AN OVERVIEW OF THE INTERVIEW PROCESS CHAPTER 6 Uzm. Psk. Özlem Ataoğlu

There is no one – way direction in clinical interviews, with every new patient you have to re – organize your interview progress However, there are some core parts of every interview which we will discuss in this section Beginner interviewers are stressed about doing the right thing at the right time Experienced interviewers, on the other hand, doing and thinking all of the things at the same time

All of the routine things we do in our daily lives, we do them comfortably because they are practiced a lot We will look at the unspoken rules of the clinical interviewing

STRUCTURAL MODELS According to Shea an interview includes Introduction Opening Body Closing Termination ** This general model can be applied to all of the sessions – crisis interview, intake interview, psychotherapy sessions, etc.

According to Foley & Sharf you should Put the patient at ease Collect information Maintain control Maintain rapport Close the interview

According to Ivey & Ivey during the interview you should Establish rapport Collect information, define the problem and the resources Identify the goals Discover the alternatives by eliminating the client – patient incompatibilities Encouraging the patient to apply alternative beliefs and skills in real life situations

During intake interviews and therapy sessions, we do them all together At the beginning of the interviews, let the patient decide the pace By this way, you will be able to collect all of the cues, your patient feels in control and comfortable You are responsible for the topic change, check the time, to be sure whether you have covered all of the important points At the same time, you have to be flexible and planned

The Introduction The introduction part starts with the first time the patient and the client sees (or talks to) each other, ends when s/he is asked the reason of consultation It is the part which we ask for personal information We also try to ease the patient at this part

Telephone contact The therapeutical relationship starts with the first contact so arranging an appointment actually is the starting point of the introduction part You or your secretary can do this Arranging the appointments, phone calls, filling the forms, greeting the patient in a warm way will all lead to relaxation of the patient and creation of a strong therapeutic bond

The information about session fees and payment procedures, session lengths, etc. can be given by your secretary, can be handed in or can be given orally at the beginning of the interview Either way, the important thing is the quality of your contact

Arranging the first interview session is done by both of the parties’ will/effort Arranging an interview can be really easy with some patients and can be really hard with some others Your job is to be sure and clear about your available times You have to clear your status and job title with your patient You need to ask whether the patient knows how to get your office, if not you have to clear it for him/her Ask about the available times of your patient. If your program is too busy, you may offer your vacant hours

You do not have to explain why you are not available at times the patient requests Repeat the arranged interview date and time again, get an approval, tell what the patient should do when s/he arrives to the clinic

Face – to – face meeting Since the waiting lounges are crowded and you have to be careful about the confidentiality, your secretary can direct you to your patient, describe the patient. You can go towards your patient, have a contact by telling his/her name and introduce yourself, shake hands, direct your patient to your interviewing room Since seeing a therapist can be stressful to most of the people, it is a chance for you to follow your patient’s cues of how s/he is coping with stress/anxiety/tense

Generally we do the same rituals before we start the session in order to create stability, predictability What is done generally is – greet your patient, shake hands, offer something to drink, talk about something neutral This standards will eliminate your patient’s anxiety and you will be able to connect the dots of your patients’ reactions to the same greeting style

Although we generally use standard greeting rituals, it can vary depending on your patient’s pathology/personality How you address your patient is also a sensitive area, you should consider their social group, age, status, etc –the ground rules If your patient is middle – aged, for instance, s/he will probably wanted to be addressed as “… Hanım/Bey” It also depends on your patient’s pathology If you are not really sure about how to address him/her, you can always ask and check their claim – this is a sign that you respect to their preferences

Establishing Rapport It can be referred as having a harmonious connection between you and the client – acceptance of differences, bonding, warm relationship We work with different patients with different backgrounds HOWEVER we need to have a standard ritual of reactions (for predictability and stability) and our reactions should be humane Start your session with the confidentiality issues and you may talk about how it is hard to know a person  it is standard but you are still sincere and emphasize the limits

