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 RAPPORT1. Elicit one goalBe more efficient by learning the patient’s agenda2. Validate three different waysBe authentic in your validation by expanding the ways in which you can agree with the patient3. Mirror the patient’s language to build rapportUse the patient’s phrasing to avoid misinterpretationJodi Zik, MD4. 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 changeAshley Curry, MD5. Redirect demanding patientsReinforce that the patient, like everyone, is entitled to good medical care6. Be silentUse active silence to support the patient’s emotional expressionJesse Markman, MD, MBA7. Be playfulIntroduce playful irreverence to challenge rigidity, signal affection, and build social connectionAmy Dowell, MD, and Alexia Giblin, PhD, CEDS8. Handle the hollering with a calming questionThrough tone of voice, active listening, and setting limits, invite a conversation to de-escalate a shouting patientThomas Dunn, PhD9. Recognize your own emotionsIdentify 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, MS10. Reflect the patient’s statementsUse a well-timed reflection to disrupt a negative thought spiralJesse Markman, MD, MBA11. Introduce progressive muscle relaxationGive the patient an active task to change their emotional experienceJesse Markman, MD, MBA12. Use emotional validation to manage negative countertransferenceDisarm your negative emotions and humanize your patients Melanie Rylander, MD13. Consider fear when the patient is angryAssess what the patient might be afraid of when they become upset14. Validate the patient’s perspective of where they are now and where they need to goUnderstand and support the patient’s reality and goals to enhance motivation for treatment15. Share how you feelPut your own feelings into words to reset a difficult conversation16. Agree to disagreeDe-escalate an argument by repeating this short phrase17. Be honest about your limitationsRelieve yourself of unobtainable expectations and reset the conflictual encounterSECTION II. TAKING A HISTORY18. Be curiousWhen curious about what a patient has said, ask more questions to obtain useful information and show the patient that you are interestedRachel Glick, MD19. Prioritize information you need right nowShift your line of questioning without shifting the topicDavid Kroll, MD20. Use open-ended questions for sensitive topicsInvite greater honesty and avoid a sense of judgment through open-ended questions21. Attend to affectEmphasize the patient’s emotional words for a richer history 22. Validate and moveUse validation as a transitional tool in the unwieldy interview23. Write a timelineOrganize chaotic histories and validate the patient’s experience24. Ask "How come?" instead of "Why?"Vary your phrasing slightly to improve the tone of the interview25. Observe caregivers’ nonverbal cuesGather information from caregivers to increase accuracy and efficiency in diagnosis of cognitive disordersJoleen Sussman, PhD, ABPP26. Roll with impaired reality testingProvide a validating and grounded interview for patients with psychotic symptomsErin O’Flaherty, MD27. Ask for help understandingFrame an open-ended question as a plea for the patient’s assistance28. Collect the social history firstRe-order the traditional interview to better engage reluctant patientsSarah Schrauben, MD29. Ask about family historyUse the family history as a lead-in to sensitive questions30. Wonder aloud with the patientUse and re-use a brief, non-committal phrase to explore the patient’s history and treatment optionsSECTION III. MAKING AN ASSESSMENT31. Track symptoms and behaviorsKeep a log to aid diagnosis and begin treatment32. Find the key worryConsider the anxious patient’s most important worry in making the diagnosis33. Consider past healthcare encountersAsk how patients’ past healthcare experiences may inform their current experience34. Identify what is solvableFocus on concrete objectives that you and the patient can realistically solve together35. Talk about traits, not diagnosisThink of maladaptive thoughts and behaviors on a spectrum of normalJodi Zik, MD, and Melanie Rylander, MD36. Label the patient’s affectHelp manage the patient’s emotional experiences by putting it into wordsEdward MacPhee, MD37. Talk about the mind-body connectionConnect psychiatric and medical symptoms to encourage openness to mental health interventionsThida Thant, MD38. Emphasize function over feeling in chronic illnessShift the visit’s focus to capability to reinforce the patient’s self-efficacy and agree on achievable outcomes39. Consider the social history in your assessmentApply the social history as a tool for understanding the patient’s diagnosis and treatmentJodi Zik, MD40. Remind the patient what is not workingAsk how the patient feels about their current behaviors in order to motivate change41. Ask about medication side effectsAssess experiences of side effects when medications are seemingly ineffectiveVivian Cheng, PharmD, and Jeffrey Clark, PharmD, BCPP42. Ask the "why" about online informationFocus on the patient’s motivations for sharing information brought to the encounter43. Recall the patient’s strengthsConsider how the patient’s abilities can be used in the service of their health44. Accept or changeSimplify the possible outcomes to help the patient stop venting and decide on actionSECTION IV: PLANNING TREATMENT45. Set the stageSpend one visit preparing to make significant treatment changes46. Fish for change talkGuide the patient into talking about behavior change more quicklyAlex Kipp, MD, MALS47. Imagine the futureEnvision the patient’s healthy life in order to prioritize treatment goals48. Prescribe changeUse a prescription pad to emphasize