The Psychiatric Interview E-Book

Allan Tasman

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 409

Veröffentlichungsjahr: 2013

Beschreibung

The patient interview is at the heart of psychiatric practice. Listening and interviewing skills are the primary tools the psychiatrist uses to obtain the information needed to make an accurate diagnosis and then to plan appropriate treatment. The American Board of Psychiatry and Neurology and the Accrediting Council on Graduate Medical Education identify interviewing skills as a core competency for psychiatric residents.

The Psychiatric Interview: Evaluation and Diagnosis is a new and modern approach to this topic that fulfils the need for training in biopsychosocial assessment and diagnosis. It makes use of both classical and new knowledge of psychiatric diagnosis, assessment, treatment planning, and doctor–patient collaboration. Written by world leaders in education, the book is based on the acclaimed Psychiatry, Third Edition, by Tasman and Kay et al., with new chapters to address assessment in special populations and formulation. The psychiatric interview is conceptualized as integrating the patient’s experience with psychological, biological, and environmental components of the illness.

This is an excellent new text for psychiatry residents at all stages of their training. It is also useful for medical students interested in psychiatry and for practicing psychiatrists who may wish to refresh their interviewing skills.

Leseprobe

Contents

Contributors

Preface

Acknowledgments

CHAPTER 1 Listening to the Patient

Listening: The Key Skill in Psychiatry

The Primary Tools: Words, Analogies, Metaphors, Similes, and Symbols

How Does One Hear Words in This Way?

Listening as More Than Hearing

Common Blocks to Effective Listening

Crucial Attitudes That Enable Effective Listening

Theoretical Perspectives on Listening

Using Oneself in Listening

To Be Found: The Psychological Product of Being Heard

Listening to Oneself to Listen Better

Listening in Special Clinical Situations

Growing and Maturing as a Listener

References

CHAPTER 2 Physician–Patient Relationship

Formation of the Physician–Patient Relationship

Special Issues in the Physician–Patient Relationship

The Physician–Patient Relationship in Specific Populations of Patients

Conclusion

References

CHAPTER 3 The Cultural Context of Clinical Assessment

Introduction: The Cultural Matrix of Psychiatry

What Is Culture?

Culture and Gender

The Cultural Formulation

Ethnocultural Identity

Illness Explanations and Help-Seeking

Psychosocial Environment and Levels of Functioning

Clinician–Patient Relationship

Overall Assessment

Cultural Competence

Working with Interpreters and Culture-Brokers

Conclusion: The Limits of Culture

References

CHAPTER 4 The Psychiatric Interview: Settings and Techniques

Goals of the Psychiatric Interview

The Psychiatric Database

Database Components

Mental Status Examination

Conduct of the Interview: Factors That Affect the Interview

General Features of Psychiatric Interviews

References

CHAPTER 5 Psychiatric Interviews: Special Populations

Psychiatric Interview in Special Circumstances

Psychiatric Interview in Special Patient Populations

Conclusions

References

CHAPTER 6 Formulation

Biological Contributions

Social Factors

Psychological Factors

Summary

References

CHAPTER 7 Clinical Evaluation and Treatment Planning: A Multimodal Approach

Psychiatric Interview

Identifying Information

Chief Complaint

History of Present Illness

Past Psychiatric History

Personal History

Family History

Medical History

Substance Use History

Mental Status Examination

Physical Examination

Neurological Examination

Psychological and Neuropsychological Testing

Structured Clinical Instruments and Rating Scales

Laboratory Assessments

Neurophysiologic Assessment

Brain Imaging

Special Assessment Techniques

Treatment Planning

Case Formulation

Assessment of Risk

Suicide Risk

Differential Diagnosis

Initial Treatment Plan

Conclusion

References

CHAPTER 8 Professional Ethics and Boundaries

Introduction

Ethical Behavior and Its Relationship to the Professional Attitude

WPA Guidelines on Euthanasia

WPA Guidelines on Torture

WPA Guidelines on Sex Selection

WPA Guidelines on Organ Transplantation

WPA Guidelines on Genetic Research and Counseling in Psychiatric Patients

WPA Guidelines on Ethnic Discrimination and Ethnic Cleansing

WPA Guidelines on Psychiatrists Addressing the Media

The Coherent Treatment Frame and the Role of Therapeutic Boundaries in Effective Psychiatric Treatment

Boundary Violations

Components of the Coherent Psychiatric Frame

Stability

Avoiding Dual Relationships

Autonomy and Neutrality

Coherent and Noncollusive Compensation

Confidentiality

Anonymity

Abstinence

Self-respect and Self-protection

Summary

References

Index

This edition first published 2013© 2013 John Wiley & Sons, Ltd

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Library of Congress Cataloging-in-Publication Data

The psychiatric interview : evaluation and diagnosis / [edited by] Allan Tasman, Jerald Kay, Robert J. Ursano.p. ; cm.Includes bibliographical references and index.

