general priciples of the interview

8/3/2019 General Priciples of the Interview

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GENERAL PRICIPLES OF THE

INTERVIEW



The Medical Interview

The psychiatric Interview

Diagnostic and Therapeutic Interview Initial & Later Interview

Data of the Interview



Interview: Art vs Science

Skill: Acquired vs taught

Psychodynamics: Imperative competency



MEDICAL vs PSYCHIATRIC INTERVIEW

MEDICAL PSYCHIATRIC

Patient desires relief-doctor expected to provide relief

Sought voluntarily -

cooperation assumed

Occasions when interviewee has not

voluntarily consulted.

Medical history taking facts to

establish correct diagnosis and

appropriate treatment .

Subjective evaluation of self is

unwelcome.

More that facts are needed.

Total life history, life style, and self

appraisal included.

Willing to divulge anything that will

help with physical illness.

Ego defences conceal unconscious

psychological conflicts of unconscious

fear of disrespect or ridicule.



DIAGNOSTIC and THERAPEUTIC INTERVIEW

DIAGNOSTIC THERAPEUTIC

Centered on eliciting

psychopathology.

Centered on understanding the

patient.

Gives a patient the feeling he is a

specimen of pathology being

examined.

Yields more information.

A hindrance for patient to open-up. Even a one time interaction can prove

truly therapeutic.



The Psychiatric Interview

The Therapeutic Alliance

Be warm, courteous, and emotionally sensitive

Actively diffuse the strangeness of the clinical situation.

*Size-up your patient

Give your patient the opening word.

Gain your patients trust by projecting competence.



INITIAL and LATER INTERVIEWS

What is a later interview really?

How long is the initial interview?



DATA OF THE INTERVIEW

Content and Process

Introspective and Inspective Data

Affect and Thought




CONTENT and PROCESS

CONTENT

Factual information from patient and specific

interventions of interviewer.

Verbal and non verbal

* Language style, between the lines



PROCESS

Developing relationship between doctor and patient

Concerned with the implicit meaning of the

communications

Doctor should always aware of the process

Includes the manner the patient related to the

interviewer (attitude and transference)

Counter-transference




INTROSPECTIVE and INSPECTIVE DATA

INTROSPECTIVE

- Report of his feelings and experiences

INSPECTIVE

- Non-verbal behavior

* Emotional responces

* Physical qualities of voice

* Motoric behavior




AFFECT and THOUGHT

AFFECT

Ask what the patient feels

Ask what he thinks elicited those feelings

Do not ask when emotion is obvious, go to the secondquestion

When corrected, accept correction and ask secind question

THOUGHT PROCESS

Q uality

Rate of production

Content

Organization/Coherence




THE PATIENT

Psychopathology

Phenomenology of emotional disorders

Symptoms, behavioural or characterologicaldisturbances, incapacities in functioning.

Effectiveness of defences, interrelationship between

them, overall integration into personality.




THE PATIENT

Psychodynamics

Science that attempts to explain the patients total

psychic development

Also includes strength and personality assets




THE PATIENT

Personality Strengths

Reassuring for patient to know you are also

interested in these

what do you like about yourself?

Be sensitive in how you ask and the timing

Respond appropriately




THE PATIENT

Transference

Process whereby patient unconsciously and

inappropriately displaces onto individuals in his

current life those patterns of behavior and emotional

reactions that originated with significant figures from

his childhood.

Patients realistic and appropriate reactions are nottransference.




THE PATIENT

Transference

- Distinguish from therapeutic alliance

*Relationship between doctors analyzing ego

and healthy rational component of patients ego.

* Based on real trust between child and mother




THE PATIENT

Transference

- Positive Transference

* Eg. Delegated Transference* Do not think you need to maintain a positive

transference

* Certain patient such as paranoids work better

early in treatment if they are permitted to maintain amoderate negative transference




THE PATIENT

Transference

- Transference Neurosis

* New form of neurosis develops duringpsychotherapy; physician central character; pervasive

* Vs. true transference which is fragmentary




THE PATIENT

Transference

- Realistic factors can be starting point

- Recreation of various stages of patients emotionaldevelopment

- Reflection of complex attitudes towards key figures




The Patient: Transference

- Common Patterns

Desire for affection, respect and gratification of

dependent needs

Fear of rejection/self-contempt

Omnipotence

Concern about status ability to understand the patient

Doctor as ego-ideal (introjection) Competitiveness

Treating physician as a child (when older)




