THE

PSYCHIATRIC INTERVIEW

Ian Stevenson
 e-Book 2015 International Psychotherapy Institute

From American Handbook of Psychiatry: Volume 1 edited by Silvano Arietti

Copyright © 1974 by Basic Books

All Rights Reserved

Created in the United States of America

Table of Contents

THE PSYCHIATRIC INTERVIEW

What the Psychiatrist Wants to Learn

The Physician-Patient Relationship

The Optimal Attitude and Behavior of the Psychiatrist

The Technique of Interviewing

Guiding the Interviewer Toward Significant Topics

Bibliography

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 THE PSYCHIATRIC INTERVIEW
Ian Stevenson

The psychiatric interview as practiced in most American psychiatric

facilities has undergone a marked change during the past 60 years. Formerly

a question-and- answer type of interview satisfied the requirements of

psychiatric interviewing, as it did and still does satisfy those of medical

history-taking with regard to exclusively physical illnesses. But the modern

psychiatric interview, although it includes questions, puts much more

emphasis on a free-flowing exchange between the psychiatrist and the

patient. This alteration in our practice has resulted from changes in the kinds

of information we want about patients and in our ideas of how we can best

obtain this information. We also have learned the limitations of verbal

communications. We now notice not only what the patient says but also his

manner of saying it, for this may show what his words conceal. And we have

learned that, when two people talk together, what they say depends not only
upon what they want to tell each other but also upon what they think about

each other. In what follows I shall discuss first the information a psychiatrist

usually wishes to obtain in an initial interview, next how the psychiatrist’s

relationship with the patient influences what the patient tells him, then the

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 psychiatrist’s optimal attitude, and finally some techniques that can increase
the yield of an interview.

Both the theory and technique of psychiatric interviewing receive

attention from American research psychiatrists, although not as much as they

should. We may hope that from their efforts will emerge changes fully as

great as those that the last 60 years have brought. This will require, among
other things, that each of us challenge constantly his own habits and remain

unwilling to practice, for the rest of his lifetime, only whatever his teachers

have taught him.

I shall discuss the psychiatric interview chiefly with regard to the initial

evaluation of a patient. Sometimes we can achieve this in one interview, but

quite often we need several. Moreover, the initial interview or interviews

should blend with the psychiatric examination. Chapter 54 discusses the

psychiatric examination and the methods of including part of the examination

in the psychiatric interview and of making a transition from the interview to

the more definitive examination.

What the Psychiatrist Wants to Learn

The psychiatrist should obtain first what the patient usually most wants

to give, namely, a description of his symptoms and the story of their onset and

progress. After this the importance of life stresses in precipitating mental

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illness requires a detailed review of the patient’s current environment. The
discussion of this can lead easily into talk about the patient’s early

environment and thence toward his family history. From this may naturally

follow an account of the patient’s own earlier life—his personal history.

Most psychiatrists understand the importance of eliciting this material

in initial interviews, and only two items deserve further emphasis. First, much
importance must be attached to a detailed account of the patient’s symptoms.

We should try to imagine what the patient has experienced and now

experiences. We should try to see the world as he sees it, but we can do this

only if we let him talk to us in great detail. Moreover, many psychological

symptoms require study not only as direct experiences of the patient but also

with regard to the purpose they serve the patient in adapting to other people

or to other forces within himself. In short, we enter into detail so that we may
know both what functions are disturbed and how these functions relate to

others. Second, the study of the patient’s current environment must be

emphasized. Although we all recognize the importance of major life stresses

in precipitating mental illnesses, we often neglect, to our and the patient’s

disadvantage, the careful study of how the patient lives. Only by entering into

his daily life, as it were, can we come to appreciate the subtle but

cumulatively powerful relationships between the patient and others close to

him. And usually only such an appreciation will permit us to dissect the
respective contributions of the patient and those around him to the strain he

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experiences.

While listening to the history, the psychiatrist should not only attend to
the bare facts of peoples, places, and events as chronicled by the patient; he

must also study the meaning of these events for the patient and the attitudes

that the patient showed to them then and, if those have changed, the attitudes
he now shows toward them. In studying attitudes the psychiatrist must

include, in addition to the patient’s words, observations of the patient’s

emotions.

We have also another important reason for observing the patient’s

emotions as he talks. The psychiatric interview begins and includes much of

the psychiatric examination. The patient’s recital of his complaints and his
history contributes valuable data about the illness. But that illness is a

product (in most instances) of the action of stresses on sensitivities. The

psychiatric interview should therefore study the special sensitivities and

vulnerabilities of the patient. As the patient talks, the psychiatrist should scan
him and his remarks for signs that certain events or topics are of special

importance to him. The signals that reveal such events or topics deserve a

brief review.

One may ask the patient directly about the events, people, and thoughts

that bother him most. More often than is usually done, we should ask for this

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information directly. At the same time we should remember the frequent,
almost invariable, inability of patients to give a frank and complete answer to

direct questions. In studying physical illnesses we can ask patients about the

occurrence of nausea bloody stools, or swollen feet and usually expect

reasonable and valuable answers. But we cannot ask a patient to tell us about
his marriage, his parents, or his employer and expect that the words he

returns us can alone contain all we need to know. Several factors are

responsible for this difference. In the first place our society strongly
emphasizes the importance of other persons having a good opinion of us. For

psychiatric patients this becomes especially important, since they usually

think poorly of themselves and have become doubly dependent upon

approval by other people. When a patient finds himself in a psychiatrist’s

office, he has additional reasons for winning and preserving the favorable

opinion of the psychiatrist. Consequently with his words he attempts to

portray himself (unless he is very depressed or self-effacing) as a person who

is in all respects lovable and “normal.” Second, even the patient with the

greatest candor has within himself large and important aspects of mind and

behavior that lie quite outside his awareness. With the best will in the world
he cannot tell us what he does not know about himself. And finally, even if he

knew much more than he does, words would still furnish only a feeble

channel for the communication of life’s richest experiences, both of suffering

and of happiness.

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 The psychiatrist needs to remember also that what the patient tells him

about some past event or experience, even a rather recent one, may not

correspond closely with the facts, if they could be ascertained, or the

memories of other persons, if they are interviewed about the same events.

Investigations of memories have shown them to be much less stable than was

at one time thought true.’ A person’s account of his past given at one time may

differ markedly from his account of the same events given at another time.
And some events are remembered more accurately than others.

Despite these limitations of verbal communications and memories, the

psychiatrist can use certain valuable clues provided by the patient to guide

him toward at least some of what he wants to learn. These clues lie in the

various signs of emotion shown by the patient as he talks, for our most

important experiences become bound to emotions, or, more accurately, they

become important because they affect us deeply.

Emotions show themselves in many and sometimes unexpected ways.

