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The psychiatrist's primary assessment tool is the direct face-to-face interview of the patient. Evaluations based solely on review of records and interviews of persons close to the patient are inherently limited by a lack of the patient's perspective. Furthermore, the clinical interview provides the psychiatrist with a sample of the patient's interpersonal behavior and emotional processes. It can either support or qualify diagnostic inferences from the history and can also aid in prognosis and treatment planning. Important information can be derived by observing the patient's general style of relating, the ways in which the patient minimizes or exaggerates certain aspects of his or her history, and whether particular questions appear to evoke hesitation or signs of discomfort. Additional observations concern the patient's ability to communicate about emotional issues, the defense mechanisms the patient uses when discussing emotionally important topics, and the patient's responses to the psychiatrist's comments and to other behavior, such as the psychiatrist's handling of interruptions or time limits.

The interview should be done in a manner that facilitates the patient's telling of his or her story, while simultaneously obtaining the necessary information. Time constraints need to be considered and adequate time allowed for the interview. High-priority tasks include an assessment of the patient's safety and the identification of signs, symptoms, or disorders requiring urgent treatment.

Opening with a discussion of the purpose of the interview offers the patient an understanding of the process. Empirical studies of the interview process suggest that the most comprehensive and accurate information emerges from a combination of 1) open-ended questioning with empathic listening and 2) structured inquiry about specific events and symptoms (87–92). When the purpose is a general evaluation, beginning with open-ended, empathic inquiry about the patient's concerns usually is best. Attention to the patient's most pressing concerns, whenever possible, will improve the therapeutic alliance and is likely to facilitate increased patient cooperation; other inquiries may be more limited initially in the service of the alliance. Patient satisfaction with open-ended inquiry is greatest when the psychiatrist provides feedback to the patient at multiple points during the interview. Structured, systematic questioning has been shown to be especially helpful in eliciting information about substance use and traumatic life events and in ascertaining the presence or absence of specific symptoms and signs of particular mental disorders (93–102) (Section IV.A.3).

Throughout the interview, useful clinical information is obtained by being sensitive to issues of development, culture, race, ethnicity, primary language, health literacy, disabilities, gender, sexual orientation, familial/genetic patterns, religious and spiritual beliefs, social class, and physical and social environment influencing the patient's symptoms and behavior. Respectful evaluation involves an empathic, nonjudgmental attitude and appropriate responses concerning the patient's cultural identity, his or her own explanation of illness and treatment pathways, sociocultural stressors and supports, and modes of interpersonal communication, both verbal and nonverbal. An awareness of one's possible biases or prejudices about patients from different subcultures and an understanding of the limitations of one's knowledge and skills in working with such patients may help one determine when it is advisable to consult with a clinician who has expertise concerning a particular subculture (103–105).

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a) Use of interpreters in the interview

When available, professionally trained interpreters with mental health experience should be used for encounters involving patients with limited English proficiency and those who are deaf or have severely limited hearing and who prefer to communicate using sign language (106, 107). Bilingual and bicultural staff may also be helpful (108). With cooperative patients, over-the-phone language interpretation services can be used when other professionally trained interpreters are unavailable, although establishing rapport with the patient may be more difficult. Family members, community members, or friends should not be used unless the patient refuses to use the professional interpreter or under emergency circumstances, in which case this should be noted in the patient record. The interpreter should be instructed to translate the patient's own words and to avoid paraphrasing except as needed to translate the correct meaning of idioms and other culture-specific expressions (109–111).

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b) Interviews with agitated or aggressive individuals

When evaluating individuals who are agitated or aggressive, the psychiatrist needs to give consideration to the patient interview as well as to his or her own safety (13, 77, 112–116). Establishing the presence of backup personnel and choosing an appropriate space in which to conduct the interview are useful preparations before meeting with an agitated or aggressive patient. Because such individuals may become more agitated if they feel trapped within a small room or are too closely positioned to the interviewer, a distance of several arms' length from the patient, with both psychiatrist and patient having access to the door, is generally optimal. A safe office environment should not contain potentially dangerous objects (e.g., decorative items), and the clinician should avoid clothing that can be used against him or her (e.g., neckties, scarves, prominent dangling earrings). Depending on the configuration of the office or interview room and its proximity to other staff, a mechanism for summoning assistance (e.g., a panic button) may also be indicated.

During the interview, a nonconfrontational and straightforward approach is often most effective. Attending to the patient's comfort, using reflective or active listening techniques, and showing respect for the patient's feelings and stated concerns may aid in establishing rapport. The key to calming an aggressive patient is affect management. Patients who are affectively aroused will need to ventilate their feelings, and the clinician should allow the patient to tell his or her own story. Logical or rational responses to an affectively flooded individual may further inflame the patient. Affect management involves acknowledging the patient's affect, validating the affect when appropriate, and encouraging the patient to talk about his or her feelings (116).

In some circumstances, it may be appropriate to set limits (e.g., noting that aggressive behavior cannot be permitted) while simultaneously emphasizing the need to attend to the safety of the patient and others. Throughout the interview, the clinician needs to be alert for signs that the patient's agitation is escalating (e.g., increased body movements or pacing, clenched fists, verbal threats, or increasing verbal volume); such signs may indicate a need to adjust the interview style or timing. At times, it will be best to postpone in-depth history taking or discussion of distressing topics that are not germane to the patient's current presentation.

In some instances, administration of psychotropic medications or judicious use of seclusion or restraint may be necessary to enhance the safety of the patient and others (114) or to permit essential physical examination, laboratory studies, or other diagnostic assessment. Reliance on such measures should be justified by the urgency of obtaining the diagnostic information and should be in compliance with applicable laws and regulations. The psychiatrist should consider how any special circumstances of the interview or examination may influence clinical findings. When the patient is able to cooperate, parts of the examination that cannot be completed or that are significantly influenced by the use of medication, seclusion, or restraint should be repeated if possible.

Guidelines for reducing the use of seclusion and restraint while at the same time maintaining the safety of patients and staff are available in a report developed by the APA with the American Psychiatric Nurses Association and the National Association of Psychiatric Health Systems (117). Recommendations of the report include assessing for anger management problems, identifying risk factors (e.g., pregnancy, asthma, head or spinal injury) before using restraint, identifying triggers, involving patients in treatment planning, asking patients about past experiences of seclusion and restraint, involving family, and documenting interventions attempted before using seclusion or restraint.

References

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