I

GENERAL
PRINCIPLES
OF EFFECTIVE
INTERVIEWING
 1 The Initial Interview: A Preview

Essential Concepts
The Four Tasks
Build a therapeutic alliance.
Obtain the psychiatric database.
Interview for diagnosis.
Negotiate a treatment plan with your patient.

The Three Phases

Opening phase
Body of the interview
Closing phase

Four Tasks of the Diagnostic Interview

When you meet a patient for the first time, you know very little about her, but
you know that she is suffering. (Note: Throughout this book, I switch genders
when discussing theoretical patients rather than resorting to the awkward
“him or her.”) While this may seem obvious, this implies something that we
often lose sight of. Our job, from the first “hello,” is to ease our patients’
suffering, rather than to make a diagnosis.
Don’t get me wrong—the diagnosis is important. Otherwise, I wouldn’t
be subjecting you to yet another edition of this book! But diagnosis is only
one step on the path of relieving suffering. And often, you can do plenty to
help a patient during the first session without having much of a clue as to the
official DSM diagnosis.
Since 2005, when the second edition of this book was published,
psychiatry has begun to question its fixation on the value of diagnostic
categories. We have come to realize that “major depression” does not imply
a specific “disease” but rather a huge range of potential problems. Each of
our patients present with their own versions of depression, in other words,
and each version requires an individualized treatment approach. A 24-year-
old woman floundering around after graduating from college a few years ago
is depressed—and the solution may lie in helping her to clarify her goals. A
45-year-old public relations manager just found out his wife has been having
an affair and he is depressed—the solution may be helping him to decide if
he can ever trust her enough to engage in couple’s therapy. A 37-year-old
woman with three well-adjusted children and a good marriage says her life
seems okay but she is depressed—she may need a course of antidepressants.
My point with these examples? Before you dive into the worthy project
of becoming a world-class DSM diagnostician, experiment with spending
much of your face-to-face patient time thinking about their lives, rather than
your diagnosis of their lives. Engage your natural empathy, compassion, and
intuition—because these represent the essence of psychological healing. And
even as you progress through your career and have logged thousands of
patient hours (as I have), always remind yourself of something that a wise
colleague, Brian Greenberg, once told me: “I often put the DSM manual
aside and tell myself, ‘Brian, how are you going to make this person’s
journey easier?’”
The diagnostic interview is really about treatment, not diagnosis. It is
important to keep this larger goal in mind during the interview, because if
you don’t, your patient may never return for a second visit, and your finely
wrought Diagnostic and Statistical Manual of Mental Disorders, Fifth
Edition (DSM-5) diagnosis will end up languishing in a chart in a file room.
Studies show that up to 50% of patients drop out before the fourth
session of treatment, and many never return after the first appointment
(Baekeland and Lundwall 1975). The reasons for treatment dropout are
many. Some patients do not return because they formed poor alliances with
their clinicians, some because they weren’t really interested in treatment in
the first place, and others because the initial interviews alone boosted their
morale enough to get them through their stressors (Pekarik 1993). The upshot
is that much more than diagnosis should occur during the initial interview:
Alliance building, morale boosting, and treatment negotiating are also vital.
The four tasks of the initial interview blend with one another. You
establish a therapeutic alliance as you learn about your patient. The very act
of inquiry is an alliance builder; we tend to like people who are warmly
curious about us. As you ask questions, you formulate possible diagnoses,
and thinking through diagnoses leads naturally to the process of negotiating a
treatment plan.

Build a Therapeutic Alliance

A therapeutic alliance forms the groundwork of any psychological treatment.
Chapter 3, The Therapeutic Alliance, focuses on the alliance directly, and
Chapters 4 to 13 provide various interviewing tips that will help you
increase rapport with your patient.

Obtain the Psychiatric Database

Also known as the psychiatric history, the psychiatric database includes
historical information relevant to the current clinical presentation. These
topics are covered in Section II, The Psychiatric History, and include history
of present illness, psychiatric history, medical history, family psychiatric
history, and aspects of the social and developmental history. Gleaning this
information is the substance of the interview, and throughout this step, you
will have to work on building and maintaining the alliance. You will also
make frequent forays into the next task, interviewing for diagnosis.

Interview for Diagnosis

The ability to interview for diagnosis—without sounding as if you’re reading
off a checklist of symptoms and without getting sidetracked by less relevant
information—is one of the supreme skills of a clinician, and one that you will
hone and develop over the course of your professional life. Section III,
Interviewing for Diagnosis: The Psychiatric Review of Symptoms, is
devoted to this skill; it contains chapters on how to memorize DSM-5 criteria
(Chapter 19) and on the art of diagnostic hypothesis testing (Chapter 20) and
several disorder-specific chapters that focus on how to use screening and
probing questions for each of the major DSM-5 disorders (Chapters 22 to
31).
Negotiate a Treatment Plan and Communicate It to
Your Patient
This process is rarely taught in residency or graduate school, and yet, it is
probably the most important thing you can do to ensure that your patient
adheres to whatever treatment you recommend. If your patient doesn’t
understand your formulation, doesn’t agree with your advice, and doesn’t
feel comfortable telling you so, the interview may as well never have taken
place. See Section IV, Interviewing for Treatment, for tips on the art of
patient education and clinical negotiation.

Three Phases of the Diagnostic Interview

The diagnostic interview, like most tasks in life, has a beginning, a middle,
and an end. Although this may seem obvious enough, novice interviewers
often lose sight of it and therefore fail to actively structure the interview and
control its pacing. The result is usually a panic-filled ending, in which 50
questions are wedged into the last 5 minutes.
It’s true that there’s a huge amount of information to obtain during the first
interview, and time may feel like the enemy. Excellent interviewers,
however, rarely feel rushed. They have the ability to obtain large amounts of
information in a brief period, without giving patients the sense that they are
being hurried along or made to fit into a preordained structure. One of the
secrets of a good interviewer is the ability to actively structure the interview
in its three phases.