The patient’s arrangement and manner of presenting his verbal statements

reveal much. The psychiatrist should note what the patient says first (both at
the beginning of an interview and subsequently in response to questions),

what he talks about most, what he returns to many times, and what he omits

or glides over quickly. Thus the psychiatrist needs to learn what the patient
especially wants to talk about and what he especially wants to avoid talking

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about. Unusual speed of speech, hesitations, blockings, amnesias, and
confusions all deserve attention as signs of emotion and, hence, clues to the

significance of events or topics. The order of the patient’s remarks deserves

attention, and especially the connections of thoughts associated in one

sentence or adjoining ones. Verbal associations betray affective links.

The psychiatrist should notice changes in the pitch and timbre of the
patient’s voice as he talks. Such changes express alterations in the tensions of

skeletal muscles, of which many other indications can appear in the patient’s

face and limbs. Accordingly, the psychiatrist should watch for the play of

emotion in the patient’s face, in the posture of his body, and in the

movements and gestures of his limbs.

Changes in the patient’s viscera deserve equal attention, for emotions

affect the autonomic nervous system as markedly as the central nervous

system. Physiological investigations have shown the occurrence of many

important visceral changes during emotional disturbances. Not many of these

lie exposed to the unaided eye of the interviewing physician. Nevertheless, he

may notice changes in the patient’s breathing and in his heart rate, observed

perhaps in the beat of the carotid artery in the neck. He can notice flushing
and pallor of the face and sometimes perspiration. The patient’s mouth may

dry up, or tears may glisten in his eyes. During an interview emotional
changes may bring on (and sometimes remove) the patient’s symptoms. Thus

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palpitations may occur, or a headache may disappear. A patient with a
psychophysiological skin reaction may scratch a tender spot on the skin when

the conversation touches something tender in his mind. Each patient has his

own special mode of expressing his emotions, almost as characteristic as his

gait or his fingerprints. Some patients, for example, rub their eyes, others

glance swiftly away from the interviewer, and still others swallow whenever

they experience anxiety. The psychiatrist should watch the patient for

characteristic traits especially in the early phases of the interview, partly

because the patient is then usually most anxious and partly because the

psychiatrist can use what he then learns to identify moments of anxiety later

in the interview.

The identification of an important emotion only begins its study by the

psychiatrist. With techniques described later he should try to open a further

discussion of the topic that has evoked the emotion, although he may often

defer this to a more appropriate time. In that discussion he wants to learn in

what way this topic is important to the patient and how it became so. Exactly

what thoughts does the patient have about the event, person, or topic that
causes these strong emotions? The psychiatrist cannot consider that his study

of an emotion is complete unless he has elicited from the patient the details of
the accompanying thoughts. For this he returns again to the patient’s words

through which alone (outside art) the patient can communicate his thoughts.

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 The detection of emotion during the psychiatric interview contributes

to the examination of the patient, which, as already mentioned, starts at the

beginning of the interview and, indeed, cannot and should not be separated

from it. During the interview the psychiatrist has ample opportunities to

examine other aspects of the patient’s mental functioning, as described in

Chapter 54.

A final purpose of the psychiatric interview is the evaluation of the

patient’s readiness for psychiatric treatment and efforts to improve this when

necessary. Since this properly belongs to psychiatric treatment, it is

mentioned here without further discussion. But the psychiatrist should

remember it during his interview. Although his assigned tasks may resemble

those of a juggler keeping five balls in the air, unless the psychiatrist can

include in his technique a study and strengthening of the patient’s motivation

for treatment, he may conduct a superb interview that leads to nothing.

The Physician-Patient Relationship

As mentioned earlier, the patient’s wish to tell his story is frequently

obstructed by his wish to win and preserve the psychiatrist’s approval and

assistance. This interference is experienced by all patients to some degree.

But each patient varies from every other one in the experiences that have led
to this shielding of himself and to other behavioral patterns. And each

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psychiatrist differs from all others in his capacity to stimulate or reduce such
patterns in his patients.

When the patient was a child, like everyone else he learned from

experiences what to expect that his parents (and other people) would do. He

then generalized many of these expectations, first learned with particular

persons, to guide his behavior with other persons. Sometimes his

generalizations guided him correctly, at other times inappropriately. A dog

conditioned to respond to a sound with a frequency of 512 cycles per second

may respond (unless carefully trained) to a range of sound, say, between 475

and 550 cycles per second. The more careful and prolonged the conditioning,

the more discriminating will be the dog’s response to different stimuli. But his

discrimination may weaken under stress or without proper reinforcement. In

much the same way humans may discriminate poorly as well as correctly.

They may respond to physicians as if they were duplicates of their parents.

Such misperceptions on the part of a patient never occur first with regard to
the psychiatrist; on the contrary, they have happened often before and have

contributed importantly to the patient’s difficulties with other people. But the
psychiatrist should especially notice how the patient perceives him, first,

because he can study this directly instead of depending upon observations of

other people and, second, because the patient’s perceptions of the

psychiatrist furnish important clues to his difficulties with other people.

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 The more closely the psychiatrist resembles the significant persons of

the patient’s earlier life, the more he will be likely to evoke the behavior in

which they trained the patient. (The frequency of 512 cycles per second

stimulates the conditioned dog, mentioned above, to the greatest extent, even

though he may respond to a lesser extent to other frequencies. ) Suppose that

the psychiatrist, after studying in advance a portrait of the patient’s father or,

better still, a moving picture sequence, should carefully disguise himself in

appearance and manner to resemble the patient’s father. We could hardly

blame the patient for responding to the psychiatrist-actor as if somehow his

father had wandered into the psychiatrist’s office and sat behind his desk.

After a moment of initial surprise the patient would engage in conversation,

so he would believe, with his father. Now suppose that the disguise has been

arranged very poorly, that, in fact, the psychiatrist has put on a mustache like

the father’s but does not shave his head to a similar baldness or imitate the
father’s gruff voice or smoke cheap cigars. If then the patient still acts as if the

psychiatrist is his father, the psychiatrist would have important evidence of

poor discrimination.

By partially resembling earlier persons in the patient’s life, the

psychiatrist may stimulate the conditioned responses of his patients in many

ways. Each deserves brief mention here and much attention in the interviews.

