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GENERAL PRINCIPLES OF
THE INTERVIEW
help to put the patient at ease. The interviewer could comment on the
family resemblances or what feelings are apparent in the picture, indi-
cating that he takes the patient's offering sincerely. He could also ask the
patient to name the persons in the picture.
rosis is a constant and pervasive theme of the patient's life. His fantasies
and dreams center on the clinician.
Realistic factors concerning the clinician can be starting points for
the initial transference. Age, sex, personal manner, and social and ethnic
background all influence the rapidity and direction of the patient's re-
sponses. The female clinician is likely to elicit competitive reactions
from female patients and erotic responses from male patients. If the cli-
nician's youth and appearance indicate that she is a trainee or a student,
these factors also influence the initial transference. With male clinicians
the reverse holds true. Transference is not simply positive or negative
but rather a re-creation of the various stages of the patient's emotional
development or a reflection of his complex attitudes toward key figures
of importance in his life. In terms of clinical phenomenology, some com-
mon patterns of transference can be recognized.
Desire for affection, respect, and the gratification of dependent needs
is the most widespread form of transference. The patient seeks evidence
that the interviewer can, does, or will love him. Requesting special time
or financial considerations, borrowing a magazine from the waiting
room, and asking for a glass of water can be common examples of the
symbolic expressions of transference wishes. The inexperienced inter-
viewer tries to differentiate "legitimate," realistic requests from "irratio-
nal" transference demands and then to respond to the former while frus-
trating and interpreting the latter. As a result, many errors are made in
the management of such episodes. The problem could be simplified if it
is assumed that all requests include unconscious transference meaning.
The question then becomes the appropriate mixture of gratification and
interpretation. The decision depends on the timing of the request, its
content, the type of patient, the nature of the treatment, and the reality
of the situation. One is wise not to make most transference interpreta-
tions until a therapeutic alliance has been firmly established.
For example, at their first meeting a new patient might greet the
interviewer saying, "Do you have a tissue?" This patient begins his re-
lationship by making a request. The clinician should simply respond to
this request, since refusals or interpretations would be premature and
quickly alienate the patient. However, once an initial relationship has
been established, the patient might ask for a tissue and add parentheti-
cally, "I think I have one somewhere, but I'd have to look for it." If the
interviewer chose to explore this behavior, he could simply raise his
eyebrows and wait. Usually the patient will search for his own while
commenting, "You probably attribute some significance to this!" "Such
as?" the interviewer might reply. This provides an opportunity for fur-
ther inquiry into the patient's motives.
General Principles of the Interview • 13
contact that he craves. Here the interviewer can explore the subject of the
patient's friendships and inquire whether he has attempted to discuss
his problems with friends and whether they were helpful. If this had
helped sufficiently, the patient would not be in the clinician's office.
Later in the process, the therapist often becomes an ego-ideal for the
patient. This type of positive transference is often not interpreted. The
patient may imitate the mannerisms, speech, or dress of the therapist,
usually without conscious awareness. Some patients openly admire the
clinician's clothing, furniture, or pictures. Questions such as "Where
did you buy that chair?" can be answered with "What leads to your
question?" The patient usually replies that he admires the item and
wants to obtain one for himself. If the therapist wishes to foster this
transference, he may provide the information; if he wants to interpret it,
he will explore the patient's desire to emulate him. With increasing
experience the interviewer is more comfortable occasionally answering
such questions, first because he grows more at ease in his therapist role
and second because he is more likely to find an opportunity to refer to
the episode in an interpretation later in the session or in a subsequent
session after he has accumulated additional similar material.
Competitive feelings stemming from earlier relations with parents
or siblings can be expressed in the transference. An illustration occurred
with a young man who regularly arrived for morning appointments
earlier than the therapist. One day he uncharacteristically arrived a few
minutes late and remarked, "Well, you beat me today." He experienced
everything as a competitive struggle. The therapist replied, "I didn't
realize that we were having a race," thereby calling attention to the
patient's construction of the event and connecting it with a theme that
had been discussed in the past.
Other common manifestations of competitive transferences include
disparaging remarks about the therapist's office, manners, and dress;
dogmatic, challenging pronouncements; or attempts to assess the cli-
nician's memory, his vocabulary, or his fund of knowledge. Belittling
attitudes may also appear in other forms, such as referring to a clinician
as "Doc" or constantly interrupting him. Other examples include using
the therapist's first name without invitation or talking down to the
interviewer. The clinician can directly approach the underlying feeling
by asking, "Do you feel there is something demeaning about talking to
me?" In general, competitive behavior is usually best ignored in the ini-
tial interview because the patient is vulnerable to what will be experi-
enced as a criticism.
Male patients show interest in the male clinician's power, status, or
economic success; with a female clinician they are more concerned with
General Principles of the Interview • 15
her motherliness, her seduceability, and how she is able to have a career
and a family. Female patients are concerned about a male therapist's
attitude concerning the role of women, whether he can be seduced,
what sort of father he is, and what his wife is like. The female patient is
interested in a female therapist's career and in her adequacy as a
woman and mother. She may ask, "How do you manage it all?" or
"How do you make the difficult choices?"
Competitive themes may reflect sibling rivalry as well as oedipal
conflicts. The patient's competitive feelings may become manifest when
he responds to the therapist's other patients as though they were sib-
lings. Spontaneous disparaging remarks such as "How could you treat
someone like that?" or "I hate the smell of cheap perfume" are common
examples. In initial interviews no response is preferable.
Older patients may treat a young interviewer as a child. Maternal
female patients may bring a therapist food or caution him about his
health, working too hard, and so on. Paternal male patients may offer
fatherly advice about investments, insurance, automobiles, and so on.
Early attention to either the ingratiating or the patronizing dimensions
of these comments would be disruptive to the developing relationship.
These transference attitudes can also occur with younger patients. Such
advice is well intentioned at the conscious level and is indicative of pos-
itive conscious feelings. It is therefore often not interpreted, particularly
in the first few interviews. Older interviewers with younger patients
often elicit parental transferences. If the patient has a positive relation-
ship with his parents, he may develop an early positive transference,
deferring to the interviewer's wisdom and experience or seeking advice
in a specific situation. Older patients usually prefer older clinicians, and
high-status patients generally seek high-status professionals. Older
men of importance are particularly prone to address the male inter-
viewer early on by his first name, sometimes asking or stating, "I hope
that you don't mind that I call you John!" This situation can be handled
with a reply such as "Whatever you prefer." This is unlikely to happen
with a female patient unless it is with a female interviewer.
Some therapists use first names with their patients. This is neither
inherently good nor inherently bad, but it always means something,
and that meaning should be understood. Symbols used in the relation-
ship should reflect mutual respect and comfortable social forms. Gener-
ally, therapists call children or adolescents by first name, as do other
adults. Patients who would expect to be on a first-name basis with the
therapist outside the therapeutic situation may prefer to use first names
in the professional setting, and there is no reason not to do so. However,
this should always be symmetrical. The patient who wants to be called
16 • THE PSYCHIATRIC INTERVIEW IN CLINICAL PRACTICE
by his or her first name but calls the therapist "Dr. — -" is expressing a
desire for an asymmetric relationship that has important transference
meaning that should be explored but not enacted by the therapist. It
usually suggests the patient's offer to submit to the therapist, with the
submission entailing authority or social, racial, generational, sexual, or
other power. The therapist who accepts such an invitation not only
abuses the patient but also misses an important therapeutic opportu-
nity. Conversely, the therapist who, uninvited, has the impulse to call an
adult patient by his or her first name should explore that impulse for
countertransference significance. This occurs most commonly with pa-
tients of perceived lower status—socially, economically, or because of
pathology or great age. Understanding the temptation can help the
patient; acting on it is destructive.
