5.3The Psychiatric Interview

Crijnen, AAM, & Kraan, HF (1990). Towards a model of the initial psychiatric interview. In: Presentation at Department of Clinical Psychiatry, Amsterdam Medical Center / University of Amsterdam, the Netherlands (pp. 1–26).

The interview and minor psychiatric disorder

Residents and psychiatrists working at an outpatient clinic are confronted with a new patient about three times a week. The communication that takes place between the two of them is important:

• The patient is uncertain and tense, and it often took them a long time to dare to make an appointment;
• The patient wonders whether the doctor will understand them, tell them what is going on, and will provide some relief from the symptoms;
• The doctor is faced with the task of arranging the complaints and problems such that he can manage them, place them in a framework, and can draw up treatment plans for the short and somewhat longer term.

This chapter is about this type of psychiatric interview, an interview in which the patient presents a new complaint or a new mental health problem, and in which the complaints are usually mild in nature.

Functions of the medical interview

Schouten (1982) defined the medical interview from a functional perspective:

• He formulated the first function as collecting information for diagnostics and further patient management;
• The second function would be to provide the patient with information on diagnosis, etiology, prognosis and treatment;
• He defined the third function as establishing and maintaining the doctor-patient relationship, in such a way that a climate of trust and acceptance was created.

The purpose of communication is to create a working alliance of trust and acceptance

We find these functions in a number of textbooks on psychiatry. For example, Reiser (1986) wrote that the purpose of all communication is to facilitate diagnosis and therapy and to establish a working alliance to promote trust and acceptance. Ginsberg (1985) stated the goal of determining what the patient is suffering from, so that interventions could be considered. After the patient has been advised on this, mutual agreements can be made about further treatment. These functions are performed in practice through the concrete interview behavior of the physician.

In Primary Care 

Pendleton (1984) expanded the number of functions and created thus a model of the initial medical interview for primary care.

In Mental Health

Eisenthal and Lazare (1973) developed a model for the interview in primary mental health care, which they called the Customer’s approach to patienthood or the Negotiated consensus model. The model is very similar to the Pendleton model just mentioned and to the Dutch Methodical Working (Holten-Vriesema, 1976), but is more focused on psychiatric problems. 

Clarifying Request for Help

We give you here a brief description of the model by Eisenthal and Lazare. The model is based on the premise that, before visiting the psychiatrist, patients already know what goal they want to achieve and what need must be met. They know exactly how they want or wish the doctor to behave towards them. It is, according to Eisenthal and Lazare, the task of the doctor to get this request for help on the table as explicitly as possible. Discussing the request for help requires an optimal relationship between doctor and patient. Research conducted by Eisenthal and Lazare showed that the complaints were usually mentioned by the patient, but that the request for help was usually not mentioned.

Negotiation

After the doctor has made a diagnosis, the second step of this consultation model follows. The second step consists of a negotiation process. The patient has already formulated what he thinks he needs. At that moment, the doctor formulates what is medically appropriate or desirable. During the negotiation, the patient has the right to evaluate the wording and ultimately accept or reject a proposal for treatment. On the basis of the negotiation, the physician can provide additional statements, propose other treatment plans, or state that he cannot meet this request for help. Research into this model showed that most patients wanted to receive explanations about the treatment plan and the relationship between disease and treatment. The patients also wanted to be involved in decisions about their treatment.

Patients want to be involved in treatment decisions and to receive an explanation about condition and treatment plan

You can see that during the initial interview a number of functions have to be fulfilled. These are expressed most concisely by Schouten as:

• Obtaining information for diagnosis;
• Providing information about disease and treatment plan;
• Finally creating a working alliance of trust and acceptance.

The Medical Interview in Mental Health

The functions indicate that there must be a phasic structure underlying the initial psychiatric interview:

Content Skills

• During the Exploration of Reasons for Encounter, the question of the patient must be explicitly on the table.
• The diagnosis must be made during the medical History-taking:
  • History-taking in the-narrow-sense;
  • Psychiatric Examination;
  • Socio-emotional Exploration.
• During Presenting Solutions, information is provided and the physician and patient must reach an agreement. 

Process Skills that optimize the relationship and communication between doctor and patient:

• Structuring Skills;
• Interpersonal Skills;
• Communication Skills.