Your patient will probably have anxiety, fear and doubts about sessions and about you and have a lot of questions in their minds It is not possible to ease all of them all of a sudden within the same session – this is normal What you should do is try to create a positive relationship with your patient You are perceived as an authority by the patient. So they will expect the same behaviour patterns as in their repertoire and have a relationship with you accordingly - observe

Even if you like this power – DO NOT USE IT on your patient explicitly Try to use this power to create a bond and show collaborative behaviour patterns. To do this: Give information Show collaboration Ease them Give assurance

Avoid from giving general and early assurance  create an impression of your biases, show that you are bossy The best thing to do is to create a room that will not make the patient feel awkward or isolated or not to know what to do You can say “Sizin gibi gelen pek çok kişi de benzer kaygıları yaşıyorlar, bu da gayet normal aslında çünkü ikimiz de birbirimize yabancıyız. Zamanla bu kaygılarınız geçecektir, merak etmeyin.” and give information about the first intake interview process

Conversation and Small Talk Make short, informal chit chats with the patient – relaxation techniques Interviewer who can easily eliminate their patients’ tense are the ones who can read their unspoken words – they are sensitive and flexible, do not insist on rules You can talk about traffic, weather, whether they have found the office easily, daily news, etc. Do not talk about your patient’s personal issues (clothes, where they live, hair style, odor, etc.) – however you can use differences in these areas later on your therapy sessions as a therapy agenda Do not emphasize your similarities – it is not an area of sociability

Educating the Patient and Evaluating their Expectations Even though your patient has been signed informed consent, you should talk about confidentiality rules again You should be clear about your confidentiality rules, ask whether your patient has any questions about these rules If your patient asks many questions about this, s/he may have trust issues (which you can discuss later on your sessions) or may have suicide or homicide thoughts The situation does not matter – you have to be HONEST

If you are under supervision, declare this and its reasons Give the reasons and goals behind the interview You should not say “Neden burada olduğumuzu bildiğimize göre sizi buraya getiren sebeplere geçebiliriz.”  it destroys the chance to create a relationship, be clear about this Your explanations depend on the type of your interview – give information about what will happen during the session Try to see whether your goals of your session overlap with your patients’. If your patient understands the goals and feels free to ask questions, it will make it easier for you to progress

The Opening It starts with the questions about the patient’s concerns, then you may specify your questions and direct the patient The opening part is non – directive, the interviewer uses basic listening and action skills, encourages and opens a gate for the patient to talk about the problems While doing this, observe the patient and create pre – diagnoses/inference

The Opening Sentence It means that the chit chat, introduction and confidentiality part is over. It is the first question what did lead him/her to look for a psychotherapy process/psychotherapist. “Bugün sizi buraya (terapistle görüşmeye/terapi almaya) getiren sebep neydi, bahsedebilir misiniz?”, “Randevu alırken durumun aciliyetinden bahsetmişsiniz, oldukça önemli olmalı sizin için. Buyrun, sizi dinliyorum.” Bugün  there is a reason behind the timing of your consultation Buraya/Terapistle görüşmeye/Terapi almaya  it is not an ordinary thing we do everyday in our lives. makes it easy for the patient to talk about the problem Getiren sebep  tell me about yourself and which area of your life you would like to talk/change Bahsedebilir misiniz/Buyrun, sizi dinliyorum  i am interested in your problems and gives the message that you, as a patient, are responsible for talking about yourself

The Opening Reaction The first reaction from the patient to this open – ended, non – directive question will give us information about the personality dynamics S/he may be prepared and without hesitation, starts to talk about the problem areas It is advantageous because the patient is direct, organized, able to talk about the problems, knows the problems and the reason why s/he needs a professional help It is disadvantageous because the patient is ready to answer all of your questions, can be realistic and informative but also means s/he is using defense mechanisms which is way distant than emotions. In an ideal interview  we want to surprise the patient so that we can collect the real reactions

