’s illness)
at multiple levels)
4. Hypothesis generation and
o Interviewers’ STYLES, EXPERIENCE, AND
testing THEORETICAL ORIENTATIONS have a significant
5. Developing a therapeutic impact.
relationship (function II)
II. 1. The px’s willingness 1. Defining the nature of the
o TIMING OF INTERJECTIONS (such as ―uh huh‖ can
Developing to provide diagnostic relationship influence when a patient will speak, as they tend to
and information 2. Allowing the px to tell his story follow subtle leads and cues.)
maintaining a 2. Relief of physical 3. Hearing, bearing, and tolerating
therapeutic and psychological the px’s expression of painful
relationship distress feelings 1. BEGINNING THE INTERVIEW
3. Willingness to accept 4. Appropriate and genuine  Beginning: provide both a powerful first impression and
a treatment plan or interest, empathy, support, and
a process of cognitive understanding influence how the remainder of the interview will go.
negotiation 5. Attending to common px  Patients= often anxious, intimidated & vulnerable @ 1st
4. Px satisfaction concerns over embarrassment,
5. Physician shame, and humiliation
satisfaction 6. Eliciting the px’s perspective  Physician, who can quickly establish rapport, put the
7. Determining the nature of the patient at ease and show respect will conduct a
problem productive interview, critical to making a correct diagnosis
8. Communicating information and
recommending treatment and establishing treatment goals.
(function III)
III. 1. Px’s understanding of 1. Determining the nature of the  Physicians should:
Communica the: problem (function I)
-ting  illness 2. Developing a therapeutic  Make sure they know their patients name, and their
information  suggested relationship (function II) patient knows the physicians name.
and diagnostic 3. Establishing the differences in  Patients have a right to know the position
implemen- procedures perspective between Dr & px
ting a  treatment 4. Educational strategies and professional status of the persons
treatment possibilities 5. Clinical negotiations for conflict involved in their care.
plan 2. Consensus between resolution  Inquire if the patient desires another person to be
physician and patient
about the above present in the initial interview.
3. Informed consent  Such requests should be honored but the
4. Improve coping physician might want to ask the patient if there
mechanisms
5. Lifestyle changes is anything he would like to be kept from the
other person.
TABLE 2. PREDICTABLE REACTIONS TO ILLNESS  An initial remark such as: ―Can you tell me about the
INTRAPSYCHIC CLINICAL troubles that bring you in today?‖ followed by ―What
Lowered self image  loss  grief Anxiety or depression other problems have you been experiencing?‖ often
Threat to homeostasis  fear Denial or anxiety elicits information patients are reluctant to give in the
Failure of (self) care  helplessness, Depression beginning. It also indicates interest on the part of the
hopelessness Bargaining and blaming physician.
Sense of loss of control  shame (guilt) Regression  A less directive approach is to ask the patient “Where
Isolation would you prefer to begin?”
Dependency  If the patient is from a referral, an initial remark indicating
Anger the consulting doctor’s knowledge of the referred patient
Acceptance can be useful.

SPIRITUALITY  Most patients do not speak until they are assured of

 Spirituality has gained a more important role in medicine
with some suggesting that it become part of the
Biopsychosocial model.
 There is some evidence that strong spiritual beliefs have a
positive influence on a person’s mental and physical
health.
 Theologians are better equipped to handle this, but doctors
need to be aware and sensitive to their patient’s spiritual
beliefs.
their privacy and that they will not be overheard.
 Securing this communicates the importance placed by the
physician on what the patient has to say.
 A physician may comment gently and supportively on any
unease that a patient may initially show.
 Acknowledging a patient’s anxiety = first step to
understanding and reducing it.
 Another important question is ―Why now?‖
 A physician should be clear on why a patient chose a
particular time to ask for help.