First, as already mentioned, the psychiatrist’s physical appearance influences

the patient’s responses. The psychiatrist’s sex and age, especially, but other

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features of appearance hardly less, strongly guide the patient’s thinking about

what it will be useful or safe to reveal. Second, the patient responds to the

social role of the psychiatrist as he conceives it. In this he mingles his concept

of the role of the physician. Two features usually blend. Physicians have
authoritative roles in our culture, with power to recommend and execute

drastic treatments or to commit to certain hospitals. This aspect of our work

leads the patient to confuse us with policemen, sergeants, judges, teachers,

and, most important of all, with fathers. But physicians also have a role of

succoring the sick and weak; in this connection a patient frequently achieves

a mental montage of a physician and his own mother. Third, our behavior

may also stimulate in the patient patterns of behavior laid down in earlier

experiences. Some of this behavior derives from our professional work. We

ask questions and so we may remind the patient of his mother, who always
asked her little boy pressing questions, sometimes requiring painful answers,

when he came home from school. However, some of what we do our work
does not require and may indeed be better off without it. Thus suppose we,

like the patient’s mother, have an inordinate preoccupation with sex, and we
question the patient excessively about this. He may then react strongly,

although not necessarily irrationally.

In all these various ways the psychiatrist may evoke behavioral patterns

in the patient that can partly, or sometimes entirely, interfere with that part

of him that perceives the psychiatrist as a helpful expert to whom he should

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tell his story. Patients vary greatly in their capacities to see the psychiatrist as

he is and to avoid confusing him with other people. If the psychiatrist is to

study the patient’s discrimination, he not only must attend to the patient’s

behavior but also must learn as much as he can about himself. If the patient
falsely attributes a mustache to the psychiatrist, the psychiatrist can only

evaluate the possible misperception in this if he can recall whether he himself

has shaved during the last few days. He must know what he himself brings as
stimuli into the interview. He must remember that the patient responds both

to what the psychiatrist does and to what he is.

In this connection it is worth mentioning that even when different

interviewers adopt a somewhat uniform approach in the conduct of an

interview, they may have markedly different effects on different patients. In

drawing attention to this fact, I am not recommending the adoption of a

uniform style in interviewing. This would be as undesirable as it would be

unfeasible. But I do exhort the interviewer to become as much aware as he

can of his own behavior with patients and its differing effect on different

patients.

A physician-patient relationship is clearly not fixed or capable of

permanent description. It is a shifting complex of behavior that includes

changes in both patient and physician. The patient does not necessarily
continue in his misperceptions of the psychiatrist, and his speed of correcting

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them furnishes an important point of prognostic value. During their further
contacts psychiatrist and patient have the opportunity to correct their initial

and frequently false categorizations of each other. If first impressions repel,

they may discover— with the ever fresh pleasure this brings—that each is,
after all, rather a pleasant person once one gets to know him a little. More

often first impressions attract, because each shows socially conventional

behavior. In a new situation our behavior at first tends to conform to the

social roles we believe the situation assigns to us. Afterward, closer

acquaintance may bring to the fore traits at first concealed. For with growing

intimacy there emerge various patterns of behavior learned in the less

uniformly structured experiences of the family. Thus it happens that after a

time the psychiatrist does something or fails to do something that frustrates

one of the patient’s expectations of him, or he may offend the patient in many

such ways. These events he must also study carefully.

The usual initial positive attraction of psychiatrist and patient for each
other is largely sustained by their fantasies of what each can expect from the

other. When the fantasies yield to closer inspection, and when at the same
time intimate behavior begins to replace more formal behavior, the

relationship may weaken. At this point one factor alone saves most physician-
patient relationships from dissolving. In the time taken for the patient’s

irrational expectations of him to collapse, the psychiatrist has a chance to

show, one should not say to display, his real professional competence. Then,

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as the patient learns that the psychiatrist is not what he first thought him to

be—perhaps a doting mother or an eternally patient father—he may discover

that as a helpful physician the psychiatrist can now contribute even more

than the mother or father. This transition from a tenuous relationship based
on fantasy to a firm one based on an experience of competence demands that

the psychiatrist offer the patient something considerably more than he can

find in ordinary social intercourse. The following sections of this chapter offer
suggestions concerning the content of this “something.”

The importance of the physician-patient relationship in influencing

what the patient will tell the psychiatrist and what the psychiatrist should tell

the patient requires that the psychiatrist constantly evaluate this relationship.

He should note how readily the patient talks and all other behavior of the
patient toward him. Psychiatrists notice minutiae of social conduct—for

example, punctuality, hesitancy in smoking, deference in going through doors

—that would and should be overlooked or not noticed at all in other

situations. But in an interview psychiatrists should observe all these items of

behavior as clues to the attitudes that such behavior expresses. The

psychiatrist should also help the patient to use any opportunity that arises to

state what he thinks of the psychiatrist. In initial interviews most patients

cannot achieve much candor in such comments. The psychiatrist can usually

expect conventional formulas. But often, and even in guarded remarks, the

patient may say something revealing and relevant. In drawing out the

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 patient’s thoughts about ourselves, if we press the patient artificially we will

usually only increase his conformity to socially acceptable platitudes. Natural

opportunities will arise, however, that we can exploit. If the patient has

referred himself or chosen the psychiatrist from among several of whom he

has heard, we can ask him, “Why did you select me to consult?” If he

generalizes about physicians or psychiatrists, we can say, “Are you including

me in that?” I shall discuss later the special value and importance of

discussing the patient’s thoughts about the psychiatrist whenever the patient

seems to become unusually anxious.

The Optimal Attitude and Behavior of the Psychiatrist

We should often ask ourselves in what ways we can be of more use to

our patients than even their best friends can be. The difference may lie
principally in the degree to which we show a friend’s helpful qualities and,

most of all, in the tenacity and patience that permit us (and the best of

friends) to sustain a relatively stable relationship with another person over a

long period of time. In addition, four other qualities for the psychiatrist—

interest, acceptance, detachment, and flexibility—are recommended.

For his task the psychiatrist certainly requires interest in the patient

and in his difficulties. This interest can include to a degree the biologist’s

curiosity about the wonders of living organisms, yet we cannot allow

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ourselves to become so preoccupied with the details of morbid anatomy and
physiology that we lose interest in the whole patient. Our specialty

particularly concerns itself with the responses of the whole man. Our interest

should be in the patient and for the patient; it should not pursue, disguised as
diagnostic fervor, our own special predilections and curiosities. We rarely can

entirely prevent these from interfering with our guidance of interviews, but

we can at least strive to become aware of the ways in which our interest in

ourselves may mingle harmfully with our interest in our patients. The interest
we show in patients should include. and chiefly derive from, an attempt to

understand them. Our limited success in this task may matter less than our

efforts to try and to improve. We know that a fumbling medical student may
learn much from a patient in a psychiatric interview. At present there is so

little difference in skill between the worst and the best of us that we must

rank the wish to understand as hardly less important than any understanding

we achieve. At any rate patients respond well to both. Finally our interest
should always include attention to the assets of the patient as well as to his

deficiencies and difficulties. To this aspect of our interest patients also

respond favorably, and with it we may help them to tell us more freely about

their sufferings.