In general, transference is not discussed early in treatment except in
the context of resistance. This does not mean that only negative trans-
ference is discussed; positive transference can also become a powerful
resistance. For example, if the patient discusses only affection for the
clinician, the interviewer can remark, "You spend much more time dis-
cussing your feelings about me than talking about yourself or your
problems." Other patients avoid mentioning anything that is related to
the interviewer. In this case, one waits until the patient seems to sup-
press or avoid a conscious thought and then inquires, "You seemed to
hesitate for a moment. Did you avoid some thought?" When a patient
who has spoken freely suddenly becomes silent, it is usually because of
thoughts or feelings about the clinician. The patient may remark, "I
have run out of things to talk about." If the silence persists, the inter-
viewer could comment, "Perhaps there is something you are uncom-
fortable talking about?"
tition with the therapist instead of working together with him. These
processes may assume subtle forms—for example, the patient may
present material that is of particular interest to the clinician simply to
please him. Just as transference can be used as a resistance, so can it
serve as a motivating factor for the patient to work together with the
clinician.
For example, a resident came to one of us for analysis. Soon the patient
was informing the therapist (who held an important administrative
position in the program) of the misbehavior of other residents. Attempts
to explore the meaning of the tattling were useful, but the behavior con-
tinued. Finally, the therapist suggested that the patient omit the names
of the other residents. This was after exploring the obvious fantasy that
the analyst received gratification from this private source of informa-
tion. The patient replied angrily, "Aren't I supposed to say whatever
comes to mind?" The therapist replied, "You can continue to discuss the
incidents and their meanings to you, but I don't need to have the
names." At that point the patient stopped tattling on colleagues.
Candor Rado was decades ahead of his time with his belief in a neurobiologi-
cal basis for resistance to change and that the patient had to actively change his
behavior before he could develop new responses to old situations.
18 • THE PSYCHIATRIC I N T E R V I E W IN CLINICAL PRACTICE
the patient finds it helpful, go with the flow. If it largely has a transfer-
ential message, let it emerge.
Generalization is a resistance in which the patient describes his life
and reactions in general terms but avoids the specific details of each
situation. When this occurs, the interviewer can ask the patient to give
additional details or to be more specific. Occasionally, it may be neces-
sary to pin the patient down to a "yes" or "no" answer to a particular
question. If the patient continues to generalize despite repeated re-
quests to be specific, the therapist interprets the resistant aspect of the
patient's behavior. That does not mean telling the patient, "This is a re-
sistance" or "You are being resistant." Such comments are experienced
only as criticisms and will not be helpful. Instead, the clinician could
say, "You speak in generalities when discussing your husband. Perhaps
there are details concerning the relationship that you have trouble tell-
ing me." Such a comment, because it is specific, illustrates one of the
most important principles in coping with generalization. The inter-
viewer who makes vague interpretations such as "Perhaps you gener-
alize in order to avoid upsetting details" will encourage the very resis-
tance he seeks to remove.
The patient's preoccupation with one aspect of his life, such as
symptoms, current events, or past history, is a common resistance. Fo-
cusing on symptoms is particularly common with psychosomatic and
panic attack patients. The clinician can interpret, "You seem to find it
difficult to discuss matters other than your symptoms" or "It is easier
for you to talk about your symptoms than about other aspects of your
life." The interviewer must find ways to demonstrate to the patient that
constant reiteration of symptoms is not helpful and will not lead to the
relief he seeks. The same principle applies to other preoccupations.
Concentrating on trivial details while avoiding the important topics
is a frequent resistance with obsessive patients. If the interviewer com-
ments on this behavior, the patient insists that the material is pertinent
and that he must include such information for "background." One pa-
tient, for instance, reported, "I had a dream last night, but first I must
tell you some background." Left to his own devices, the patient spoke
most of the session before telling his dream. The interviewer can make
the patient more aware of this resistance if he replies, "Tell me the
dream first." In psychoanalysis, the patient might be permitted to dis-
cover for himself that he never allowed enough time to explore his
dreams.
Affective display may serve as a resistance to meaningful communi-
cation. Hyperemotionality is common in histrionic patients; affects such
as boredom are more likely in obsessive-compulsive patients. The his-
22 • THE PSYCHIATRIC INTERVIEW IN CLINICAL PRACTICE
trionic patient uses one emotion to ward off deeper painful affects; for
example, constant anger may be used to defend against injured pride.
Frequent "happy sessions" indicate resistance in that the patient ob-
tains sufficient emotional gratification during the session to ward off
depression or anxiety. This can be dealt with by exploring the process
with the patient and by no longer providing such gratification.
In addition to resistances that involve patterns of communication,
there is a second major group of resistances called acting out. These
involve behavior that has meaning in relationship to the therapist and
the treatment process. It does not necessarily occur during the session,
but the clinician is directly involved in the phenomenon, although he
may be unaware of its significance. An enactment is a little drama in
which the patient's transference fantasy is played out rather than ver-
balized or even consciously recognized by the patient. Examples would
be the patient who answers his cell phone during the session to drama-
tize his own importance compared with that of the therapist or the
woman who has her secretary call to check the time of the next appoint-
ment, which she was too preoccupied to write in her book.
Acting out is a form of resistance in which feelings or drives pertain-
ing to treatment or to the clinician are unconsciously displaced to a per-
son or situation outside the therapy. The patient's behavior is usually
ego-syntonic, and it involves the acting out of emotions instead of expe-
riencing them as part of the therapeutic process. Genetically, these feel-
ings involve the reenactment of childhood experiences that are now re-
created in the transference relationship and then displaced into the out-
side world. Two common examples involve patients who discuss their
problems with persons other than the therapist and patients who dis-
place negative transference feeling to other figures of authority and
become angry with them rather than with the therapist. This resistance
usually is not apparent during the first few hours of treatment, but
when the opportunity presents itself, the interviewer may explore the
patient's motives for the behavior. In most cases the patient will change,
but at times the clinician may have to point out the patient's inability to
give up the behavior despite his recognition that it is irrational.
Requests to change the time of the appointment may be a resistance.
The patient may communicate his unconscious priorities by saying,
"Can we change Thursday's appointment? My wife can't pick up the
kids at school that day." To interpret this simply as resistance can miss
an opportunity to help the patient recognize that he is saying that he is
more afraid of his wife than of his therapist. One patient may look for
an excuse to miss the appointment altogether, whereas another may
become involved in a competitive power struggle with the clinician,
General Principles of the Interview • 23
saying, in effect, "We will meet when it is convenient for me." A third
patient may view the clinician's willingness to change the time as proof
that he really wants to see the patient and therefore will be a loving,
indulgent parent. Before interpreting such requests, the clinician needs
to understand the deeper motivation. The clinician may indicate that he
is unwilling to grant such a request. The claim that he is unable to grant
them often reveals a fear of displeasing the patient. Special problems ex-
ist for the patient whose job demands change abruptly so that absence
on short notice occurs. Keeping one's job is more important than pleas-
ing the therapist. The clinician's best response is empathy for the situa-
tion.
The use of minor physical symptoms as an excuse in missing ses-
sions is a common resistance in narcissistic, phobic, histrionic, and so-
matization disorder patients. Frequently, the patient telephones the
clinician prior to the interview to report a minor illness and to ask if he
should come. This behavior is discussed in Chapter 14, "The Psychoso-
matic Patient." When the patient returns, the clinician explores how the
patient felt about missing the meeting before he interprets the resis-
tance.
Arriving late and forgetting appointments altogether are obvious
manifestations of resistance. Early attempts at interpretation will be met
with statements such as "I'm sorry I missed the appointment, but it had
nothing to do with you"; "I'm late for everything; it has no bearing on
how I feel about treatment"; "I've always been absentminded about ap-
pointments"; or "How can you expect me to be on time? Punctuality is
one of my problems." If the interviewer does not extend the length of
the appointment, the lateness will become a real problem that the pa-
tient must face. It will often become clear that the patient who arrives
late expects to see the clinician the moment he arrives. It is not appro-
priate for the interviewer to retaliate, but it is not expected that he sit
idly, waiting for the patient's arrival. If the clinician has engaged in
some activity and the patient has to wait for a few minutes when arriv-
ing late, additional information concerning the meaning of the lateness
will emerge. In general, the motive for lateness involves either fear or
anger.