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 Patient-Doctor Rel & Interviewing Techniques for Special Px Pop’ns

 It may be that this was the only convenient time for the Pros and Cons of Open-Ended and Closed-Ended Questions
patient, or because of particular stressful events have BROAD, OPEN-ENDED NARROW, CLOSED-
ASPECT
QUESTIONS ENDED QUESTIONS
contributed significantly to the patient’s current problem.
High Low
 Examples of stressful events: They produce They lead the
 real or symbolic losses Genuineness
spontaneous patient.
 Physical changes such as intensification of symptoms. formulations.
 Physicians who are unaware of such stresses in people’s Low High
lives may miss unspoken fears and questions that can They may lead to Narrow focus, but
Reliability
compromise well-being. nonreproducible they may suggest
answers. answers.
Low High
2. THE INTERVIEW PROPER Precision Intent of question is Intent of question
 When physicians discover in detail what is troubling the vague. is clear.
patient. Low High
 CONTENT OF THE INTERACTION/INTERVIEW Time efficiency Circumstantial May invite yes or
o what the patient and the doctor actually say elaborations. no answers.
o literally what is said between doctor and patient. Completeness Low High
of diagnostic Patient selects topic. Interviewer selects
 PROCESS OF THE INTERACTION coverage topic.
o what the patient or the doctor mean to say Varies Varies
o what happens beneath the surface, which involves Most patients prefer Some patients
feelings and reactions that are unacknowledged or Acceptance by expressing themselves enjoy clear-cut
unconscious. patient freely; others feel checks; others hate
guarded and insecure. to be pressed into a
 Patients may: yes or no format.
o use body language to convey their thoughts or feelings
o shift the interview from anxiety-provoking subjects to
3. Reflection
a neutral topic.
 Paraphrase that indicates the MD has perceived the
o May also return again and again to a topic regardless
essential meaning.
of the direction of the interview.
 Doctor repeats to a patient, in a supportive manner,
 Trivial remarks and apparently casual asides may reveal
something that the patient has said.
serious underlying concerns.
 Goal is twofold: to assure the MD that he has correctly
understood what the patient is trying to say and to let
COMMON INTERVIEW TECHNIQUES: the patient know that the MD perceives what is being
1. Establish rapport as early in the interview as possible. said.
2. Determine the patient's chief complaint.
3. Use the chief complaint to develop a provisional Px: fears of dying and effects of talking about these
differential diagnosis. fears with his or her family.
4. Rule the various diagnostic possibilities out or in by MD replies: “It seems that you are concerned with
using focused and detailed questions. becoming a burden to your family.”
5. Follow up on vague or obscure replies with enough
persistence to accurately determine the answer to the 4. Facilitation
question.  Helps the patient to continue in the interview by
6. Let the patient talk freely enough to observe how tightly providing both verbal and nonverbal cues that
the thoughts are connected. encourage patient to keep talking
7. Use a mixture of open-ended and closed-ended
questions. Nodding one's head
8. Don't be afraid to ask about topics that you or the patient Leaning forward in the chair
may find difficult or embarrassing. “Yes, and then...?” or “Uh-huh, go on.”
9. Ask about suicidal thoughts.
10. Give the patient a chance to ask questions at the end of 5. Silence
the interview.  May indicate disapproval or disinterest
11. Conclude the initial interview by conveying a sense of  Constructive
confidence and, if possible, of hope.  Allows the patient to contemplate, to cry, or just to
sit in an accepting, supportive environment in which
SPECIFIC TECHNIQUES IN INTERVIEWING the doctor makes it clear that not every moment must
1. Open-Ended Questions be filled with talk.

“Can you tell me more about that?” 6. Confrontation

2. Close-Ended Questions
 Asks for specific information
 Effective in eliciting information about absence of
certain symptoms.
 Effective in assessing factors such as frequency,
severity, and duration of symptoms.
“How long have you been taking the medication?”
 Point out to a patient something to which the MD thinks
the patient is not paying attention, is missing, or is in
some way denying
 Helps the patient face whatever needs to be faced in a
direct but respectful way
“What you have done may not have killed you, but
it's telling me that you are in serious trouble right
now and that you need help so that you don't try
suicide again.”