The psychiatrist should next try to reach a capacity for complete

acceptance of his patients. Our profession does not ask that we approve all

that our patients do or abandon our own ethical principles in favor of moral

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relativism. But we do improve our skill when we can accept patients

unreservedly, regardless of what they may say or do that would be quite

offensive in another context. Just how offensive people can be, the

psychiatrist has a better chance than anyone to learn. But he also can learn
more easily just how important it is to all of us to gain and hold the affection

of others despite our shortcomings. Here we can often be of more help than

the patient’s family and friends. Because they frequently have become
alienated by his behavior or their own, so that the patient believes himself to

be without the friends we all need, we should have the deepest reservoirs of

kindness.

If the psychiatrist does surpass the performance of family and friends in

this regard, he often owes his success to the cultivation of a third quality
required in his work. We may call it detachment, separating this sharply from

the aloofness with which it has sometimes been confused. Because we live

outside the circle of the patient’s family and friends, we are not so closely—
and hence so emotionally—involved in the patient’s difficulties as they are.

What the patient does cannot affect us so much. It should affect us somewhat,

or we would not want to help him or be capable of doing so, but it must not

affect us to the extent that the strength of our emotions disturbs our
judgment of the patient in the manner that the strength of his emotions has

disturbed his judgment. His anxiety prevents him from thinking clearly. He

needs a less troubled mind to help him correct his misperceptions and faulty

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reasoning. Here again we can establish maxims more easily than we can

follow them, and for this reason among many, psychiatrists should know

themselves as well as they can.

Every internist taking a history and performing a physical examination

finds that he omits less if he follows a routine order of procedure. The

psychiatrist’s study of his patient should be equally thorough and usually

must be longer. But the psychiatrist cannot afford to impose a rigid form on

his interviews and examinations. Although careful to think and ask about

everything that might relate to the patient’s symptoms or difficulties, he

should not expect always to learn things in the same order. Nor should he

expect ever to learn the same things in every interview, for different

symptoms require different emphases in the discussions. Lack of space

prohibits a review here of some of the common variations in interviewing

that occur with, for example, patients who have depressions,

hypochondriasis, schizophrenia, anxiety states, and psychophysiological

reactions. For these variations alone, flexibility becomes another desirable

attribute of a successful interviewer, but he also needs this quality especially

to reduce the resistances within patients that often prevent their talking

freely about many important topics. Some patients can talk easily about their
wives but dare not discuss their parents. Others may pour out a cataract of

information about their parents and close up like a bank vault when the

psychiatrist inquires about their wives. Many varieties occur in such

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 resistances, but the physician can nearly always count on finding some.

Fortunately time helps the psychiatrist. Talking itself predisposes the patient

to further talking. If the physician yields at first to the patient’s reluctance to

talk about certain subjects and lets him discuss others, he may thus prepare
him eventually to return to the previously avoided material. This is not to say

that the patient should be permitted to seize and retain control of the

interviews. On the contrary, the physician should preserve guidance

throughout and, if necessary, make his guidance explicit to the patient, but he

should not use his skill and power to confront the patient prematurely with

subjects that are seriously disturbing. This can trouble and even shatter the

developing positive attraction of the patient for the physician. The flow of the

patient’s remarks is sometimes delicately balanced between the wish for help

and the fear of injury at the hands of those to whom he gives his confidence. If
he experiences painful emotions too much and too early, his expectation that

he could be hurt may be confirmed (not unreasonably), even though the

interviewer said nothing intended to hurt him. We all turn away, from pain

and often also from those with whom we associate the pain, even when they
have tried to help us. And so the psychiatrist should let things come gently

and naturally, perhaps learning this lesson from skillful obstetricians.

The Technique of Interviewing

Arrangements for the Interview

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 In any interview stimuli reach the patient not only from the physician

but also from the entire setting in which it takes place. The psychiatrist will

find worthwhile a study of the setting of his interviews even if, and perhaps

especially if, he cannot change the setting. Privacy and reasonable comfort for

the patient and the physician are absolutely essential. A separate room best

assures complete privacy, but not if telephones ring and secretaries run in

and out. A public ward, with its chatter and other hubbub, gives more privacy
than a semiprivate room. Bright precinct-station lights should not blind the

patient as he talks. The physician and patient should preferably sit so that

each can look at the other without having to do so continuously if they prefer

not. The psychiatrist should reserve enough time for a satisfactory interview.
In the present state of our knowledge anyone who does not keep at least 45

minutes or an hour for an interview identifies himself as practicing some

psychiatric formula that does not include listening to patients. Brief

interviews may have their place in medicine, surgery, and even in certain

authoritative and directive psychotherapies, but they have no relevance to

diagnostic and therapeutic psychiatric interviewing at its best. (A later section

will discuss reasons for this.) Moreover, one interview, even of the length

suggested, rarely suffices for a thorough exploration of the patient’s

difficulties, and the psychiatrist will usually have to arrange for several

further meetings.

The psychiatrist should always make notes during or after an interview.

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Apart from the value of having some record of the talk, the process of making

notes passes the material through the mind of the psychiatrist again and

thereby adds to his study of it. If he makes his notes during the interview, he

should be reasonably certain that the note taking does not interfere with his
own spontaneity. Some psychiatrists can pass this test, others cannot. And lie

should also be certain that the note taking does not trouble the patient. About

this he should not necessarily expect to hear from his patients, many of whom
will communicate their objections indirectly rather than with words.

In connection with notes and records I shall refer briefly to the use of
questionnaires in eliciting a medical history. Questionnaires can be filled out

by the patient before an interview, perhaps in the waiting room. They often

save time and they provide a valuable check for completeness of the survey of
the patient’s history and condition. They cannot, however, substitute for the

interview, and this for at least two reasons. First, the psychiatrist cannot

usually observe the patient’s emotional responses as he fills out the

questionnaire, and these provide important clues to the feelings and events of

importance. (He may watch for signs of emotion as he discusses the

questionnaire later, but this reduces the time saved, and in any case the

strong emotions usually only come to expression during a fairly free

conversation, not in response to questions.) Second, the psychiatric interview

has other purposes than that of gathering information. It should provide the

beginning of a trustful relationship in which psychiatrist and patient

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 collaborate for the improvement of the patient’s condition. Since

questionnaires cannot replace interviews their main value at present lies in

research and sometimes in supplementing the interview by assuring

comprehensiveness of the topics covered.

Starting the Interview

As patient and psychiatrist meet, the initiative lies with the psychiatrist.
He should introduce himself, lead the patient to his office, offer him a chair,

and start the conversation. One can begin well enough with a brief

introductory statement such as, “I know about you only the little that Dr. X

told me.

