I remember when it first struck me with full force that being a patient undergoing a psychiatric interview can seem like torture, worse than getting a tooth pulled. It was about 15 years ago during one of our Beat The Boards! Psychiatry Oral Board training courses. I was mock-examining a candidate interviewing a patient with schizoaffective disorder and the interview questions came in more or less this order:
- What medications are you taking?
- How many times have you been hospitalized?
- What issues most commonly lead to your hospitalizations?
- Do you have any suicidal thoughts right now?
- When was the last time you had them?
- Have you ever tried to take your life?
- How did you do it?
- Do you have any voices right now?
- When was the last time you had them?
- What do they say to you?
- Do they ever tell you to hurt yourself or other people?
- Do they ever put you down?
- Have you ever been abused?
- Tell me about how you’ve been abused.
You get the picture. On the one hand this series of questions is common and predictable. I’ve conducted many interviews in just this way. Thus, I’m not being critical of the candidate. After all, he was doing what he – what most of us – was trained to do. It is our job, after all, to understand as best we can the patient’s symptoms, dysfunctions, treatments, adherence to treatment, and current and potential risks. It is our job to assess the adequacy of the current diagnosis, treatment, and risk-management approach.
On the other hand, a series of questions such as the one above can make being interviewed by us a painful and disheartening experience. “So what,” a devil’s advocate would say, “Not everything in life can be pleasant. These hard questions must be asked.”
I both agree and disagree, and that’s why I’m writing this post. I hope to share with you an interview approach that does not shy away from the hard questions while also leading to greater hope, willingness to participate in treatment, and motivated action towards a compelling goal. Rather than immediately naming and characterizing this alternative approach, let me ask you to consider the following two possibilities to kicking off an interview with a psychiatrically hospitalized patient.
- What happened that led to your hospitalization?
- Imagine this hospitalization is the last time you need to be hospitalized. Tell me what your life would be like when you no longer need to be hospitalized.
Before you continue reading, imagine what directions the above two approaches can lead a patient. I’m sure you’ve evaluated hospitalized patients; imagine one of these patients and how they might respond to each approach.
The benefits of the first approach is that it is focused and will provide much useful information. And its downside is that it is focused, but perhaps too narrowly.
The downside of the second approach is that it is perhaps too broad, not easily understood and answered by the patient, and may take too much time to get to the core information needed to develop a management plan. Its upside is that it may lead to a change in mindset (in patient and in clinician) that can break a cycle of continued treatment failure and revolving door hospitalizations. Here is a possible conversation between patient and clinician that the second approach can set in motion.
Clinician: Hello Mr. Smith. I’m Dr. Jack and I’ll be your psychiatrist during your stay. Before I came in here to talk with you, I looked over the admission note and your past medical records. Is this a good time for us to talk? Good. I want to start off with an unusual question. I want you to imagine this hospitalization is the last psychiatric hospitalization you will ever need… You will never have to come here again, not because you’re not welcome but because you won’t need us. You will live your life in such a way that you’ll be fine without us here. Here’s what I would like you to tell me: describe to me what your life would have to be like if you no longer needed to come to the psych hospital.
Patient: I don’t know, doc. That’s a hard one. [Pauses]
Clinician: [Remains silent and looking at patient in anticipation of the patient’s response]
Patient: Well, if you looked at my chart you might have noticed I wasn’t in the hospital for about five years.
Clinician: [Nods silently]
Patient: Well, I had a dog at that time, Scout. [Patient looking up and to the right as if accessing memories from that time.] He had three legs … [Patient chuckles.] That’s what first attracted him to me… He was a broken-down mutt … just like me. If it wasn’t for me, they would have put him down …. It was me who kept him alive … And you know he kept me alive too…. I probably drank just as much during those years …. But I never tried to kill myself … I had thoughts alright, but I knew I couldn’t act on them… I never even came to the hospital … not once in five years … who would have taken care of Scout if I was in the hospital? Or if I was dead? … And then Scout died … he was old and had a good life with me … In fact, I buried him in my back yard … I didn’t tell anyone. I was afraid the health department or something wouldn’t allow it and dig him up and cremate him or something.
Clinician: You loved that dog …. Thanks for telling me about him … So, tell me, what would your life be like if you no longer needed to be hospitalized anymore? … Recall that was what I asked you that led you to tell me about Scout.
Patient: Well, it’s been crossing my mind. I’ve heard they have programs for training dogs to be companions to wounded warriors. I thought I might be good at training those dogs. I have the patience for dogs … I’d like it if other vets had a Scout in their lives like I had in mine … it would give me something to do everyday … something that made sense to me.
Clinician: Thank you for telling me all this. It makes sense to me and would make a difference. You probably already know this, but there are many steps between right here right now and that life you imagine. It may take longer than you think, or be more complicated, but that’s ok because that’s just the way it is. Why don’t we take a break now and meet later today to dive into some details. Also, why don’t you take the opportunity to talk to other patients and staff to gather ideas on how to make this happen. You seem like the right person for this job.
I don’t mean to suggest that this approach works every time, but when it works it may work in instances – with particular patients – in which the standard “tell-me-about-your-pain-and brokenness” hasn’t worked. Also note that taking this positive approach does incorporate discussion of the pain and brokenness. It’s just that it places the pain and brokenness into a larger, more positive context, a context of positive, meaningful action being available to every human being, irrespective of their pain, brokenness, and history of failure. Note also that this positive approach does not ignore the hard work that must be undertaken to reach that better life, that life worth living. This positive approach incorporates features of motivational interviewing, dialectical behavioral therapy’s (DBT’s) skill-training, and Acceptance and Commitment Therapy’s (ACT’s) focused meaningful action. I’ll cover all three of these in upcoming posts I’m sure.
I would ask you give this approach some thought and, if you’re so bold, give a whirl. I’m sure you have some patients who seem to you like good candidates for this approach. When you try it, let me know how it went.
“The purpose of life is not to be happy. It is to be useful, to be honorable, to be compassionate, to have it make some difference that you have lived and lived well.”
Ralph Waldo Emerson
“I don’t know if our life has a purpose and I don’t see that it matters. What does matter is that we’re a part. Like a thread in a cloth or a grass-blade in a field. It is and we are. What we do is like wind blowing on the grass.”
Ursula K. Le Guin
“True glory consists in doing what deserves to be written, in writing what deserves to be read, and in so living as to make the world happier and better for our living in it.”
Pliny the Elder