دانلود کتاب Psychiatric Interviewing: The Art of Understanding

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Praise for Psychiatric Interviewing, 3rd Edition
Advance Praise for the Third Edition
Praise for Previous Editions of Psychiatric Interviewing: the Art of Understanding
Praise From the Reviewers
Praise From the Experts and Faculty for Previous Editions
Psychiatric Interviewing
Copyright Page
Dedication
Foreword
Foreword to the 2nd Edition
Preface
A Few Stylistic Notes From the Author
Acknowledgments
Video Table of Contents
1 The Delicate Dance
In Search of a Definition
A Bit of Interviewing Examined and the Discovery of a Map
Person-Centered Interviewing
The Next Step
Creating the Therapeutic Alliance
First Things First: The Difference Between Engagement and Blending
Using Blending to Gauge the Degree of Engagement
Conveying Empathy: Traps, Strategies, and Solutions
The Empathy Cycle
First Phase of the Empathy Cycle: Patient Expresses a Feeling
Second Phase of the Empathy Cycle: Clinician Recognizes the Patient’s Feelings
Third Phase of the Empathy Cycle: Clinician Conveys Recognition of the Patient’s Feelings
Strategic Empathy
Interpersonal Stance
Empathic Valence
Valence of Implied Certainty
Valence of Intuited Attribution
Basic Guideposts for Effectively Using Strategic Empathy
Three Examples of Using Strategic Empathy to Transform Difficult Moments
1: The Paranoid Spiral
2: Transforming Anger with Defusing Statements
3: Shoring Up a Young Empathic Bond with Paraphrasing Statements
Generic Paraphrases.
The Metaphorical Paraphrase.
Frequency, Timing, and Length of Effective Empathic Statements
Fourth Phase of the Empathy Cycle: Patient Accurately Perceives the Clinician’s Empathic Statement
Fifth Phase of the Empathy Cycle: Patient Communicates an Appropriate Acceptance of the Clinician’s Empathic Statement
References
2 Beyond Empathy
The Person Before the Letters
Inducement of a Safe Relationship
Clinician Genuineness
Clinician Expertise
Collaborative Interviewing Models: New Tools for Enhancing Engagement
Solution-Focused Goal Setting
The Miracle Question
Concluding Statements
References
3 The Dynamic Structure of the Interview
Introduction: Phase 1
Creating a Safe Environment
Addressing Confidentiality
Opening: Phase 2
Patient’s Perspective and Conscious Agenda
Assessment of the Patient’s Immediate Mental State
Clinician’s Perspective of the Patient’s Problems and the Patient’s Unconscious Goals
Evaluation of the Interview Itself
Degree of Openness Continuum (DOC): Open-Ended Questions, Gentle Commands, Swing Questions, and the Power of Language
In Search of an Answer: What Is an Open-Ended Question?
Open-Ended Verbalizations
Closed-Ended Verbalizations
Variable Verbalizations
Transforming Shut-Down Interviews
Characteristics of Shut-Down Interviews
Unlocking Shut-Down Interviews
Transforming Wandering Interviews
Characteristics of Wandering Interviews
Transforming Rehearsed Interviews
Characteristics of Rehearsed Interviews
Breaking Through a Rehearsed Interview
Body of the Interview: Phase 3
The Gathering of the Database
Conveying Expertise, the Generation of Hope, and the Return Visit
Closing of the Interview: Phase 4
Termination of the Interview: Phase 5
Conclusion
References
4 Facilics
Sensitively Creating Conversational Interviews
Secrets from Everyday Conversation
A Solution to the Dilemma
Introduction to the Practical Application of Facilics
Part I: Learning How to Tag the Flow of the Interview – What Topics, When?
Descriptions and Characteristics of Facilic Regions
Content Regions
Process Regions
1. Free Facilitation Regions
2. Transformational Regions
3. Psychodynamic Regions
The Scouting Region: A Unique Combination of Content and Process
Part II: Practical Tips for Applying Facilic Principles to the Exploration of Regions
Using Time Effectively
The Core Conundrum: Well-Timed Tracking Versus Poorly Timed Tracking
A Basic Paradigm for Successfully Structuring an Initial Interview
Recognizing and Transforming Two Structuring Gremlins
1. Overly Lengthy Scouting Region: The “Five-Minute Fix”
2. The Dead Zone: Two Errors in One
The Eight Golden Rules for Structuring Effectively
Exploring Content Regions in a Sensitive Fashion
Part III: Facilic Gating – The Fine Art of Making Graceful Transitions
Gates: The Pathways of Conversational Flow
Spontaneous Gates
Natural Gates
Manufactured “Gates”
Referred Gates
Phantom Gates
Implied Gates
Miscellaneous Gates
Introduced Gate
Observed Gate
The Finishing Touches: Summarizing the Principles of Facilics
Concluding Comments
References
5 Validity Techniques for Exploring Sensitive Material and Uncovering the Truth
Understanding the Challenge of Exploring Sensitive Material
Validity Techniques: Keys to Eliciting Sensitive Material
Cluster One: Techniques for Improving Generalized Recall
The Dilemma
Anchor Questions
Anchor Questions (Focused Upon Time)
Anchor Questions (Focused on Location)
Tagging Questions
Exaggeration
Cluster Two: Validity Techniques for Avoiding Miscommunication
Defining Technical Terms
Clarifying Norms
Cluster Three: Validity Techniques for Raising a Sensitive or Taboo Topic
Normalization
Shame Attenuation
Shame Attenuation Used to Bridge From Pain or Situational Stress
Shame Attenuation Used to Uncover Aggressive, Unethical, and Antisocial Behaviors
Induction to Bragging
Cluster Four: Validity Techniques for Exploring a Sensitive Topic Once It Has Been Raised
Behavioral Incident
Interviewer 1
Interviewer 2
Helping a Patient to Describe an Episode of Intimate Partner Violence (IPV)
Limitations of Behavioral Incidents
Gentle Assumption
Denial of the Specific
Catch-All Question
Symptom Amplification
Validity Technique Combinations
Miscellaneous Tips for Specific Situations Where Validity Is a Concern
Malingering
Gauging Motivation
Taking a Sexual History
Interview Illustrating the Use of Various Validity Techniques