ISBN 978-1-118-34097-4 (epdf) – ISBN 978-1-118-34098-1 (epub) – ISBN 978-1-118-34099-8 (emobi) – ISBN 978-1-118-34100-1 (obook) – ISBN 978-1-119-97623-3 (cloth : alk. paper)I. Tasman, Allan, 1947– II. Kay, Jerald. III. Ursano, Robert J., 1947–[DNLM: 1. Interview, Psychological–methods. 2. Ethics, Professional. 3. Mental Disorders–diagnosis. 4. Physician-Patient Relations. WM 143]616.89′075–dc23

2012050615

A catalogue record for this book is available from the British Library.

Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.

Cover image: © iStockphoto/Henry ChaplinCover design by Grounded Design

Contributors

Deborah L. CabanissDepartment of Psychiatry,Columbia University College of Physicians and Surgeons,New York, NY, USANew York State Psychiatric Institute,New York, NY, USAKenneth CertaDepartment of Psychiatry and Human Behavior, Thomas Jefferson University, Philadelphia, PA, USAFrancine CournosNew York State Psychiatric Institute,New York, NY, USAAllison CowanDepartment of Psychiatry,Boonshoft School of Medicine, Wright State University, Dayton, OH, USARichard S. EpsteinF. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USAJaswant GuzderDivision of Social and Transcultural Psychiatry, McGill University, Montreal, Quebec, CanadaG. Eric JarvisDivision of Social and Transcultural Psychiatry, McGill University, Montreal, Quebec, CanadaAbigail KayDepartment of Psychiatry and Human Behavior, Thomas Jefferson University, Philadelphia, PA, USAJerald KayDepartment of Psychiatry, Boonshoft School of Medicine, Wright State University, Dayton, OH, USALaurence J. KirmayerDivision of Social and Transcultural Psychiatry, McGill University, Montreal, Quebec, CanadaDavid A. LowenthalNew York State Psychiatric Institute,New York, NY, USAPaul C. MohlDepartment of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, USAAhmed OkashaWHO Collaborating Center for Research and Training in Mental Health, Ain Shams University, Cairo, EgyptCécile RousseauDivision of Social and Transcultural Psychiatry, McGill University, Montreal, Quebec, CanadaEdward K. SilbermanDepartment of Psychiatry, Tufts University, Boston, MA, USAStephen M. SonnenbergDepartment of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, MD, USAAmy M. UrsanoDepartment of Psychiatry, University of North Carolina, Chapel Hill, NC, USARobert J. UrsanoDepartment of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, MD, USARandon WeltonDepartment of Psychiatry, Boonshoft School of Medicine, Wright State University, Dayton, OH, USAPTSD Program, Dayton Veterans Administrative Hospital, Dayton, OH, USA

Preface

The tools of diagnosis in psychiatry, as is true for all of medicine, have vastly improved in the past decades. We now can image the brain to look at structures, see changes in the brain with development, identify functional areas of the brain as they are operating, and measure blood levels of hormones and medications. All of these allow us to better assess and care for our patients. Although these have been remarkable advances, the patient interview and the evolving doctor–patient relationship continue to provide the setting and the structure to gather core data to begin assessment and treatment in all of medicine and especially in psychiatry. This is true regardless of the clinical setting, whether inpatient, outpatient, consultation/liaison, the emergency department, or telepsychiatry. This book provides both the information needed to conduct an in-depth psychiatric evaluation as well as a thorough discussion of how to begin forming and maintaining the therapeutic alliance. The heart of the philosophy embodied in this work is that we must learn who is the person with the illness, as well as what is the illness, and why it appeared, reappeared, or continues, in order to maintain the treatment relationship most likely to produce a positive clinical outcome. The strengthening of this relationship and assuring the best treatment is facilitated through the development of a case formulation which also is addressed in depth within the book.

The clinical interview is the process of listening to and understanding the patient, and effectively communicating that understanding within the context of the doctor–patient relationship. How to conduct an interview to maximize discerning the most important information while developing and maintaining the best long-term relationship on which to build treatment is the goal of this book. Interviewing requires ­knowing how to listen for information often outside of the patient’s awareness, how to communicate, how to ­maintain the therapeutic relationship, and appreciate the dynamic, interpersonal, cultural, and ethical issues central to the clinical process. The advances in both understanding the effect of development on the patient’s capacities to form meaningful relationships and the improved diagnostic systems used to recognize specific psychopathology have helped improve the clinician’s assessment of the varying degrees of the individual patient’s pre-existing capability to trust the physician. The ability to discern these limitations alerts the interviewer to the need to tailor the style of the interview for each patient in order to ­maximize the success of a ­multimodal treatment plan.

We believe this book will be of particular importance for students, postgraduate trainees, and those in the early stages of their careers. But we also know that no matter what the stage of a clinician’s career, the material in this book will serve as a useful guide and reference. We hope you find this book as useful to your practice as we have found it gratifying to prepare.

Allan TasmanJerald KayRobert J. Ursano

Acknowledgments

The editors would like to extend their gratitude to the contributors of the third edition of Psychiatry, on which some of this book is based. They would also like to thank Paul C. Mohl, Laurence J. Kirmayer, Cécile Rousseau, G. Eric Jarvis, Jaswant Guzder, Edward K. Silberman, Kenneth Certa, Abigail Kay, Richard S. Epstein, Ahmed Okasha, Amy M. Ursano, Stephen M. Sonnenberg, Robert J. Ursano, Francine Cournos, David A. Lowenthal, and Deborah L. Cabaniss.