The Patient: Transference

- Generally, transference is not discussed early

in the treatment

- Interpreting transference reactions can be agood tool to explore the patients

psychodynamics further




The patient: RESISTANCE

- Any attitude of the patient that opposes the

objectives of the treatment

- Insight oriented therapy necessitates exploration of

symptoms and behavior and this leads to anxiety

- Patient resist the therapy to maintain repression,

ward off insight, and avoid anxiety

- Concept is one of the cornerstones of DynamicPsychotherapy





Repression Resistance

- Results from egos attempts to ward off

threatening impulses by holding them out of awareness

Transference Resistance

- Rather than resolving his basic conflict, patient may

merely attempt an identification with the physician or

may adopt an attitude of competition instead of working together with him





Secondary-gain Resistance

- Reflected by patients unwillingness to relinquish secondary

benefits of illness

Super-Ego Resistance- Manifested by unconscious need for punishment

- Prominent in depression

Repetition-Compulsion Resistance

- Manifestation of a biological aspect of the organism- Patients maintain fixed maladaptive patterns of behavior

despite insight and the undoing of repression





Clinical Manifestation of Resistance

- Resistance that are expressed by patterns of

communications

* Silence

* Garrulousness

- Censoring or Editing Thoughts

- Intellectualization- Generalization

- Pre-occupation with one phase of life





Clinical Manifestation of Resistance

- Concentration on trivial details while avoiding important

topics

- Affective Display* Hypermotionality, Constant Anger, Happiness

- Acting-In, Acting-Out

* Change of Time, Minor Physical Sickness, Forgetting to

Pay Bill* Second guessing / getting one up

* Seductive Behavior

* Asking for favors





Clinical Manifestations of Resistance

- Acting In

* Partial Discharges of tension

- Lightning a cigarette, excusing to go to the loo, walking while

talking

* Postural rigidity or ritualized behavior

- Acting Out

* Feelings or drives pertaining to treatment or doctor is displaced

outside the therapy (usually ego-syntonic)

- Reluctance to participate in treatment but do not involve transference

* Psychopaths

* Some who are forced into treatment

* With other motives



What is the most important tool in the psychiatric

interview?



The Beginning Interview

Anxiety

Resentment

Insecurity

Defiant Attitudes Guilt

Do not be preoccupied with Diagnosis

Obsessive completeness

Interrupting

Inference

Omission



The Beginning Interview

Use patients clues not the checklist!

Dont talk too much. Dont be afraid of silence or

tears

Emulating elders

Do not use gimmicks. Be yourself.



Countertransference

Same categories

Dependence on patients affection

Exhibitionism

Insistence in infallibility

Over-identification

Vicarious pleasure is sexual or aggressive behavior of

patient Forcing your own concepts on the patients

I told you so



Transference and Countertransference

Do not negate transference reactions. The feelings

may be REAL.

Countertransference reactions can be a hindrance or

a big help. Learning how to manage them, andKNOWING YOURSELF will be an important tool.



THE SPECIAL PATIENT

Case to case

Inherently special vs someone who becomes special



THE ROLE OF THE INTERVIEWER

Primary Role: Listen and Understand

Sympathy

Q uestions

Suggestions for Treatment

Help in Practical Matters

Provisions of certain gratifications or frustrations



The Role of the Interview

INTERPRETATION

- Aim: undo the process of repression and allow

unconscious thoughts to surface

- Confrontation -> Clarification

- Confrontation

*Pointing out that the patient is avoiding

something- Clarification

*Formulating the area to be explored

- Can be directed at resistances, defences or content



The Role of the Interviewer

INTERPRETATION

- Aim at the material closes to consciousness

* Defences first before the unconscious impulses

they help ward off

- Earliest interpretations are aimed at area in which

the conscious anxiety is greatest (presenting symptom,

resistance or transference)- BE SPECIFIC



The Role of the Interviewer

INTERPRETATION

- Effective timing

* Premature increases anxiety and resistance

* Delayed wont help anymore* Optimal Time patient is not aware of the material but is

able to recognize and accept it.

i.e. px finds it not too threatening

- Impact* Significance

* Effect on Transference Relationship

* Effect on Therapeutic Alliance

general priciples of the interview

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