S/he may show hesitation to start talking about the problems with this non – directive question You may get these kind of reactions: “Nereden başlayayım?”, “Ne anlatmam lazım?”, “Nasıl ifade etmem lazım, bilemiyorum.” When you get these kind of reactions, stop and give some more time to your patient to struggle  a good chance to observe your patient, again. can show that how much they need support to open up themselves. can give a chance to reorganize their attitude towards you Then give emotional support  “Bir anda kendini anlatmaya başlamak zor olabilir.”, “Problemlerden bahsetmek zorlayıcı/sıkıntı verici olabilir.” Then you may add more concrete questions  sometimes we benefit from this

Evaluate the patient’s verbal behaviours If your patient is too talkative, you should be ready to interrupt the patient and ask more close – ended questions You need to catch whether you patient is internalizing or externalizing the problems Regardless of your patient’s predisposition – s/he is right AND wrong at the same time Problems are because of both personal factors and situational factors. At this point, we need to make sure our patient has understood – the problems are because of both inside and outside factors In a positive, gentle and constructive way, give the message that you need to accept your own responsibilities over the problems and focus on your own emotions, beliefs, and behaviours

Be careful about the followings: We need more than first few sentences to generate a hypothesis on our patients but give a general idea about the patient attitude Be careful about the followings: Is the patient able to express him/herself directly and consistently? Is the first reaction too organized? Does the patient has a difficulty with the non – directive question? If experiences a difficulty, what is the reason? (more concrete, anxiety, talks in a complicated way?) Is the speech normal or do you feel any awkwardness? Internalizing or externalizing the problems?

The Body It focuses on collecting information from the patient about the problem areas. What you will focus on and the amount of it depends on the interview’s goal (whether s/he is a good candidate to work with, differential diagnosis, crisis intervention, etc.) This is the part where you do case formulation, catch the information, know your patient, direct your patient to talk about some specific areas in a more detailed way

It is too risky to make inferences from one clinical interview however sometimes it is expected you to make a judgment and decision  at that point you have to be target – oriented In order to differentiate normal, healthy emotional and psychological functioning from abnormal and nonfunctioning, some references have been created  DSM – V (The Diagnostic and Statistical Manual of Mental Disorders), ICD – 10 (The International Classification of Diseases) Depending on these references, you also need to consider your clinical judgment

If a behaviour/pattern/experience is rare and untypical, it is considered as abnormal/psychopathological/behavioural disturbance When you compare these to the references (statistically normal), you may start to evaluate your patient as abnormal HOWEVER it dos not mean that something rare is abnormal, not necessarily How do we differentiate? You can ask whether your patient is disturbed from this behaviour. “Peki bu sizin için bir sorun mu?” Also, you may ask whether they are experiencing some relational problems with other people: “Peki bu davranış/durum yakınlarınızla hiç problem yaşamanıza sebep oldu mu?”, “Yakınlarınız bu konuda ne düşünüyor?”, “Bu yüzden yakınlarınızla tartışma yaşadığınız hiç oldu mu?”

Repetitive behaviours that lead the patient feel obstructed and/or uncomfortable; continues to think about beliefs that give disturbance; experiences negative emotions  has mental and/or behaviour disorder Probably those dysfunctional behaviours, emotions and beliefs has a function in your patient’s life BUT mostly they are negative and dysfunctional patterns and expectations

You should be careful about these steps while deciding abnormality: Is this feeling exaggerated/abnormal/too much for this situation? Does it give disturbance to the patient? Does it give disturbance to other people around the patient? Does it affect the patient’s functionality areas? Is there a relation about a specific event/cultural pattern that leads the patient feel this way?

INTERVENTION Gives a chance to apply the techniques for a change The ideal is to move intervention after you have collected enough information about the patient However, especially when you progress during the therapy sessions, it is very likely to come up with new areas to work on  this means you will need to collect information So, sometimes you need to collect information and do intervention simultaneously

The Closing You need to be careful about the timing, if your body part takes too long, you may feel an urge to end the session which may look like rudeness The patient will have an anxiety about the things you tell, how effective they are, how effectively s/he has expressed him/herself, the worse feelings, etc.  you need to have an amount of time to wrap all of these things