So it would be best for you to tell me in your own words what troubles

you.” After this the physician should usually remain silent until the patient’s
first responsive flow has dried up. He can soon tell whether the patient can

talk freely or needs additional help. If the patient does need help the

physician should give it promptly, not letting him bathe in the sweat of tense
silences. Sometimes the patient does not know what he should give in the way

of a history. Since psychiatrists do ask for kinds of information different from

that required by internists and surgeons, the patient may simply need a little

guidance. Sometimes the patient’s anxiety mounts so high that it blocks his
free expression. In that case the physician can channel the conversation into

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 something less painful to the patient. Often he can reduce the patient’s
anxiety by asking questions that free the patient of the fear that he will say

too much and of the responsibility for giving emphasis to important topics.

Later the patient may relax enough to talk freely. If such measures fail, often
the psychiatrist should ask the patient about his anxiety and should suggest

possible origins of it in order to encourage further expression. He can say, for

example, “You seem frightened. Can you tell me what makes you so?” If the

patient still blocks, the physician can suggest, “Perhaps you are afraid of how I
will react to the things you may want to tell me about. Is that so?” The patient

may then respond by verbalizing the origins of his immediate anxiety and can

then continue with other parts of the interview.

Once the patient has begun to talk, the physician’s task consists in
helping him to talk freely and in guiding him to speak about the most relevant

topics. These will be discussed separately, although in an interview they

naturally intermingle.

How to Help the Patient Talk Freely

If the physician has a strong interest in his patients, he can influence

most of them to talk freely, because everyone talks better to an interested

listener than to a bored and reluctant one. The awareness of the psychiatrist’s
interest reinforces the patient’s wish to talk and his conviction that the

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psychiatrist merits his confidences. It may often be difficult to listen without
interrupting. The psychiatrist’s other medical training frequently impels him

to intrude a question about a date or place so that he is sure to know all the

data. Or something the patient says may infect him a little with the patient’s
anxiety or depression. Then he can quite unconsciously deflect the patient

from such sensitive topics (for him more than for the patient perhaps) by

asking the patient about something else. Each little interruption in itself may

seem trivial, and usually is, but each adds to a cumulative effect on the patient
that tells him, “The doctor wants something from me. What is it? How can I

tell him what he wants to know?” When patients become occupied in giving

us the information they think we want, they can easily forget to tell us what
they want and need to say, of which we as yet know nothing. Every time we

let the patient talk as he wishes, we encourage him to say something else that,

perhaps up until that moment, he thought he ought never to confide in

anyone.

In addition to deflecting the patient’s line of thought, the interruptions

by the psychiatrist also tell the patient more about the psychiatrist. There are
advantages to the patient’s knowing rather little about the psychiatrist; the

less he knows, the less he can censor what he says in accordance with the
assumed attitudes of the psychiatrist. This may make for a freer revelation of

the patient himself.

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 Should the psychiatrist then always say and do nothing as the patient

talks? Certainly not. He should say and do whatever becomes necessary to

sustain the patient’s flow and to guide it. Silence may suffice, or it may not.

Sooner or later some further responses become necessary or additionally

helpful. In offering these the psychiatrist may move from silence toward

levels of increasing activity, each designed to emphasize to the patient a little

more strongly his wish to hear more. Thus grunts of “uh-uh” and leaning
forward expectantly stimulate the patient a little more, or sometimes much

more, than silence. If such gestures prove inadequate, the psychiatrist can

questioningly repeat the last word or phrase of something the patient has

said. After this come gentle urgings such as, “What happened then?” “Go
ahead,” and “I’d like to hear some more about that.” Should these fail, and

assuming that the patient knows in general what he should talk about, his

anxiety toward the psychiatrist has probably interfered too greatly. The
psychiatrist should then bring this into the discussion directly, help the

patient verbalize it, and, if necessary, apply appropriate reassurance. Thus he

can begin by saying, “something makes it hard for you to talk to me about this
matter. Can you tell me what it is?” Often the patient will respond

satisfactorily to such leads. If not, the psychiatrist should suggest possible

misperceptions of him by the patient, such as those mentioned above in

connection with reducing initial anxiety.

He can say, for example, “Perhaps you are afraid of what I will think of

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you?” If all such efforts to loosen the patient’s tongue fail, the psychiatrist’s

task usually includes pointing out to the patient his share of responsibility for

their difficulties in talking. The psychiatrist might say, for example, “We have

to work together on this, I’m sure you know. It’s a collaboration between us,
and I can do little for you unless you can tell me more about yourself.” At this

point the psychiatrist may learn of the patient’s distrust about the privacy of

his communications. On this matter and other similar doubts, the psychiatrist
should provide firm reassurance based on actual performance. He should not,

for example, assure the patient that what he learns from the patient goes no

further and then schedule an interview with the patient’s parents without the

patient’s knowledge.

With this repertoire of techniques increasing serially in stimulating the

patient to talk, when should the psychiatrist use his influence? I believe he

usually needs to increase his activity in the following circumstances: to show

his interest, to reduce the patient’s anxiety, to encourage the patient’s

emotional expression, to control garrulity and irrelevance, and to channel the

interview toward topics of the greatest importance. I will defer discussion of

the last two of these to a section on guiding the interview, but the first three

pertain to helping the patient talk freely.

Some psychiatrists have more interest in their patients than they show.
I think young psychiatrists are especially liable to make this error when they

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mistakenly apply in initial interviews the silence that is conventional and
sometimes helpful in certain psychotherapeutic techniques. In attempting to

stay out of the patient’s way, a psychiatrist may say so little as to give the

patient the impression he is mute. Patients have been known to leave some
psychiatrists after one or two interviews because they do not understand

these psychiatrists’ unresponsiveness and become alienated by it. Most

patients have already received training by internists and surgeons in the

question-and-answer method of history-taking. They may misinterpret

excessive silence on the part of the psychiatrist as simply incompetence.

Moreover, previously important persons have often communicated aloofness,

indifference, disapproval of, or even anger toward the patient by means of

silence. The patient may confuse the psychiatrist with these persons, and if so

the interview can perish, or it can become unnecessarily uncomfortable for

the patient as well as less productive, since anxiety interferes with thinking

and with expression. It makes sense, therefore, for the psychiatrist to remain
silent if he can and needs to do no more, but also to offer freely whatever

signs of interest the patient seems to require. He can easily insert such
additional communications of interest often enough with nods of the head,

with “Uh-uhs,” or with simple words such as, “Surely,” “Naturally,” “Of
course,” and “I see.” Words matter less than attitudes. With a friendly attitude

we will find the right words, expressing them in a gentle speech and with a

kind face. The psychiatrist should also offer, from time to time, more explicit

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signs of his understanding of what the patient did or felt with remarks such

as, “I can see how hard that must have been for you,” or “That must have

made you feel better.” Remarks of this kind should articulate what the patient

has rather clearly expressed and should not influence him to agree, against

his own knowledge, with the psychiatrist’s interpretation of events. When the

psychiatrist does not understand what a particular experience meant for the

patient, he should usually inquire further, but when he does understand, if he

will occasionally echo what the patient says he can lubricate the interview.