References
6 Understanding the Person Beneath the Diagnosis
Introductory Illustration: The Person Beneath the Diagnosis
Part I: Phenomena That Hinder the Understanding of the Person
Parataxic Distortion
Further Problems With Inaccuracy: The Issue of Reliability
Part II: Phenomena That Deepen the Understanding of the Person Beneath the Diagnosis
Sullivan’s Interpersonal Perspective Revisited
Phenomenological Inquiry
The Search for Wellness: Patient Strengths, Skills, and Interests
Exploring Component #1 of the Wellness Triad: Patient Strengths
Strengths of Knowledge:
Strengths of Courage:
Strengths of Humanity:
Strengths of Justice:
Strengths of Temperance:
Strengths of Transcendence:
Exploring Component #2 of the Wellness Triad: Patient Skills
Creative Skills:
Task Related:
Interpersonal Skills:
Athletic Skills:
Manual Dexterity:
Specific Career Training:
Exploring Component #3 of the Wellness Triad: Patient Interests, Hobbies, and Pastimes
Part III: Understanding Cultural Diversity – Its Vital Role in the Initial Interview
Misperceptions Related to Cultural Biases: Impact on the Initial Therapeutic Alliance
Culture Impacting Directly on Treatment Planning in the Initial Interview
References
7 Assessment Perspectives and the Human Matrix
Clinical Presentation: the Initial Interview
The Diagnostic Perspective of the DSM and ICD Systems
The Healing Power of Differential Diagnosis
Limitations of Formal Diagnostic Systems Such as the DSM and ICD
The Loss of Multiaxial Formulation: a Historical Footnote
Major Psychiatric Disorders (Other Than Personality Disorders)
Personality Disorders
Non-Psychiatric Medical Conditions
Psychosocial Context and Stressors
Level of Current Functioning and Impairment
Clinical Application of the DSM-5
Matrix Treatment Planning
Introduction
Basic Paradigm and History of the Biopsychosocial Treatment Planning Model
A Revitalizing Change in Language
Matrix Treatment Planning: General Clinical Principles and Specific Applications to Debbie in the Initial Interview
First Wing of the Matrix: Biologic
Biological Intra-Wing Interventions
Biological Inter-Wing Interventions
Question #1: Healing Matrix Effects Arising From the Biologic Wing
Question #2: Healing Matrix Effects to the Biologic Wing From Other Wings
Second Wing of the Matrix: Psychological
Psychological Intra-Wing Interventions
Psychological Inter-Wing Interventions
Question #1: Healing Matrix Effects on Other Wings Arising From the Psychological Wing
Question #2: Healing Matrix Effects to the Psychological Wing From Other Wings
Third Wing of the Matrix: Dyadic
Dyadic Intra-Wing Interventions
Dyadic Inter-Wing Matrix Effects
Fourth Wing of the Matrix: Family
Familial Intra-Wing Interventions
Familial Inter-Wing Matrix Interventions
Fifth Wing of the Matrix: Cultural, Societal, and Environmental
Cultural, Societal, and Environmental Intra-Wing Interventions
Cultural, Societal, and Environmental Inter-Wing Matrix Interventions
Sixth Wing of the Matrix: Worldview (Framework for Meaning)
Worldview Intra-Wing Interventions
Worldview Inter-Wing Matrix Interventions
Conclusion: Matrix Treatment Planning Redux
Assessment of Core Pains
Review of the Clinical Course of Ms. Baker
Conclusion
References
8 Nonverbal Behavior
Introduction
Basic Terminology of Nonverbal Behavior
Nonverbal Communications (Emblems)
Nonverbal Activities
A Cautionary Note on Interpreting Nonverbal Behaviors and Nonverbal Research
Organization of the Chapter
Part 1: Core Fields of Study in Nonverbal Behavior
Proxemics
Kinesics
Paralanguage
Immediacy and Context: the Delicate Interface of Proxemics, Kinesics, and Paralanguage
Immediacy
Nonverbal Context
Part 2: Clinical Application of Nonverbal Behavior
Section A: Assessment of the Patient
Nonverbal Hints of Hidden Psychopathology
Uncovering Hidden Psychotic Process
Nonverbal Hints of Classic Psychiatric Diagnoses
Nonverbal Hints of Specific Personality Diagnoses
Nonverbal Indicators of Anxiety
Nonverbal Hints of Deception
Nonverbal Correlates of Patient Ambivalence and Discordance
Nonverbal Signals During Collaborative Treatment Planning
Nonverbal Behaviors Functioning as Social Scripts
Section B: Utilization of Nonverbal Behaviors to Engage Patients
Seating Arrangement and Proxemics
Intentional Use of Head Nodding and Other Facilitative Techniques
Nonverbal Techniques for Engaging Guarded or Paranoid Patients
Clinician’s Self-Awareness of Paralanguage
The Impact of Clinician Gestures and Facial Expressions on the Patient
A Few Notes on Note Taking
Nonverbal Aspects of Calming Potentially Violent Patients
Recognizing Contextual Clues of Impending Violence
Nonverbal Clues of Impending Violence
Nonverbal Techniques for Calming a Potentially Violent Patient
Part 3: Bold New Frontiers – the Nonverbal Impact of Technology, the Web, and Mobile Connectedness on Interviewing
Interactive Audio-Visual Technology (IATV) and the “Phantom Presence Effect”
Interviewing on the Telephone
Problems Assessing Patients on the Phone
Problems Engaging Patients on the Phone
The Ultimate Nonverbal Challenge: Interviews Done by Chatting, Instant Messaging, and Texting
Conclusion
References
9 Mood Disorders
Introduction
Diagnostic Systems: There Has Never Been a Perfect One and There Never Will Be
The Nature of the Dilemma for Front-Line Clinicians
Validity Versus Reliability
Construct Validity, Face Validity, and Descriptive Essence
Categorical Diagnostic Systems Versus Dimensional Diagnostic Systems
Categorical Diagnostic Systems
Dimensional Diagnostic Systems
A Pivotal Step Forward in the DSM-5
First Steps in the Differential Diagnosis of Mood Disorders
Clinical Presentations and Discussions
Clinical Presentation #1: Mr. Evans
Discussion of Mr. Evans
The Painful World of Anhedonia: Its Role in Diagnosis
Uncovering the Neurovegetative Symptoms of Depression
What Are the Neurovegetative Symptoms of Depression?