CHAPTER 1

Listening to the Patient

Listening: The Key Skill in Psychiatry

It was Freud who raised the psychiatric technique of examination – listening – to a level of expertise unexplored in earlier eras. As Binswanger (1963) has said of the period prior to Freudian influence: psychiatric “auscultation” and “percussion” of the patient was ­performed as if through the patient’s shirt with so much of his essence remaining covered or muffled that layers of meaning remained unpeeled away or unexamined.

This metaphor and parallel to the cardiac examination is one worth considering as we first ask if listening will remain as central a part of psychiatric examination as in the past. The explosion of biomedical knowledge has radically altered our evolving view and practice of the doctor–patient relationship. Physicians of an earlier generation were taught that the diagnosis is made at the bedside – that is, the history and physical examination are paramount. Laboratory and imaging (radiological, in those days) examinations were seen as confirmatory exercises. However, as our technologies have blossomed, the bedside and/or consultation room examinations have evolved into the method whereby the physician determines what tests to run, and the tests are often viewed as making the diagnosis. So can one imagine a time in the not-too-distant future when the psychiatrist’s task will be to identify that the patient is psychotic and then order some benign brain imaging study which will identify the patient’s exact disorder?

Perhaps so, but will that obviate the need for the psychiatrist’s special kind of listening? Indeed, there are those who claim that psychiatrists should no longer be considered experts in the doctor–patient relationship, where expertise is derived from their unique training in listening skills, but experts in the brain. As we come truly to understand the relationship ­between brain states and subtle cognitive, emotional, and interpersonal states, one could also ask if this is a distinction that really makes a difference. On the other hand, the psychiatrist will always be charged with finding a way to relate effectively to those who cannot effectively relate to themselves or to others. There is something in the treatment of individuals whose illnesses express themselves through disturbances of thinking, feeling, perceiving, and behaving that will always demand special expertise in establishing a therapeutic ­relationship – and that is dependent on special expertise in listening (Clinical Vignette 1).

All psychiatrists, regardless of theoretical stance, must learn this skill and struggle with how it is to be defined and taught. The biological or phenomenological psychiatrist listens for subtle expressions of symptomatology; the cognitive–behavioral psychiatrist listens for hidden distortions, irrational assumptions, or global inferences; the psychodynamic psychiatrist listens for hints at unconscious conflicts; the behaviorist listens for covert patterns of anxiety and stimulus associations; the family systems psychiatrist listens for hidden family myths and structures.

   Clinical Vignette 1

A 28-year-old white married man suffering from paranoid schizophrenia and obsessive–compulsive disorder did extremely well in the hospital, where his medication had been changed to clozapine with good effects. But he rapidly deteriorated on his return home. It was clear that the ward milieu had been a crucial part of his improvement, so partial hospitalization was recommended. The patient demurred, saying he didn’t want to be a “burden”. The psychiatrist explored this with the patient and his wife. Beyond the obvious “burdens” of cost and travel arrangements, the psychiatrist detected the patient’s striving to be autonomously responsible for handling his illness. By conveying a deep respect for that wish, and then educating the already insightful patient about the realities of “bearing schizophrenia”, the psychiatrist was able to help the patient accept the needed level of care.

This requires sensitivity to the storyteller, which integrates a patient orientation complementing a disease orientation. The listener’s intent is to uncover what is wrong and to put a label on it. At the same time, the listener is on a journey to discover who the patient is, employing tools of asking, looking, testing, and clarifying. The patient is invited to collaborate as an active informer. Listening work takes time, concentration, imagination, a sense of humor, and an attitude that places the patient as the hero of his or her own life story. Key listening skills are listed in Table 1.1.

Table 1.1Key Listening Skills

Hearing

Connotative meanings of words

Idiosyncratic uses of language

Figures of speech that tell a deeper story

Voice tones and modulation (e.g., hard edge, voice cracking)

Stream of associations

Seeing

Posture

Gestures

Facial expressions (e.g., eyes watering, jaw clenched)

Other outward expressions of emotion

Comparing

Noting what is omitted

Dissonances between modes of expression

Intuiting

Reflecting

Attending to one’s own internal reactions

Thinking it all through outside the immediate pressure to respond during the interview

The enduring art of psychiatry involves guiding the depressed patient, for example, to tell his or her story of loss in addition to having him or her name, describe, and quantify symptoms of depression. The listener, in hearing the story, experiences the world and the patient from the patient’s point of view and helps carry the burden of loss, lightening and transforming the load. In hearing the sufferer, the depression itself is lifted and relieved. The listening is healing as well as diagnostic. If done well, the listener becomes a better disease diagnostician. The best listeners hear both the patient and the disease clearly, and regard every encounter as potentially therapeutic.