Experience will teach the psychiatrist the level of anxiety proper with

each patient for a flowing interview. When a patient’s anxiety becomes too

great, the physician should try to reduce it by some of the techniques

mentioned earlier. As already mentioned, excessive anxiety during an

interview usually derives from misperceptions of the psychiatrist as being

more menacing than he is. Anxiety felt by the patient with regard to other
persons drives him to talk, while anxiety felt toward the psychiatrist blocks

his talking. The psychiatrist should generally try to reduce or keep minimal
the patient’s anxiety toward him in initial interviews. Certainly he should note

it and may subsequently wish to allow its full exposure, but if the patient

becomes very anxious with regard to the psychiatrist before a strong

attachment has developed, he may block harmfully or fail to return. Since the

patient nearly always hungers for the psychiatrist’s approval, his anxiety
toward the psychiatrist can often be easily reduced by encouraging and

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praiseful remarks with regard to the patient’s exposition of his difficulties.

For example, the psychiatrist can say, at a moment when the patient hesitates

and looks inquiringly at him, “Go ahead, you’re doing very well. Keep going

the way you were.”

Yet we need to remember also that anxiety can run too low in an
interview. Physician and patient can unwittingly exclude the patient’s anxiety

from expression and agree that he is much better than he (or a referring

physician ) thought he was. This comes about when the human wish to reduce

human suffering urges the psychiatrist to offer reassurance prematurely. In

doing this the psychiatrist deprives himself of the opportunity of tracing the

patient’s anxiety to its specific origins. For example, suppose a patient says,

“Doctor, I think I am going crazy.” To this the psychiatrist can immediately

reply, “Oh, no you’re not. You don’t have the symptoms.” More useful remarks

would be either, “What do you mean by ‘crazy’?” or “What makes you think

you are going crazy?” To such questions the patient may then answer with
details of his anxious thoughts. It then turns out, perhaps, that he thought he

was going crazy because his memory has faltered recently and an aunt who

died in a mental hospital also complained of this at one time. Further

inquiries remind the patient that she was, as a matter of fact, an aunt by
marriage. To such specific details the psychiatrist can then provide specific

reassurance. The best reassurance comes from understanding and

explanation. Patients can usually distinguish reassurance based on careful

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inquiry and explanation from shallow statements to the effect that

“everything is going to be all right.” Their ability to penetrate our weaknesses

in this respect provides another reason for avoiding premature reassurance.

Such reassurance can seal off further exposures of the patient’s anxiety. He
may think to himself, “Why should I tell my troubles to someone who

minimizes them all as my family does?” Moreover, premature reassurance,

when the patient does accept it, tends to promote the patient’s excessive
dependence on the psychiatrist. If we say, “Everything is going to be all right”

(and there may be times and places when we should), we should realize that

we have thereby accepted responsibility for their being so. When we insist

that the patient join us in a careful exploration of his symptoms and

difficulties, we communicate firmly to him our expectation that he will also

share responsibility for his getting well.

We can control the amount of anxiety in the patient rather well by

changes in the amount of talking we do. As the patient talks more and the
psychiatrist less, the patient’s anxiety tends to increase, at least initially,

although after catharsis it may decrease again. As much as possible the

psychiatrist should talk to modify the patient’s anxiety, not his own. To do

this he needs to remember that patients often tolerate silences rather well
and frequently use them to think before speaking. A patient occupied in

telling his story may not even notice silences, and sometimes does not seem

even to notice the interviewer. But if a patient uses a silence to delete some

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repellent thoughts, he usually becomes aware of the silence, and his anxiety

mounts. Then, if the psychiatrist has not prematurely spoken in order to ease

his own tension, the patient will speak to reduce it in himself.

A common dissimilarity between the interviews of interested amateurs,

such as sensitive internists, and experienced psychiatrists exists in the

differing extents to which they permit, encourage, and facilitate the

expression of their patient’s emotions. This being so, we may ask why we

psychiatrists encourage the free expression of emotions. We do it first

because, as I mentioned earlier, emotions give importance to an experience

and at the same time communicate that importance to other people. They

should also communicate its importance to the person himself. And this they

do when the emotions become strong enough. But often patients have not
expressed themselves freely to other people. Consequently the related

emotions may recede somewhat, and the patient may think himself

untroubled by them. Talking brings the emotions to the surface, and if they
become strong enough the patient may be astonished by the extent to which

he has been affected. Patients frequently comment on this with remarks such

as, “I never cry when I think about these things at home, but when I come

here and talk I seem to cry all the time.” This illustrates Sir Charles
Sherrington’s comment that in motor activity talking lies midway between

thinking and acting. And it brings us to an additional reason for encouraging

the patient’s expression of emotions—the therapeutic benefit to him.

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Although this subject properly belongs to therapy rather than to diagnostic

interviewing, the psychiatrist can remind himself that initial interviews begin

therapy by observing the simultaneous benefit for both diagnosis and therapy

of the patient’s freely expressing strong emotions. Moreover, the relief usually
experienced by the patient cements his attachment to the psychiatrist and

makes the patient eager to talk more at the next interview.

This does not always happen. Sometimes patients recoil in anger or guilt

when they find they have talked too freely and shown some emotion they

previously condemned and imagined they could not experience. A patient

may resent the psychiatrist’s hearing him criticize his parents perhaps for the

first time, or seeing him cry, or eliciting the confession of some wickedness.

One cannot easily predict which patients will react in this way. Fortunately
the best safeguards lie within the patients, for those who are most likely to be

hurt by too rapid a release of emotions are those who are most inhibited in

the first interviews. They will require several or many interviews before they
talk freely. But the psychiatrist should still observe the patient’s reaction to

the interview itself and notice whether the patient shows concern about the

things he says and the emotions he displays. Within the patient’s tolerance

the psychiatrist should encourage the patient to express his emotions fully.
Weak emotions, like mild pain, are often of doubtful significance, but strong

emotions tell both psychiatrist and patient alike that they are working in

relevant subjects.

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 Some of the chief techniques for encouraging the patient’s expression of

emotions have already been mentioned. The physician should sustain and

show his interest over at least forty-five minutes or an hour. In brief

interviews the patient rarely has time to overcome his almost invariable

initial reserve. In a ten- minute interview discussion of the weather may take

five; in a fifty-minute interview one can give five to the weather and still do

much besides. In addition, emotions cut grooves for related thoughts of the
same theme, which, in turn, bring stronger emotions to the surface. The

longer one talks about a particular subject, the more emotion accompanies

the evoked thoughts. Fully developed emotions usually occur only in longer

interviews, because shorter ones do not permit this self-fueling of emotions

to occur.

