I would like to emphasize some aspects:
- First of all, we recognize the screening questions that ask about characteristic symptoms.
- In the second place, the episode is clearly delineated in time so that the doctor and patient know what is being discussed.
- It then asks for a large number of accompanying and well-defined symptoms. The number of symptoms present determines which branch of the flowchart is followed.
In this way, the doctor continues the interview and comes to one or more diagnoses with a high degree of reliability.
The advantage of this method is the precision and clarity with which the entire problem area, in this case depression, is covered.
The disadvantage is that the method is not entirely consistent with the clinical problem-solving process of the physician, which is based more on pattern recognition than on a decision tree. In addition, this method sometimes does a great appeal on the patient’s memory and patience. Nevertheless, these and other methods will have to be further developed and researched in order to arrive at a psychiatric study that links diagnostics to a doctor- and patient-friendly use.
3. Socio-emotional exploration
During the socio-emotional exploration, problems in a number of life areas are discussed. The reason for discussion can be a suggestion in the patient’s story that there is, for example, a connection between (the origin of) the complaints and certain living conditions. The purpose of the discussion is to learn as concretely as possible what is going on and what the consequences have been for the patient. Furthermore, in this phase of the conversation, areas of psychological dysfunction can be discussed that do not reach the threshold value of ‘psychological problem’. Regier (1982) developed a classification system for social or psychological problems that includes the most common problems. You will find this system in a slightly modified form in MAAS-Mental Health – Socio-emotional Exploration.
So much for the discussion of history-taking.
Presenting Solutions
The presenting of solutions takes place during the third phase. The presenting of solutions is a complex process consisting of information exchange followed by a negotiation process. The ‘Presenting Solutions’ that I present here relies heavily on the negotiated consensus model of Eisenthal and Lazare that I mentioned earlier.
Information provision The information provided by the physician relates to four well-defined subjects, also referred to as key information by Tuckett (1985):
- First of all, it is about the diagnostic significance of the problem, i.e. what caused it, is it life-threatening, what is the prognosis;
- Second, an explanation is given about the most suitable treatment intervention;
- The third aspect of information provision concerns the preventive measures to prevent a new disease episode: what measures can be taken, what is the purpose of this, how are they related to the original cause;
- Finally, information can be given about the social and emotional consequences of the problem or of the treatment.
Negotiation Information is provided within a negotiation process about problem definition and treatment plan. Katon (1980) worked out the negotiation process most concretely. It includes the following steps:
- Clarification of the patient’s lay explanations, as happens during clarification of request for help, but also during the presentation of solutions;
- Explanation of a medical explanatory model and treatment options in terms understandable to the patient;
- Clarification and recognition of discrepancies between doctor and patient about the treatment, whereby the patient is given space to speak and the doctor does not impose his opinion;
- Deciding on an acceptable compromise when the discrepancies cannot be resolved;
- After all, the compromise must be constantly monitored.
Some of you wonder whether this extensive information transfer and negotiation are necessary. Eisenthal and Lazare examined their model in practice and came to the conclusion that explaining the problems is one of the three most frequently mentioned questions for help in psychiatry. Patient satisfaction is strongly related to the ‘why’ of the treatment. Patients also find it important that the doctor tries to reach an agreement in mutual consultation. Patients who do not receive the treatment they have asked for, but have been negotiated with their physician, are ultimately satisfied and will follow the treatment faithfully.
We can therefore conclude that the entire process of information provision and negotiation contributes to a more effective treatment in which the patient is satisfied, has more insight and better follow-up of the treatment.
I now move on to a discussion of the different process skills. As we go through the extensive literature on process skills, we are overcome by a sense of despair: each author uses his own theoretical framework, if any, and his own definition of skills. We have therefore decided to include an arbitrary selection of skills in our model. The system is based on the extensive taxonomy of Ivey (1983) and the important distinction between interpersonal and communication skills.
We divided the process skills into the categories structuring, interpersonal and communicative interview behavior.
A. Structuring
First of all, the structuring interview behavior. Interviews can be structured on three levels, namely by setting an agenda, by sticking to the 3 phases, and by announcing and completing the phases. When the patient’s question has been clarified, the doctor can draw up an agenda in which he indicates how he wants to approach the problem or complaint. The most important item on the agenda for the doctor is going through the three phases. Although no clear preference is expressed in the literature about the order in which this occurs, from an educational standpoint we find that the clarification of the request precedes the history-taking, and the presenting solutions is discussed afterwards (Levenstein, 1986). By introducing and concluding the phases, the doctor makes the topic of conversation explicit. This not only prevents straying as much as possible, but also focuses the attention of both doctor and patient on the topic of conversation.
Although various authors recommend structuring procedures, no research has yet been conducted into the positive effect of this on communication (van Dorp, 1977; Ivey, 1983; Holten-Vriesema, 1978). In the last part of this presentation I will come back to this and show that structuring has a positive influence on both the transfer of information and the conversation climate.
B. Interpersonal Skills
Interpersonal skills refer to interview behaviors that promote rapport with the patient, and induce trust and acceptance. In our model we have emphasized facilitating skills and emotional reflections. According to the literature, the following interview behaviors have this positive influence on the conversation climate:
- Facilitating skills enable and stimulate the patient to tell his story in his own words and to show feelings;
- Feeling reflections clarify and make explicit feelings that are more or less covered up in the words and behavior of the patient;
- Non-verbal interview skills have always been highly valued. Yet meaningful behavioral descriptions appear to be rare;
- Empathy is the ability to understand the patient’s experiences as if they were their own feelings;
- Reassurance consists of a generally optimistic and hopeful attitude expressed in specific remarks that aim to reduce strong or unfounded fears;
- Finally, in self-disclosure, the physician provides the patient with personal information to help the patiënt understand the normality of his behavior and to achieve a basis of equality between both partners.
C. Communication Skills
Finally, communication skills promote the quality of the information transfer between doctor and patient (Schouten 1982).
Obtaining information Four types of interview behavior are important for obtaining information: open questions, closed questions, directive questions and summary.
- Open questions do not show response bias and stimulate the patient to give the most appropriate answer;
- Closed questions direct the interview to obtain specific information;
- Directive questions, also called concretizing, occupy an intermediate position and lead to a more personal, concrete and specific discussion of important topics;
- Summaries, you know, are a test for the doctor whether he has listened carefully.
Providing information Providing information is more difficult, because we have to take into account cognitive aspects, such as memory and understanding, and emotional aspects, such as fear level and processing bad news.
Ley (1983) made the following recommendations:
- Simplify, i.e., use simple words, short sentences and no jargon;
- Repeat important information;
- Use explicit categories;
- Provide tailored advice instead of general comments.
Furthermore, psychological research showed that information that is provided first is also best remembered, while information that has clear meaning to the patient is more easily remembered.
The emotional aspect of giving information relates to the patient’s level of fear and the processing of bad news. Bad news can trigger defense mechanisms that allow the patient to adapt insufficiently to a new situation. Tuckett therefore recommended discussing the consequences for daily life of illness or problems that would promote acceptance. Furthermore, DiMatteo and DiNicola (1982) showed that patients who are anxious, do not understand information well. Patients learn the most from explanation when they experience only a moderate level of anxiety. There is therefore little point in educating patients without reducing their anxiety.
Anxious patients do not understand information well
So much for the discussion of content and process skills, but for the initial interview see: Mental Health.