The Primary Tools: Words, Analogies, Metaphors, Similes, and Symbols

To listen and understand requires that the language used between the speaker and the hearer be shared – that the meanings of words and phrases are commonly held. Patients are ­storytellers who have the hope of being heard and understood. Their hearers are ­physicians who expect to listen actively and to be with the patient in a new level of understanding. Because all human beings listen to so many different people every day, we tend to think of listening as an automatic ongoing process, yet this sort of active listening remains one of the central skills in clinical psychiatry. It underpins all other skills in ­diagnosis, alliance building, and communication. In all medical examinations, the patient is telling a story only she or he has experienced. The physician must glean the salient information and then use it in appropriate ways. Inevitably, even when language is common, there are subtle differences in meanings, based upon differences in gender, age, culture, religion, socioeconomic class, race, region of upbringing, nationality and original language, as well as the idiosyncrasies of individual history. These differences are particularly important to keep in mind in the use of analogies, similes, and metaphors. Figures of speech, in which one thing is held representational of another by comparison, are very important windows to the inner world of the patient. Differences in meanings attached to these figures of speech can complicate their use. In psychodynamic assessment and ­psychotherapeutic treatment, the need to regard these subtleties of language becomes the self-conscious focus of the psychiatrist, yet failure to hear and heed such idiosyncratic distinctions can affect simple medical diagnosis as well (Clinical Vignettes 2 and 3).

   Clinical Vignette 2

A psychiatric consultant was asked to see a 48-year-old man on a coronary care unit for chest pain deemed “functional” by the cardiologist who had asked the patient if his chest pain was “crushing”. The patient said no. A variety of other routine tests were also negative. The psychiatrist asked the patient to describe his pain. He said, “It’s like a truck sitting on my chest, squeezing it down”. The psychiatrist promptly recommended additional tests, which confirmed the diagnosis of myocardial infarction. The cardiologist may have been tempted to label the patient a “bad historian”, but the most likely culprit of this potentially fatal misunderstanding lies in the connotative meanings, each ascribed to the word “crushing” or to other variances in metaphorical communication.

   Clinical Vignette 3

A psychiatrist had been treating a 35-year-old man with a narcissistic personality and dysthymic disorder for 2 years. Given the brutality and deprivation of the patient’s childhood, the clinician was persistently puzzled by the patient’s remarkable psychological strengths. He possessed capacities for empathy, self-observation, and modulation of intense rage that were unusual, given his background. During a session, the patient, in telling a childhood story, began, “When I was a little fella…”. It struck the psychiatrist that the patient always said “little fella” when referring to himself as a boy, and that this was fairly distinctive phraseology. Almost all other patients will say, “When I was young/a kid/a girl (boy)/in school”, designate an age, etc. On inquiry about this, the patient immediately identified “The Andy Griffith Show” as the source. This revealed a secret identification with the characters of the TV show, and a model that said to a young boy, “There are other ways to be a man than what you see around you”. Making this long-standing covert identification fully conscious was transformative for the patient.

In psychotherapy, the special meanings of words become the central focus of the treatment.

How Does One Hear Words in This Way?

The preceding clinical vignettes, once described, sound straightforward and easy. Yet, to listen in this way, the clinician must acquire specific yet difficult-to-learn skills and attitudes. It is extremely difficult to put into words the listening processes embodied in these examples and those to follow, yet that is what this chapter attempts to do.

Students, when observing experienced psychiatrists interviewing patients, often express a sense of wonder such as: “How did she know to ask that?” “Why did the patient open up with him but not with me?” “What made the diagnosis so clear in that interview and not in all the others?” The student may respond with a sense of awe, a feeling of ineptitude and doubt at ever achieving such facility, or even a reaction of disparagement that the process seems so indefinable and inexact. The key is the clinician’s ability to listen. Without a refined capacity to hear deeply, the chapters on other aspects of interviewing in this textbook are of little use. But it is neither mystical nor magical nor indefinable (though it is very difficult to articulate); such skills are the product of hard work, much thought, intense supervision, and extensive in-depth exposure to many different kinds of patients.

Psychiatrists, more than any other physicians, must simultaneously listen symptomatically and narratively/experientially. They must also have access to a variety of ­theoretical perspectives that effectively inform their listening. These include behavioral, interpersonal, cognitive, sociocultural, and systems theories. Symptomatic listening is what we think of as traditional medical history taking, in which the focus is on the presence or absence of a particular symptom, the most overt content level of an interview. Narrative–experiential listening is based on the idea that all humans are constantly ­interpreting their experiences, attributing meaning to them, and weaving a story of their lives with ­themselves as the central character. This process goes on continuously, both consciously and unconsciously, as a running conversation within each of us. The conversation is between parts of ourselves and between ourselves and what Freud called “internalized objects”, important people in our lives whose images, sayings, and attitudes become permanently laid down in our memories. This conversation and commentary on our lives includes personal history, repetitive behaviors, learned assumptions about the world, and interpersonal roles. These are, in turn, the products of individual background, cultural norms and values, national identifications, spiritual meanings, and family system forces (Clinical Vignette 4).

   Clinical Vignette 4

A 46-year-old man was referred to a psychiatrist from a drug study. The patient had both major depression and dysthymic disorder since a business failure 2 years earlier. His primary symptoms were increased sleep and decreased mood, libido, energy, and interests. After no improvement during the “blind” portion of the study, he had continued to show little response once the code was broken, and he was treated with two different active antidepressant medications. He was referred for psychotherapy and further antidepressant trials. The therapy progressed slowly with only episodic improvement. One day, the patient reported that his wife had been teasing him about how, during his afternoon nap, his snoring could be heard over the noise of a vacuum cleaner. The psychiatrist immediately asked additional questions, eventually obtained sleep polysomnography, and, after appropriate treatment for sleep apnea, the patient’s depression improved dramatically.