Tips for Exploring Early Morning Awakening and Other Sleep Disturbances
Sensitively Asking Patients About Libido
Gracefully Weaving the Neurovegetative Symptoms Into the Interview
The Concept of Melancholia
Anxiety: Another Important Dimensional Specifier
The Role of Substance Abuse in the Differential Diagnoses of Depression
Important Data Points When Taking a Past Psychiatric History
Spotting Bipolar I Disorder: Traps and Nuances
Bipolar I Disorder
Classic Euphoric Mania
Psychotic Process in Mania
The Importance of Family Members and Collaborative Sources When Delineating Mania
Cognitive Deficits in Mania
Differential Diagnosis on Mr. Evans and Summary of Key Interviewing Tips
Clinical Presentation #2: Danny Ramirez
Discussion of Danny Ramirez
Bipolar I Disorder, Mixed Presentation
History Repeats Itself: An Evolving Diagnosis
A Practical Solution From the DSM-5
“Dysphoric Mania”: One Type of Mixed Bipolar Disorder
Differentiating a Dysphoric Mania From an Agitated Depression
Three Practical Tips for Spotting a Dysphoric Mania.
Historical Tip-Offs That Raise the Suspicion of Mixed Bipolar States in General
Over-Diagnosing Bipolar Disorder: A Serious Diagnostic Error
Bipolar II Disorder
Substance/Medication-Induced Bipolar and Related Disorder
Recognizing Suicidal Ideation Unleashed During Partial Manic Responses to a Medication
Cyclothymic Disorder and Rapid Cycling
Differential Diagnosis on Danny Ramirez and Summary of Key Interviewing Tips
Clinical Presentation #3: Mr. Whitstone
Discussion of Mr. Whitstone
Patient Hesitancies to Admit to Depression and How to Transform Them
Cross-Cultural Issues in Recognizing Depression
Problems With Concentration and Cognitive Functioning in Depression
Spotting Atypical Depression
Psychotic Process in Depression
Ruling Out Non-Psychiatric Biological Causes of Depression
Differential Diagnosis on Mr. Whitstone and Summary of Key Interviewing Tips
Clinical Presentation #4: Ms. Wilkins
Discussion of Ms. Wilkins
The Need to Determine the Persistence of Depressive Symptoms and How to Do It
Red Herrings: Disorders That Mimic Major Depressions
Tips for Delineating an Accurate History of the Presenting Disorder
Ruling Out Peripartum Depressions, Grief, Adjustment Disorders, and V-Codes
Differential Diagnosis on Ms. Wilkins and Summary of Key Interviewing Tips
Clinical Presentation #5: Mr. Collier
Discussion of Mr. Collier
Techniques for Eliciting a Family History
Difficulties in Taking a Family History and How to Transform Them
Cross-Cultural Sensitivity When Taking a Family History
Family History as a Reflection of Family Dynamics
Differential Diagnosis on Mr. Collier and Summary of Key Interviewing Tips
References
10 Interviewing Techniques for Understanding the Person Beneath the Mood Disorder
Introduction
The Pain Beneath Depression
Fields of Interaction
The Biological Wing of the Matrix
The Psychological Wing of the Matrix
1. Depressive Changes in How the World Is Perceived
The Window Shade Response
2. Cognitive Changes Caused by Depression
Changes in the Flow of Thought and Ideational Caging
Cognitive Distortions as Conceptualized by Aaron Beck
First Distortion in Beck’s Triad: Negative View of the World
Second Distortion in Beck’s Triad: Negative Self-Concept
Third Distortion in Beck’s Triad: Negative View of the Future
3. Alterations in Thought Content Found in Depression
Depressive Loneliness
Depressive Guilt and Self-Loathing
Depressive Helplessness
Depressive Hopelessness
4. Psychodynamic Defenses and Their Role in Depression
The Dyadic Wing of the Matrix
The Impact of the Patient’s Depression on the Interviewer
How a Clinician’s Behaviors Can Submerge a Depression From View
Effectively Addressing Tearfulness
The Familial and Societal Wing of the Matrix
An Illustration of the Insidious Impact of Depression on a Family
Addressing the Pain of Family Members
Uncovering Potentially Damaging Family Impacts on the Patient
The Impact of Depression on Societal and Cultural Systems
Cultural Impacts on the Patient’s Depression
The Wing of the Matrix Encompassing Worldview and Spirituality
References
11 Psychotic Disorders
Introduction
The Differential Diagnosis of Psychotic States
Clinical Presentations and Discussions
Clinical Presentation #1: Mr. Williams
Discussion of Mr. Williams
Phenomenology of Visual Hallucinations and Illusions: Their Diagnostic Implications
Recognizing Psychotic Process Induced by Alcohol Withdrawal
Recognizing Psychotic Process Induced by Street Drugs
Recognizing Medication-Induced Psychosis
Effectively Interviewing and Collaborating With Law Enforcement Officers
Differential Diagnosis on Mr. Williams and Summary of Key Interviewing Tips
Clinical Presentation #2: Mr. Walker
Discussion of Mr. Walker
Spotting Disturbances of Affect as Seen in Schizophrenia
Diagnostic Significance of the Presence of Delusions: Delineating Schizophrenia From Delusional Disorders
Negative (Deficit) Symptoms of Schizophrenia
The Importance of Family Members in Uncovering Psychotic Process
Differential Diagnosis Between Schizophrenia and Mood Disorders With Psychotic Features
Schizoaffective Disorder and the Schizo–Bipolar Continuum
Differential Diagnosis on Mr. Walker and Summary of Key Interviewing Tips
Clinical Presentation #3: Ms. Hastings
Discussion of Ms. Hastings
Types of Delusional Disorders
Paranoid Delusions: Techniques for Uncovering Potential Dangerousness
Delusions in the Elderly and Paraphrenia
Differential Diagnosis on Ms. Hastings and Summary of Key Interviewing Tips
Clinical Presentation #4: Ms. Fay
Discussion of Ms. Fay
The Life Cycle of a Psychosis
Delusional Mood
Delusional Perception
The Emergence of Concrete Delusional Ideation
Soft Signs of Psychosis: How to Spot Hidden Psychotic Process
Helping Patients to Share Delusional Material
Tapping Intense Affect
Tapping Odd Language, Illogical Thought, and Idiosyncratic Phrasing
Indirect Techniques for Exploring Delusional Material
Examples
Illustrative Dialogue
How to Respond When a Delusional Patient Asks, “Do You Believe Me?”
