Brief psychiatric interview: Interview tips
Make the mind–body link
If a patient presents with somatic complaints that do not feel organic in origin but rather seem to be stress-based, you can do some things to help make the mind–body connection:
- Assure the patient that his or her complaints are "real" and "not all in your head."
- Assure the patient that you will do the necessary physical work-up to look for possible physical origins of the complaints, but also mention that emotional factors may be a possible cause of the symptoms.
You can use the examples of tension headache or butterflies in the stomach as illustrations of a pain that is "real" but has emotional rather than organic underpinnings. This helps to build a collaborative relationship with the patient while shifting into a mind–body paradigm.
Ask about sexual abuse
Ask about your patient's sexual life and any history of sexual abuse or assault. The number of people who have been abused is distressingly high. Patients may not offer the information themselves, but if you open the door to this conversation, patients may often disclose abuse. By asking questions, you are giving the patient a "meta-message": you are saying that you are aware of these issues, that you are open to discussing these issues, and that you are comfortable dealing with issues that may arise out of the discussion.
Follow the patient's lead
Primary care providers may avoid certain topics, even though the patient hints at them, because they fear opening a "Pandora's box" of issues. However, it is useful to capitalize on openings patients provide when they bring up subjects themselves.
If something comes up near the end of an interview, you can underline its importance and schedule another interview. This "shelving" manoeuvre is a good way to use patient initiative to obtain psychiatric data. Obviously, if crucial information, such as suicidal ideation, comes out, you cannot put off the discussion and will have to extend the interview.
Practise active listening
"Active listening" is a good way to get information. Watch the patient's body language and speech and label things directly with the patient. For example, you may say, "I noticed you have been talking more quietly as you talk about your marriage." This may lead to important information about the marriage.
Summarizing things for the patient is another helpful strategy. This shows that you have been listening and gives the patient a chance to correct any wrong assumptions. Simply repeating the last word a patient says may encourage the person to say more.
Patient: "I have been having trouble recently with my mother-in-law."
Clinician: "Your mother-in-law?"
No matter how busy you feel, give the patient time to speak. One study found that physicians interrupted their patients in 69 per cent of interviews, on average within the first 18 seconds. Interruptions lead to inaccurate understanding of the patient's problems and incomplete data. Allowing the patient to speak for a minute or two will elicit useful information.
Prioritize and shelve topics
When patients speak freely at the beginning of an interview, they may raise a lot of issues, which can be daunting. A helpful strategy to deal with this is called "prioritizing and shelving." The clinician and patient prioritize the top one, two or three complaints to deal with that day. Other complaints can be "shelved" for another day.
The patient identifies priorities, but if the clinician feels another issue is urgent, it is considered as well. This "meshing of agendas" helps patients feel that they are being listened to and that their complaints are validated.
Having a flexible schedule that accommodates certain patients can be useful, as well. For example, if you know that particular patients are coming in to discuss emotional issues, you may schedule a slightly longer time with them.
Psychiatry in primary care toolkit
The Psychiatry in Primary Care App has been decommissioned.
The revised print version of Psychiatry in Primary Care is avaible through the CAMH store.