It seems that three factors were present that enabled the psychiatrist in Clinical Vignette 4 to listen well and identify an unusual diagnosis that had been missed by at least three other excellent clinicians who had all been using detailed structured interviews that were extremely inclusive in their symptom reviews. First, the psychiatrist had to have readily available in mind all sorts of symptoms and syndromes. Second, he had to be in a curious mode. In fact, this clinician had a gnawing sense that something was missing in his understanding of the patient. There is a saying in American medicine designed to focus students on the need to consider common illnesses first, while not totally ignoring rarer diseases: when you hear hoofbeats in the road, don’t look first for zebras. We would say that this psychiatrist’s mind was open to seeing a “zebra” despite the ongoing assumption that the weekly “hoofbeats” he had been hearing represented the everyday “horse” of clinical depression. Finally, he had to hear the patient’s story in multiple, flexible ways, including the possibility that a symptom may be embedded in it, so that a match could be noticed between a detail of the story and a symptom. Eureka! The zebra could then be seen although it had been standing there every week for months.

Looking back at Clinical Vignette 3, we see the same phenomenon of a detail leaping out as a significant piece of missing information that dramatically influences the treatment process. To accomplish this requires a cognitive template (symptoms and syndromes; developmental, systemic, and personality theories; awareness of cultural perspectives), a searching curious stance, and flexible processing of the data presented. If one is able to internalize the skills listed in Table 1.1, the listener begins automatically to hear the meanings in the words.

Listening as More Than Hearing

Listening and hearing are often equated in many people’s minds. However, listening involves not only hearing and understanding the speaker’s words, but attending to inflection, metaphor, imagery, sequence of associations, and interesting linguistic selections. It also involves seeing – movement, gestures, facial expressions, subtle changes in these – and constantly comparing what is said with what is seen, looking for dissonances, and comparing what is being said and seen with what was previously communicated and observed. Further, it is essential to be aware of what might have been said but was not, or how things might have been expressed but were not. This is where clues to idiosyncratic meanings and associations are often discovered. Sometimes, the most important meanings are embedded in what is conspicuous by its absence.

There appears to be a biogrammar of primary emotions that all humans share and express in predictable, fixed action patterns. The meaning of a smile or nod of the head is universal across disparate cultures. The amygdala and the inferior temporal lobe gyrus have been identified as the neurobiological substrate for recognition of and empathy for others and their emotional states. Further research has identified that these parts of the brain are, on the one hand, prededicated to recognizing certain ­gestures, facial expressions, and so on, but require effective maternal–infant ­interaction in order to do so (Schore, 2001). All of this is synthesized in the listener as a “sense” or intuition as to what the speaker is saying at multiple levels. The availability of ­useful cognitive templates and theories enables the listener to articulate what is heard (Clinical Vignette 5).

   Clinical Vignette 5

A 38-year-old Hispanic construction worker presented himself to a small-town emergency department in the Southwest, complaining of pain on walking, actually described in Spanish-accented English as “a little pain”. His voice was tight, his face was drawn, and his physical demeanor was burdened and hesitant. His response to the invitation to walk was met by a labored attempt to walk without favor to his painful limb. A physician could have discharged him from the emergency department with a small prescription of ibuprofen. The careful physician in the emergency department responded to the powerful visual message that he was in pain, was beaten down by it, and had suffered long before coming in. This recognition came first to the physician as an intuition that this man was somehow more sick than he made himself sound. A radiograph of the femur revealed a lytic lesion that later proved to be metastatic renal cell carcinoma. To hear the unspoken, one had to be keenly aware of the patient’s tone and how he looked, and to keep in mind, too, the cultural taboos forbidding him to give in to pain or to appear to need help.

As has been implied, not only must one affirmatively “hear” all that a patient is ­communicating, one must overcome a variety of potential blocks to effective listening.

Common Blocks to Effective Listening

Many factors influence the ability to listen. Psychiatrists come to the patient as the product of their own life experiences. Does the listener tune in to what he or she hears in a more attentive way if the listener and the patient share characteristics? What blocks to listening (Table 1.2) are posed by differences in sex, age, religion, socioeconomic class, race, culture, or nationality? What blind spots may be induced by superficial similarities in different personal meanings attributed to the same cultural symbol? Separate and apart from the differences in the development of empathy when the dyad holds in common certain features, the act of listening is inevitably influenced by similarities and differences between the psychiatrist and the patient.

Table 1.2Blocks to Effective Listening

Patient–psychiatrist dissimilarities

Race

Sex

Culture

Religion

Regional dialect

Individual differences

Socioeconomic class

Superficial similarities

May lead to incorrect assumptions of shared meanings

Countertransference

Psychiatrist fails to hear or reacts inappropriately to content reminiscent of own unresolved conflicts

External forces

Managed care setting

Emergency department

Control-oriented inpatient unit

Attitudes

Need for control

Psychiatrist having a bad day

Would a woman have reported the snoring in Clinical Vignette 4 or would she have been too embarrassed? Would she have reported it more readily to a woman psychiatrist? What about the image in Clinical Vignette 2 of a truck sitting on someone’s chest? How gender and culture bound is it? Would “The Andy Griffith Show”, important in Clinical Vignette 3, have had the same impact on a young African-American boy that it did on a Caucasian one? In how many countries is “The Andy Griffith Show” even available, and in which cultures would that model of a family structure seem relevant? Suppose the psychiatrist in that vignette was not a television viewer or had come from another country to the USA long after the show had come and gone? Consider these additional examples (Clinical Vignette 6).