Hallucinations and Other “Hard Signs of Psychosis” in the Normal Population
Auditory and Visual Hallucinations in the Normal Population
Cultural Competence: Its Importance in Distinguishing True Psychotic Symptoms From Culturally Accepted Behaviors
The Interface Between Cultural Phenomena and the Life Cycle of a Psychosis
Back to Ms. Fay: An Illustration of How to Tap a Piece of Illogical Thought for Underlying Delusional Material
Differential Diagnosis on Ms. Fay and Summary of Key Interviewing Tips
Clinical Presentation #5: Mr. Lawrence
Discussion of Mr. Lawrence
A Deadly Trap: Missing Deliria in Patients With Illnesses Such as Schizophrenia
Practical Tips for Spotting a Delirium: The Nature of the Beast
Four Cognitive Tests Useful for Recognizing a Subtle Delirium
Differential Diagnosis on Mr. Lawrence and Summary of Key Interviewing Tips
Clinical Presentation #6: Kate
Discussion of Kate
Spotting Non-Delirial Psychoses Caused by Underlying Medical Conditions
When to Refer for a Physical Exam and What to Do If You Can Perform One
Differential Diagnosis on Kate and Summary of Key Interviewing Tips
Clinical Presentation #7: Ms. Flagstone
Discussion of Ms. Flagstone
“Micropsychotic Episodes” Seen in People Coping With Personality Disorders
Psychotic Processes With a Rapid Onset/Offset
Differential Diagnosis on Ms. Flagstone and Summary of Key Interviewing Tips
Recognizing Psychotic Process Triggered by Seizure Disorders
References
12 Interviewing Techniques for Understanding the Person Beneath the Psychosis
The Pain Beneath Psychotic Process
Fields of Interaction
I. The Biological Wing of the Matrix
Sleep Disturbances in Psychosis
Psychotic Disruption of the “Sensation of the Physical Boundaries of the Body” and the Concept of a “Porous Ego”
Schneiderian First-Rank Symptoms of Psychosis
Exploring Somatic Passivity and “Made Feelings”: The World of the Porous Ego
Thought Withdrawal and Thought Insertion
Thought Broadcasting (Unintentional and Intentional)
Spotting Medication-Induced Akathisia
Establishing an Alliance With a Patient Experiencing Catatonia
II. The Psychological Wing of the Matrix
Auditory Hallucinations: Their Nature, Phenomenology, and Exploration
The Directional Location of Auditory Hallucinations
The Reality of Auditory Hallucinations to the Patient
Distinction Between Auditory Hallucinations and Auditory Illusions
The Uniqueness of Auditory Hallucinations
Schneiderian Symptoms Related to Auditory Hallucinations
The Relationship Between the Patient and the Patient’s Voices
Uncovering and Sensitively Exploring Auditory Hallucinations
Sensitively Raising the Topic of Auditory Hallucinations
Sensitively Exploring the Phenomenology of Auditory Hallucinations Once Raised
Illustrative Transcript of a Clinician Exploring Auditory Hallucinations
Exploring Command Hallucinations
Exploring the Content of Command Hallucinations
Exploring the Auditory Quality of Command Hallucinations
Exploring the Degree to Which a Patient Feels Able to Resist a Command Hallucination
Exploring the Emotional Impact of Command Hallucinations on a Patient
Psychotic Disruptions in Cognition, Logic, and Communication
How to Safely Interact With an Illogical, Agitated Psychotic Patient
Unobtrusively Screening for Paranoid Process, Delusions, and Other Psychotic Process
Understanding the Demoralization and Self-Denigration Spurred by Psychotic Process
III. The Dyadic Wing of the Matrix
Uncovering Social Withdrawal and Recognizing Social Inappropriateness
The Impact of Psychotic Process on the Interviewer’s Emotions and Behaviors
The Impact of the Interviewer’s Behaviors on Psychotic Process
IV. The Familial, Cultural, and Societal Wing of the Matrix
Understanding the Exquisite Pain of Family Members
Practical Techniques for Engaging Family Members in the Initial Interview
Opening the Conversation in an Initial Encounter With a Family Member
Tips for Initial Interviews With Family Members on Inpatient Units
Talking With Patients About Involving Their Family Members in Assessment and Treatment
Cultural and Societal Impacts on Psychotic Process
Encountering Culture-Bound Syndromes and Behaviors
Missing Culturally Specific Psychotic Process
Mistaking Culturally Normal Phenomena for Psychotic Process Redux
The Community Mental Health Center as a Subculture
Language and Culture: Potential Roadblocks When Uncovering Psychotic Process
V. The Wing of the Matrix Encompassing Worldview and Spirituality
Psychotic Destruction of the Patient’s Religious Worldview
The Personalized Meaning of Psychotic Symptoms to Patients
References
13 Personality Disorders
Introduction
The Mystery of Personality Disorders Revealed: Core Principles and Definitions
In Search of a Definition
The Gestalt of Personality Dysfunction
DSM-5 Definitions of a Personality Disorder
Personality Disorders as Reflections of the Social History
The Nature of Personality Diagnoses: Abuses and Uses
A Cautionary Note
The Beneficial Uses of Personality Diagnoses
A Useful Metaphor
The Etiology of Personality Disorders
References
14 Personality Disorders
Introduction
Section I: A Survey of the DSM-5 Personality Disorders
Goals and Limitations of the Survey
1. Anxiety-Prone Disorders
Obsessive–Compulsive Personality Disorder
Dependent Personality Disorder
Avoidant Personality Disorder
2. Poorly Empathic Disorders
Schizoid Personality Disorder
Antisocial Personality Disorder
Histrionic Personality Disorder
Narcissistic Personality Disorder
3. Psychotic-Prone Disorders
Borderline Personality Disorder
Schizotypal Personality Disorder
Paranoid Personality Disorder
Section II: Common Problems Encountered When Diagnosing Personality Disorders
Premature Diagnosis: “Label Slapping”