Opening Phase (5 to 10 Minutes)

The opening phase includes meeting your patient, learning a bit about her life
situation, and then shutting up and giving her a few uninterrupted minutes to
tell you why she came. This is discussed in more detail in Chapter 3, because
the opening phase is a crucial period for alliance building; the patient is
making an initial decision as to your trustworthiness. The opening phase is
based on careful, preinterview preparation, covered in Chapter 2, Logistic
Preparations: What to Do Before the Interview. Attention to logistics ensures
that you will be completely attuned to the relationship with your patient
during the first 5 minutes.
Body of the Interview (30 to 40 Minutes)
Over the course of the opening phase, you will come up with some initial
diagnostic hypotheses (Chapter 20), and you will decide on some
interviewing priorities to explore during the body of the interview. For
example, you may decide that depression, anxiety, and substance abuse are
likely problems for a particular patient. You will map out an interviewing
strategy for exploring these topics, which will include asking about the
history of the present illness (Chapter 14); history of depression, suicidal
ideation, and substance abuse (Chapters 22, 23, and 26); family history of
these disorders (Chapter 17); and a detailed assessment of whether the
patient actually meets DSM-5 criteria (Chapters 20, 21, and 24) for each
disorder. Once you’ve accomplished these priority tasks, you can move on to
other topics, such as the social/developmental history (Chapter 18), medical
history (Chapter 16), and psychiatric review of symptoms (Section III).

Closing Phase (5 to 10 Minutes)

Although you may be tempted to continue asking diagnostic questions right up
to the end of the hour, it’s essential to reserve at least 5 minutes for the
closing phase of the interview. The closing phase should include two
components: (a) a discussion of your assessment, using the patient education
techniques outlined in Chapter 32, and (b) an effort to come to a negotiated
agreement about treatment or follow-up plans (Chapter 33). Of course, early
in your career, it will be difficult to come up with a coherent assessment on
the spot, without the benefit of hours of postinterview supervision and
reading. This skill will improve with practice.

The most tactful question in the world is still

inquisitive and requests an answer. To some
measure, it carries the memory of all questions
that could not be answered or were shaming or
damning to acknowledge.
Leston Havens, M.D.
A Safe Place
 2 Logistic Preparations: What to
Do Before the Interview

Essential Concepts
Prepare the right space and time.
Use paper tools effectively.
Develop your policies.

The work of psychological healing begins in a

safe place, to be compared with the best of
hospital experience or, from an earlier time,
church sanctuary. The psychological safe place
permits the individual to make spontaneous,
forceful gestures and, at the same time, represents
a community that both allows the gestures and is
valued for its own sake.
Leston Havens, M.D.
A Safe Place

Logistic preparation for an interview is important because it sets up a

mellower and less stressful experience for both you and your patient. Often,
trainees are thrown into the clinic without training in how to find and secure
a room, how to deal with scheduling, or how to document effectively. You’ll
eventually arrive at a system that works well for you; this chapter will help
speed up that process.

Prepare the Right Space and Time

Secure a Space
A space war is raging in most clinics and training programs, and you must
fight to secure territory. Once secured, dig trenches, call for the cavalry, and
do whatever you need to do.
I remember one early lesson in this reality: I was 2 months into my
training and just finishing supervision in the Warren Building of the
Massachusetts General Hospital (MGH) campus. It was 12:55 p.m., and I
had a therapy patient scheduled for 1:00 p.m. in the Ambulatory Care Clinic,
a building so far from Warren that it practically had its own time zone. I
zigged and zagged around staff and patients in the hallways on their way to
the cafeteria and rushed into the clinic by 1:05 p.m. My patient was in the
waiting room and got a good view of sweat trickling down my forehead. I
scanned the room schedule and found that no rooms were free. Panic set in,
until the secretary pointed out that the resident who had room 825 for that
hour had not yet shown up. So I led my patient to 825, and we started, 10
minutes late. Five minutes later, there was a knock on the door. I opened it,
and there stood the resident and his patient. I redeposited my patient in the
waiting room and scoured the list for another room.
I won’t torture you with the rest of this saga. Suffice it to say, we were
evicted from the next room as well, and the therapy session was, in the end,
only 15 minutes long, with much humiliation on my part and good-natured
amusement on my patient’s.
Here are some time-honored tips on how to secure a room and what to
do with it once you have it:

Schedule the same time every week. Try to secure your room for the
same time every week. That way, you’ll be able to fit interviews into
your weekly schedule routinely. When it comes to psychiatric
interviewing, routine is your friend. Psychodynamic psychotherapists
call this routine—the same time, the same room, the same greeting—the
“frame.” Making it invariable reduces distractions from the work of
psychological exploration.
Make your room your own in some way. This isn’t easy when you
only inhabit it for a few hours a week. Clinic policy may forbid this, or
it may be impolite (e.g., if you’re using an office that belongs to a
regular staff member). If possible, put a picture on the desk or the wall,
 bring a plant in, place some reference books on a shelf, hang some files.
The room will feel more like your space, and it will seem homier to
your patient. In my current office, I have a photo of my two children on
my desk. In the past, I worried that this little piece of self-disclosure
could cause problems with transference. Would lonely patients envy me
for having a family? Would angry patients believe that I was “bragging”
by showcasing my “beautiful family”? In fact, these problems haven’t
occurred (at least to my knowledge)—the photo is generally a good
conversation starter and, for most patients, makes me seem more human
and less intimidating.
Arrange the seating so that you can see a clock without shifting your
gaze too much. A wall clock positioned just behind your patient works
well. A desk clock or a wristwatch placed between the two of you is
also acceptable. The object is to allow you to keep track of the passage
of time without this being obvious to your patient. It is alienating for a
patient to notice a clinician frequently looking at a clock; the perceived
message is “I can’t wait for the end of this interview.” You do need to
monitor the time, though, to ensure that you obtain a tremendous amount
of information in a brief period. Actually, keeping track of time will
paradoxically make you less distracted and more present for your
patient, since you’ll always know that you’re managing your time
adequately.