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 Patient-Doctor Rel & Interviewing Techniques for Special Px Pop’ns
7. Clarification
 Attempt to get details from the patient about what he
has already said
“You are feeling depressed. When do you feel most
depressed?”
8. Interpretation
 Used when an MD states something about a patient’s
behavior or thinking of which the patient may not be
aware
 Requires careful listening
 Sophisticated technique used only after the doctor has
established rapport with the patient and has a
reasonably idea of what inter-relationships are
(interrelationships that the patient may not see)
“When you talk about how angry you are that your
family has not been supportive, I think you're also
telling me how worried you are that I won't be there
for you either. What do you think?”
9. Summation
 Periodically during the interview, briefly summarize
what a patient has said thus far
 Assures both the patient and MD that the MD has heard
the same information
“Ok, I just want to make sure that I've got everything
right up to this point.”
10. Explanation
 Explain in understandable language and allow patients
to respond and ask questions
“You will be given a small dose of medication that
will make you sleepy. The medication is called
Lorazepam, and the dose you will be getting is 0.25
mg. I will see you again first thing in the morning,
and we'll go over all the procedures that will be
required before anything else happens. Now, what
are your questions?”
11. Transition
 Allows doctor to convey the idea that sufficient info has
been obtained on one subject, and that the MD's words
encourage patients to continue on to another subject
“You've given me a good sense of that particular
time in your life. Perhaps now you could tell me a bit
more about an even earlier time in your life.”
12. Self-Revelation
 Self-disclosure by physicians may be useful in certain
situations if MD feels at ease and can communicate a
sense of self-comfort (e.g. civil status of MD)
“I will be happy to tell you whether or not I am
married, but first let's talk a little about why it is
important for you to know that. If we talk about it,
I'll have a bit more information about who you are
and what your concerns are regarding me and my
involvement in your care.”
Gisela, Jess, Noe 
13. Positive reinforcement
 Allows the patient to feel comfortable telling a
doctor anything, even about such things as non-
compliance with treatment
“I appreciate your telling me that you have stopped
taking your medication. Can you tell me what the
problem was?”
14. Reassurance
 Can lead to ↑ trust and compliance and can be
experienced as an empathic response of a concerned
doctor
 False reassurance is often given from a desire to make
a patient feel better, but once a patient knows that an
MD has not told the truth, the patient is unlikely to
accept or believe truthful reassurance
Example of false reassurance:
Px: “Am I going to be all right, Doctor?”
MD: “Of course you're going to be all right.
Everything's fine.”
Example of truthful reassurance:
“We both know that what you have is serious. I'd like
to know exactly what you think is happening to you
and to clarify any questions you have.”
15. Advice
 To be effective and to be perceived as empathic rather
than inappropriate or intrusive, the advice should be
given only after patient is allowed to talk freely
about their problems so that MD has an adequate
info base from which to make suggestions.
Px: “I can't take this medication. It's bothering me.”
MD: “Fine. I think you should stop taking it, and I'll
prescribe something different.”
3. Ending the Interview
 MD’s want patients to leave an interview feeling understood
and respected.
 MD should give the patient a chance to ask questions and
let the patient know as much as possible about future
plans.
 MD should thank patients for sharing the necessary
information.
 Doctors should make another appointment or give a referral
and some indication about how patients can reach help
quickly if it is necessary before the next appointment.
SPECIFIC ISSUES IN PSYCHIATRY
1. Fees
 Openly discuss payment of fees
 Consider HMO’s
2. Confidentiality
 Extent and limitations of info, so that the patient will
have an idea of what can and cannot remain
confidential
 Other issues related to confidentiality include who has
access to the patient's medical record, information
required by insurance companies (which may be
extensive), and the degree to which the patient's case
will be used for teaching purposes
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 Patient-Doctor Rel & Interviewing Techniques for Special Px Pop’ns