Failing or forgetting to pay the clinician's bill is another reflection
of both resistance and transference. This topic is considered in greater
detail later in this chapter (see "Fees").
Second-guessing or getting "one up" on the clinician is a manifesta-
tion of a competitive transference and resistance. The patient trium-
phantly announces, "I bet I know what you are going to say next" or
"You said the same thing last week." The interviewer can simply re-
24 • THE PSYCHIATRIC INTERVIEW IN CLINICAL PRACTICE
main silent, or he can ask, "What will I say?" If the patient has already
verbalized his theory, the clinician might comment, "Why should I
think that?" It is generally not a good idea to tell the patient if he was
correct in second-guessing the interviewer, but as with every rule, there
are exceptions.
Seductive behavior is designed either to please and gratify the inter-
viewer, thereby winning his love and magical protection, or to disarm
him and obtain power over him. Further illustrations are such ques-
tions as "Would you like to hear a dream?" or "Are you interested in a
problem I have with sex?" The interviewer might reply, "I am interested
in anything that is on your mind." If these questions occur repeatedly,
he could add, "You seem concerned with what I want to hear." Various
"bribes" offered to the interviewer, such as gifts or advice, are common
examples of seductive resistance.
Beginning interviewers are often made anxious by overt or covert
sexual propositions. Most frequently these propositions involve a male
therapist and a female patient. The clinician knows that accepting such
an invitation is a boundary violation, and he recognizes it as transfer-
ence resistances. Nevertheless, discomfort is frequent. Most often, it
stems from guilt that he is pleased by the invitation, and he fears that
his feelings may interfere with proper management of the patient. Fre-
quently, this is revealed by statements such as "That would not be
appropriate in a doctor-patient relationship" or by a comment to the
supervisor that "I don't want to hurt the patient's feelings by rejecting
her." The clinician must explore in his own mind whether he subtly
invited such behavior from the patient, as is often the case. If he did not
elicit the invitation, he can ask the patient, "How would that help you?"
If the patient indicates that she needs love and reassurance, the clinician
can reply, "But we both know that accepting your invitation would
mean the opposite. My job is to help you work out your problem, but
your plan would make that impossible." When a therapist has an ade-
quate amount of professional self-confidence, he or she will no longer
respond to overt seduction by feeling flattered and anxious, provided
he or she also has adequate self-confidence as a man or woman.
Asking the clinician for favors, such as borrowing small sums of
money or requesting the name of his lawyer, dentist, accountant, or
insurance broker, is a form of resistance. It attempts to shift the therapy
from helping the patient to cope more effectively to becoming depen-
dent on the therapist's coping skills. It often involves the erroneous
assumption, on the part of both, that the therapist knows more than the
patient about how to get along in the outside world. One makes excep-
tions, at times, in the treatment of patients who may have deficiencies
General Principles of the Interview • 25
past. The more intense the interviewer's neurotic patterns, and the
more the patient actually resembles such figures, the greater the likeli-
hood of such countertransference responses. In other words, the inter-
viewer who had an intensely competitive relationship with her sister is
more likely than other therapists to have irrational responses to female
patients of her own age. If she reacts in this way to all patients, regard-
less of their age, sex, or personality type, the problem is more serious.
Countertransference responses can also be a valuable vehicle for an un-
derstanding of the patient's unconscious (see Chapter 10, "The Border-
line Patient"). These countertransference responses are less related to
the interviewer's psychology and more a manifestation of the patient's
psychodynamics.
Countertransference responses could be classified into the same cat-
egories as are used in the discussion of transference. The clinician may
become dependent on his patient's affection and praise as sources of his
own self-esteem or, conversely, may feel frustrated and angry when the
patient is hostile or critical. Any therapist may use the patient in this
way occasionally. The clinician may unconsciously seek the patient's
affection and only come to recognize that he is doing so when the pa-
tient responds. Beginning male clinicians may find female patients
writing love notes or poems or proposing marriage. One trainee com-
mented that his prior model for male-female relationships was that of
dating. There are more subtle manifestations of this problem, such as of-
fering excessive reassurance, helping the patient obtain housing or a
job, and so forth, when such assistance is not really necessary and
serves as a bribe to earn the patient's love rather than an appropriate
therapeutic intervention. Going out of one's way to rearrange time or
fees, providing extra time, and being overly kind may all be ways of
courting the patient's favor. Not allowing the patient to get angry is the
other side of the same coin. On the other hand, clinicians are people,
and some are warmer or friendlier or more helpful than others. There is
nothing wrong with being nice.
The clinician can utilize exhibitionism as a way of soliciting affection
or admiration from patients. Displaying one's knowledge or social or
professional status to an inappropriate degree is an example, and it usu-
ally stems from the therapist's wish to be omniscient to compensate for
some deep feeling of inadequacy.
Experienced therapists have commented that it is difficult to have
only one case in long-term therapy, because that patient becomes too
important to them. Other factors can cause a clinician to experience a
particular patient as having special importance. The "VIP" creates so
much difficulty for the clinician that a later subsection (see "The special
30 • THE PSYCHIATRIC INTERVIEW IN CLINICAL PRACTICE
encouraging exploration of it. Both the clinician and the patient will
understand the patient's feelings better if the interviewer asks, "How
am I a son-of-a-bitch?" or "What is it that you love about me?" Such an
approach takes the patient's feeling seriously. When the patient elabo-
rates his feeling, he will usually discover the transference aspect of his
response by himself. As he fully delineates the details of his reaction, he
often volunteers, "You don't react the way my father did when I felt like
this" or "This makes me think of something that happened years ago
with my sister." Then the interviewer can demonstrate the transference
component of the patient's feeling.
In the pursuit of the details of the patient's emotional reactions, dis-
torted perceptions of the therapist frequently emerge. For instance,
when describing why she felt that she loved her therapist, a patient
said, "For some strange reason I pictured you with a mustache." Explo-
ration of such clues identified the original object of the transference feel-
ing from the patient's past.
Discussions of countertransference typically leave the beginner feel-
ing that this reaction is bad and must be eliminated. It would be more
accurate to say that the therapist tries to minimize the extent to which
his neurotic responses interfere with the treatment. The clinician who is
aware of his countertransference can use it as another source of infor-
mation about the patient. In interviews with borderline patients, the
mutual recognition of the clinician's countertransference can be partic-
ularly useful in the process of therapy (see Chapter 10, "The Borderline
Patient").
The role of the interviewer. The most important function of the in-
terviewer is to listen and to understand the patient so that he may help.
An occasional nod or "Uh-huh" is sufficient to let the patient know that
the interviewer is paying attention. Furthermore, a sympathetic com-
ment, when appropriate, aids in the establishment of rapport. The clini-
cian can use remarks such as "Of course," "I see," or "Naturally" to sup-
port attitudes that have been communicated by the patient. When the
patient's feeling is quite clear, the clinician can indicate his understand-
ing with statements such as "You must have felt terribly alone" or "That
must have been very upsetting." In general, the interviewer is nonjudg-
mental, interested, concerned, and kind.
The interviewer frequently asks questions. These may serve to
obtain information or to clarify his own or the patient's understanding.
Questions can be a subtle form of suggestion, or by the tone of voice in
which they are asked, they may give the patient permission to do some-
thing. For example, the interviewer might ask, "Did you ever tell your
boss that you felt you deserved a raise?" Regardless of the answer, the
interviewer has indicated that such an act would be conceivable, per-
missible, and perhaps even expected.