Content Skills

Exploring Reasons for Encounter

During the Exploration of the Reasons for Encounter, the physician collects relevant information from the period before the patient visits the physician and attempts to clarify the request for help. In order to understand the content of this phase, we must realize that the visit to the doctor is not an isolated action of the patient, but takes place within a process that sociologists have called the ‘acceptance of the disease role’ (Philipsen, 1969).

The acceptance of the disease-role process goes as follows: Someone experiences a feeling of un-wellness. This person tries to explain this feeling of discomfort and places it within a manageable framework by means of layman’s explanations. He discusses the complaints with persons in the immediate vicinity, and adjusts his frame of reference and takes some actions to alleviate the complaints himself. When all this does not work sufficiently, this person may decide to go to the doctor just to ask for help.

This process is important for a good understanding of the patient and an optimal handling of the consultation:

• Important is to discuss these lay statements, because they color expectations about the help offered and are strongly linked to the patient’s ideas about the further course of the complaints.
• A second important goal is to answer the question of how the patient wants to be helped.

With this we go back to the model of Eisenthal and Lazare in which the answer to this question is central to the first part of the conversation. They showed that 60%-80% of psychiatric patients are able to formulate a specific request for help and that its wording is largely influenced by the behavior of the doctor. Doctors tend to believe that complaint reduction is the most important priority. However, patients seem to find it equally important to be informed about their disease and its course. When listening, you will hear that your patient usually comes well-prepared to you during your consultation hours.

History-taking, psychiatric examination and socio-emotional exploration

During the history-taking, the doctor collects data for the problem-solving process, the cognitive process in his mind, in order to eventually arrive at a diagnosis and to generate hypotheses about the origin and impact of the main complaint. We have divided the history-taking of psychiatric problems into three areas, namely the history-taking in a-narrow-sense, the psychiatric examination and the socio-emotional exploration.

1. History-taking in a-narrow-sense

The history-taking in a-narrow-sense aims, among other, to describe the complaint and to reconstruct the time-intensity curve. To do this, the doctor examines characteristics of the main complaint, how the main complaint has developed over time, and which factors have contributed to changes in nature or intensity. The history-taking in a-narrow-sense provides structure to the problem and is an important resource for the generation of hypotheses.

2. Psychiatric examination

Psychiatric examination has a dual purpose, namely to confirm the presence of a psychiatric disorder, as well as to refute the presence of other disorders. Until now, psychiatric research during an initial consultation has hardly been the subject of scientific research.

We will present you with two different approaches which have attempted to conduct psychiatric research in a scientifically sound manner.

Goldberg (1988) developed a screening approach for primary care.

He compared answers to a set of questions by the General Practitioner with a psychiatric examination by a psychiatrist, and subjected the GP questions to a rigorous statistical analysis. The result is a short list of detailed questions. If the patient answers ‘yes’ to two questions, then there is a high probability that there is a psychiatric disorder according to DSM-III.

This scientific approach to psychiatric examination leads to a significant improvement of the diagnosis by the general practitioner without burdening the practice. My impression is that similar short questionnaires, tailored to morbidity in outpatient mental health care, can help the psychiatrist to make a responsible decision that the patient has no problems in a number of areas.

However, making a diagnosis clearly requires more. Classification is done by asking for key symptoms. Its presence or absence sends the psychiatrist through a flow chart, ultimately resulting in a diagnosis. At the AMC psychiatry outpatient clinic, a streamlined interview was developed for anxiety and depression based on the DSM-III-R selection criteria. The onset of the depression section is as follows.

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.

Process Skills

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.

Structure of the psychiatric examination

Starting from the stages of the interview and process skills described above, we arrive at the following model of the initial psychiatric interview:

• Question-clarification, in which aspects from the pre-patient phase and the request for help are discussed;
• History-taking in which, among other things, the time-intensity curve is reconstructed;
• Psychiatric examination in which a diagnosis is made and other illnesses or disorders are excluded;
• Socio-emotional exploration in which relevant circumstances are discussed;
• Presenting solutions in which information is provided and negotiation takes place.

This process is driven by the following process skills:

• Structuring, which accentuates the phases;
• Interpersonal skills that contribute to a good interview climate of trust and acceptance;
• Communication skills, which promote the quality of information transfer.