3. Supervision Equanimity The ability to handle stressful

 When young medical doctors are receiving supervision situations with an undisturbed,
from senior MD’s, patients should know from the even temper
beginning. *Discussed by Dr. William Osler in his book, Aequanimitas;
Are ideals to be strived for but are rarely reached
4. Missed Appointments and Length of Sessions
 Patients need to be informed about a doctor's policies INTERVIEWING TECHNIQUES FOR SPECIAL PATIENT
for missed appointments and length of sessions (e.g. POPULATIONS
charge for missed sessions)
 Psychiatrists generally see patients in regularly A. PSYCHOTIC PATIENTS
scheduled blocks of time ranging from 15 to 45 General Description: They have poor or absent reality
minutes. testing abilities.
 Psychiatrists who are treating psychotic inpatients Dos in the interview Don’ts in the interview
may determine that a patient cannot tolerate a
 Evaluation of a patient  Open-ended questions and
lengthy session and may decide to see the patient in a
with psychotic symptoms long periods of silence are
series of 10-minute sessions throughout the
needs to be more focused apt to be disorganizing.
week.
and structured.  Questions calling for
 Some doctors ask patients to give 24 hours’ notice to
abstract responses or
avoid being billed for a missed session, others decide
hypothetical conjectures
on a case-case basis, others do not charge at all.
may be unanswerable.
5. Availability of Doctor
THOUGHT DISORDERS
 Once a patient enters into a contract to receive care
General Description: Have impaired communication skills.
from a particular physician, the doctor is responsible
for having a mechanism in place for providing Dos in the interview
emergency service outside scheduled appointment  When derailment is evident, the psychiatrist proceeds
times, e.g. emergency phone number or a covering with questions calling for short responses.
physician.  For a patient experiencing thought blocking, the
psychiatrist needs to repeat questions to remind the patient
6. Follow-Up of what was already said and in general, to provide an
 Events can disrupt the continuity of the patient-MD organization for thinking that the patient is unable to
relationship, e.g. residents ending their training, provide.
patients must be assured that regardless of what
occurs in the course of treatment the care will be Hallucinations
ongoing General Description: They have false sensory perceptions.
 Reason for telling the truth is that patients will Dos in the interview Don’ts in the interview
fantasize reasons about why the doctor has stopped  The patient is asked to  Hallucinations are
seeing them and may fear that something about them describe the sensory perceived as real sensory
has made the doctor leave. misperception as fully as stimuli and should not be
possible. dismissed as fanciful;
CHARACTER AND QUALITIES OF THE PHYSICIAN  For auditory however, the
Imperturbability Stability to maintain extreme calm hallucinations, include psychiatrist should ask
and steadiness content, volume, clarity, questions about their
and circumstances. fixity and the patient’s
Presence of mind Self-control in an emergency or
 For visual level of insight.
embarrassing situation so that one
hallucinations, include
can say or do the right thing
content, intensity, the
Clear judgment The ability to make an informed
situations in which they
opinion that is intelligible and free
occur, and the patient’s
of ambiguity
response.
Ability to endure The capacity to remain firm and  “Does it ever seem that
frustration deal with insecurity and the voices are coming
dissatisfaction from your own
Infinite patience The unlimited ability to bear pain thoughts?” or “What do
or trial calmly you think is causing the
Charity toward To be generous and helpful, esp voices?”
others toward the needy and suffering Delusions
The search for To investigate facts and pursue General Description: They have fixed, false beliefs not in
absolute truth reality keeping with the culture.
Composure Calmness of mind, bearing, and - Delusional patients often come to psychiatric evaluation
appearance having had their beliefs dismissed or belittled by friends and
family. They are on guard for similar reactions from
Bravery The capacity to face or endure
the examiner.
events with courage
Tenacity To be persistent in attaining a goal Dos in the interview
or adhering to something valued  “Does it seem that people are intent on hurting you?”
Idealism Forming standards and ideals and  “It must be frightening to think there are people you
living under their influence do not know who are plotting against you.”

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 Patient-Doctor Rel & Interviewing Techniques for Special Px Pop’ns

