The Clinical Interview

Scott A. Simpson, MD, MPH, is Medical Director of Psychiatric Emergency Services at Denver Health Medical Center and an Associate Professor at the University of Colorado School of Medicine. Dr. Simpson has advanced the treatment of behavioral emergencies through clinical practice, scholarship, and program development. A practicing emergency psychiatrist, he appreciates the unique challenge and privilege of working with patients and families in crisis. He lectures frequently across the country and has numerous peer-reviewed publications. Dr. Simpson is board certified in psychiatry, consultation-liaison psychiatry, and addiction medicine. Anna K. McDowell, MD, is a psychiatrist and Co-Director of the Depression Consultation Team at the Rocky Mountain Regional Veterans Affairs Medical Center. As clinical faculty at the University of Colorado School of Medicine, Dr. McDowell teaches students, residents, and clinical staff. She is passionate about treating patients with complex mood, anxiety, and personality disorders and integrates multiple psychotherapeutic modalities in her patients’ treatment. Dr. McDowell has formal training in dialectical behavior and psychodynamic psychotherapies and is board certified in psychiatry and addiction medicine.

SECTION I. BUILDING RAPPORT

1. Elicit one goal

Be more efficient by learning the patient’s agenda

2. Validate three different ways

Be authentic in your validation by expanding the ways in which you can agree with the patient

3. Mirror the patient’s language to build rapport

Use the patient’s phrasing to avoid misinterpretation

Jodi Zik, MD

4. Use the power of "and"

Introduce "and" rather than "or/but" statements to your interview to establish rapport, validate the patient’s experience, and facilitate change

Ashley Curry, MD

5. Redirect demanding patients

Reinforce that the patient, like everyone, is entitled to good medical care

6. Be silent

Use active silence to support the patient’s emotional expression

Jesse Markman, MD, MBA

7. Be playful

Introduce playful irreverence to challenge rigidity, signal affection, and build social connection

Amy Dowell, MD, and Alexia Giblin, PhD, CEDS

8. Handle the hollering with a calming question

Through tone of voice, active listening, and setting limits, invite a conversation to de-escalate a shouting patient

Thomas Dunn, PhD

9. Recognize your own emotions

Identify and process your countertransference during the interview to improve the patient’s well-being (and your own)

Jonathan Buchholz, MD, Lionel Perez, MD, Lindsay Lebin, MD, and Heidi Combs, MD, MS

10. Reflect the patient’s statements

Use a well-timed reflection to disrupt a negative thought spiral

Jesse Markman, MD, MBA

11. Introduce progressive muscle relaxation

Give the patient an active task to change their emotional experience

Jesse Markman, MD, MBA

12. Use emotional validation to manage negative countertransference

Disarm your negative emotions and humanize your patients

Melanie Rylander, MD

13. Consider fear when the patient is angry

Assess what the patient might be afraid of when they become upset

14. Validate the patient’s perspective of where they are now and where they need to go

Understand and support the patient’s reality and goals to enhance motivation for treatment

15. Share how you feel

Put your own feelings into words to reset a difficult conversation

16. Agree to disagree

De-escalate an argument by repeating this short phrase

17. Be honest about your limitations

Relieve yourself of unobtainable expectations and reset the conflictual encounter

SECTION II. TAKING A HISTORY

18. Be curious

When curious about what a patient has said, ask more questions to obtain useful information and show the patient that you are interested

Rachel Glick, MD

19. Prioritize information you need right now

Shift your line of questioning without shifting the topic

David Kroll, MD

20. Use open-ended questions for sensitive topics

Invite greater honesty and avoid a sense of judgment through open-ended questions

21. Attend to affect

Emphasize the patient’s emotional words for a richer history

22. Validate and move

Use validation as a transitional tool in the unwieldy interview

23. Write a timeline

Organize chaotic histories and validate the patient’s experience

24. Ask "How come?" instead of "Why?"

Vary your phrasing slightly to improve the tone of the interview

25. Observe caregivers’ nonverbal cues

Gather information from caregivers to increase accuracy and efficiency in diagnosis of cognitive disorders