Based on this model, we constructed the Maastricht History-taking and Advice Scoring List for Mental Health Problems, the MAAS. The MAAS is no more than an observation instrument that registers whether certain behavior occurs during a conversation or not. So it is not a standardized interview like the DIS, a copy of the MAAS-MH is included.

Functions of the Psychiatric Interview Investigated

In the third part of this paper, I would like to present the results of our own research into the relationship between the functions of a psychiatric interview and actual interview behavior. Because we developed a number of outcome measures for each position, we were able to determine to what extent the different interview skills meet a particular position.

Investigation  In order to investigate this, we organized a simulation consultation hour for 40 physician residents in training to become a general practitioner. During this simulation consultation, the doctors spoke with 4 patients, 2 of which presented a psychiatric problem: one patient visited the doctor because of fatigue and gloom in the context of a major depression, while the second patient suffered from panic attacks without agoraphobia. The doctors spoke with the patient for a maximum of 15 minutes and then filled in some open questions about the diagnosis, about the factors that caused the complaints, and about the way in which the problem could be tackled. The simulation patients wrote down how they evaluated the communication on the Patient Satisfaction with Communication Checklist; see at: MAAS-MI / Instrumental Utility. We observed the doctor-patient communication and recorded outcomes from the physician and patient.

First Function: Acquiring Information

We formulated the first function as: the doctor collects information to be able to make a diagnosis. We determined the effect of the first function by assessing the quality of the diagnosis and the quality of the theoretical patient management plan.

Diagnosis  The link between quality of diagnosis and psychiatric interview behavior can be seen in Table 4. The different types of interview behavior are shown horizontally; + means a significant positive correlation exists (p <.01), – means a significant negative correlation exists (p <.01), and 0 means the correlation is not significant.

We expect to see a positive relationship between ‘diagnosis’ on the one hand and History-taking, Psychiatric Examination, and Socio-emotional Exploration on the other. Because the information exchange must proceed optimally, we also expect to see a positive relationship with Effective Communication.

Indeed, we find positive correlations with History-taking, Psychiatric Examination and Socio-emotional Exploration. These findings support the first function, because they indicate that data collection through targeted questioning about specific topics and exploration of potential problem areas is necessary to make a diagnosis.

The negative relationship between ‘diagnosis’ and Effective Communication is striking. We have to interpret this correlation as follows: doctors who make good diagnoses take little care of an effective exchange of information. One explanation for this may be that these doctors know what they are looking for. The cognitive problem-solving process influences the interview behavior, because the doctor wants to quickly confirm or refute diagnoses, using, e.g., negations or asking double questions. Further research in this area is certainly necessary; in particular we need to know under which conditions it is possible to combine good diagnostics with an effective exchange of information.

Patient Management Plan  We also measured the first function by determining the quality of the patient management plan and its correspondence with the request for help. The patient management plan relates to the interventions with which the doctor wants to help the patient. We expect a positive relationship with Exploring Reasons for Encounter, Psychiatric Examination,  Socio-emotional Exploration and Presenting Solutions. In our research, we find strong connections with Psychiatric Examination and Presenting Solutions.

Based on the disease model, which is also used in psychiatry, we can imagine that the presence of an Axis I diagnosis, in other words a disease, strongly determines the assistance offered. This emphasizes the importance of a good exchange of information in the psychiatric diagnostic field, because the diagnosis also determines our range of help.

The positive relationship between the ‘patient management plan’ and the Presenting Solutions seems self-evident, but we must nevertheless realize that in the first the quality of theoretical considerations with regard to the help offered is measured and in the second current interview behavior. It seems that doctors, who have a good idea of ​​what they can and want to offer their patients, also provide a more extensive and, in our opinion, better offer about care. However, the reverse can also be true: doctors who pay attention to more aspects of Presenting Solutions, have a more intensive exchange of thoughts with their patient and therefore know better what information they want to offer. In the latter case, the significant correlation can substantiate the validity of the negotiation aspect during Presenting Solutions. Probably both mechanisms work: knowing better what you want leads to a more extensive range of presented help, so that you know better what the patient expects from you.

Knowing better what you want to offer the patient leads to a more extensive range of presented help, so that you know better what the patient expects from you

Disappointing is the weak correlation with Exploring Reasons for Encounter, because we had stated that during this phase the expectations about the help provided would be made explicit. It may be that during the exploration of the reasons for encounter, attention is paid to the instantaneous assistance process, i.e., the treatment of the problem during this consultation, while the approach to the problem in the longer term is made explicit and discussed during the Presentation of Solutions. The variable ‘patient management plan’ only measures the last aspect.