Protect Your Time

Time is but the stream I go a-fishing in.
Henry David Thoreau

This is not to say that you should go fly-casting with your patients (though
you’re usually fishing for something or other during an interview). Rather,
you should protect the time you schedule for interviews, so that it has that
same peaceful, almost sacred quality. How to do it?

Arrive Earlier than the Patient

You need time to prepare yourself emotionally and logistically for the
interview. Compose yourself. Lay out whatever forms or handouts you’ll
need. Answer any urgent messages that you just picked up at your message
box. Breathe, meditate, do a crossword puzzle, or whatever you do to relax.
I once observed an interviewer who was visibly anxious. He crossed
and uncrossed his legs and constantly kneaded his left palm with his right
thumb. Eventually, the patient interrupted the interview and asked, “Doctor?
Are you all right? You look nervous.” He laughed. “Oh, I’m fine,” he said.
And no, this was not a resident, but one of my professors.

Prevent Interruptions
There are various ways to prevent interruptions:

Ask the clinic secretary to take messages for you.

Ask the page operator to hold all but urgent pages.
Put your pager on vibrate mode and only answer urgent pages.
Sign your pages out to a colleague.

Don’t Overbook Patients

Know your limits. At the beginning, it may take you an hour and a half to
complete an evaluation, not including the write-up. If so, book only one
patient per 2-hour slot. Obviously, your training program won’t allow you to
maintain such a leisurely schedule for long, but you will improve and
become more efficient. Eventually, you should aim toward completing the
evaluation and write-up (or dictation) in 1 hour.

Leave Plenty of Time for Notes and Paperwork

The time required for paperwork will vary, depending on both the setting and
the clinician. The key is to figure out how long it takes you and then to make
room for it in your schedule. Don’t fall into denial. If you happen to be very
slow at paperwork, admit it and plan accordingly.
I know an excellent psychiatrist who has learned from experience that he
has to spend 30 minutes on charting, telephoning, and miscellaneous
paperwork related to patients for every hour of clinical work he does. If he
spends 6 hours seeing patients, he schedules 3 hours in the evening to take
care of the collateral work. Although his hourly wage decreases, he gains the
satisfaction of knowing that he’s doing the kind of job he wants to do.
 Now, that wouldn’t work for me. I schedule slightly less time with
patients so that I can finish all collateral work before I see my next
appointment. The point, as Polonius said in Hamlet, is to “Know thyself, and
to thine own self be true.”

Use Clinical Tools Effectively

By “clinical tools,” I mean the whole array of interview forms, cheat sheets,
patient handouts, and patient questionnaires. Since the last edition of this
book, many of us have moved to electronic health records, so we might fill
out the forms on the computer and we might e-mail patients handouts.
Regardless, these tools are indispensable when you see a lot of patients
every day. All of the paper versions of the tools that I discuss below are in
the appendices of this manual, and you are welcome to copy and use what
you want. You might find all, some, or none of them useful, or you may want
to adapt them to better suit your needs.

Psychiatric Interview Long Form

This psychiatric interview long form (in Appendix B) is adapted from the
one used by Anthony Erdmann, an attending psychiatrist at MGH. He takes
notes on it while talking to patients and puts it in his chart.

Advantages
Use of this form ensures a thorough data evaluation and saves time, because
notes can be placed directly into the chart.

Disadvantages
Some patients may be alienated if you seem more interested in completing a
form than in getting to know them.

Psychiatric Interview Short Form

The short form (in Appendix B) can be used for rough notes when you are
going to dictate the evaluation or write it up in a longer version later.
Advantages
This form presents less of a barrier between clinician and patient than the
long form and is easy to refer to while dictating.

Disadvantages
Use of the short form may lead to a less thorough evaluation.

Psychiatric Interview Pocket Card

The pocket card (in Appendix A) is used to remind you of all the topics to
cover. You can jot rough notes on a blank piece of paper or not take notes at
all, if you’re able to remember most information.

Advantages
The card allows maximum interaction between clinician and patient, since
there is no form to fill out.

Disadvantages
Required information is not fully spelled out on the pocket card, so more use
of memory is required.

Patient Questionnaire1
Some clinicians give their patients a questionnaire (in Appendix B) such as
this one before the first meeting, to decrease the time needed to acquire basic
information.
1 Adapted from the questionnaire of the late Edward Messner, M.D.

Advantages
The patient questionnaire allows more time during the first session to focus
on issues of immediate concern to the patient. It may heighten the patient’s
sense that he is actively participating in his care.
Disadvantages
If all of the patient’s answers on the questionnaire are accepted at face value,
invalid information may be collected. Some patients may view filling out the
questionnaire as a burden.

Patient Handouts
Patients usually appreciate receiving some written information (in Appendix
C) about their disorder, and it probably increases treatment compliance.

Advantages
Patient handouts increase patients’ understanding of their diagnosis and give
them a sense that they are collaborating in their treatment.

Disadvantages
The handouts may present more information than some patients can handle
early in their treatment. Information may also be misinterpreted.

Develop Your Policies

From the first appointment with a particular patient, you are entering into a
relationship. You need to determine the parameters of this relationship,
including issues such as how and when you can be contacted, what the patient
should do in case of an emergency, who you can talk to about the patient, and
how to deal with missed appointments. As you face this array of decisions,
the following tips and ideas should help you devise policies that fit your
personality and clinical setting.

