The Psychiatric Interview Today

Since the inception of psychiatry as a formal clinical discipline in the 19th century, the psychiatric interview has been, and remains, an essential and critical element in its practice. The careful psychologically sensitive interview is psychiatry’s main diagnostic instrument carrying therapeutic import in the manner of conduct and the delineation of effective future treatment.

From its beginnings, there has been a tension between the need for comprehensive data collection and the empathic engagement with the patient. The creation of an interactive dialogue between clinician and patient and awareness of its emotional currents that facilitate the emergence of pertinent clinical material and that obviate the patient’s feeling like a “specimen” under the scrutiny of a “pathologist” of the mind is the sine qua non of the well-conducted interview. The interview is a human interaction—a relationship—and the paternalistic dogma that once permeated its conduct is now, or should be, an artifact of the past. In my opinion, this is the most profound change that has occurred in the nature of the psychiatric interview. Today no matter what the degree of pathology, the psychiatric interview is recognized as an exchange between two people of equal status.

Psychiatry has undergone revolutionary changes in the past 40 years: the refinement of phenomenological diagnoses embodied in DSM-III and subsequent DSM revisions, an increasing and ongoing biological knowledge base for understanding the somatic origins of mental illness and effective pharmacological treatments, the expansion of psychodynamic thinking beyond ego psychology to incorporate differing theoretical perspectives, and a dramatic and progressive shift in sociocultural attitudes toward the clinician-patient relationship. All these changes in the discipline and culture of psychiatry inform the psychiatric interview today.

The advent and continued development of DSM has emphasized descriptive phenomenological approaches to psychopathology and, unfortunately, sometimes encourages a psychiatric interview that is overly focused on describing symptoms and establishing diagnoses rather than learning about the patient and his/her problems, illnesses, and life. As an example, while advances in biological psychiatry have definitively established that schizophrenia is a “brain disease” and neurodevelopmental disorder, there persists a diminution in the attention given to the subjective experiences of individual psychotic patients. Since psychosis can be expressed only through the personality of the individual patient, that person’s personal history and character structure determine many aspects of the psychotic “experience” and should be recognized and addressed.

We now know that the subjective experience of being “different” is universal, and the psychiatric interview today should recognize and explore that experience, validating its existence and its universality as we attempt to understand how it influences the patient’s life.

The psychiatric interview engages the clinician in a spoken dialogue with the patient. In that sense, it is about “voice” and its interplay—the vocalist and the response of the listener. Notwithstanding the need to conduct a careful mental status examination, elucidate symptomatology, establish a diagnosis, and so on, the sophisticated psychiatric interview today involves hearing the “music” in the interchange between clinician and patient. Learning through practice, supervision, and clinical experience to “hear the music” is central to the identity and professional competence of the psychiatrist. ■