The interviewer frequently makes suggestions to the patient either
implicitly or explicitly. The recommendation of a specific form of treat-
ment carries the clinician's implied suggestion that he expects it to be
helpful. The questions that the clinician asks often give the patient the
feeling that he is expected to discuss certain topics, such as dreams or
sex. In psychotherapy, the clinician suggests that the patient discuss any
major decisions before acting on them, and he may suggest that the pa-
tient should or should not discuss certain feelings with important per-
sons in his life.
Clinicians may help patients with practical matters. For instance, a
young married couple requested psychological counseling because of
difficulty getting along with each other. At the end of the consultation,
they asked whether it would be helpful if they tried to have a baby. A
well-intentioned clergyman had suggested that a child might bring the
couple closer together. The clinician advised that a baby could be a
source of additional stress to have at that time and recommended that
they wait until their relationship had improved.
The clinician provides the patient with certain gratifications and
frustrations in the process of treatment. He helps the patient with his
interest, understanding, encouragement, and support. He is the pa-
tient's ally and in that sense offers him opportunities to experience
closeness. When the patient becomes unsure of himself, he may provide
reassurance with a comment such as "Go ahead, you're doing fine."
36 • THE PSYCHIATRIC INTERVIEW IN CLINICAL PRACTICE
A male patient reported having a rageful fit when his wife threw out a
pair of his old shoes without his permission. He revealed that he did not
completely understand his reaction because the shoes no longer fit, and
he had planned to throw them out himself. Relevant family history in-
cluded his description of his anger with his mother for her repeated vio-
lations of his space, privacy, and possessions. The interviewer, who al-
ready had elicited that information, said to the patient, "So your worst
General Principles of the Interview • 37
nightmare came true; your wife turned into your mother." "That's it,"
replied the patient, "she made me feel I was still a little boy. I may have
had something to do with that," the patient added. "I may have set her
up by dressing in a manner that is inappropriate to a man of my age in
Manhattan." The patient fell silent, reflecting on his comment. The ther-
apist remarked, "So you are devoting your life to changing your mother
into the mother you wish you had." The patient was visibly moved and
remarked, "I have to get over this or I'll ruin my marriage."
The outline for organizing the data of the interview is referred to as the
psychiatric examination. It is emphasized in a number of psychiatric text-
books and is therefore discussed here in terms of its influences on the
interview. It is usually divided into the history (or anamnesis) and the
mental status. Although this organization is modeled after the medical
history and physical examination, it is actually much more arbitrary.
2This section ("The Psychiatric Examination") is closely adapted from the fol-
lowing: MacKinnon RA, Yudofsky SC: Principles of the Psychiatric Evaluation.
Baltimore, MD, Lippincott Williams & Wilkins, 1986, pp. 40-57. Copyright
1986, Lippincott Williams & Wilkins. Used with permission.
40 • THE PSYCHIATRIC INTERVIEW IN CLINICAL PRACTICE
are required before the novice can respond quickly and directly to the
initial cues provided by the patient that tell the senior clinician how and
where to proceed with the history.
Techniques
tunity to explore feelings that are elicited while answering the ques-
tions. Questionnaires may also inject an artificial quality to the inter-
view. When the patient finally meets the clinician, he may experience
him as yet another bureaucratic functionary, more interested in pieces
of paper than in his patient. A good clinician can overcome this unde-
sirable mental set, but it is an undesirable bit of pseudo-efficiency to cre-
ate it in the first place.
Psychiatric histories are vital in delineating and diagnosing major
neurotic or psychotic illnesses. Nevertheless, in the realm of personality
diagnosis many psychiatric histories are of minimal value. This is par-
ticularly true when they are limited to superficial reports such as histor-
ical questionnaires filled out by the patient.
Another frequent deficiency in the psychiatric history is when it is
presented as a collection of facts and events that are organized accord-
ing to date, with relatively little attention to the impact of those experi-
ences on the patient or the role that the patient may have played in
bringing them about. The history often reveals that the patient went to
a certain school, held a certain number of jobs, married at a certain age,
and had a certain number of children. Often, none of that material pro-
vides distinctive characteristics about the person that would help to dis-
tinguish him from another human being with similar vital statistics.
In most training programs, there is relatively little formal psychiat-
ric training in the techniques involved in eliciting historical data. The
novice clinician is given an outline and is expected somehow to learn to
acquire the information requested. It is unusual for each of his written
records to be corrected by his teachers and still more unusual for him to
be required to rewrite the report and to incorporate any suggested cor-
rections. In his supervised psychotherapy training, the trainee usually
begins with a presentation of the history as it has been organized for the
written record rather than as it flowed from the patient. The supervisor
is often unaware of the trainee's skill in the process of eliciting historical
information. Supervisors are usually more interested in the manifesta-
tions of early transference and resistance than in teaching the technique
of eliciting a smooth, flowing history. As a result, this deficit in the su-
pervisor's own training is unintentionally passed on to another gener-
ation of young clinicians.
The Psychotic Patient
Mr. A is a 5-foot, 5-inch tall, powerfully built, heavyset man with coarse
features and a swarthy complexion who appears quite unfriendly. His
short, curly, dark brown hair is parted on the side, and one is immedi-
44 • THE PSYCHIATRIC INTERVIEW IN CLINICAL PRACTICE
ately aware that his gaze follows the interviewer's every move. He cre-
ates an intimidating image as he nervously paces the floor and
repeatedly looks at his watch. He spontaneously says, "I gotta get outta
here, Doc. They're comin' to get me, Doc!" His perspiration-drenched
T-shirt is dirty and is tucked into his paint-stained, faded jeans. He ap-
pears younger than his stated age of 30, and he obviously has not
shaved for several days.
Chief Complaint
The chief complaint is the presenting problem for which the patient
seeks professional help (or has been referred for it). The chief complaint
should be stated in the patient's own words if possible. Certain patients,
particularly those with psychoses or certain character disorders, have
difficulty in formulating a chief complaint. In such situations the inter-
viewer can work with the patient to help him uncover or formulate his
reason for seeking treatment as well as understand the separate issue,
"Why now?" If the chief complaint is not supplied by the patient, the
record should contain a description of the person who supplied it and
his relationship to the patient. At first glance, this part appears to be the
briefest and simplest of the various subdivisions of the psychiatric his-
tory; however, in actuality it is often one of the most complex.
In many cases the patient begins his story with a vague chief com-
plaint. One or more sessions may be required for the clinician to learn
what it is that the patient finds most disturbing or why he seeks treat-
ment at this particular time, hi other situations, the chief complaint is
provided by someone other than the patient. For example, an acutely
confused and disoriented patient may be brought in by someone who
provides the chief complaint concerning the patient's confusion. Occa-
sionally, a patient with multiple symptoms of long duration has great
difficulty explaining precisely why he seeks treatment at a particular
time. Ideally, the chief complaint should provide the explanation of
why the patient seeks help now. That concept must not be confused
with the precipitating stress (often unconscious in nature) that resulted
in the collapse of the patient's defenses at a particular time. The precip-
itating stress may be difficult to determine. Usually, the ease of deter-
mining the chief complaint correlates directly with the ease of deter-
mining the precipitating stress. At times the clinician uncovers the chief
complaint in the course of looking for a precipitating stress or in consid-
General Principles of the Interview • 45
Precipitating Factors
As the patient recounts the development of the symptoms and behav-
ioral changes that culminated in his seeking assistance, the interviewer
should attempt to learn the details of the patient's life circumstances at
the time these changes began. When asked to describe these relation-
ships directly, the patient is often unable to give correlations between
the beginning of his illness and the stresses that occurred in his life. A
technique referred to as the parallel history is particularly useful with the
patient who cannot accept the relationship between psychological de-
terminants and psycho-physiological symptoms. In eliciting a parallel
history, the interviewer returns to the same time period covered by the
present illness, but later in the interview. He specifically avoids making
his inquiry in phrases that suggest that he is searching for connections
between what was happening in the patient's life and the development
of the patient's symptoms. The clinician, without the patient's aware-
ness, makes connections (i.e., the parallel history) between stresses that
the patient experienced and the development of his disorder. The pa-
tient may notice some temporal connection between a particular stress
and the appearance of his symptoms that impresses him and arouses
his curiosity about the role of emotional factors in his illness. Neverthe-
less, premature psychological interpretations concerning the interrela-
tionship of the stress and the symptom may undermine that process
and intensify the patient's resistance. Unless the patient makes a spon-
taneous connection between his emotional reaction to a life event and
the appearance of his symptoms, the clinician should proceed slowly.