Contacting You
You define the boundaries of the clinical relationship by setting limits on
where and when patients can reach you. Do this early on; if you don’t, you’ll
eventually suffer for it.
I found this out the hard way with my very first therapy patient during
residency. She was a 40-year-old woman I’ll call Sally who had panic
disorder and depression. I first met her in the crisis clinic, where she came
after an upsetting conversation with her father. I spoke to her for half an hour,
and I gave her a follow-up appointment for the next week—and I gave her my
pager number and told her that this was a way to reach me, “anytime.” The
next Saturday morning, over breakfast and the paper, I got my first page:
“Call Sally.” She was in the middle of a panic attack, which subsided after a
10-minute conversation. Later that day, as I was riding my bike, I got another
page. “Call Sally.” I was somewhere on a country road in Concord,
Massachusetts, and far from a phone. Ten minutes later: “Call Sally. Urgent.”
Over the next hour, I received six pages, each sounding more urgent as the
alarmed hospital operator added more and more punctuation. The last page
read, “Call Sally!!! Emergency!!!!!!” When I finally found a pay phone, my
heart pounding, Sally said, “Doctor! I just had another panic attack.”
I felt the first hint of what I later learned was “countertransference.” At
the time, I called it “being pissed off.” I tried to keep the irritation out of my
voice as I told her she didn’t have to call me every time she had a panic
attack. At our next appointment, after some good supervision, I laid out some
ground rules. Sally could page me only during the week between 8 a.m. and 5
p.m. Otherwise, she was instructed to go to the crisis clinic. This in itself
helped decrease the frequency of her panic attacks, since it took away the
reinforcement of a phone conversation with her therapist every time she
panicked.

Suggestions
Never give your home or cell phone number to patients, and consider
keeping an unlisted phone number. Having made that pronouncement, I
acknowledge that some of my colleagues disagree, and give patients
their cell phone numbers. They do so with the understanding that they
are to use that phone only under extraordinary, life-threatening
circumstances. They tell me that this privilege is rarely abused and that
sharing their cell phone number tells patients that you care enough about
them to make sure that they can always reach you.
You may give out your paging number, but specify the times when you’re
available to be paged. Don’t let your life revolve around your pager.
Tell your patient what to do if there is an emergency at a time when you
are not available for paging. For example, he can call the crisis clinic,
 and you can give the clinic instructions to page you after hours if the on-
call clinician judges that the situation warrants your immediate
involvement.
If you have a voice-mail system, have patients reach you there. Your
voice mail is accessible 24 hours a day, and you can check it whenever
you want and decide who to call back and when. Some patients will
call your voice mail just to be soothed by your recorded voice.
When you’re on vacation, I suggest you sign your patients out to a
clinician you know and trust, rather than have them call the crisis clinic
during regular hours. That way, you can ensure that someone is prepared
to deal with any impending crises. For example, you may have patients
who are chronically suicidal but rarely require hospitalization and can
be managed through crises with frequent outpatient support. Letting your
colleague know about these patients may prevent inappropriate
hospitalization. Before you go on vacation, don’t forget to change your
outgoing voice-mail message to tell patients how to reach your
coverage. I make things easy by writing out two scripts: one for regular
outgoing messages and one for vacations.

Many clinicians use e-mail as a way of contacting patients. This can be a

time-saver, because you can answer quick questions without being at the
mercy of the availability of your patient’s cell phone or voice mail. But
again, without certain ground rules, this can (and will) get out of hand. Make
sure your patients know that e-mail communication is not a form of treatment.
Specify what you are willing to use e-mail for. Typically, this will be limited
to scheduling changes and requests for prescription refills. If you start
answering more involved clinical questions over e-mail, be aware that this is
part of the medical record, and you should print out a copy of any
correspondence and put it in the chart. In addition, many authorities believe
that HIPAA regulations require that you use an encrypted e-mail system for
any electronic communication. Such systems are expensive and somewhat
inconvenient, so I personally do not follow this guidance. Instead, I append a
message at the end of my e-mails to patients saying: “Please be aware that e-
mail communication can be intercepted in transmission or misdirected. Your
use of e-mail to communicate protected health information to us indicates that
you acknowledge and accept the possible risks associated with such
communication. Please consider communicating any sensitive information by
telephone, fax, or mail. If you do not wish to have your information sent by e-
mail, please contact the sender immediately.” (See The Carlat Psychiatry
Report, October 2015 for information on a variety of encrypted methods for
communicating with patients).

Contacting the Patient

Be sure to get your patient’s various phone numbers (e.g., home, work, day
treatment program) and e-mail (if applicable to your practice). Ask whether
it’s okay for you to identify yourself when you call, because some patients
don’t want employers or family members to know that they’re in treatment.
Obtain numbers of family members or close friends so that you can contact
them either to gather clinical information or in emergency situations. You’ll
need to obtain your patient’s consent for this ahead of time.

Missed Appointments
The usual practice is to tell patients that they must inform you at least 24
hours in advance of any missed appointments or they will be charged, except
in emergency situations. As a salaried trainee, the financial aspects of this
policy aren’t relevant, but there are important clinical benefits. Patients who
make the effort to show up for sessions show a level of commitment that
bodes well for therapeutic success. This policy encourages that commitment.
What if a patient repeatedly cancels sessions (albeit in time to avoid
paying)? First, figure out why she is canceling. Is it for a legitimate reason,
or is she acting out some feelings of anxiety or hostility? Did you just return
from vacation? If so, this is a common time for patients to act out a sense of
having been abandoned by you.
One way to approach this issue is head-on:

I notice that since I returned from vacation,

you’ve canceled three sessions in a row. What’s
going on? Sometimes, people get angry at their
therapists.
I’ve noticed that since we started talking about
the causes of your bulimia, you’ve missed a lot of
sessions. Should we be going a bit more slowly
with these issues?
 3 The Therapeutic Alliance: What
It Is, Why It’s Important, and How
to Establish It

Essential Concepts
Be warm, courteous, and emotionally sensitive.
Actively defuse the strangeness of the clinical situation.
Give your patient the opening word.
Gain your patient’s trust by projecting competence.

The therapeutic alliance is a feeling that you should create over the course of
the diagnostic interview, a sense of rapport, trust, and warmth. Most research
on the therapeutic alliance has been done in the context of psychotherapy,
rather than the diagnostic interview. Jerome Frank, author of Persuasion and
Healing (Frank and Frank 1991) and the father of the comparative study of
psychotherapy, found that a therapeutic alliance is the most important
ingredient in all effective psychotherapies. Creating rapport is truly an art
and therefore difficult to teach, but here are some tips that should increase
your success.

