Contemporary Clinical Interviewing: Integration of the Dsm-Iv, Managed Care Concerns, Mental Status, and Research
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CHAPTER 1 3 CONTEMPORARY CLINICAL INTERVIEWING: INTEGRATION OF THE DSM-IV, MANAGED CARE CONCERNS, MENTAL STATUS, AND RESEARCH Shawn Christopher Shea INTRODUCTION DSM-IV, to more classic psychodynamic approaches and engagement skills. This clinical Interviewing is the backbone of all mental health challenge has been made even more difficult by yet professions. It is a dynamic and creative process, another new influence, the powerful presence of which represents a somewhat elusive set of skills. managed care and the constant ticking of "the The importance of this set of skills has been high- clock" concerning the number of sessions avail- lighted by Langsley and Hollender (1982). Their able to the client. In the past a skilled clinican survey of 482 psychiatric teachers and practitio- could perform a sound diagnostic assessment ners revealed that 99.4 percent ranked conducting within an hour, although many chose to take a comprehensive interview as an important longer. The difference is that today the clinician requirement for a psychiatrist. This represented the does not have a choice; managed-care principles highest ranking of 32 skills listed in the survey. dictate that he or she must complete the assessment Seven of the top 10 skills were directly related to within an hour and subsequently rapidly write up interviewing technique, including skills such as the the document as well. assessment of suicide and homicide potential, the Such a daunting integrative task, performed ability to make accurate diagnoses, and the ability under tight time constraints, can represent a major to recognize countertransference problems and hurdle for the developing clinician. This educa- other personal idiosyncrasies as they influence tional expectation was somewhat wryly stated by interactions with patients. These results were repli- Sullivan (1970) decades ago when he wrote: "The cated in a follow-up survey (Langsley & Yager, psychiatric expert is presumed, from the cultural 1988). definition of an expert, and from the general It can be seen from this list that the contempo- rumors and beliefs about psychiatry, to be quite rary clinician is being asked to combine an impres- able to handle a psychiatric interview." But the sive list of complex skills, ranging from structuring ability to handle the initial assessment interview techniques and diagnostic explorations using the has become a considerably more complicated task 339 340 HANDBOOK OF PSYCHOLOGICAL ASSESSMENT since the time of Sullivan's quote, for there has By utilizing these two concepts, several inter- been an evolution in psychiatry and mental-health view types can be defined. In the free-format inter- care of immense proportions in the past 40 years. view, the interviewer has little standardization of This chapter is about this ongoing evolution and database and is highly interested in the spontane- its impact on assessment interviewing. Perhaps the ous content produced by the patient. Such free-for- single most striking legacy of the evolution is the mat interviews place little emphasis on scheduling disappearance of the psychiatric interview. Instead and tend to follow the natural wanderings of the of a single style of interviewing, the contemporary patient. These interviews are valuable for uncover- clinician must learn to perform an impressive array ing patient psychodynamics and revealing patient of interviews suited to the specific clinical task at feelings, opinions, and defenses. hand, including assessments as diverse as those At the opposite end of the spectrum is the fully required in an emergency room; an inpatient unit; a structured interview that is highly standardized and psychotherapy practice, consultation and liaison strictly scheduled. In fully structured interviews setting; and a managed-care clinic. the required informational areas are specified in This chapter is designed for both academicians detail and the ways of exploring them are also pre- interested in the theoretical and research underpin- scribed. An example of this type of interview is the nings of the interview process and clinical students Diagnostic Interview Schedule (Robins, Helzer, concerned with practical interviewing techniques. Croughan, & Ratcliff, 1981), developed for com- It makes no attempt to be an exhaustive overview; munity surveys by lay interviewers. instead, the reader is provided with a conceptual Semistructured interviews represent procedures guide that provides a wealth of references for more in which the informational areas to be explored are in-depth study. specified, but the sequence and wording to be used The following areas are discussed: (a) an histor- in data gathering are only moderately predeter- ical overview and description of the influences that mined. In these interviews, general guidelines have shaped the evolution of clinical interviewing about the interview sequence, such as beginning mentioned earlier; (b) a practical introduction to with the chief complaint and following with epi- two of the major clinical cornerstones of current sodes of the present illness, may be provided, but assessment interviewing: the mental status exami- the clinician is given some latitude to move within nation and the DSM-IV; and (c) a review of some this framework. Semistructured interviews are of of the major research efforts with regard to inter- value in both research and clinical settings. They viewing, including clinician phrasing of responses, frequently can provide standardized databases as nonverbal concerns, alliance issues and empathy, pioneered by Mezzich in the Initial Evaluation structured interviews, and educational research. Form (Mezzich, Dow, Rich, Costello, & Himmel- Before proceeding it will be of use to define a hoch, 1981; Mezzich, Dow, Ganguli, Munetz, & few terms that clarify many of the complicated Zettler-Segal, 1986). issues regarding interviewing style. The style of The last major type of interview is the flexibly any specific clinical or research interview is structured interview. The flexibly structured inter- greatly determined by the following structural fac- view represents the most popular clinical inter- tors: (a) specific content areas required to make a view, and when performed by an experienced clinical decision or to satisfy a research data base, clinician, holds promise as a research tool. With (b) quantity of data required, (c) importance placed the flexibly structured interview, the clinician has a on acquiring valid historical and symptomatic data standardized database (pre-determined by the clin- as opposed to patient opinion and psychodynamic ical or research task at hand) but is given total free- understanding, and (d) time constraints placed dom in scheduling. The interview begins with a upon the interviewer. free-format style in which the clinician moves with With regard to these structural concerns of the whatever topics appear to be most pressing for the interview, two concepts outlined by Richardson, patient. Once the engagement is secured the clini- Dohrenwend, and Klein (1965) are useful: stan- cian begins to structure the interview sensitively. dardization and scheduling. Standardization refers With flexibly structured interviews the actual to the extent to which informational areas or items scheduling will be relatively unique to each clini- to be explored are specified in the interview proce- cian-patient dyad, for the interviewer fluidly alters dure. Scheduling refers to the prespecification of the style of scheduling to gather the standardized the wording and sequence of the interview process. database most effectively while working with the CONTEMPORARY CLINICAL INTERVIEWING 341 specific needs and defenses of the patient. These his interests would move forward both the flee-for- interviews require a high degree of sophistication mat style and a more semistructured approach. from the clinician and allow him or her to insert Meyer professed a psychobiological approach to areas of free format and dynamic questioning the patient, in which it was deemed important to whenever expedient. Most experienced clinicians, determine a "biography" of the patient that whether consciously or by habit, utilize a flexibly included biological, historical, psychological, and structured format. The complexities and nuances social influences on the patient's current behavior of the flexibly structured clinical interview have (Kaplan, Freedman, & Sadock, 1980). His interest been most recently explored in detail by Shea in psychological and social influences further (1998) and Othmer and Othmer (1994). A compre- advanced a style of interviewing in which there hensive annotated bibliography on the literature was an appreciation for the value of the flee-format concerning clinical interviewing and training style (Siassi, 1984). appears in Core Readings of Psychiatry (Shea, On the other hand, Meyer' s interest in determin- 1995). ing a sharp conceptualization of biological influ- Historically, clinical interview styles have var- ences as well as a clear presentation of the patient' s ied in popularity; they have ranged from semis- immediate symptomatology moved him toward an tructured interviews that were partially based on appreciation of semistructured or flexibly struc- the medical model to more free-form analytic tured formats. For instance, Meyer believed that interviews and flexibly structured styles. It is to the clinician should begin the interview with a this evolution that attention is now turned. careful exploration of the patient' s chief