non-pharmacologic interventions49. Ask the patient’s beliefs regarding medicationsUnderstand what patients think medications will do for them to clarify treatment and improve adherence50. Anticipate challengesBe specific in planning ahead and removing obstacles to treatment success51. Experiment with changeIntroduce change as something the patient can simply try out—no commitment necessary!52. Operationalize improvementBe specific with the patient about what "better" means53. Frame limit-setting from the patient’s perspectiveConsider how setting effective limits will improve the patient’s careDavid Kroll, MD54. Share difficult decisionsGive the patient options when collaborating on a treatment plan with which the patient is reluctant to engage55. Define efficacy for medication changesUnderstand the patient’s goals and how they will know if a medication change is working56. Help patients resist urgesReview how patients can refrain from acting on unhelpful impulses57. Accept ambivalence: "It’s okay not to change"Allow patients to acknowledge and accept when they are not ready to changeJodi Zik, MD, and Melanie Rylander, MD58. Plan for a crisisWrite a three-step crisis plan to anticipate patients’ triggers and coping skills59. Normalize challengesValidate that treatment is difficult for many patients60. Reinforce the positiveEncourage healthy decision-making and adherence with plentiful encouragement

"This book goes beyond nuts and bolts to capture the art and soul of clinical interviewing. It offers a treasure chest of practical tips for clinicians to increase effectiveness, build collaboration and empathy, avoid power struggles, and in general create a therapeutic alliance with patients in health settings. The sample dialogues provide excellent illustrations of techniques. Bravo!"Stacey Freedenthal, PhD, LCSW, author of Helping the Suicidal Person: Tips and Techniques for Professionals"Drs. Simpson and McDowell and their contributors have done a superb job presenting the keys to good clinical interviewing. The book is illuminated with the pleasure of engaging with patients as people and achieving better outcomes in the process. The unique format of 60 brief chapters, each one on a different technique, is highly accessible: there are an abundance of practical and well-organized pearls and tips, each with sample dialogue and a brief review of supporting theory and literature. Useful for quick reference or sustained study, the eclectic approach will benefit any healthcare practitioner, beginner to expert, medical or psychiatric, practicing ambulatory or acute care. The book’s themes are familiar—therapeutic alliance, collaboration with the patient, intertwining treatment with evaluation, promoting change—but I learned some new things reading it. It is heartening to see this aspect of medicine remain so creative and alive."Jon S. Berlin, MD, clinical professor in psychiatry, Medical College of Wisconsin"The Clinical Interview is a highly practical and user-friendly guide to the clinical application of evidence-based psychotherapeutic techniques to enrich the patient-clinician encounter. When patients feel heard, history taking is smooth, troubling thoughts and feelings are easier to elicit, and treatment planning becomes a team approach. Drs. Simpson and McDowell elegantly display a variety of psychotherapeutic approaches thorough the use of patient vignettes. This book will be a valuable tool to clinicians at all levels of experience."Jagoda Pasic, MD, PhD, Professor of Psychiatry, University of Washington"Even the best clinician will walk out of the occasional clinical encounter thinking, 'Well, that could have gone better,' but still being unsure just what we could have done differently with our interviewing technique or brief interventions. The Clinical Interview gives readers a quick refresher of basic and advanced approaches to common and complex scenarios. It reads easily with brief and digestible tutorials which can be read quickly between clinical encounters or absorbed at length. A worthy addition to the library of any mental health clinician, new or experienced."Jack Rozel, MD, MSL, President, American Association for Emergency Psychiatry, Associate Professor of Psychiatry and Adjunct Professor of Law, University of Pittsburgh"In this eminently practical and insightful book, written in plain English, Drs. Simpson, McDowell, and their colleagues offer helpful strategies and techniques that address key aspects of the clinical interview. These wise guiding principles and techniques will assist clinicians at all levels—from novices through experts—learn, reflect on, and call upon a huge variety of important ‘tricks of the trade,’ helpful for building and maintaining better alliances, treatment plans, and therapeutic interactions."Joel Yager, MD, Professor, Department of Psychiatry, University of Colorado School of Medicine"This book provides guidance to a wide range of providers who deal with patients that run the spectrum from mundane to difficult. This textbook is a recommended read for all."Leslie S. Zun, MD, MBA, Medical Director, Lake County Health Department, Chairman and Professor, Department of Emergency Medicine and Psychiatry, RFUMS/Chicago Medical School"The Clinical Interview is a terrific compilation of top experts providing a kaleidoscopic study of varied aspects of psychiatry’s backbone, the clinical interview. The well-structured format of individual concepts should make this an inviting read, and an invaluable resource, for students and seasoned professionals alike."Scott Zeller, MD, University of California, Riverside, Editor of Emergency Psychiatry: Principles and Practice and The Diagnosis and Management of Agitation