   Clinical Vignette 6

A female patient came to see her male psychiatrist for their biweekly session. Having just been given new duties on her job, she came in excitedly and began sharing with her therapist how happy she was to have been chosen by her male supervisor to help him with a very important project at their office. The session continued with the theme of the patient’s pride in having been recognized for her attributes, talents, and hard work. At the next session, she said that she had become embarrassed after the previous session at the thought that she had been “strutting her stuff”. The therapist reflected back to her the thought that she sounded like a rooster strutting his stuff, connecting her embarrassment at having revealed that she strove for the recognition and power of men in her company, and that she, in fact, envied the position of her supervisor. The patient objected to the comparison of a rooster, and likened it more to feeling like a woman of the streets strutting her stuff. She stated that she felt like a prostitute being used by her supervisor. The psychiatrist was off the mark by missing the opportunity to point out in the analogous way that the patient’s source of embarrassment was in being used, not so much in being envious of the male position.

It is likely that different life experiences based on gender fostered this misunderstanding. How many women easily identify with the stereotyped role of the barnyard rooster? How many men readily identify with the role of a prostitute? These are but two examples of the myriad different meanings our specific gender may incline us toward. Although metaphor is a powerful tool in listening to the patient, cross-cultural barriers pose potential blocks to understanding (Clinical Vignettes 7 and 8).

   Clinical Vignette 7

A 36-year-old black woman complained to her therapist (of the same language, race, and socioeconomic class) that her husband was a snake, meaning that he was no good, treacherous, a hidden danger. The therapist, understanding this commonly held definition of a snake, reflected back to the patient pertinent, supportive feedback concerning the care and caution the patient was exercising in divorce dealings with the husband.   In contrast, a 36-year-old Chinese woman, fluent in English, living in her adopted country for 15 years and assimilated to Western culture, represented her husband to her Caucasian, native-born psychiatrist as being like a dragon. The therapist, without checking on the meaning of the word “dragon” with her patient, assumed it connoted danger, one of malicious intent and oppression. The patient, however, was using “dragon” as a metaphor for her husband – the fierce, watchful guardian of the family – in keeping with the ancient Chinese folklore in which the dragon is stationed at the gates of the lord’s castle to guard and protect it from evil and danger.

   Clinical Vignette 8

In a family session, a psychiatrist from the South referred to the mother of her patient as “your mama”, intending a meaning of warmth and respect. The patient instantly became enraged at the use of such an offensive term toward her mother. Although being treated in Texas, the patient and her family had recently moved from a large city in New Jersey. The use of the term “mama” among working-class Italians in that area was looked upon with derision among people of Irish descent, the group to which the patient was ethnically connected. The patient had used the term “mother” to refer to her mother, a term the psychiatrist had heard with a degree of coolness attached. What she knew of her patient’s relationship with her mother did not fit in with a word like mother; hence, almost out of awareness, she switched terms, leading to a response of indignation and outrage from the patient.

Even more subtle regional variations may produce similar problems in listening and understanding.

Psychiatrists discern meaning in that which they hear through filters of their own – cultural backgrounds, life experiences, feelings, the day’s events, their own physical sense of themselves, nationality, sex roles, religious meaning systems, and intrapsychic conflicts. The filters can serve as blocks or as magnifiers if certain elements of what is being said resonate with something within the psychiatrist. When the filters block, we call it countertransference or insensitivity. When they magnify, we call it empathy or sensitivity. One may observe a theme for a long time repeated with a different tone, embellishment, inflection, or context before the idea of what is meant comes to mind. The “little fella” example in Clinical Vignette 3 illustrates a message that had been communicated in many ways and times in exactly the same language before the psychiatrist “got it”. On discovering a significant meaning that had been signaled previously in many ways, the psychiatrist often has the experience: “How could I have been so stupid? It’s been staring me in the face for months!”

Managed care and the manner in which national health systems are administered can alter our attitudes toward the patient and our abilities to be transforming listeners. The requirement for authorization for minimal visits, time on the phone with utilization review nurses attempting to justify continuing therapy, and forms tediously filled out can be blocks to listening to the patient. Limitations on the kinds and length of treatment can lull the psychiatrist into not listening in the same way or as intently. With these time limits and other “third-party payer” considerations (i.e., need for a billable diagnostic code), the psychiatrist, as careful listener, must heed the external pressures influencing the approach to the patient. Many health benefit packages will provide coverage in any therapeutic setting only for relief of symptoms, restoration of minimal function, acute problem solving, and shoring up of defenses. In various countries, health-care systems have come up with a variety of constraints in their efforts to deal with the costs of care. Unless these pressures are attended to, listening will be accomplished with a different purpose in mind, more closely approximating the crisis intervention model of the emergency room or the medical model for either inpatient or outpatient care. In these settings, the thoughtful ­psychiatrist will arm himself or herself with checklists, inventories, and scales for objectifying the severity of illness and response to treatment: the ear is tuned only to measurable and observable signs of responses to therapy and biologic intervention (Clinical Vignette 9).