Be Yourself
While there is much to be learned from books and research about how to be a
good interviewer, you’ll never enjoy psychiatry very much unless you can
find some way to inject your own personality and style into your work. If you
can’t do this, you’ll always be working at odds with who you are, and this
work will exhaust you.
CLINICAL VIGNETTE

My friend and colleague, Leo Shapiro, does both inpatient and outpatient
work. He’s a character, no question about it. As a patient, you either love him
or hate him, but either way, what you see is what you get.
Two examples of Dr. Shapiro’s unorthodox style:
1. Walking down the hallway of the inpatient unit, Dr. Shapiro spotted the
patient he needed to interview next.

“Hey, what’s wrong, does your face hurt?”

Patient: “No, my face doesn’t hurt.”
Dr. Shapiro: “Well, it’s killing me!”
The patient chuckled, and the rapport was solidified.

2. The Shapiro thumb wrestling ploy

An angry, depressed man was demanding to be discharged, prematurely

according to staff reports. Dr. Shapiro agreed that discharge would be
risky, partly because the patient had developed little in the way of
rapport with anyone.
Dr. Shapiro: “I understand you want to be discharged?”
Patient: “Of course, this place is stupid, no one’s helping me.”
Dr. Shapiro: “If you can beat me at thumb wrestling, I’ll let you leave.”
Patient: “What?!!!”
Dr. Shapiro (putting out his hand): “Seriously. Or are you afraid of the
challenge?”
Patient (reluctantly joining hands with Shapiro): “This is crazy.”
Dr. Shapiro: “One, two, three, go”
Dr. Shapiro quickly wins, as he always does. “Well, I guess you have to
stay another day. See you tomorrow.”
Patient (smiling, despite himself): “That’s it?”
Dr. Shapiro: “What? You wanna talk, OK, let’s talk.”
A significant exchange ensued, and the patient was in fact discharged that
afternoon with appropriate follow-up.
No, I’m not endorsing the Shapiro technique. It works great for him,
because that’s his personality, but it would be a disaster for me, a mellow
 Californian at heart. The key is to be able to adapt your own personality
to the task at hand—helping patients feel better.

Be Warm, Courteous, and Emotionally

Sensitive
Are there any specific interviewing techniques that lead to good rapport?
Surprisingly, the answer appears to be “no,” and that is good news. A group
of researchers from London have studied this question in depth and published
their results in seven papers in the British Journal of Psychiatry (Cox et al.
1981a,b; 1988). Their bottom line was that several interviewing styles were
equally effective in eliciting emotions. As long as the trainees whom they
observed behaved with a basic sense of warmth, courtesy, and sensitivity, it
didn’t particularly matter which techniques they used; all techniques worked
well.
No book can teach you warmth, courtesy, or sensitivity. These are
attributes that you probably already have if you are in one of the helping
professions. Just be sure to consciously activate these qualities during your
initial interview.
There are, however, some specific rapport-building techniques that you
should be aware of:

Empathic or sympathetic statements, such as “you must have felt

terrible when she left you,” communicate your acceptance and
understanding of painful emotions. Be careful not to overuse empathic
statements, because they can sound wooden and insincere if forced.
Direct feeling questions such as “How did you feel when she left
you?” are also effective.
Reflective statements, such as “You sound sad when you talk about
her,” are effective but also should not be overused, because it can seem
as though you are stating the obvious.

What do you do if you don’t like your patient? Certainly, some patients
immediately seem unlikeable, perhaps because of their anger, passivity, or
dependence. If you are bothered by such qualities, it’s often helpful to see
them as expressions of psychopathology and awaken your compassion for the
patient on that basis. It may also be that your negative feelings are
expressions of countertransference, which is discussed in Chapter 13.

Actively Defuse the Strangeness of the

Clinical Situation
It’s easy to lose sight of the fact that an hour-long psychiatric interview is a
strange and anxiety-provoking experience. Your patient is expected to reveal
his or her deepest and most shameful secrets to a perfect stranger. There are
several ways to quickly defuse that strangeness.

Greet your patient naturally. While there are many perfectly

acceptable ways to greet patients, a general rule of thumb is to act
naturally, which usually means introducing yourself and shaking hands. I
often engage in some small talk for the first few seconds, because many
patients have a distorted view of psychiatrists as mysterious, silent
types who busily scrutinize a patient’s smallest gestures. Small talk
undermines this projection and puts the patient at ease. Acceptable
topics include the weather and difficulties arriving at the office.

Hi, I’m Dr. Carlat. Nice to meet you. I hope you were able to make your way
through the maze of the hospital without too much trouble.
Ask the patient what he wants to be called, and make sure to use that
name a few times during the interview.
Do you prefer that I call you Mr. Whalen, or Michael, or something else?
Using the patient’s name, especially the first name, is a great way of
increasing a sense of familiarity.
Caveat: Some patients (as well as some clinicians) view small talk as
unprofessional. I try to size up my patient visually before deciding how to
greet him or her. For example, small talk is rarely appropriate for patients
who are in obvious emotional pain or for grossly psychotic patients,
particularly if they are paranoid.

Get to know the patient as a person first. Some patients find it

awkward to reveal sensitive information to a stranger. If you sense that
 this is the case, you might want to begin by learning something about
them as people.

Before we get into the issues that brought you here, I’d like to know a little
bit about you as a person—where you live, what you do, that sort of thing.
Learning a bit about your patient’s demographics at the outset has the
added advantage of helping you start your diagnostic hypothesizing. There’s a
reason why the standard opening line of a written or oral case presentation is
a description of demographics: “This is a 75-year-old white widower who is
a retired police officer and lives alone in a small apartment downtown.” You
can already begin to make diagnostic hypotheses: “He’s a widower and thus
at high risk for depression. He’s elderly, so at higher risk for dementia. He
apparently had a career as a police officer, so probably is not
schizophrenic,” and so on. Knowing basic demographics at the outset doesn’t
excuse you from asking all the questions required for a diagnostic evaluation,
but it certainly helps set priorities in the direction of inquiry.