After the clinician has completed his initial study of the patient's
present illness, he can inquire about the patient's general medical health
and carefully review the functioning of the patient's organ systems.
Emotional disturbances are often accompanied by physical symptoms.
A systems review is a traditional medical step in which the interviewer
learns the medical problems that the patient has not volunteered or that
are not part of the chief complaint or present illness. The systems review
is the same as that performed by an internist, but through the particular
perspective of a psychiatrist. No psychiatric evaluation is complete
without statements concerning the patient's sleep patterns, weight reg-
ulation, appetite, bowel functioning, and sexual functioning. If the pa-
tient has experienced a sleep disturbance, it would be described here
unless it is part of the present illness. The clinician should inquire about
whether the insomnia is initial, middle, terminal, or a combination. In-
somnia can be an extremely disturbing problem, and the interviewer is
well advised to explore in detail the circumstances that aggravate it and
the various remedies the patient has attempted and their results. Other
organ systems commonly involved in psychiatric complaints are the
gastrointestinal, cardiovascular, respiratory, urogenital, musculoskele-
tal, and neurological systems.
It is logical to inquire about dreams while asking the patient about
sleep patterns. Freud stated that the dream is the royal road to the un-
48 • THE PSYCHIATRIC INTERVIEW IN CLINICAL PRACTICE
the areas that are pertinent to the patient's major complaints and to
defining the patient's underlying personality structure. Each interview
is modified according to the patient's underlying character type as well
as according to important situational factors relating to the setting and
circumstances of the interview. To modify the form of the interview, the
clinician must be familiar with the psychodynamic theory of psycho-
logical development and with the phases and conflicts that are most
important for each condition. In that way, he may concentrate the
questions in the areas that will be most significant in explaining the
patient's psychological development and the evolution of the patient's
problems.
A thorough psychodynamic explanation of the patient's illness and
personality structure requires an understanding of the ways in which
the patient reacts to the stresses of his environment along with the rec-
ognition that the patient has played a major role in selecting his current
situation and choice of environment. Through an understanding of the
interrelationship between external stress and the patient's tendency to
seek out situations that frustrate him, the clinician develops a concept
of the patient's core intrapsychic conflict.
The personal history is perhaps the most deficient section of the typ-
ical psychiatric record. A statement about whether the patient was
breast- or bottle-fed, followed by statements of questionable accuracy
concerning the patient's toilet training or early developmental land-
marks such as sitting, walking, and talking, is of limited value. That
entire area may be condensed in a statement such as "Developmental
landmarks were normal." The clinician might replace these routine and
often meaningless inquiries by an attempt to understand and utilize
new areas of knowledge germane to child development, as explained in
the next sections.
Prenatal History
In the prenatal history, the clinician considers the nature of the home sit-
uation into which the patient was born and whether the patient was
planned and wanted. Were there any problems with the mother's preg-
nancy and delivery? Was there any evidence of defect or injury at birth?
What were the parents' reactions to the gender of the patient? How was
the patient's name selected?
Early Childhood
The early childhood period considers the first 3 years of the patient's
life. The quality of the mother-child interaction during feeding is more
50 • THE PSYCHIATRIC INTERVIEW IN CLINICAL PRACTICE
important than whether the child was breast or bottle fed. Although an
accurate account of this experience is difficult to obtain, it is frequently
possible to learn whether, as an infant, the patient presented problems
in feeding, was colicky, or required special formulas. Early disturbances
in sleep patterns or signs of unmet needs, such as head banging or body
rocking, provide clues about possible maternal deprivation. In addi-
tion, it is important to obtain a history of caretakers during the first 3
years. Were there auxiliary maternal objects? The clinician should dis-
cover who was living in the patient's home during early childhood and
should try to determine the role that each person played in the patient's
upbringing. Did the patient exhibit problems with stranger anxiety or
separation anxiety?
It is helpful to know if the loving parent and the disciplining parent
were one and the same person. In one case, a child received most of her
love from a grandmother but was trained and disciplined by a maid. In
her adult life she rejected housework, which was associated with the
cold punitive authority of the maid, but pursued a career in music,
which had served in her childhood as a connection to her loving grand-
mother. The fact that her actual mother had not enjoyed childrearing
and had been emotionally distant caused further problems in maternal
identification. It was not surprising that the patient did not have a
cohesive sense of herself as a woman and had great difficulty integrat-
ing her career with being a wife and mother.
Toilet training is another traditional area that is of limited value in
the initial history. Although an age may be quoted, useful and accurate
information concerning the more important interaction between parent
and child usually is not remembered. Toilet training is one of the areas
in which the will of the parent and the will of the child are pitted against
each other. Whether the child experienced toilet training chiefly as a de-
feat in the power struggle or as enhancing his own mastery is of critical
importance for characterological development. However, this informa-
tion usually is not possible to obtain during the evaluation.
The patient's siblings and the details of his relationships with them
are other important areas that often are underemphasized in the psychi-
atric history. The same deficiency is often reflected in psychodynamic
formulations as well. Psychodynamics is too often conceptualized only
in terms of oedipal or preoedipal conflicts. Other psychological factors
such as sibling rivalries and positive sibling relationships may signifi-
cantly influence the patient's social adaptation. The death of a sibling
before the patient's birth or during his formative years has profound
impact on developmental experience. The parents, particularly the
mother, may have responded to the sibling's death with depression,
General Principles of the Interview • 51
first tolerated being separated from his mother. Data about the patient's
earliest friendships and peer relations are valuable. The interviewer can
ask about the number and the closeness of the patient's friends,
whether the patient took the role of leader or follower, his social popu-
larity, and his participation in group or gang activities. Early patterns of
assertion, impulsiveness, aggression, passivity, anxiety, or antisocial be-
havior often emerge in the context of school relationships. A history of
the patient's learning to read and the development of other intellectual
and motor skills is important. A history of hyperactivity or of learning
disabilities, their management, and their impact on the child is of par-
ticular significance. A history of nightmares, phobias, bed wetting, fire
setting, cruelty to animals, or compulsive masturbation is also impor-
tant in recognizing early signs of psychological disturbance.
Psychosexual History
The sexual history is a personal and embarrassing area for most pa-
tients. It will be easier for the patient to answer the physician's ques-
tions if they are asked in a matter-of-fact, professional manner. Such a
concentration of attention on the patient's sexual history provides a
therapeutic structure that is supportive of the patient and that makes
sure the therapist will not fail, as a result of countertransference, to
General Principles of the Interview • 53
gious practices to his present beliefs and activities. Even though the
patient may have been raised without formal religious affiliation, most
families have some sense of identification with a religious tradition.
Furthermore, each family has a sense of social and moral values. These
typically involve attitudes toward work, play, community, country, the
role of parents, children, friends, and cultural concerns or interests.
Adulthood
Occupational and Educational History
ate himself from potential friends? The major character disorders all
show some disturbance in this crucial area of functioning. For example,
the obsessive-compulsive personality typically is excessively control-
ling in his relationships with others, whereas the histrionic is seductive
and manipulative.
Adult Sexuality
Although the written record organizes adult sexuality and marriage in
separate categories, in the conduct of the clinical interview it is often
easier to elicit that material together. The premarital sexual history
should include sexual symptoms such as frigidity, vaginismus, impo-
tence, and premature or retarded ejaculation as well as preferred fanta-
sies and patterns of foreplay. Both premarital and marital sexual expe-
riences should be described. Responses to menopause are described
here when appropriate.