Mistaking Behaviors Shown in the Interview as Personality Traits
Problems With Countertransference
Inappropriate Hesitation to Make a Personality Diagnosis
Section III: Using the DSM-5 to Arrive at a Personality Diagnosis
Step #1: Limiting the Field of Diagnostic Choices
Passively Scouting for Clues to Personality Dysfunction
Signal Signs
Signal Symptoms
Actively Limiting the Diagnostic Field With Probe Questions
Illustration of a Clinician Limiting the Field of Diagnostic Possibilities
Step #2: Actively Expanding the Diagnostic Criteria for a Specific Diagnosis
Illustration of a Clinician Expanding the Diagnostic Criteria of a Specific Diagnosis
Verifying the Validity of Patient-Reported Diagnostic Traits
Enhancing Validity by Maintaining Engagement
Techniques for Verifying Historical Persistency
Techniques for Ruling Out State Dependency
Verifying Pathological Severity
Tapping for Epiphenomena
Section IV: Future Diagnostic Systems of Personality Dysfunction and the Usefulness of Dimensionality Today
Dimensionality: A Note of Caution
The Power of Dimensionality in the Initial Interview
Entrance Questions for Exploring Personality Traits
Differential Diagnosis of Personality Disorders: A Glimpse Into the Future
Building Upon the DSM-5 Categorical System
Conclusion
References
15 Understanding and Effectively Engaging People With Difficult Personality Disorders
Introduction to Object Relations and Self Psychology
Goals of This Chapter and Core Definitions
Defining Object Relations and Self Psychology
What Propels the Development of the Self?
The Four Developmental Stages of the Self and Their Clinical Applications
Developmental Stage #1: Discovering the Boundaries of the Body
Developmental Stage #2: Seeking Safety by Merging With Others
Winnicott, Merger Objects, and Transitional Objects
Signal Signs Arising From Merger Dynamics
Signal Symptoms Arising From Merger Dynamics
Enhancing Engagement as Related to Merger Objects
Kernberg, Splitting, and the Move Towards Mobility
Signal Signs Arising From Splitting Defenses
Signal Symptoms Arising From Splitting Defenses
Enhancing Engagement as Related to Splitting Defenses
Developmental Stage #3: Securing the Self Through Grandiosity and Idealization
Kohut, the Bipolar Self, and the Search for Independent Functioning
Signal Signs Arising From the Psychodynamics of the Bipolar Self
Signal Symptoms Arising From the Psychodynamics of the Bipolar Self
Enhancing Engagement Via an Understanding of the Bipolar Self
Complementary Shifts
Countertransference: Short-Circuiting a Clinical Gremlin
Accepting Idealization
Developmental Stage #4: Achieving a Stable Self and the Advent of Empathy
Concluding Comments: on the Utility of Mirrors
References
16 The Mental Status
Introduction
The Impact Status
The Mental Status
General Characteristics of the Mental Status: What Is It?
Documenting the Mental Status
Components of the Mental Status
1. Appearance and Behavior
2. Speech Characteristics and Thought Process
3. Thought Content
Ruminations
Obsessions
Compulsions
Delusions
Thought Concerning Dangerousness to Self and Others
4. Perception
5. Mood and Affect
6. Sensorium, Cognitive Functioning, and Insight
References
17 Exploring Suicidal Ideation
Introduction
Section 1: Risk Factors, Warning Signs, and Protective Factors: Their Role in the Clinical Formulation of Risk
Important Distinctions and Critical Limitations
Risk Factors Versus Risk Predictors (Warning Signs)
Static Versus Dynamic Risk Factors
Protective Factors
Uncovering and Weighing Risk Factors and Warning Signs: The State of the Art
Clinical Illustrations
Clinical Illustration #1: Michael
Clinical Illustration #2: Mrs. Kelly
Risk Factors and Warning Signs: Summary and Effective Utilization
Useful Mnemonics
Loose Ends and a New Mnemonic
Differentiating Between Concerns of Chronic Suicide Risk Versus More Immediate Risk
The Tetrad of Lethality: Four Common Indicators That Hospitalization May Be Required
Section 2: the Elicitation of Suicidal Ideation, Planning, Behaviors, and Intent
1. Before the Interview Begins: Secrets, Countertransference, and Problematic Myths
2. The Importance of Uncovering Suicidal Ideation and Why It Is Hard to Do So
Roadblocks to Sharing Suicidal Ideation
Reflected Intent: One of the Master Keys to Unlocking Real Intent
Pitfalls of an Incomplete Elicitation of Suicidal Ideation
Premature Crisis Resolution
Lost Data for the Receiving Clinician
The Power of a Thorough Elicitation of Suicidal Ideation, Behavior, and Intent to Save a Life
The Issue of Credibility
Reaching for Life
3. Setting the Platform for the Suicide Inquiry
The “Elicitation of Suicidal Ideation Triad”
Step 1 of the Elicitation Triad: Enhancing Engagement With a Potentially Suicidal Patient
Step 2 of the Elicitation Triad: Helping the Potentially Suicidal Patient to Share Highly Charged Emotional States
Three Gateways to Suicidal Ideation
Step 3 of the Elicitation Triad: The Patient Hints at Suicide or Raises the Topic Spontaneously
4. Eliciting Suicidal Ideation, Planning, and Intent Using the Chronological Assessment of Suicide Events (CASE Approach)
Background, Rationale, and Limitations
The Question of Validity: Its Central Role in the CASE Approach
Two Validity Techniques for Sensitively Raising the Topic of Suicide
Normalization
Shame Attenuation
A Note on Word Choice: “Killing Yourself” Versus “Committing Suicide”
Five Validity Techniques Used to Explore the Extent of Suicidal Ideation
Behavioral Incident
Gentle Assumption
Denial of the Specific
Catch-All Question
Symptom Amplification
The Macrostructure of the CASE Approach: Avoiding Errors of Omission
The Microstructure of the CASE Approach: Exploring the Four Specific Timeframes