Educate the patient about the nature of the interview. Not every
patient understands the nature of an evaluation interview. Some may
think that this is the first session in a long-term psychotherapy. They may
come into the interview with the negative, media-fed expectation of a
clinician who sits quietly and inscrutably while the patient pours out his
soul. Others may have no idea why they are talking to you, having been
referred to a “doctor” by an internist who believes psychological
factors are interfering with their medical treatment. Thus, it’s helpful to
begin by asking the patient if he understands the purpose of the
interview and then to give him your explanation, including the expected
length of time of the interview, what sorts of information you’ll be
asking about, and whether you will follow him for further treatment if
needed.
Interviewer (I): So, Mr. Johnson, did your doctor explain the purpose
of this interview?Patient (P): She said you might be able to help me
with my nerves.I: I certainly hope I can do that. This is what we call
an evaluation interview. We’ll be meeting for about 50 minutes today,
and I’ll be asking you all sorts of questions, some about your nerves,
some about your family and other things, all so I can best understand
what might be causing you the troubles you’ve been having.
 Depending on your problem, we may need to meet twice to complete
this evaluation, but the way our clinic works is that I won’t
necessarily be the one who will treat you over the long term;
depending on what I think is going on, I may refer you to someone
else for treatment.
Address your patient’s projections. Keep in mind that a lot of shame
is associated with psychiatric disorders. Patients commonly project
aspects of their own negative self-images onto you. They may see you as
critical or judgmental. Havens (1986) recognized this and encouraged
the use of “counterprojective statements” to increase the patient’s sense
of safety:

It may be embarrassing for you to reveal all these things to a stranger. Who
knows how I’d react? In fact, I’m here to understand you and to help you.

CLINICAL VIGNETTE

Paranoid patients often project malevolent intentions onto the interviewer. In

this example, the interviewer addresses these projections directly:

I: Are you concerned about why I’m asking all these questions?
P: Sure. You’ve got to wonder—What’s in it for you? How are you going to
use all this information?
I:I’m going to use it to understand you better and to help you. It won’t go any
further than this room.
P: (Smirking) I’ve heard that before.
I:Did someone turn it against you?
P: You bet.
I:Then I can understand that you’d be careful about talking to me—you
probably think I’d do the same thing.
P: You never know.

With the distrust issue brought out into the open, the patient was more
forthcoming throughout the rest of the interview.
Give Your Patient the Opening Word
In one study of physicians, patients were allowed to complete their opening
statements of concern in only 23% of cases (Beckman and Franckel 1984).
An average of 18 seconds elapsed before these patients were interrupted.
The consequence of this highly controlling interviewing style is that
important clinical information may never make it out of the patient’s mouth
(Platt and McMath 1979).
You should allow your patients about 5 minutes of “free speech”
(Morrison 2014) before you ask specific questions. This accomplishes two
goals: First, it gives your patient the sense that you are interested in listening,
thereby establishing rapport, and second, it increases the likelihood that you
will understand the issues that are most troubling to the patient and thereby
make a correct diagnosis. Shea (1998) has called this initial listening phase
the “scouting period,” because you can use it to scout for clues to
psychopathology that you will want to follow up on later in the interview. It
has also been called the “warm-up” period by Othmer and Othmer (2001),
because one of its purposes is to create a comfort level between you and the
patient so that the patient is not put off by the large number of diagnostic
questions to come.
Of course, you have to be flexible. Some patients begin in such a vague
or disorganized fashion that you will have to ask your questions right away,
whereas others are so articulate that if you let them talk for 10 or 20 minutes,
they will tell you almost everything you need to know.
Each clinician develops his or her own first question, but all first
questions should be open-ended and should invite the patient’s story. Here
are several examples of first questions:

What was it that brought you to the clinic today?

What brings you to see me today?
What sorts of things have been troubling you?
How can I be of help to you?
What can I do for you?

A somewhat different way of approaching the first question is to view it as a

way of immediately exploring what that patient’s goals are for the interview.
Called “solution-focused interviewing,” this approach is recommended by
Chang and Nylund (2013).
Rather than asking “What brings you in?” or “What troubles you?” he
recommends “What would make this a helpful visit?” “What would you like
to see different from coming here?” This approach may work out particularly
well with reluctant patients, who may not believe they have any problems in
the first place.
A related question type is “the Miracle question,” which goes like this:
“Imagine that tonight you go to bed, like you normally do. Then, imagine that
while you’re asleep…. [pause)] …a miracle happens. Imagine that because
of this miracle, your depression [or whatever the patient’s problem is] goes
away. What will your day be like tomorrow?”
Patient: “Well, I guess I would wake up, and rather than sleep in, I’d
wake up on time and get ready instead of procrastinating. Then I’d eat
breakfast rather than skipping it, and at breakfast, we’d all get along better
without fighting. Then I’d go to work, and I’d have more confidence, so I
would say ‘no’ to people if they ask me to do too much….”

Gain Your Patient’s Trust by Projecting

Competence
This is always a tricky issue for novice interviewers, who often feel anything
but competent. In fact, your patient usually gives you the benefit of the doubt
here, because of something called “ascribed” competence. This is the
competence your patient attributes to you purely because of your institutional
ties. You work for Hospital X or University Y, so you must be competent.
Ascribed confidence will get you through the first several minutes of the
interview, but after that, you have to earn your patient’s respect.
Gaining a patient’s trust is easier than you might think. Even as a novice,
you know much more about mental illness than your patient, and this
knowledge is communicated by the kinds of questions you ask. For example,
your patient tells you she is depressed. You immediately ask questions about
sleep and appetite. Most patients will be impressed by your ability to elicit
relevant data in this way.
Other, more prosaic ways of projecting competence include dressing
professionally and adopting a general attitude of confidence. At the end of the
interview, your ability to provide meaningful feedback will further cement
your patient’s respect.
 4 Asking Questions I: How to
Approach Threatening Topics

Essential Concepts
Use normalizing questions to decrease a patient’s sense of
embarrassment about a feeling or behavior.
Use symptom expectation and reduction of guilt to defuse the
admission of embarrassing behavior.
Use symptom exaggeration to determine the actual frequency of a
sensitive or shameful behavior.
Use familiar language when asking about behaviors.