Marital History
In the marital history the clinician describes each marriage or other sus-
tained sexual relationship that the patient has had. The story of the mar-
riage should include a description of the courtship and the role played
by each partner. The evolution of the relationship, including areas of
agreement and disagreement, the management of money, the roles of
the in-laws, attitudes toward raising children, and a description of the
couple's sexual adjustment, should be described. The last description
should include who usually initiates sexual activity and in what man-
ner, the frequency of sexual relations, sexual preferences, variations,
techniques, and areas of satisfaction and dissatisfaction for each part-
ner. It usually is appropriate to inquire whether either party has en-
gaged in extramarital relationships and, if so, under what circum-
stances and whether the spouse learned of the affair. If the spouse did
learn of the affair, describe what happened. The reasons underlying an
extramarital affair are as important as its subsequent effect on the mar-
riage. Of course, these questions should be applied to the spouse's be-
havior as well as the patient's. In the written record care should be taken
not to include material that could be harmful to the patient if it were re-
vealed to an insurance company or a court.
In the event that a marriage has terminated in divorce, it is indicated
to inquire about the problems that led to this. Has there been a continu-
ing relationship with the former spouse, and what are the details? Have
similar problems arisen with subsequent relationships? Has the patient
been monogamous in his or her relationships? Does he maintain trian-
56 • THE PSYCHIATRIC INTERVIEW IN CLINICAL PRACTICE
The clinician should inquire about where the patient lives and include
details about the neighborhood and the patient's particular residence.
Include the number and types of rooms, the other persons living in the
home, the sleeping arrangements, and how issues of privacy are han-
dled. Particular emphasis should be placed on nudity of family mem-
bers and bathroom arrangements. Ask about family income, its sources,
and any financial hardships. If there has been outside support, inquire
about its source and the patient's feelings about it. If the patient is hos-
pitalized, have provisions been made so that he will not lose his job or
home? Will financial problems emerge because of the illness and asso-
ciated medical bills? The interviewer should inquire about who is car-
ing for the home, children, pets, and even plants as well as who visits
the patient in the hospital and how frequently visits occur.
Military History
For those patients who have been in the military, it has usually been a
significant experience. The interviewer should inquire about the pa-
tient's general adjustment to the military, his rank, and whether he saw
combat or sustained an injury. Was he ever referred for psychiatric con-
sultation, did he suffer any disciplinary action during his period of ser-
vice, and what was the nature of his discharge?
Family History
Summary
In summary, we want to emphasize the following points: 1) There is no
single method to obtain a history that is appropriate for all patients or
all clinical situations. 2) It is necessary to establish rapport and to obtain
the patient's trust and confidence before the patient will cooperate with
a treatment plan. 3) The history is never complete or fully accurate. 4)
The description of the patient, the psychopathology, and the develop-
mental history should all fit together, creating a cohesive picture. 5) The
clinician should link the patient's mental life with his symptoms and
behaviors. 6) Psychodynamics and developmental psychology help us
to understand the important connections between past and present.
Without this as a foundation, dynamic psychotherapy is based only on
concepts about communication and the therapeutic relationship. There-
fore the clinician is unable to exploit the potential of reconstructive or
psychogenetic approaches. 7) This discussion is far more comprehen-
sive than any real clinical history. No clinician can respond to every
issue raised in this chapter for any patient he interviews.
Therapeutic Formulation
Although the techniques of case formulation exceed the scope of this
book, it has been demonstrated that those clinicians who have carefully
General Principles of the Interview • 59
Practical Issues
Time Factors
Duration of the session. Psychiatric interviews last for varying
lengths of time. The average therapeutic interview is about 45-50 min-
utes. Often, interviews with psychotic or medically ill patients are more
brief, whereas in the emergency department longer interviews may be
required. This is discussed in the appropriate chapters.
Frequently, new patients will ask about the length of the appoint-
ment. Such questions usually represent more than simple curiosity, and
the clinician might follow his answer with "What makes you ask?" For
example, the patient may be making a comparison between the inter-
viewer and previous clinicians or checking to see if his insurance will
cover the cost. Another common experience is for patients to wait until
near the end of an interview and then ask, "How much time is left?"
When the interviewer inquires, "What did you have in mind?' the pa-
tient usually explains that there is something he does not wish to talk
about if there are only a few minutes remaining. Delaying an important
subject until the last few minutes has significance—a resistance the in-
terviewer might want to discuss now or at some time in the future. He
might suggest that the patient bring the topic up at the beginning of the
next appointment or, if there is enough time, that he begin now and then
continue in the following interview.
The patient. The patient's management of time reveals an important
facet of his personality. Most patients arrive a few minutes early for
their appointments. Very anxious patients may arrive as much as half
an hour early. This behavior usually causes little problem for the inter-
viewer, and it is often not noted unless the patient mentions it. Like-
60 • THE PSYCHIATRIC INTERVIEW IN CLINICAL PRACTICE
wise, the patient who comes precisely on time or even a few minutes
late does not often provide an opportunity to explore the meaning of his
behavior in the early weeks of treatment.
A difficult problem is created by the patient who arrives very late.
The first time this occurs, the interviewer might listen to the patient's
explanation, if one is volunteered, but avoid making comments such as
"Oh, it's quite all right"; "That's OK"; or "No problem." Instead he may
call the patient's attention to the limitations this creates with a remark
such as "Well, we'll cover as much as we can in the time remaining." It
is important that this is said in a pleasant tone of voice! On occasion, the
patient's reason for being late is a blatant resistance. For instance, he
might explain, "I forgot all about the appointment until it was time to
leave." In this situation the interviewer can ask, "Did you feel some re-
luctance about coming?" If the answer is "Yes," the clinician might con-
tinue his exploration of the patient's feeling. If the answer is "No," he
should allow the matter to rest for the time being. It is important that
the interview be terminated promptly in order to avoid collaborating
with the patient in an attempt to avoid the limitations of reality.
An even more difficult situation exists when the patient arrives
quite late for several interviews, each time showing no awareness that
his actions might be caused by factors within himself. After the second
or third time, the clinician might remark, "Your explanations for being
late emphasize factors outside yourself. Do you think that the lateness
may have something to do with your feelings about coming here?" An-
other method is to explore the patient's reaction to the lateness. The cli-
nician could ask, "How did you feel when you realized you would be
late today?"; "Did it bother you that you were late?"; or "How did you
imagine I would react to your lateness?" Such questions may uncover
the meaning of the lateness. The main concern is that the clinician re-
spond with interest in the meaning of the behavior rather than with crit-
icism or even anger.
The clinician. The interviewer's handling of time is also an important
factor in the interview. Chronic carelessness regarding time indicates a
characterological or a countertransference problem, a specific one if it
involves only a particular patient or a general one if the interviewer is
regularly late for most patients. However, on occasion the interviewer
is detained. If it is the first interview, it is appropriate for the clinician to
express his regret that the patient was kept waiting. After the first few
interviews, other factors must be considered before the interviewer of-
fers an apology for lateness. For certain patients, any apologetic com-
ment from the clinician only creates more difficulty in expressing their
General Principles of the Interview • 61
annoyance. With such patients, the clinician could call attention to his
lateness by glancing at his watch and remarking on the number of min-
utes remaining. Unless the patient appears annoyed or has nothing to
say, the interviewer can allow the matter to drop. Depending on the
effectiveness of his repression and reaction formation, the patient may
either acknowledge some mild irritation or say that he did not mind
waiting. The interviewer can listen for indications that the patient had
some unconscious response that should be explored. When the clinician
is late, he should extend the length of the interview to make up the time.
He will show respect for the patient's other time commitments if he
inquires, "Will you be able to remain 10 minutes longer today?"