Joleen Sussman, PhD, ABPP

26. Roll with impaired reality testing

Provide a validating and grounded interview for patients with psychotic symptoms

Erin O’Flaherty, MD

27. Ask for help understanding

Frame an open-ended question as a plea for the patient’s assistance

28. Collect the social history first

Re-order the traditional interview to better engage reluctant patients

Sarah Schrauben, MD

29. Ask about family history

Use the family history as a lead-in to sensitive questions

30. Wonder aloud with the patient

Use and re-use a brief, non-committal phrase to explore the patient’s history and treatment options

SECTION III. MAKING AN ASSESSMENT

31. Track symptoms and behaviors

Keep a log to aid diagnosis and begin treatment

32. Find the key worry

Consider the anxious patient’s most important worry in making the diagnosis

33. Consider past healthcare encounters

Ask how patients’ past healthcare experiences may inform their current experience

34. Identify what is solvable

Focus on concrete objectives that you and the patient can realistically solve together

35. Talk about traits, not diagnosis

Think of maladaptive thoughts and behaviors on a spectrum of normal

Jodi Zik, MD, and Melanie Rylander, MD

36. Label the patient’s affect

Help manage the patient’s emotional experiences by putting it into words

Edward MacPhee, MD

37. Talk about the mind-body connection

Connect psychiatric and medical symptoms to encourage openness to mental health interventions

Thida Thant, MD

38. Emphasize function over feeling in chronic illness

Shift the visit’s focus to capability to reinforce the patient’s self-efficacy and agree on achievable outcomes

39. Consider the social history in your assessment

Apply the social history as a tool for understanding the patient’s diagnosis and treatment

Jodi Zik, MD

40. Remind the patient what is not working

Ask how the patient feels about their current behaviors in order to motivate change

41. Ask about medication side effects

Assess experiences of side effects when medications are seemingly ineffective

Vivian Cheng, PharmD, and Jeffrey Clark, PharmD, BCPP

42. Ask the "why" about online information

Focus on the patient’s motivations for sharing information brought to the encounter

43. Recall the patient’s strengths

Consider how the patient’s abilities can be used in the service of their health

44. Accept or change

Simplify the possible outcomes to help the patient stop venting and decide on action

SECTION IV: PLANNING TREATMENT

45. Set the stage

Spend one visit preparing to make significant treatment changes

46. Fish for change talk

Guide the patient into talking about behavior change more quickly

Alex Kipp, MD, MALS

47. Imagine the future

Envision the patient’s healthy life in order to prioritize treatment goals

48. Prescribe change

Use a prescription pad to emphasize non-pharmacologic interventions

49. Ask the patient’s beliefs regarding medications

Understand what patients think medications will do for them to clarify treatment and improve adherence

50. Anticipate challenges

Be specific in planning ahead and removing obstacles to treatment success

51. Experiment with change

Introduce change as something the patient can simply try out—no commitment necessary!

52. Operationalize improvement

Be specific with the patient about what "better" means

53. Frame limit-setting from the patient’s perspective

Consider how setting effective limits will improve the patient’s care

David Kroll, MD

54. Share difficult decisions

Give the patient options when collaborating on a treatment plan with which the patient is reluctant to engage

55. Define efficacy for medication changes

Understand the patient’s goals and how they will know if a medication change is working

56. Help patients resist urges

Review how patients can refrain from acting on unhelpful impulses

57. Accept ambivalence: "It’s okay not to change"

Allow patients to acknowledge and accept when they are not ready to change

Jodi Zik, MD, and Melanie Rylander, MD

58. Plan for a crisis

Write a three-step crisis plan to anticipate patients’ triggers and coping skills

59. Normalize challenges

Validate that treatment is difficult for many patients

60. Reinforce the positive

Encourage healthy decision-making and adherence with plentiful encouragement