   Clinical Vignette 9

An army private was brought to the emergency room in Germany by his friends, having threatened to commit suicide while holding a gun to his head. He was desperate, disorganized, impulsive, enraged, pacing, and talking almost incoherently. Gradually, primarily through his friends, the story emerged that his first sergeant had recently made a decision for the entire unit that had a particularly adverse effect on the patient. He was a fairly primitive character who relied on his wife for a sense of stability and coherence in his life. The sergeant’s decision was to send the entire unit into the field for over a month just at the time the patient’s wife was about to arrive, after a long delay, from the USA. After piecing together this story, the psychiatrist said to the patient, “It’s not yourself you want to kill, it’s your first sergeant!” The patient at first giggled a little, then gradually broke out into a belly laugh that echoed throughout the emergency room. It was clear that, having recognized the true object of his anger, a coherence was restored that enabled him to feel his rage without the impulse to act on it. The psychiatrist then enlisted the friends in a plan to support the patient through the month and to arrange regular phone contact with the wife as she set up their new home in Germany. No medication was necessary. Hospitalization was averted, and a request for humanitarian dispensation, which would have compromised the patient in the eyes of both his peers and superiors, was avoided as well. And, with luck, the young man had an opportunity to grow emotionally as well.

With emphasis on learning here and now symptoms that can bombard the dyad with foreground static and noise, will the patient be lost in the encounter? The same approach to listening occurs in the setting of the emergency department for crisis intervention. Emphasis is on symptom relief, assurance of capacities to keep oneself safe, restoration of minimal function, acute problem solving, and shoring up of defenses. Special attention is paid to identifying particular stressors. What can be done quickly to change stressors that throw the patient’s world into a state of disequilibrium? The difference in the emergency room is that the careful listener may have 3–6 hours, as opposed to three to six sessions for the patient with a health maintenance organization or preferred provider contract, or other limitations on benefits. If one is fortunate and good at being an active listener–bargainer, the seeds of change can be planted in the hope of allowing them time to grow between visits to the emergency department. If one could hope for another change, it would be for a decrease in the chaos in the patient’s inner world and outer world.

Crucial Attitudes That Enable Effective Listening

The first step in developing good listening skills involves coming to grips with the importance of inner experience in psychiatric treatment and diagnosis. The advent of modern diagnostic classifications has been responsible for enormous advances in reliability and accuracy of diagnosis, but their emphasis on seemingly observable ­phenomena has allowed the willing user to forget the importance of inner experience even in such basic diagnoses as major depressive disorder. Consider the symptom “depressed mood most of the day” or “markedly diminished interest or pleasure” or even “decrease or increase in appetite”. These are entirely subjective symptoms. Simply reporting depression is usually not sufficient to convince a psychiatrist that a diagnosis of depression is warranted. In fact, the vast majority of psychiatric patients are so demoralized by their illnesses that they often announce depression as their first complaint. Further, there are a significant number of patients who do not acknowledge depression yet are so diagnosed. The clinician might well comment: “Sitting with him makes me feel very sad”.

The psychiatrist must listen to much more than the patient’s overt behavior. There are qualities in the communication, including the inner experiences induced in the listener, that should be attended to. The experienced clinician listens to the words, watches the behavior, engages in and notices the ongoing interaction, allows himself or herself to experience his or her own inner reactions to the process, and never forgets that depression and almost all other psychiatric symptoms are exclusively private experiences. The behavior and interactions are useful insofar as they assist the psychiatrist in inferring the patient’s inner experience.

Therefore, to convince a clinician that a patient is depressed, not only must the patient say she or he is depressed, but the observable behavior must convey it (sad-looking face, ­sighing, unexpressive intonations, etc.); the interaction with the interviewer must convey depressive qualities (sense of neediness, sadness induced in the interviewer, beseeching qualities expressed, etc.). In the absence of both of these, other diagnoses should be considered, but in the presence of such qualities, depression needs to remain in the differential diagnosis.

Even when we make statements about brain function with regard to a particular patient, we use this kind of listening, generally, by making at least two inferences. We first listen to and observe the patient and then infer some aspect of the patient’s private experience. Then, if we possess sufficient scientific knowledge, we make a second ­inference to a disturbance in neurochemistry, neurophysiology, or neuroanatomy. When ­psychiatrists prescribe antidepressant medication, they have inferred from words, moved into inner experiences, and come to a conclusion that there is likely a dysregulation of serotonin or norepinephrine in the patient’s brain.

As one moves toward treatment from diagnosis, the content of inner experience inferred may change to more varied states of feelings, needs, and conflicts, but the fundamental process of listening remains the same. The psychiatrist listens for the meaning of all behavior, to the ongoing interpersonal relationship the patient attempts to establish, and to inner experiences as well.

Despite all of the technological advances in medicine in general and their growing presence in psychiatry, securing or eliciting a history remains the first and central skill for all physicians. Even in the most basic of medical situations, the patient is trying to communicate a set of private experiences (how does one describe the qualities of pain or discomfort?) that the physician may infer and sort into possible syndromes and diagnoses. In psychiatry, this process is multiplied, as indicated in Figure 1.1.