The transition between interviews. It is a good idea for the inter-
viewer to have a few minutes to himself between interviews. This pro-
vides an opportunity to "shift gears" and to be ready to start fresh with
the next interview rather than continue to think about the patient who
has just left. A telephone call or glancing at the mail or at a magazine
will facilitate this transition. One can also provide a brief extension of
the interview when that is clinically indicated. An example is the pa-
tient who is crying uncontrollably at the end of the session. Telling the
patient "We will have to stop shortly" allows the patient time to re-com-
pose himself.
Space Considerations
Privacy. Most patients will not speak freely if they feel that their con-
versation might be overheard. Quiet surroundings also offer fewer dis-
tractions that might interfere with the interview, and clinicians try to
avoid interruptions. Privacy and some degree of physical comfort are
minimal requirements.
Seating arrangements. Many clinicians prefer to conduct interviews
while seated at a desk, but even then it is preferable not to place the
chairs so that there is furniture between the interviewer and patient.
Both chairs should be of approximately equal height so that neither
party is looking down on the other. If the room contains several chairs,
the interviewer can indicate which chair is for himself and then allow
the patient to select the location in which he will feel most comfortable.
The main factors that influence the patient's choice involve the physical
distance and location in relation to the clinician's chair. Patients who
seek more intimacy, for example, prefer to sit as close to the interviewer
as possible. Oppositional or competitive patients will sit farther away
and often directly across from the clinician.
62 • THE PSYCHIATRIC INTERVIEW IN CLINICAL PRACTICE
Fees
Money is the common unit of value for goods and services in our culture,
and the fee that the patient pays symbolizes the value of treatment to
both patient and clinician. The fee signifies that the relationship is mutu-
ally advantageous, and the payment of a fee can reflect the patient's de-
sire to be helped, but it is not true that a patient must undergo some
financial hardship or sacrifice in order to benefit from psychotherapy.
The average clinician has little opportunity to determine and collect
fees before he has completed his training. For example, it is easy for a
trainee to remain aloof from the fee-setting arrangements of the clinic
registrar, with the unfortunate result that the entire subject is ignored in
the therapy.
Therapists ignore financial arrangements with patients who do not
pay them directly, something that would never be permitted with those
who do. The clinician may not care that the patient pays little or noth-
ing. A beginner may feel that because he is so inexperienced, his ser-
vices are not worth money; that he owes the patient something because
he is learning at the patient's expense; or even that he is underpaid by
the institution, in which case he retaliates by allowing the patient to
cheat the "establishment." In one case, a patient had concealed financial
assets from the registrar only to confess to the staff therapist, who then
passively became a collaborator in "stealing from the institution." It
was some months before he realized that, in the patient's unconscious,
he was the "institution." Supervisors also often pay insufficient atten-
tion to the handling of fees, thereby losing valuable opportunities to
explore transference and countertransference.
The fee has various meanings in the therapeutic relationship. The
patient may view the fee as a bribe, offering to pay a larger fee than the
clinician would customarily charge. In the era when psychiatric evalu-
ation was a prerequisite for an abortion, one woman stated, "I hope you
realize that I would be willing to pay you any fee you ask." The clinician
replied, "I will do whatever is appropriate to help you. I understand
that you feel desperate, but a bribe isn't necessary and won't have any
impact anyway." Another patient utilized the fee as a means of control.
He had already determined the clinician's fee per session; he multiplied
it by the number of visits and presented the doctor with a check before
receiving his bill. He was symbolically in control; the clinician was not
charging him; he was giving the clinician money.
Masochism or submissiveness may be expressed by payment of
inordinately high fees without protest. The patient may express anger
or defiance to the therapist by not paying or by paying late. He may test
General Principles of the Interview • 63
can suggest that they wait to discuss that until they have more time or
are in more private surroundings. When the therapist meets the patient
outside the office and the patient becomes intrusive, the clinician can
use small talk to control the situation and keep the conversation on neu-
tral ground. Occasionally the therapist's admission of his own uneasi-
ness after meeting a patient outside the office can be useful for the
therapy.
Our perspectives on this subject reflect life in the big city, where an-
onymity is the rule rather than the exception. Nevertheless, mental
health professionals live and work in a variety of settings, including
large or small cities or small towns where they may regularly encounter
their patients in local stores, restaurants, sporting events, or back to
school nights. In these settings both the patient and the interviewer
have a natural inclination to protect the privacy of the treatment and
comfortably establish the appropriate social boundaries. If the patient
becomes intrusive in a social setting, the clinician may suggest, "This is
a topic best left for our next session."
tifying data are the skeleton of the patient's life on which all the other
information is placed. When this material does not emerge spontane-
ously during the discussion of the present illness, it is often possible to
obtain much of it with one or two questions. The interviewer could in-
quire, "Tell me about your present life." The patient may then interpret
the question as he sees fit, or he may ask, "Do you mean, am I married
and what sort of work do I do, things like that?" The interviewer merely
has to nod and then see if the patient omits anything, at which time he
can point out that the patient has not mentioned thus and such. Most
patients will provide more useful information if they are given a topic
to discuss rather than a list of questions that can be answered briefly.
Specific exceptions are discussed in Chapter 13, "The Psychotic Pa-
tient," and Chapter 15, "The Cognitively Impaired Patient."
The number of possibilities in the middle portion of the interview
are infinite, and thus it is impossible to provide precise instructions
about which choices to make. For example, the patient might indicate
that she is married and has three children, that her father is dead, and
that her mother lives with her. Experience, skill, and personal style all
influence what the interviewer will do now. He could be quiet and per-
mit the patient to continue, or he could ask about the marriage, the chil-
dren, the mother, or the father's death or ask the patient, "Could you
elaborate?" without indicating a specific choice. The feeling tone of the
patient's description is another important aspect that could be focused
on. If she seems anxious and pressured, the interviewer might remark,
"It sounds as if you have your hands full." In such a case, some clini-
cians would argue in favor of one approach over the others. However,
we feel that there is no single right answer, and we would probably
make different choices with different patients and even with the same
patient on different occasions.
Most leads provided by the patient should be followed up at the
time of presentation. This gives smooth continuity to the interview even
though there may be numerous topical digressions. To continue with
the last vignette, let us suppose that the patient goes on to reveal that
her mother has only been living with her family for a year. It would be
logical to assume that the patient's father had died at that time, and
therefore the interviewer might ask, "Is that when your father died?" If
the patient replies, "Yes," the clinician might assume that the patient's
parents had lived together until that time, but rather than jump to false
conclusions, it is better to ask, "How did it happen that your mother
came to live with you after your father's death?" The patient might sur-
prise the interviewer by saying, "You see, Mother and Dad were di-
vorced 10 years ago, and she moved in with my brother's family, but
70 • THE PSYCHIATRIC I N T E R V I E W IN CLINICAL PRACTICE
now that Dad is gone, my brother moved to Chicago to take over his
business. Mother's friends are all in this area and she didn't want to
move to Chicago, so she moved in with us." The interviewer might ask,
"What was the effect on your family?" or "How did your husband feel
about this arrangement?" At the same time, the interviewer notices that
the patient did not provide any information about the circumstances of
the father's death. When the patient "runs down" on the present topic,
the clinician could reopen that area.
Now that the interviewer has some ideas concerning the present ill-
ness and the patient's current life situation, he might turn his attention
to what sort of person the patient is. A question such as "What sort of
person are you?" will come as a surprise to most people, since they are
not accustomed to thinking of themselves in that fashion. Some patients
will respond easily, and others may become uncomfortable or offer con-
crete details that reiterate facts of their current life situation such as,
"Well, I'm an accountant" or "I'm just a housewife." Nevertheless, such
replies provide both phenomenological and dynamic information. The
first reply was made by an obsessive-compulsive man who was pre-
occupied with numbers and facts, not merely in his job but also in his
human relationships. What he was telling the interviewer was "I am
first and always an accountant, and in fact, I can never cease being an
accountant." The second reply was offered by a phobic woman who had
secret ambitions for a career. She was letting the clinician know that she
had a deprecatory view of women and, in particular, of women who are
housewives. Like the first patient, she was never able to forget herself.