At the moment, we have no explanation for the strongly negative relationship between ‘patient management plan’ and Communication Skills.

We can conclude that we can recognize the first function well in the psychiatric interview. The result, i.e. diagnosis and patient management plan, have meaning again for the second function.

Second function: Providing Information

We formulated the second function of the psychiatric interview as: the physician provides information to the patient to increase their understanding of the problem and plan, and to induce compliance with treatment. We determined the effect of the second function in three ways, namely by measuring recall, or recall of information, by measuring the increase in insight, and by measuring the degree of compliance.

Recall of information  We expect that the amount of retained information will be increased by a combined influence of the interview skills Presenting Solutions, Interpersonal Skills and Communication Skills. After all, recalling information is improved by the use of appropriate methods to inform the patient, by connecting with the patient’s concerns and expectations and by providing an explanation that is in line with the patient’s frame of reference. 

We only find a positive relationship with Effective Communication, but Presenting Solutions and Interpersonal Skills are not positively correlated. What is striking is that there is a positive connection between ‘recall’ and Structuring. Doctors who maintain the structure of the consultation help patients to remember more. One of the possible factors in this regard is the nature of the psychiatric problem: often both the illness and the stressors are a problem for the patient and can then be discussed together or as separate entities. For example, a patient becomes depressed after losing his partner. If the doctor first explores one problem (the depression) and discusses an offer of help and then discusses the next problem (loss of partner), this leads to a chaotic conversation of which the patient cannot remember much.

Doctors who maintain the structure of the consultation help patients to remember more

Even more striking is the strong negative connection with History-taking. For doctors who take an extensive history, patients can only remember little of the help that is offered. The explanation of this is not immediately clear, but it may be that taking an extensive history poses a great demand on the patient’s memory and information processing. When the doctor, in turn, provides information, the patient seems to be unable to absorb everything.

Extensive History-taking drains the resources of your patient

Gaining insight  We also observed the increase in patient insight, the theme of this site. Insight does not have the psychoanalytic meaning of the word, but relates to the patient’s knowledge of his illness, its etiology and the treatment options. We expect that ‘insight’ is strongly correlated with Presenting Solutions and Effective Communication, which is partly true.

The strong link with Presenting Solutions is the logical consequence of the nature of the offered help, which includes providing information on a number of different aspects of the problem and negotiating if necessary. When the offering of help is carried out properly, the patient’s understanding of his problem increases.

Again, the negative relationship with History-taking is noticeable, more history-taking by the doctor ultimately gives less insight to the patient. We must take this side effect of history-taking seriously, because gaining insight was one of the important motives for visiting the doctor. Just as we were just unable to indicate the exact cause of this phenomenon on recall, we cannot explain it now. More research is urgently needed. However, we can provisionally conclude that the first function of the interview is at odds with the second function.

Compliance  The willingness to comply, that is, the willingness to follow-up on therapy, is the third way in which we want to assess the effect of the second function. Compliance does not show any positive relationship with interview behavior. This is disappointing, because compliance is an important outcome of the interview, both for further treatment and for our effect measurement. Compliance is the result of a complicated interview process in which both content elements and process skills play a role. The patient must remember and understand information and be willing to follow the treatment plan, which implies emotional involvement. We are probably at the limit of what we can investigate during a simulation consultation.

We can conclude that the behavior of the second function can be found in the interview, but less clearly compared to the first function.

Third function: Establish a Climate of Trust and Acceptance

The third function is to maintain a climate of trust and acceptance in the physician-patient relation.

We measured the quality of the third function in three dimensions, namely facilitation; negative communication and directivity.

Facilitation  We expect that the degree to which the patient is facilitated to articulate thoughts, feelings and questions will be stimulated by interview behavior during Exploring Reasons for Encounter and Socio-emotional Exploration and by good use of Interpersonal Skills and Communication Skills.

An attitude of attention to the patient and their emotional and social problems will allow the patient to vent concerns and feelings

Our research shows that almost all interview behavior has a facilitating effect. In fact, the correlations with Socio-emotional Exploration and Interpersonal Skills are very high. These findings are in line with our expectation that exploring social and emotional problems and an attitude of attention to the patient are important and give the patient the feeling that they can vent their concerns and feelings.