 A gentle probe may determine how tenaciously the beliefs  Asking patients about the intended means of suicide is
are held. helpful in two ways. First, it clarifies the urgency of the
 ―Do you ever wonder whether those things might not situation. Second, the understanding of the intent is
be true?” sharpened by knowing whether a patient has thought
through the steps necessary to carry out the action.
B. SUSPICIOUS PATIENTS
General Description: Paranoid personality – have a Patients who already have PERCEIVED CONSEQUENCES
chronic, deeply ingrained suspicion that other people want in committing suicide
to cause them harm. General Description: Patients who see something desirable
- They are critical and evasive, and are sometimes called, resulting from their deaths are at increased risk for suicide.
‖grievance collectors‖ because they tend to blame others - Reunion fantasy – the belief that a person will be reunited
for everything bad happening in their lives. with a deceased loved one.
- Some potentially suicidal patients are restrained by what
Dos in the interview Don’ts in the interview they see as negative consequences. (e.g. “My children need
 The physician should try to  Expressions of warmth me too much; they’d never be able to get along without
maintain a respectful but often heighten their me.”)
somewhat formal and suspicion. Dos in the interview
distant approach with these  The psychiatric history and the family history for all
patients. patients, even those not currently suicidal, should mention
 Should try to respond any previous suicide attempt or suicides by family
non-defensively to the members. Both circumstances are recognized to
patient’s suspicions. increase the current risk.
 Even during a first evaluation session, the psychiatrist
C. DEPRESSED AND POTENTIALLY SUICIDAL PATIENTS must be prepared to make whatever professional response
General Description: They have difficulty concentrating, is necessary to safeguard the well-being of the patient.
thinking clearly, and speaking spontaneously.
D. SOMATIZING PATIENTS
Dos in the interview Don’ts in the interview General Description: They are reluctant to engage in self-
 The psychiatrist evaluating  Depressed patients should reflection and psychological exploration.
a depressed patient may not be badgered, and long - They live with the fear that their symptoms are not being
need to be more forceful silences are seldom taken seriously and the parallel fear that something
and directive than usual. useful. medically serious may be overlooked.
 The examiner needs to
repeat the question more Dos in the interview Don’ts in the interview
than once.  Acknowledge the suffering  It is foolhardy for the
 All patients must be conveyed by the symptoms psychiatrist to assume with
asked about suicidal without necessarily absolute conviction that a
thoughts; however, accepting the patient’s patient’s physical
depressed patients may explanation for the complaints have no real
need to be questioned more symptoms. medical basis.
fully.  Clinicians should be
 The examiner must feel curious about both the
sufficiently comfortable to nature of the physical
ask simple, complaints and the
straightforward, and impact of those
non-euphemistic complaints on the
questions. patient’s life.
 Asking about suicide  Expand discussion to
does not increase the include all aspects of the
risk. patient’s well-being and
emotional and physical
Patients Who Have An Intent In Committing Suicide health.
General Description: They report that they wish that they  Pragmatic Approach –
were dead but would never intentionally do anything to take one that stresses a
their own lives—PASSIVE SUICIDAL IDEATION. willingness to use whatever
works to relieve the
Dos in the interview patient’s suffering without
 Determine the seriousness of the wish to die. causing harm.
 It is useful to ask restraining influences, internal and  Form a collaborative
external. relationship with the
 ―Do you worry that you might not be able to resist primary medical doctor;
those impulses?‖ to obtain thorough copies
 ―How have you been able to keep from hurting of medical records and
yourself so far?‖ evaluations; and for them
to consult freely with one
Patients who have the MEANS to commit suicide another about the patient’s
health and symptoms.
Dos in the interview

