Brief Psychiatric Interviewing: Interview Tips

Text adapted from "The art of the brief psychiatric interview in primary care" in Psychiatry in primary care, by Jon Davine,  (CAMH, 2019).

Help patients understand the mind–body connection

If a patient comes to you with somatic complaints that do not feel organic in origin but rather seem to be stress-based, you can help the patient understand the mind–body link. In your first interview, assure the patient that the complaints are “real” and “not all in your head.” Indicate that you will do the necessary physical work-up to look at possible physical origins of these complaints, but also explain 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 due to emotional rather than organic underpinnings. This approach helps to build a collaborative relationship with the patient while shifting into a mind–body paradigm.

It is not recommended to do a full organic work-up first, and then weeks or months later bring up possible psychosocial issues if the organic work-up  is negative. Doing so may set up a paradigm that solidifies organic causes as primary, and psychological causes as secondary. Open up both pathways together as being equally valid.

Facilitate disclosure of painful events

Ask about your patient’s sexual life and past history of sexual abuse or sexual assault. The number of people who have been abused is distressingly high. Opening the door here is very important because patients may not offer the information themselves. Once you have opened that discussion, patients may often disclose abuse they have experienced. By asking these kinds of questions, you are giving the patient a “meta-message” about a few things: you are saying that you are aware of these issues, that you are fine with opening up discussion about them, and that you are comfortable dealing with issues that may arise out of this discussion. This meta-message will help people open up to you.

Follow the patient’s lead

Primary care practitioners may avoid bringing up certain topics, even though the topics are touched on by the patient, because they fear opening up a “Pandora’s box” of issues. However, it is always useful to capitalize on openings that patients naturally provide when they mention important subjects themselves. It does not matter when in the interview this happens—when the patient arrives, or when the patient is leaving, with a hand on the door. If something comes up near the end of the interview, you can always underline its importance for the patient and schedule another interview soon to continue the discussion. This “shelving” manoeuvre can be a good way to use patient initiative to obtain psychiatric data. Obviously, if the issue is urgent, for example, suicidal ideation, this discussion cannot be put off and you will have to extend the interview.

Practice active listening

Active listening includes being aware of the patient’s body language and speech and labeling things directly with the patient. For example, you might say, “I noticed that you have been talking more quietly as you tell me about your marriage.” This observation may prompt the patient to disclose more important information about the marriage. Summarize things back to the patient—this shows that you have been listening and gives the patient a chance to correct any wrong assumptions. Sometimes, simply repeating the last word a patient says may encourage the patient to say more. For example:

Patient: “I have been having trouble recently with my mother-in-law.”
You: “Your mother-in-law?”
Patient: “Yes, she has been so upset with me lately.”

No matter how busy you feel, it is essential to allow the patient time to speak. One study of internists showed that in 69 per cent of interviews, physicians interrupted their patients, on average, within the first 18 seconds of the encounter. These interruptions can get in the way of understanding the patient’s problems and obtaining complete information. Silence is golden, and allowing the patient to speak for a minute or two will help useful information emerge.

Prioritize and shelve issues

When patients speak freely, a lot of issues may be presented at the beginning of the interview. Although this information can be useful, it can be somewhat daunting. A helpful strategy for dealing with multiple problems is called “prioritizing and shelving.” You and the patient prioritize the top one, two or three complaints to be dealt with that day, and “shelve” the less urgent complaints to be dealt with on another day. Your patient of course has a say in what issues are prioritized, but if you think that other problems are more urgent, those need to be considered as well. This “meshing of agendas” helps patients feel that they are being listened to and their complaints validated.

Allocate time for addressing mental health concerns

If possible, having a flexible schedule that accommodates certain patients can be useful. For example, if you know that a certain patient is coming  in to discuss mental health problems, you can schedule a slightly longer appointment to give you more latitude with that patient.

Take a careful personal history

Taking a personal history can help you know your patients in a longitudinal way, which in turn helps patients better understand the themes permeating their lives. Although there is not time to take a personal history with every patient, doing so is extremely useful for patients who are being actively treated for current mental health problems. Table 1 presents questions you can ask to gather the essential information. These questions elicit information that captures the enduring emotional patterns of a patient’s life. They also give clues to where these patterns may have originated.

Table 1 Key questions to ask in a personal history

In The Art of the Brief Psychiatric Interview in Primary Care

• Screening 
• Interview Tips
• Conclusion & References