Step 1: The Exploration of Presenting Suicide Events
The Concept of Creating a Verbal Video
More Tips on Making a Verbal Video With Behavioral Incidents
Uncovering the Patient’s Apparent and Not-so-Apparent Motivations for Suicide
Clinical Illustration of Step 1: Exploring the Region of Presenting Suicide Events
Step 2: The Exploration of Recent Suicide Events
Clinical Illustration of Step 2: Exploring the Region of Recent Events
Step 3: The Exploration of Past Suicide Events
Clinical Illustration of Step 3: Exploring the Region of Past Events
Step 4: The Exploration of Immediate Suicide Events
Clinical Illustration of Step 4: Exploring the Region of Immediate Events
Concluding Comments
References
18 Exploring Violent and Homicidal Ideation
Introduction
Background
Characterizing Violence: Three Practical Domains for Clinicians
The Organization of the Chapter and the Role of Structured Risk Assessments
Part 1: Risk Factors for Violence
Past Violence
Sex, Age, and Environment
Presence of Psychiatric Disorders
Other Factors Suggested by the HCR-20
Part 2: Clinical Formulation of Risk – the Tetrad of Lethality
1. Patients Presenting With a Recent Violent Episode
2. Patients Presenting With Dangerous Psychotic Process
Command Hallucinations, Alien Control, and Hyper-Religiosity
Uncovering Paranoid Process
Complexities of Spotting Individuals Contemplating Mass Murder and Other Paranoid-Induced Violence
3. Indication From the Interview That the Patient Intends to Engage in Violence
4. The Patient Is Lying and Collaborative Evidence Suggests Intended Violence
A Few Caveats Regarding Domestic Violence
Part 3: the Art of Eliciting Violent and Homicidal Ideation
Setting the Stage
Chronological Assessment of Dangerous Events (the CADE Approach)
Presenting Event
Exploration of Recent Violent Events
Elicitation of Past Violent Events
Elicitation of Immediate Violent or Homicidal Ideation
Conclusion
Transitional Directions to Part IV: Advanced Interviewing and Specialized Topics
References
19 Transforming Anger, Confrontation, and Other Points of Disengagement
Introduction
Part 1: Points of Disengagement – Core Definitions
The Nature of the Beast
Points of Disengagement: Type 1 – Moments of Angry Disengagement (MADS)
The Family of MADS: Three Siblings
1. Confrontational Disagreements
Deconstructing Disagreement: The Significance of a Fallen Log Upon a Road
Not All Disagreements Are Bad
2. Oppositional Behaviors
3. Passive-Aggressive Attitudes
Points of Disengagement: Type 2 – Potentially Disengaging Questions (PDQs)
Part 2: Points of Disengagement – Developing A Contemporary Language for Their Navigation
Clinical Illustration of a Disengagement Point
Recognizing the Surface Structure of MADs and PDQs
Recognizing the Underground Structure of MADS and PDQs: Finding the Person Beneath the Anger
Learning to Move With MADs and PDQs: The “Agreement Continuum”
Three Specific Approaches for Transforming MADs and PDQs
1. Content Responses to Disengagement Points
2. Process Responses to Disengagement Points
Type 1 Process Response: Patient Asked to Look at the Interview Process and His or Her Behaviors in the Interview
Type 2 Process Response: Patient Asked to Look at His or Her Affect, Thoughts, Feelings, or Concerns
Type 3 Process Response: Clinician Shares Thoughts or Feelings Generated by the Patient’s Behavior in the Interview
Advantages of Process Responses to MADS and PDQs
Clinical Illustration of Process Responses to a PDQ
Process Responses Versus Content Responses in the Initial Interview: Which One and Why
3. Sidetracking Disengagement Points
Our Transformational Language and Principles at Work: A Return Visit to Our Clinical Illustration
Part 3: Effectively Navigating Common MADs and PDQs
Disengagement Points Challenging the Clinician’s Competence
Handling Competency Questions Concerning a Trainee’s Lack of Experience
PDQs That Attempt to Gain Personal Information About the Clinician
Patient Requests: Yet Another Commonly Encountered PDQ
Transforming Awkward Situations Encountered With Psychotic Patients
Situational Roadblocks: The Unwilling Patient and Involuntary Commitments
Transforming Overt Hostility From Family Members
References
20 Culturally Adaptive Interviewing
Introduction: A Reason to Be
Part 1: Definitions, Attitudes, and Goals – in Search of Culturally Adaptive Interviewing
Basic Definitions: Race, Ethnicity, and Culture
Culture
Race
Ethnicity
Definition of “Cultural Competency”: More Complicated Than It Looks
Towards a Third Culture
Culturally Adaptive Interviewing
Part 2: the Mystery of Cultural Identity – Unpacking Assumptions
Things Are Not Exactly What They Seem: Intersectionality and Prioritizing Cultural Identities
Intersectionality
Prioritizing Cultural Identities: A Framework for Simplifying the Complex
Clinical Illustration of the Impact of Prioritizing Cultural Identities
Part 3: Developing and Utilizing Cultural Literacy to Engage Patients and to Better Understand the Complexity of Their Problems
Using Cultural Literacy to Enhance Engagement
Acquired and Discovered Cultural Literacy
Acquired Cultural Literacy
Discovered Cultural Literacy
Using Cultural Literacy Effectively: Some Clinical Illustrations
The Story of Marin
Cultural Literacy as a Guidepost for Therapeutic Exploration: Three Important Gateways
Gateway #1: Acculturation – A Dynamic and Complex Process
Gateway #2: People of Multiple Color – The Unique Challenges of a Mixed Racial Background
Gateway #3: Human Sexuality, Sexual Orientation, and Gender Identification – Important Concerns and Hidden Difficulties for Patients From the LGBT Community
Basic Principles
Core Definitions
Heterosexual.