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E. AGITATED AND POTENTIALLY-VIOLENT PATIENTS H. DEMANDING PATIENTS

General Description: Most unpremeditated violence is General Description: They are easily frustrated and can
preceded by a prodrome of accelerating psychomotor become petulant or even angry and hostile if they do not get
agitation. Prodrome lasts from 30-60 minutes before what they want when they want it.
erupting into physical violence. - Impulsive, self-destructive, manipulative, and attention-
Dos in the interview Don’ts in the interview seeking.
 Conduct an assessment and  Avoid any behavior Dos in the interview
contain behavior and limit misconstrued as  The doctor must be firm with these patients from the
the potential for harm. menacing: standing over outset and must clearly define acceptable and
 The interview should be the patient, staring or unacceptable behavior.
conducted in a quiet, non- touching.  They must be treated with respect and care but they must
stimulating environment. also be confronted with their behavior.
 Sufficient space should be
available for the comfort of I. NARCISSISTIC PATIENTS
the patient and the General Description: They act as though they are superior
psychiatrist, with no to everyone around them, including the doctor.
physical barrier to leaving - Contemptuous of others who they perceive to be
the examination room from imperfect.
either of them. - They may initially idealize a doctor out of a need to have
 Ask whether the patient is their doctor be as perfect as they are, but the idealization
carrying weapons and may can quickly turn to disdain when they realize that the doctor
ask the patient to leave the is only human after all.
weapon with a guard or in a - Underneath their surface arrogance, narcissistic
holding area. patients feel desperately inadequate and fear that
 If the patient’s agitation others will see through them.
continues to increase,
terminate the interview. J. ISOLATED PATIENTS
 The physician’s own General Description: They do not need or want much
subjective sense of contact with other people.
comfort or fear should - Intimate contact with the doctor is viewed with distaste,
be heeded. and such patients would prefer to take care of themselves
entirely without the doctor’s help if it were possible.
F. SEDUCTIVE PATIENTS
General Description: They manifest seductiveness in their Dos in the interview
clothes, behavior and speech.  The doctor should treat these patients with as much respect
- Sex is not the only enticement with which for their privacy as possible and should not expect them to
psychiatrists can be seduced. Patients may offer insider respond to the doctor’s concern with openness.
information for profitable trading in the stock market, may
promise an introduction to a movie star friend, or they may K. OBSESSIVE PATIENTS
suggest that they will dedicate their next novel to the General Description: They are orderly, punctual, and so
psychiatrist. concerned with details that they do not see the larger picture.
- Unemotional, even aloof, especially when confronted with
Dos in the interview anything disturbing or frightening.
 The psychiatrist should make it clear that what is being - Strong need to be in control of everything in their
offered will not be accepted, in a way that preserves lives and may struggle with their doctor whenever they feel
good rapport and does not unnecessarily assault the that decisions are being imposed.
patient’s self-esteem.
 When the behavior is mild and indirect, it may be best to Dos in the interview
ignore it.  The physicians should include them in their own care and
 More explicit propositions call for more direct responses treatment as much as possible.
and may afford the psychiatrist the chance to explain  Explain in detail what is going on and what is being
the nature of the therapeutic relationship and the planned, allowing the choices on his or her own behalf.
need to establish boundaries.
 The psychiatrist should also make it clear that it is the
L. PATIENTS WHO LIE
violation of those boundaries that is being rejected
General Description: They lie consciously with the explicit
and not the patient.
intent of deceiving the therapist.
- MALINGERING – telling lies for the purpose of secondary
G. DEPENDENT PATIENTS gain. (e.g exemption from jury duty, a supply of
General Description: They are more likely to make repeated psychoactive drugs, or leave of absence from graduate
urgent calls between scheduled appointments and to demand school). Malingering is not a mental disorder in the
special consideration. revised 4th edition of Diagnostic and Statistical
Manual of Mental Disorders(DSM-IV-TR).
Dos in the interview - FACTITIOUS DISORDER – A patient explicitly lies not for
 The doctor needs to be firm in establishing limits when any obvious external advantage, but simply for whatever
reassuring the patient that his or her needs are taken psychological advantage is conferred by assuming the sick
seriously and are treated professionally. role.

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 Patient-Doctor Rel & Interviewing Techniques for Special Px Pop’ns

Dos in the interview Don’ts in the interview

 The patient’s response  The interviewer should not
must be accepted as an try to catch a practiced liar.
honest statement of Exaggerated
experience. suspiciousness leads to
ineffective therapeutic
work.

M. Patients who do not cooperate

General Description: They fail to keep appointments, refuse
to talk or to take the session seriously and failure to pay for
services.
- The patient who has been engaged in a meaningful
therapy for some time and becomes uncooperative
may be a manifestation of resistance to upsetting
material that is beginning to emerge in therapy or of
transference.

N. PATIENTS FR. DIFF. CULTURES & BACKGROUNDS

- Differences in race, nationality, and religion between
patient and interviewer can impair communication and
can lead to misunderstandings.
- When an interpreter is needed, the person should be
a disinterested third party, unknown to the patient.
Translators must be instructed to translate verbatim what
the patient says.

EMPATHIC LISTENING
- An empathic listener is affected by the sorrow or suffering
of the person being interviewed.
- The sympathetic listener says, ―I know how you feel
but I don’t feel the same way,‖ whereas the empathic
listener says, ―I know how you feel and I feel the
same way.‖
- It is important that empathic listener not be carried
too far—The therapist must be able to step out of the
patient’s shoes.
- Patients sometimes say, ‖How can you understand me if
you haven’t gone through what I’m going through?‖
Clinical psychiatry, however, is predicated on the
belief that it is not necessary to have other people’s
literal experiences to understand them.

SUMMARY OF DIFFERENT PX:

A. Psychotic Patients
B. Suspicious Patients
C. Depressed and Potentially Suicidal Patients
D. Somatizing Patients
E. Agitated and potentially-violent patients
F. Seductive Patients
G. Dependent Patients
H. Demanding Patients
I. Narcissistic Patients
J. Isolated Patients
K. Obsessive Patients
L. Patients who Lie
M. Patients who do not cooperate
N. Patients from diff cultures and backgrounds

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