Giving assurance and support They need a support to hear their effectiveness while expressing their feelings/problems You can say “Bu kadar kısa bir zamanda kendinizden bahsetmek genellikle çok zordur, bunu çok iyi yapabildiğinizi düşünüyorum.”, “Bunları benimle paylaşmış olmanızdan dolayı teşekkür ederim.”, “Pek çok zorlu ve kritik alandan bahsettiniz.” This means that you are supporting your patient and his/her efforts

They may also feel anxiety, fear, hope about the interview They may also feel anxiety, fear, hope about the interview. You need to give support about the decision of getting a professional help You may say “Bir terapiye başlamak ya da bir psikologla görüşmeye karar vermek çok zor olabilir. Bu kararınızdan dolayı öncelikle sizi tebrik etmek istiyorum. Sıkıntılarınız gerçekten tek başınıza baş edebileceğiniz boyutu aşmış olabilir. Fakat buraya gelme kararını almanız bile bu konuda güçlü olduğunuzu gösteriyor.” Even if your patient did not express all of the problems explicitly, you still need to support them by telling “Kendinizi açmanın zorluğunun farkındayım. Fakat zamanla, birbirimizi tanıdıkça bunun daha kolaylaşacağını umuyorum.”

Summarizing the important themes and topics The important thing here is to make the patient request for a second appointment and get an approval from the therapist The best thing you can do is to summarize the problematic areas very systematically and address the reason why they need a professional help to solve them You can give information about how you can progress according to their complaints/goals

Early comments If you comment, give the possible reasons behind the complaints, explain some critical points, give information about the formulation, you will catch the patient and create curiosity You want to create insight about the topics you have covered You need to be open, clear, sensitive, direct and cautious while you are giving feedback and creating insight Before you start this feedback, get an approval from your patient  “Şimdi eğer sizin için de uygunsa görüştüklerimizle ilgili birkaç şey söylemek, fikirlerimi paylaşmak istiyorum.” For example  “Perfectionism”

Create a collaborative treatment plan While you are creating your treatment plan, you need to share this with your patient, explain the rationale behind this plan and go together Giving hope Summarizing and giving feedbacks can be disturbing for your patient. You need to give some hope that psychotherapy will probably solve their problems and how you can do this: “Terapinin size faydalı olacağına inanıyorum, burada konuştuklarımızı hayatınıza uyguladığınız sürece sizin de iyi sonuç elde edecek danışanlardan biri olduğunuzu düşünüyorum.”

Directing and strengthening the patient Since this point you have asked some questions, your patient talked about him/herself, you made inferences  sounds really disturbing! Before you close the session, you can ask your patient whether s/he has any questions to ask. “Benim sormayı atladığım veya sizin önemli bulduğunuz, bundan da bahsetmem gerek dediğiniz bir konu var mı?”, “Bana seanslarımızla ya da kendinizle ilgili soracağınız bir şey varsa cevaplayabilirim.”, “Görüşmemiz sizin için nasıl geçti?” Clear the unknown Talk about whether you will progress or not. If yes, then plan the sessions

The Termination Sometimes it is really hard for your patients to end the session. Some of them avoid emotional contact, some of them cannot leave your room, sometimes you may observe serious emotional breakdowns  this gives information about patient’s pathology, as well It gives information about how your patient will behave when you come to an end, how they react to separation, personal areas and the conflicts

Tracking the time You need to control your time in order to spare enough part for your closing. If you run out of time and are in a hurry, this will probably affect the closing part During the termination time, observe your patient because they will behave/feel/think in a certain way that give information about therapeutic field, psychopathology and diagnosis

Directing and controlling the termination Some patients do not want to leave the room. You may start with giving cues with body language and then end the session If the patient wants to end the session early, it may be because they felt anxious about something or ignoring an important topic Still, you need to talk about this with your patient to eliminate incompatibilities or reveal the “problem” Face with the termination How we terminate the session actually depends on our character and how much we are sure about our expertise You need to be a model, as well, while you are ending the session  live a real world sample within the session. You cannot know everything, you cannot be everything, you cannot be always there for your patient and you cannot have extra time for your patient’s difficulties You have to show resistance against all flexibility attempts. This may be because of your patient’s pathology (feeling special, no boundaries, separation issues, bonding problems, etc.)