Lesbian.
Gay.
Bisexual.
Cross-Dresser or Transvestite.
Transgender.
Transsexual.
Intersex.
Genderqueer.
Relationship Terms.
Obsolete Terms.
Sensitively Raising the Topic of Sexuality and Gender Identification
Issues of Intersectionality, Loss, and Violence for Patients From the LGBT Community
Intersectionality
Potential Issues of Loss in the LGBT Community
Violence and Hate Crimes
Part 4: Cultural Disconnects – How to Prevent Them Before They Occur, Recognize Them as They Occur, and Transform Them Once They Occur
Before the Interview Begins: The Look Inward
Core Definitions Related to Prejudice
Traditional Prejudice.
Induced Prejudice.
Incorporated Prejudice.
Dominant Cultures: Emerging Theoretical Nuances and Clinical Implications
Telescoping Prejudice
Towards a More Sophisticated Understanding of Power Differentials
Uncovering Potential Prejudice Within Ourselves
Clinician Prejudice: Reflections in a Mirror
A Psychodynamic Mirror
Transforming Moments of Cultural Disconnection
Six-Step Transformation of Cultural Disconnects
Transforming Cultural Disconnects: Interviewing Illustrations
Interviewing Illustration #1
Interviewing Illustration #2
A Note on Working With Interpreters
Part 5: Practical Tips for Exploring Religion, Spirituality, and Framework for Meaning
Distinctions Between Religion, Spirituality, and Worldview
The Clinical Value of Exploring Spirituality
1. Spiritual and religious explorations can improve engagement, enhancing the development of a therapeutic third culture.
2. An understanding of the patient’s spirituality or, perhaps in a more overarching fashion, his or her worldview can increase a patient’s interest in utilizing medication or psychotherapy.
3. At times patients may have a specific religious proscription against using medications and/or a specific form of psychotherapy.
4. Although a patient may not have immediate spiritual opposition to a specific treatment recommendation, on an unconscious level the moral codes and values by which the patient was raised may still be active or hesitancies being voiced on the web or other popular cultural media may be active, resulting in concerns regarding a specific treatment.
5. Spiritual crises can precipitate psychiatric symptoms.
6. Spiritual explorations may uncover rigid and damaging beliefs.
7. Spiritual explorations may uncover rich arenas for psychological growth and support.
8. An exploration of a patient’s framework for meaning may help to instill resiliency and hope.
9. An understanding of a patient’s worldview can provide critical information regarding suicide risk.
10. Spiritual explorations may help short-circuit cultural/spiritual practices that could interfere or disrupt the healing process.
Handling Countertransference Regarding Spirituality and Worldview
Self-Disclosure Regarding Spirituality: Uses and Cautions
A Caveat on Self-Disclosure Pertaining to Cultural Diversity
Should a Clinician Self-Disclose Religious Affiliation in an Initial Interview?
What to Do if a Patient Asks, “What Is Your Religious Background?” or “Do You Believe in God?”
How to Sensitively Raise the Topics of Spirituality, God, and Goddess
Indirect Methods for Raising the Topic of Spirituality
Griffith and Griffith’s Three Indirect Strategies
1. Sometimes patients will spontaneously use words, sometimes as points of emphasis (or even as a point of jest), that indirectly suggest a religious heritage.
2. Sometimes patients may betray significant current religious issues and/or past concerns by showing a shift in affect when mentioning a religious issue in passing.
3. If a patient brings up a religious or spiritual parable or metaphor that is common to a particular religion and/or spiritual tradition of which the interviewer has cultural awareness (cultural literacy), one can use this as a gateway for further exploration.
Indirect Exploration via Existential Questions
Direct Methods for Raising the Topic of Spirituality
Conclusion and Final Clinical Illustration
References
21 Vantage Points
Exploration of the Attentional Vantage Points
Looking at the Patient
Looking With the Patient
Somatic Empathy
Deep and Surface Structure
Counterprojective Statements
Looking at Oneself
Looking Within Oneself
Intuitive Reactive Responses
Associational Responses
Transferential Responses
Fantasy
Exploration of the Conceptual Vantage Points
Assessment for Psychodynamic Psychotherapy
Recognizing the Developmental Level of the Patient’s Defense Mechanisms and Sense of Self
Gauging Therapy-Facilitative Characteristics
Using Interpretive Questions to Test for Psychodynamic Readiness
Structural Interviewing of Kernberg
Illustration 1
Illustration 2
Illustration 3
Intuitive Vantage Point
References
22 Motivational Interviewing (MI)
Introduction
Motivational Interviewing
Introduction to Motivational Interviewing
Definition
Spirit of MI
Development of MI
Core Principles and Techniques of MI
Four Guiding Interviewing Principles
1. Resist the Righting Reflex
2. Understand and Explore the Patient’s Motivations for Change
3. Listen With Empathy
4. Empower the Patient
OARS: Pivotal Interviewing Techniques for Applying the Principles of MI
Asking Open Questions
Cautionary Note
Affirming Responses
Affirmations Created by the Interviewer
Affirmations Created by the Patient
Reflective Listening
Deconstructing “Reflective Responses”
Summarizing
The Four Processes of Motivational Interviewing
Process #1: Engaging
Process #2: Focusing
Focusing Utilized in the Opening Phase of the Interview
Focusing Utilized in the Closing Phase of the Interview
EPE: Elicit – Provide – Elicit
Step 1 – Eliciting Permission
Asking Permission
Exploring Prior Knowledge
Querying Interest
Step 2 – Providing Information
Step 3 – Eliciting Feedback on the Information Provided
Process #3: Evoking
Ambivalence, “Change Talk,” and “Sustain Talk”
Discrepancy
Process #4: Planning
Putting It All Together: An Illustrative Dialogue
The Bridge to Improving Medication Interest and Use
References
23 Medication Interest Model (MIM)
Introduction
Part 1: “Nonadherence” – More Than Meets the Eye
Extent of the Problem
Nonadherence: The Nature of the Beast
Part 2: The MIM – Development and Roots
Development of the MIM
Roots of the MIM
Pulling on Clinician Wisdom
Pulling on the Wisdom of Educational Theory and Research on Clinical Interviewing
Part 3: The Spirit of the MIM
Collaborative Exploration: The Transformative Engine of the MIM
The Truth About So-Called Medication “Nonadherence”
In Search of a New Word
Part 4: The Choice Triad – The Foundation of the MIM
Part 5: Practical Interviewing Techniques and Strategies for Enhancing Medication Interest and Use
Building the Medication Alliance: Toolboxes for Collaborative Exploration
Section 1: Toolbox for the First Prescription
The Medication Passport
Follow-Up on Uncovering the Patient’s Medication Passport
The Past Prescribers Passport
Introducing Your Personal Approach to Using Medications to the Patient
Section 2: Toolboxes for the Three Steps of the Choice Triad
Toolbox for Step 1 of the Choice Triad
Wisdom From a Past Century
Techniques for Uncovering the Patient’s Priorities for Symptom Relief
What to Do When Patients Do Not Believe They Have a Mental Illness
The Diagnostic Passport
The “Heading for Common Ground” Strategy: A Practical Approach When Patient and Clinician Disagree About Diagnosis
Toolbox for Step 2 of the Choice Triad
Tying Medication Use to Achieving Positive Life Goals
What if the Disorder Has No Symptoms?