It was widely assumed that development, and problems related to development, effect the inner experiences of various affects. Does, for example, a person with borderline personality disorder experience “anxiety” in the same qualitative and quantitative manner in which a neurotic person does? What is the relationship between sadness and guilt and the empty experiences of depression? This perspective underlies the principle articulated in text after text on interviewing that emphasizes the importance of establishing rapport in the process of history taking. It is incredibly easy for the psychiatrist to attribute to the patient what she or he would have meant and what most people might have meant in using a particular word or phrase. The sense in the narrator that the listener is truly present, connected, and with the patient enormously enhances the accuracy of the story reported.

Figure 1.1Finding the patient (Kay and Tasman, 2006).

Words that have been used to describe this process of constant attention to and inference of inner experience by the listener include interest, empathy, attentiveness, and ­noncontingent positive regard. However, these are words that may say less than they seem to. It is the constant curious awareness on the listener’s part, that she or he is trying to grasp the private inner experience of the patient, and the storyteller’s sense of this stance by the psychiatrist that impel the ever more revealing process of history taking. This quality of listening produces what we call rapport, without which psychiatric histories become spotty, superficial, and even suspect. There are no bad historians, only patients who have not yet found the right listener.

It is well established that two powerful predictors of outcome in any form of ­psychotherapy are empathy and the therapeutic alliance. This has been shown again and again in study after study for dynamic therapy, cognitive therapy, behavior therapy, and even medication management. The truth of this can be seen in the remarkable therapeutic success of the “clinical management” cell of the National Institutes of Mental Health Collaborative Study on the Treatment of Major Depression. Although the Clinical Management Cell was not as effective as the cells that included specific drugs or specific psychotherapeutic ­interventions, 35% of patients with moderate to severe major depressive disorder improved significantly with carefully structured supportive clinical management alone (Elkin et al., 1989).

Table 1.3Attitudes Important to Listening

The centrality of

inner experience

There are no bad historiansThe answer is always inside the patientControl and power are shared in the interviewIt is OK to feel confused and uncertainObjective truth is never as simple as it seemsListen to yourself, tooEverything you hear is modified by the patient’s filtersEverything you hear is modified by your own filtersThere will always be another opportunity to hear more clearly

Helpful psychiatric listening requires a complicated attitude toward control and power in the interview (see Table 1.3). The psychiatrist invites the patient/storyteller to collaborate as an active informer. He or she is invited, too, to question and observe himself or herself. This method of history taking remains the principal tool of general clinical medicine. However, as Freud pointed out, these methods of active uncovering are more complex in the psychic realm. The use of the patient as a voluntary reporter requires that the investigator keep in mind the unconscious and its power over the patient and listener. Can the patient be a reliable objective witness of himself or herself or his or her symptoms? Can the listener hold in mind his or her own set of filters, meanings, and distortions as he or she hears? The listener translates for himself or herself and his or her patient the patient’s articulation of his or her experience of himself or herself and his or her inner world into our definition of symptoms, syndromes, and differential diagnoses, which make up the concept of the medical model.

Objective–descriptive examiners are like detectives closing in on disease. The psychiatric detective enters the inquiry with an attitude of unknowing and suspends prior opinion. The techniques of listening invoke a wondering and a wandering with the patient. Periods of head scratching and exclamations of “I’m confused”, or “I don’t understand”, or “That’s awful!”, or “Tell me more”, allow the listener to follow or to point the way for the dyad. Finally, clear and precise descriptions are held up for scrutiny, with the hope that a diagnostic label or new information about the patient’s suffering and emotional pain be revealed.

It is embarking on the history taking journey together – free of judgments, opinions, criticism, or preconceived notions – that underpins rapport. Good listening requires a complex understanding of what objective truth is and how it may be found. The effective psychiatrist must eschew the traditional medical role in interviewing and tolerate a collaborative, at times meandering, direction in which control is at best shared and sometimes wholly with the patient. The psychiatrist constantly asks: What is being said? Why is it being said at this moment? What is the meaning of what is being said? In what context is all this emerging? What does that tell me about the meaning of and what does it reflect about the doctor–patient relationship?

Theoretical Perspectives on Listening

Listening is the effort or work of placing the therapist where the patient is (“lives”). The ear of the empathic listener is the organ of receptivity – gratifying and, at times, indulging the patient. Every human being has a preferred interpersonal stance, a set of relationships and transactions with which she or he is most comfortable and feels most gratified. The problem is that for most psychiatric patients, they do not work well, but the psychiatrist, through listening and observing, must understand the patient. Beyond attitudes that enable or prevent listening, there is a role for specific knowledge. It is important to achieve the cognitive structure or theoretical framework and use it with rigor and discipline in the service of patients so that psychiatrists can employ more than global “feelings” or “hunches”. In striving to grasp the inner experience of any other human being, one must know what it is to be human; one must have an idea of what is inside any person. This provides a framework for understanding what the patient – who would not be a patient if he fully understood what was inside of him – is struggling to communicate. Personality theory is absolutely crucial to this process.