Always the beautiful answer who asks a more

beautiful question.
e. e. cummings

Over the course of the diagnostic interview, many of your questions will
be threatening to your patient. The simple admission of psychiatric symptoms
is humiliating for many people, as is the admission of behaviors considered
by society to be either undesirable or abnormal. Such behaviors include drug
and alcohol abuse, violence, and homosexuality. Beyond this, there are other
behaviors that your patients may not want to admit, because they may think
you will disapprove of them personally. These might include a history of
noncompliance with mental health treatment, a checkered work history, or a
deficient social life.
To maintain a healthy self-image, patients may lie when asked what they
perceive to be threatening questions. This has been a significant problem
among both clinicians and professional surveyors for years, and a repertoire
of interviewing techniques has been developed to increase the validity of
responses to threatening questions (Bradburn 2004; Payne 1951; Shea 1998).
Good clinicians instinctively use many of these techniques, having found
through trial and error that they improve the validity of the interview.

Normalization
Normalization is the most common and useful technique for eliciting
sensitive or embarrassing material. The technique involves introducing your
question with some type of normalizing statement. There are two principal
ways to do this:
1. Start the question by implying that the behavior is a normal or
understandable response to a mood or situation:
With all the stress you’ve been under, I wonder if you’ve been drinking
more lately?
Sometimes when people are very depressed, they think of hurting
themselves. Has this been true for you?
Sometimes when people are under stress or are feeling lonely, they binge
on large amounts of food to make themselves feel better. Is this true for
you?
2. Begin by describing another patient (or patients) who has engaged in the
behavior, showing your patient that she is not alone:
I’ve seen a number of patients who’ve told me that their anxiety causes
them to avoid doing things, like driving on the highway or going to the
grocery store. Has that been true for you?
I’ve talked to several patients who’ve said that their depression causes
them to have strange experiences, like hearing voices or thinking that
strangers are laughing at them. Has that been happening to you?
It’s possible to go too far with normalization. Some behaviors are
impossible to consider normal or understandable, such as acts of extreme
violence or sexual abuse, so don’t use normalization to ask about these.

Symptom Expectation
Symptom expectation, also known as the “gentle assumption” (Shea 1998), is
similar to normalization: You communicate that a behavior is in some way
normal or expected. Phrase your questions to imply that you already assume
the patient has engaged in some behavior and that you will not be offended by
a positive response. This technique is most useful when you have a high
index of suspicion of some self-destructive activity. A few examples follow:

Drug use. Your patient has reluctantly admitted to excessive alcohol

use, and you strongly suspect abuse of illicit drugs. Symptom
expectation may encourage a straightforward, honest response.

What sorts of drugs do you usually use when you’re drinking?

Suicidality. Your patient is profoundly depressed and has expressed

feelings of hopelessness. You suspect SI, but you sense that the patient
may be too ashamed to admit it. Rather than gingerly asking “Have you
had any thoughts that you’d be better off dead?” you might decide to use
symptom expectation.

What kinds of ways to hurt yourself have you thought about?

Remember to use this technique only when you suspect that the patient
has engaged in the behavior. For example, the question “What kinds of
recreational drugs do you use?” may be appropriate when interviewing a
young male admitted for a suicidal gesture while intoxicated, but wildly
inappropriate for a 70-year-old woman being assessed for dementia.

Symptom Exaggeration
Frequently, a patient minimizes the degree of his pathology, to fool either you
or himself. Symptom exaggeration or amplification (Shea 1998), often used
with symptom expectation, is helpful in clarifying the severity of symptoms.
The technique involves suggesting a frequency of a problematic behavior that
is higher than your expectation, so that the patient feels that his actual, lower
frequency of the behavior will not be perceived by you as being “bad.”

How much vodka do you drink each day? Two fifths? Three? More?
How many times do you binge and purge each day? Five times? Ten times?
How many suicide attempts have you had since your last hospitalization?
Four? Five?

As is true for symptom expectation, you must reserve this technique for
situations in which it seems appropriate. For example, if you have no reason
to suspect that a patient has a drinking problem, asking how many cases of
beer he drinks each day will sound quite insulting!

Reduction of Guilt
While it is true that all the techniques in this chapter boil down to reducing a
patient’s sense of shame and guilt, the reduction-of-guilt technique seeks to
directly reduce a patient’s guilt about a specific behavior in order to
discover what he has been doing. This technique is especially useful in
obtaining a history of domestic violence and other antisocial behavior.

Domestic Violence
I: When you argue with your wife, does she ever throw things at you or
hit you?
P: She sure does. See this scar? She threw a vase at me 2 years ago.
I: Do you fight back?
P: Well, yes. I’ve bruised her a few times. Nothing compared to what she
did to me.

Another version of this technique is to begin by asking about other

people:

I: Do you have any friends who push around their wives or girlfriends
when they have an argument?
P: Sure. They get pushed back, too.
I: Have you done that yourself, pushed or hit your wife?
P: Yeah. I’m not proud of it, but I’ve done it when she’s gotten out of
hand.

Dr. Mustafa Soomro has found the following question useful: “Have you
ever been in situations where fights occurred and you were affected?”
This is yet another variation on the nonjudgmental approach. If your
patient answers “yes,” you can flesh out whether his or her role was being a
witness, a victim, or a perpetrator (Shea 2007).
Antisocial Behavior
I: Have you ever had any legal problems?
P: Oh, here and there. A little shoplifting. Normal stuff.
I: Really? What was the best thing you ever stole?
P: The best thing? Well, I was into cars for a while. I spent a week
cruising around in a Porsche 924, but I returned it. I was just into
joyrides. Everyone was doing it back then.

In this example, the interviewer used induction to bragging to reduce the

patient’s sense of guilt and lead to an admission of something more
significant than shoplifting.