Toolbox for Step 3 of the Choice Triad
Where Does the Patient Weigh the Pros and Cons
Uncovering the Patient’s Pros and Cons on Axis #1: Efficacy
Opening the Door to a Medication Interest Discussion
Addressing the Patient’s Concerns About Dosage: An Invitation of Sorts
The Subtle Art of Exploring Side Effects
How to Present a Medication When One of the Potential Side Effects Is Death
Questions for Uncovering Positive Effects of Medications
Uncovering the Patient’s Pros and Cons on Axis #2: Cost
Techniques for Addressing Financial Costs
Techniques for Addressing Psychological Cost
The Hidden Cost: Inconvenience
The Tragic Cost: Disruptions in Relationships
The Lost Goals Cost
Uncovering the Patient’s Pros and Cons on Axis #3: The Soul of the Pill – Symbolic Meaning to the Patient
Addressing Concerns About Personal Weakness
Addressing a Compelling Paradox Arising With Remission
Questions for Ascertaining the Patient’s Ongoing Views About Continuing Medications
Exploring the Choice Triad: the Importance of Sequence
Section 3: Specialty Toolboxes for Difficult Clinical Challenges
Toolbox for Assessing the Patient’s Actual Medication Practices
Toolbox for Assessing Cultural Influences Upon Medication Interest
Assessing the Influence of Other Healers
Uncovering Cultural Biases About Medications
Caveats Concerning the Use of Generics
Toolbox for Assessing the Impact of the Web and Other Media on Your Patient’s Medication Interest
Toolbox for Assessing the Impact of Friends and Family on Your Patient’s Medication Interest
Toolbox for Medicating an Angrily Escalating Patient Involuntarily
Conclusion to the Book
References
Appendix I An Introduction to the Facilic Schematic System – A Shorthand for Supervisors and Supervisees (Interactive Computer Module)
Background and Foundation
Making a Longitudinal Facilic Map: Tricks of the Trade
Making a Cross-Sectional Map
Interactive Exercises for Consolidating the Understanding and Use of Facilic Shorthand
Exercise #1
Directions
Exercise #1: Interview With Answer
Answer to Exercise #1
Discussion
Exercise #2
Directions
Exercise #2: Interview With Answer
Answer to Exercise #2
Discussion
Exercise #3
Directions
Exercise #3: Interview With Answer
Answer to Exercise #3
Discussion
Exercise #4
Directions
Exercise #4: Interview With Answer
Answer to Exercise #4
Discussion
Exercise #5
Directions
Exercise #5: Interview With Answer
Answer to Exercise #5
Discussion
Exercise #6
Directions
Exercise #6: Interview With Answer
Answer to Exercise #6
Discussion
Exercise #7
Directions
Exercise #7: Interview With Answer
Answer to Exercise #7
Discussion
Exercise #8
Directions
Exercise #8: Interview With Answer
Answer to Exercise #8
Discussion
Exercise #9
Directions
Exercise #9: Interview With Answer
Answer to Exercise #9
Discussion
Exercise #10
Directions
Exercise #10: Interview With Answer
Answer to Exercise #10
Discussion
Exercise #11
Directions
Exercise #11: Interview With Answer
Answer to Exercise #11
Discussion
Exercise #12
Directions
Exercise #12: Interview With Answer
Answer to Exercise #12
Discussion
References
Appendix II Annotated Initial Interview (Direct Transcript)
Annotation:
Start of Interview
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Annotation: (2)
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Annotation: (7)
Annotation: (8)
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End of Interview
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Appendix III The Written Document/Electronic Health Record (EHR): Effective Strategies
Appendix IIIA Practical Tips for Creating a Good EHR/EMR Document
History of the Present Illness
Narrative Summary and Formulation
Assessment of Suicide and Violence Potential
Appendix IIIB Prompts and Quality Assurance Guidelines for the Written Document
Prompts for the Initial Clinical Assessment
Quality Assurance Guidelines for the Written Document
Appendix IIIC Sample Written Assessment
Initial Clinical Assessment
I Identification, Chief Complaint, and Reason for Referral
II History of the Present Illness
III Past Psychiatric History
IV History of Substance Abuse
V Past Social and Developmental History
VI Current Social History
VII Family History
VIII Medical History and Review of Systems
IX Mental Status Examination
X DSM-5 Diagnosis
Psychiatric Disorders (Excluding Personality Dysfunction)
Personality Disorders
Medical Disorders
XI Narrative Summary and Formulation
Appendix IIID Sample Initial Clinical Assessment Form