The link with Psychiatric Examination is stronger than we expected. We must conclude from this that patients experience periods of systematic and targeted questions about their complaints as facilitating. Our case studies concerned relatively mild psychiatric symptoms, which the patient experienced as a disturbance in the personal psychological functioning. If the doctor systematically asks about the complaints and therefore places them in a manageable framework, I can imagine that patients experience this as a relief, because the complaints are taken seriously and they are listened to. Moreover, for mild psychiatric problems, it is largely the case that the patient does not have his complaints, but is his complaints.

Psychiatric patients usually experience their complaints as part of their person and will therefore experience the interest in them as interest in their person. The consequence of this is that if insufficient attention is paid to the quality of the doctor-patient relationship, the exchange of information about psychiatric symptomatology deteriorates.

Patients with minor psychiatric problems are their complaints rather than have their complaints

In a poor doctor-patient relationship, any exchange of information about the complaints during psychiatric examination is therefore likely to deteriorate

Negative Communication  For ‘negative communication’, the patient was asked if he was hindered or interrupted in telling his story. This scale is the theoretical opposite of facilitation. In line with our expectations, we find negative correlations with Exploring Reasons for Encounter, Socio-emotional Exploration and Structuring. We lack negative correlations with Interpersonal Skills and Communication Skills. The feeling of being interrupted is therefore not so much influenced by the attitude of the doctor, but rather when the patient is hindered from telling personal information. In other words, patients can think to themselves: this is a nice doctor, but I did not have the opportunity to say what I thought was important. Communication problems are more likely to occur during Exploring Reasons for Encounter and Socio-emotional Exploration than during the other phases of conversation.

Another important finding is that patients experience few communication problems when the physician adheres to the structure of the interview. Structuring has a facilitating and communication-promoting effect. These results are in line with the findings of, for example, Cox et al. that systematic questioning should not interfere with the expression of feelings and should not be perceived by patients as intrusive or lack of understanding. This can be achieved by the physician creating space for it by holding on to the structure.

Structuring has a facilitating and communication-promoting effect on the interview

Directivity  A third aspect of the conversation climate is directivity, the degree to which the patient feels that the doctor is imposing his ideas and solutions on him. We see negative correlations with Exploring Reasons for Encounter, History-taking, Psychiatric Examination and Socio-emotional Exploration. These interview behaviors, which in part serve for the doctor’s problem-solving process, are not perceived as negative by the patient. This is in line with our earlier observation that the systematic and targeted asking of questions about psychiatric problems by patients is not experienced as a disturbance in the conversation climate. The Presenting Solutions is also not seen as directive when there is sufficient opportunity for co-decision.

The analyzes of the third function show that Exploring Reasons for Encounter, History-taking, Psychiatric Examination, and Socio-emotional Exploration have approximately the same effect on the patient. The distinction between patient-oriented and doctor-oriented interviewing, which we clearly observe in somatic medicine, seems to disappear when discussing psychological or psychiatric functioning.

The distinction between patient- and doctor-oriented interviewing disappears in case of psychological complaints

Recommendations

We can easily find the three functions as described by Schouten in the initial psychiatric interview. There was a time in psychiatry when technical skills were considered less important, because they would keep the patient away from his feelings. However, you have seen that the technical skills are indeed important for the diagnosis and that patients do not find it a problem to talk about their complaints. On the contrary, patients experience this as paying attention to them as a person.

Attention paid to diagnostics may well go at the expense of the second function: the provision of information to the patient

Nowadays a lot of attention is paid to diagnostics during intake interviews. There is a good chance that this will be at the cost of the second function, the provision of information. That is unfortunate, because in doing so, the doctor ignores one of the patient’s most important questions: What is wrong with me and how will it continue in the future?

However, patients experience the examination of psychiatric symptoms and socio-emotional circumstances as attention for them as a person.

The development of the MAAS and the research into the psychiatric interview will hopefully stimulate a middle position, in which attention is paid to the tasks of the doctor and in which an adequate answer to the patient’s request for help is also given. 

It will be clear to you that what we have presented to you is only a first step. More research and education are needed to gain a better understanding of the functions of the psychiatric interview.