Beyond the requirements of showing interest and allowing plenty of

time, the physician can further increase the patient’s emotional expression by
careful attention to some additional technical points. These are emphasizing

detail in the patient’s narration, reinforcing the patient’s emotion by

communicating understanding of his feelings, and naming the experienced

emotion.

When we tell others about a past experience, we partially relive the

events we tell and partially experience again the emotions we then had. The
extent to which we feel again the old emotions depends upon the vividness of

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reliving. Simple, uneducated people easily slip into a present-tense style of
narration in which they seem almost completely to relive what they describe.

More educated and more controlled patients, on the other hand, tend to talk

in the past tense or to confine themselves to general statements. The

psychiatrist should press the patient to provide specific examples of what he

says. For example, if the patient says, “My father was always mean to me,” the

psychiatrist should ask, “Do you remember that? What do you remember?”

He should frequently ask, “Can you give me an example of that?” or “Such as

what?” Questions of this type oblige the patient to focus on specific events

and, at least partially, to relive them. Moreover, the discipline of documenting

general statements contributes to the patient’s understanding of his own

misperceptions. Once the patient has begun to tell about an incident, the

psychiatrist can easily heighten the portrayal of detail by interjecting

questions that ask for further details such as, “What happened then?” “What

did your father say to that?” and “What did you do after you left the house?”
After a little guidance of this kind the patient will continue to give detail on

his own, partly because he knows what the psychiatrist wants and partly
because he begins to experience the relief of catharsis, which usually only

comes with vivid retelling.

Remembering the influence of the audience on any speaker, the

psychiatrist can increase the patient’s emotional expression by showing

understanding of his emotions and attitudes in the events narrated. This does

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not need to include or imply an endorsement of the patient’s behavior; rather

it implies an awareness that what he then did was natural for him at the time.

Remarks (offered in a questioning way) such as, “So you felt no one was on

your side,” and “At that point you thought your father was trying to control
you,” can tell the patient that he at last has someone to talk to who can

understand him, and so he will want to talk more.

Patients frequently come close to the expression of strong emotions

without quite permitting themselves to reach it spontaneously. Frequently

fears of the psychiatrist’s reaction to strong emotions inhibit them. When a

tear moistens the patient’s eye, the psychiatrist can profitably tell the patient

he has noticed the emotion with a remark such as, “I can see it makes you sad

to talk about this.” Such a statement says to the patient, as it were, “It’s all
right to cry here. Go ahead.” And frequently such little remarks will help the

patient to cry or experience other strong emotions. The psychiatrist gains

nothing if he runs too far ahead of the patient in using this technique. Many
patients have great difficulty in acknowledging and showing anger. If the

psychiatrist too rapidly confronts such a patient with a name such as “anger”

or “rage” for these emotions, the patient may shrink back in horrified denial

that he could house such feelings within himself. In that case, however, the
psychiatrist does not need to retreat all the way. If he finds himself ahead of

the patient and encounters denial, he could still say, “Well, of course, I could

be mistaken, but I think nearly everyone in your situation would have been

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annoyed at what happened to you.” This provides the patient with a hint of

the acceptability of some anger that he may later wish to use.

Although I have emphasized the importance of the patient’s talking

freely, the psychiatrist should retain general control of the interview. Free

talking does not mean unlimited free association. The right of the patient to
say what he wants does not convey also the right to babble on tediously about

irrelevant matters. The psychiatrist has the privilege and even the duty of

curtailing circumstantiality and garrulity. But before he does so he should

first ask himself (and perhaps the patient) why the patient behaves in this
way. There are many reasons, and it is worth finding out which applies.

Sometimes the irrelevant chatter results from a long-standing inability to

think clearly, a form of mental deficiency.

Sometimes it indicates failure of memory, with the patient substituting

an appearance of remembering details for accuracy of recall. Sometimes the

patient talks about something else in order to postpone talking about some
more affecting topic, or to conceal it altogether. This commonly happens in

the description of hypochondriacal complaints in which the patient, by

focusing the attention of himself and everyone else on his heart or stomach,
withdraws it from his marriage or disastrous financial predicament.

Sometimes with such excessive talk the patient tries to communicate covertly
something that he thinks about himself but cannot or dare not articulate

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 explicitly, or of which he may even be unaware. The patient who offers
unnecessary detail may never have thought that his affairs seem less

important to other people than to himself. Or when a patient recounts details

of his previous illnesses and operations in uninvited detail, he may really

want us to know in this way how much he has suffered and needs our

sympathy.

Before cutting off the patient, or while cutting him off, the psychiatrist

should usually inquire about the excessive talk. He can say, for example, “I

notice you spend a lot of time telling me about your past illnesses. I can see

that they are important to you, but I don’t think I understand why. Can you

tell me how they are important to you at this time?” If such inquiries prove

futile to stem the flow of the patient’s irrelevancies, the psychiatrist can then
move gently, but if need be also firmly, to deflect the patient. He can say, for

example, “Perhaps later we can come back to what you are talking about. But

since our time is limited, I wish you would tell me about so and so.” This
brings us to the various techniques for channeling the interview toward

significant topics.

Guiding the Interviewer Toward Significant Topics

As in his encouragement of the patient’s talking freely, the psychiatrist

should guide the interview covertly when possible and only secondarily with

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more open directions. Often he can use the devices mentioned previously for
showing greater interest in a topic of special importance that the patient only

mentions. Thus he can channel the patient into another topic without the

patient’s becoming aware of his influence. But the psychiatrist should be

aware of it. He should know that he is guiding the patient, and for a definite

reason.

All psychiatrists should study carefully reports of experiments that have

shown the profound influence on other persons of systematic utterances (by

an experimenter) of such simple sounds as “Uh-huh.” Such interjections have

been found to influence the number of plural words spoken by a subject told

to say all the words that come to his mind. As the experimenter gives an “Uh-

huh” after each plural word, the subject, even without any awareness of being
influenced, tends to increase the number of plural words he says. An even

greater effect occurs when the subject judges that the experimenter means to

communicate approval by his “Uh-huh.” Similar experiments have shown that

such interjected “Uh-huhs” can influence subjects to give more emotional

responses during an interview and to vary the types of memories recalled.

Now a patient always knows, or thinks, that the psychiatrist wants something,

and he usually wants to satisfy the psychiatrist much more than experimental
subjects want to satisfy psychologists. Consequently, if the psychiatrist

interjects his “Uh-huhs” unconsciously and pursues his special interests in

sex, religion, money, or something else, the patient will almost certainly go

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along with him. Both may find the hour enjoyable, but it may be unrewarding

because of a one-sided emphasis on their favorite topic.