Often the patient's self-perception will vary depending on the situ-
ation. Consider the businessman who is a forceful leader in his job but
is timid and passive at home or the laboratory scientist who is active
and creative in his work but feels shy and reserved in social situations.
Then there is the man who is a sexual athlete with numerous affairs
who perceives himself as inadequate and ineffectual at work. The inter-
viewer does not elicit all of the material pertinent to the patient's self-
perception in one interview. However, a more complete picture gradu-
ally emerges. Another patient revealed in the third interview, "There is
something I haven't told you that really bothers me. I have a terrible
temper, often with a member of the family." The interviewer replied,
"Could you give me the details of some recent examples?"
Other questions that pertain to the patient's view of himself include
"Tell me the things you like about yourself"; "What would you consider
your greatest assets?"; or "What things bring you the most pleasure?"
The interviewer might ask the patient to describe himself as he appears
to others, and to himself, in the major areas of his life, including family,
General Principles of the Interview • 71
example, the clinician might say, "I wonder why your husband spends
more time at his office than is necessary?" Although the interviewer has
the right to be curious about this phenomenon, a direct question could
be construed by the patient as an accusation or innuendo.
developed panic attacks who asks for medication to control the attacks
and does not want exploratory psychotherapy.
This phase of the interview provides a useful opportunity for the cli-
nician to uncover resistances and to alter his treatment plan accord-
ingly. Although the clinician is the expert, his recommendations cannot
be handed down like royal decrees. Often the clinician must modify his
treatment plan as he learns more about the patient. By presenting a
treatment plan in a stepwise fashion, the interviewer can discover in
what areas the patient has questions, confusion, or disagreement. This
cannot happen if the clinician makes a speech.
If the consultation is limited to one interview, more of that interview
must be devoted to such matters than if a second or third meeting can
be arranged. The clinician often tries to avoid giving the patient a for-
mal diagnostic label. Such terms have little use for the patient and may
be quite harmful, because the interviewer may be unaware of the mean-
ing that the patient or his family attaches to them. The patient often pro-
vides clues to the proper terms to use in giving the formulation. One
patient acknowledges a "psychological problem"; another says, "I real-
ize it's something emotional" or "I know I haven't completely grown
up" or "I realize it isn't right for me to have these fears." Although the
patient's statement may have been made earlier in the session, the clini-
cian can utilize it as a springboard for his own formulation, provided
the patient truly believes what he is saying. This is not the case with the
psychosomatic patient who says, "I know it is all in my mind, doctor."
The clinician might begin, "As you have already said, you do have a
psychological problem." He might refer to what he considers the chief
symptoms and indicate that they are all related and part of the same con-
dition. He might separate acute problems from those that are chronic
and concentrate first on treatment for the acute ones. Because it is not a
good idea to overwhelm the patient with a comprehensive statement of
all his pathology, the formulation should be confined to the major distur-
bance. For example, in the case of a young man who has difficulty get-
ting along with authority figures, including his father, the interviewer
would state, "It appears that you do have a problem getting along with
your father, which has influenced your attitude toward all figures of
authority."
In the current era, the patient is often caught in a dilemma. He may
have insurance that will provide support for treatment, but in order to
receive such benefits he must provide consent for the clinician to com-
municate with the insurer. Current law requires the medical profession
to provide the patient with a written statement regarding his right to pri-
vacy. Any information the clinician provides to a third party, whether
74 • THE PSYCHIATRIC INTERVIEW IN CLINICAL PRACTICE
If the patient was upset during the interview, the closing phase also
serves as an opportunity for him to pull himself together again prior to
leaving the clinician's office and returning to the outside world.
Some patients ask about prognosis, either seriously or in a pseudo-
jest. Common examples are "Well, is there any hope?"; "Have you ever
treated anyone like me?"; or "Is there anything I can do to speed things
up?" The clinician is advised to be careful in dealing with these ques-
tions. The patient may not have revealed all of his problems. In cases in
which statements about prognosis are indicated, such as with the de-
pressed patient, the clinician's encouraging reassurance is of great im-
portance.
Before the interview is terminated, the interviewer can set the time
and date of the next appointment. The end of the session is indicated by
the clinician's saying, "Let's stop now"; "We can go on from here next
time"; or "Our time is up for now." It is common courtesy to arise and
escort the patient to the door.
Occasionally an interview must be terminated prematurely because
the clinician receives an emergency call. This is a more common experi-
ence for resident psychiatrists who are on call. The clinician can explain
the situation to the patient and arrange to make up the time on another
occasion. A related but more infrequent occurrence is that the patient
gets angry and leaves before the session is over. The clinician can
attempt to stop the patient verbally by saying firmly, "Just a minute!" If
the patient waits, he can continue, "If you are angry with me, it is better
that we discuss it now." The clinician neither rises from his chair nor
indicates that he condones the patient's action.
Later Interviews
Often the consultation is completed within two interviews, but it may
take longer. The second interview is best scheduled from 2 days to a week
later. A single meeting with the patient permits only a cross-sectional
study. If several days are allowed to intervene before the next session,
the clinician will be able to learn about the patient's reactions to the first
visit. In this way he can determine how the patient will handle treat-
ment. There is also an opportunity for the patient to correct any misin-
formation that he provided in the first meeting. One way to begin the
second interview is for the clinician to comment, "I suspect that you
have thought about some of the things we discussed last time" or
"What thoughts have you had about our meeting?" When the patient
answers "Yes" to the former, the clinician might say, "I would like to
hear about that" or "Let's start there today." If the patient says "No," the
76 • THE PSYCHIATRIC INTERVIEW IN CLINICAL PRACTICE
clinician might raise his eyebrows questioningly and wait for the pa-
tient to continue. There are several common patterns of response. The
patient might have pursued the self-inquiry that began in the previous
meeting, often providing additional pertinent history related to a pre-
viously raised point. He might have reflected further on a question or
on suggestions of the clinician and come to some greater understand-
ing. Such activity is subtly rewarded by interviewers who in one way or
another let the patient know that he is on the right track. This response
has more important prognostic significance for analytically oriented
psychotherapy than whether the patient felt better or worse after the
session.
Another group of responses have more negative implications. The
patient might have thought about what he reported the first time and
decided that it was wrong, that he did not understand why the inter-
viewer had asked about a certain topic, or that the clinician did not un-
derstand him. He might state that he had ruminated about something
the interviewer had said and felt depressed. Frequently these responses
occur when the patient feels guilty after talking "too freely" in the first
interview. He then either withdraws or becomes angry with the inter-
viewer. In this patient's mind, criticizing his loved ones or expressing
strong emotions in the clinician's presence is personally humiliating.
While on the topic of the patient's reactions to the first interview, the
clinician might inquire whether the patient discussed the session with
anyone else. If he did, the interviewer will be enlightened by learning
with whom the patient spoke and the content of the conversation. After
this topic has been explored, the clinician will continue the interview.
There are no set rules concerning the questions that are better put off
until the second meeting. Whatever inquiries the clinician senses to be
most embarrassing for this patient may be postponed unless the patient
has already approached this material himself or is consciously preoccu-
pied with it. If the interviewer asks about dreams in the first interview,
the patient will frequently report dreams in the second meeting. It is
useful to inquire directly about such dreams, because they reveal the
patient's unconscious reactions to the clinician as well as showing key
emotional problems and dominant transference attitudes.
CONCLUSION
This chapter considers the broader aspects and general techniques of
the psychiatric interview. Subsequent chapters discuss specific varia-
tions that are determined either by the type of patient or by the clinical
General Principles of the Interview • 77