Use Familiar Language When Asking

About Behaviors
Bradburn (2004) compared two methods of asking about alcohol use and
sexuality. In the first method, they used “standard” language—words and
phrases such as intoxicated and sexual intercourse. In the second method,
they used “familiar” or “poetic” language—the language their respondents
used for the same behavior, like getting loaded and making love. They found
that the use of familiar language increased reports of these behaviors by
15%.
Apparently, patients feel more comfortable admitting to socially
undesirable behaviors if they feel the interviewer “speaks their language.”
The table below suggests various colloquial expressions to use in place of
more formal language.

Using Familiar Language

 5 Asking Questions II: Tricks for
Improving Patient Recall

Essential Concepts
Anchor questions to memorable events.
Tag questions with specific examples.
Describe syndromes in your patient’s terms.

Uttering a word is like striking a note on the

keyboard of the imagination.
Ludwig Wittgenstein

Throughout the diagnostic interview, your patient’s memory will be both your
ally and your enemy. Even when the desired information is not threatening in
any way, be prepared for major inaccuracies and frustration if the events
described occurred more than a few months ago. Nonetheless, we’ve all had
the in-training experience of watching an excellent teacher elicit large
quantities of historical information from a patient for whom we could barely
determine age and sex. How do they do it? Here are some tricks of the trade.

Anchor Questions to Memorable Events

Researchers have found that most people forget dates of events that occurred
more than 10 days in the past (Azar 1997). Instead, we remember the distant
past in relation to memorable events or periods (Bradburn 2004), such as
major transitions (graduations and birthdays), holidays, accidents or
illnesses, major purchases (a house or a car), seasonal events (“hurricane
Katrina”), or public events (such as 9/11 or President Obama’s election).
 As an example, suppose you are interviewing a young woman with
depression. You find out over the course of the interview that she has a heavy
drinking history, and you want to determine which came first, the alcoholism
or the depression. You could ask, “How many years ago did you begin
drinking?” followed by “How many years ago did you become depressed?”
but chances are you won’t get an accurate answer to either question. Instead,
use the anchoring technique:

Interviewer: Did you drink when you graduated from high school?
Patient: I was drinking a lot back then, every weekend at least.
Graduation week was one big party.
Interviewer: Were you depressed then, too?
Patient: I think so.
Interviewer: How about when you first started high school? Were you
drinking then?
Patient: Oh no, I didn't really start drinking until I hooked up with my
best friend toward the end of my freshman year.
Interviewer: Were you depressed when you started school?
Patient: Oh yeah, I could barely get up in time to make it to classes, I was
so down.

You’ve succeeded in establishing that her depression predated her

alcoholism, which may have important implications for treatment.

Tag Questions With Specific Examples

In Chapter 8, you’ll learn about the value of multiple-choice questions in
limiting overly talkative patients. Tagging with examples is similar to posing
multiple-choice questions, but it is used specifically for areas in which your
patient is having trouble with recall. You simply tag a list of examples onto
the end of your question.
To ascertain what medications your patient has taken in the past for
depression, for example:

Interviewer: What were the names of the medications you took back then?
Patient: Who knows? I really don’t remember.
Interviewer: Was it Prozac, Paxil, Zoloft, Elavil, Pamelor?
 Patient: Pamelor, I think. It gave me a really dry mouth.

Define Technical Terms

Sometimes, what appears to be a patient’s vague recall is actually a lack of
understanding of terms. For example, suppose you are interviewing a 40-
year-old man with depression, and you want to determine when he had his
first episode:

Interviewer: How old were you when you first remember feeling
depressed?
Patient: I don’t know. I’ve always been depressed.

You suspect that you and the patient have different meanings of
depression, and you alter your approach:

Interviewer: Just to clarify: I’m not talking about the kind of sadness
that we all experience from time to time. I’m trying to understand
when you first felt what we call a clinical depression, and by that I
mean that you were so down that it seriously affected your
functioning, so that, for example, it might have interfered with your
sleep, your appetite, and your ability to concentrate. When do you
remember first experiencing something that severe?
Patient: Oh, that just started a month ago.
 6 Asking Questions III: How to
Change Topics with Style

Essential Concepts
Use smooth transitions to cue off something the patient just said.
Use referred transitions to cue off something said earlier in the
interview.
Use introduced transitions to pull a new topic from thin air.

Interviewing a patient for the first time requires touching on many

different topics within a brief period. You’ll need to constantly change the
subject, which can be jarring and off-putting to a patient, especially when she
is involved in an important and emotional topic. Skilled interviewers are
able to change topics without alienating their patients and use various
transitions to turn the interview into what Harry Stack Sullivan (1970) called
a “collaborative inquiry.”

Smooth Transition
In the smooth transition (Sullivan 1970), you cue off something the patient
just said to introduce a new topic. For example, a depressed patient is
perseverating on conflicts with her husband and stepchildren; the interviewer
wants to obtain information on family psychiatric history:

Patient: John has been good to me, but I can’t stand the way his
daughters expect me to go out of my way to make their lives easy;
after all, they’re adults!
Interviewer: Speaking of family, has anyone else in your family been
through the kind of depression that you’ve been going through?
Referred Transition
In the referred transition (Shea 1998), you refer to something the patient said
earlier in the interview to move to a new topic. For example, at the beginning
of an interview, a depressed patient had briefly mentioned that he “didn’t
know if he could take this situation anymore.” Now, well into the evaluation,
the interviewer wants to fully assess suicidality:

Patient: My doctor tried me on some medication for a while, but it didn’t

do much good.
Interviewer: Earlier, you mentioned that you didn’t know how much more
of this you could take. Have you had the thought that you’d be better
off dead?

Introduced Transition
In the introduced transition, you introduce the next topic or series of topics
before actually launching into it. This transition is often begun by a statement
such as “Now I’d like to switch gears …” or “I’d like to ask some different
kinds of questions now.” For example, you need to quickly run through the
PROS, but you don’t want the patient to think that you are asking these
questions because you expect that he actually experiences all of these
symptoms:

Interviewer: Now I’d like to switch gears a little and ask you about a
bunch of different psychological symptoms that people sometimes
have. Many of these may not apply to you at all, and that is a useful
thing to know in itself.