If the psychiatrist’s subtlest signs of increased interest do not guide the

patient to talk more about some significant object, then he may direct the

patient more openly. He should exploit as much as possible the associations

and references already provided by the patient. For example, suppose the

patient says, “My headaches are getting worse every day, and my wife says

she can’t stand it much longer.” The psychiatrist can catch the patient’s

reference to his wife and inquire, “What does your wife say about your
headaches?” This broaches the subject of the patient’s marriage, and other

inquiries and information naturally follow. Sometimes the psychiatrist should

not interrupt the patient in order to pursue an association at that time. This
can interfere with the patient’s flow toward something equally important. But

the psychiatrist can make a mental note of the patient’s remark and return to

it later. He can say, for example, “You mentioned five minutes ago that your
wife couldn’t stand your headaches. Will you tell me some more about that?”

By using the patient’s own references and associations, an experienced

psychiatrist can sometimes conduct an entire and thorough history-taking

interview without ever himself introducing a new topic. Since the patient
seems always to be elaborating further on what he himself first brought out,

he cannot reasonably believe that the psychiatrist has forced him to talk of

things he did not mention.

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 Even with the most skillful use of indirect techniques, the psychiatrist

will at times have to ask questions, bring up new topics, or inquire directly for

further details. Although, as already mentioned, the psychiatrist should

usually defer questions about dates, places, and details of events omitted in

the patient’s initial story, eventually he should ask for whatever facts he

believes necessary to satisfy the requirements of a thorough history.

Before he does so, however, he should remember that questions

frequently introduce errors into histories. It has been shown that

spontaneously given accounts of events include fewer errors than accounts

elicited with interrogation. This occurs for the simple reason that most people

cannot bear to say “I don’t remember” or “I don’t know,” and they are

therefore inclined to answer questions with some information even when

they are unsure of its accuracy. Patients, who are eager to obtain help and

who often imagine that they must qualify for this help by pleasing the
interviewer, have a special vulnerability to this tendency.

When the interviewer does ask questions, his attention to careful

phrasing of them proves rewarding. Slight differences in wording can greatly

influence the patient and his responses. If our “Uh-huhs” can tell the patient

what we want to hear, our explicit questions provide a much more forceful

and sometimes harmful guidance to the patient. The questions asked should
provide the fewest possible clues to the answers expected and the least

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possible channeling of the answers. Most desirable are “open” questions that
ask about a topic in general and to which the patient must reply with one of

several sentences. The least desirable questions are leading questions to

which the patient can answer “Yes” or “No” and then remain silent. Compare,
for example, the differing values of asking the patient, “Do you and your wife

quarrel often?” and “Tell me about your marriage.” The first question, apart

from its abruptness, which can offend, may evoke a simple “No” from the

patient and nothing else, unless irritation. The second question invites and
almost obliges the patient to reply with a sentence or more. Moreover, it does

not confine the patient in his reply to the present time. The psychiatrist can

learn much from noting what the patient selects to talk about first in answer
to such a question. To illustrate this important principle further, an exercise

for a psychiatrist who wishes to improve his technique is to arrange opposite

each other in a list closed questions and more valuable open ones. For

example, one can ask a patient “Was the pain severe?” but a better question
would be, “What was your illness like?” “Did you miss your daughter when

she married?” will yield less than, “How did you feel when your daughter
married?” We can ask, “Do you have a bad temper?” but we can improve on

this by saying instead, “How is your temper?” I do not mean to proscribe all
leading questions focused sharply on a specific point, but these should come

after more general open questions have given the patient an opportunity to

answer freely without the suggestions and guidance of leading questions.

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 In asking questions that broach new topics, tact and timing reward the

interviewer for the extra care they require. Careful phrasing of questions can

greatly improve their yield. For example, in talking to an unemployed patient

one should avoid asking, “Have you been on welfare often?” Instead, one can

say more usefully “Have you had much trouble finding work?” Or, to illustrate

further, one can unnecessarily offend a patient by asking, “Have you quit

many jobs?” The patient would give the same and more information if asked,
“What has led to your various changes of jobs?”

The state of the physician-patient relationship should influence our

timing of questions and opening of topics to which the patient may be

sensitive. As the patient and psychiatrist become more attached to each other,

the patient feels freer to disclose more of himself, and the psychiatrist feels

freer to ask him to do so. We can ask questions in the last five minutes of an

interview that we could not ask in the first five, and we can ask questions in
the fifth interview that would have been inappropriate in the first.

We can make many questions less painful by embedding them, as it

were, in a matrix of other questions to which the patient is less sensitive.

Thus one can lead a woman patient fairly easily to talk about sexual

intercourse if one inquires about this at the end of a series of questions on

pregnancies. In asking about further pregnancies the physician may naturally

inquire whether the patient’s sexual relations have been satisfactory and, if

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not, why not. Similarly one can ask questions about impairment of memory
right after asking about the effects of the patient’s illness on his vital functions

such as sleep and appetite. With the question placed in this context, the

patient is much less likely to believe that the psychiatrist thinks he is “crazy”
than if a question about memory confronts him abruptly as a new topic.

Do not, however, confuse tact with timidity. The psychiatrist should

never hesitate, out of feeling for the sensitivity of the patient, to ask a

question that is necessary for thorough evaluation. In talking to a depressed

patient, for example, the psychiatrist should discover whether the patient has

had suicidal thoughts and the likelihood of his acting on these thoughts. Often

he can learn about such thoughts indirectly, but when he cannot, then he

should pose questions directly. A question firmly asked will usually elicit a
more direct answer than one offered hesitantly.

The psychiatrist should try to avoid offering gratuitous comments and

interpretations that can trip the patient as he tries to tell his story. Instead, he
should try to offer simple questions that, while asking for more information,

encourage the patient to talk further. For example, suppose the patient says,

“I feel I need affection and can’t get it.” One might respond to this with, “Well,
we all need affection, and you’re not alone in this.” A much more useful

response would be, “What interferes with your getting affection?” This second
comment reassures the patient that he needs affection, but it also inquires

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 further about what he himself may do to deprive himself of it. Or again a
patient may say, “I’m afraid I may lose control of myself.” To this one could

reply with, “Would that be bad?” but an even better response would be, “What

do you think would happen if you did?” Or as a final illustration, suppose a

patient says, “I was afraid of my parents as a child.” The psychiatrist could

answer reassuringly, “Yes, many children are afraid of their parents.” A more

productive answer, however, would be, “What about them made you afraid?”

Ending Interviews

When patients do express emotions freely, we should give them some

warning of the end of an interview before it closes. This permits the patient to

regain some calmness before leaving the office. About five minutes in advance

one can say something like, “I can see that all this is extremely important to

you, and we need to talk about it some more. But our time for today will soon

be up, and we will have to postpone the rest.”

I find it helpful always to ask the patient at the end of diagnostic

interviews if he has anything further he would like to bring out or has any

questions he would like to ask. In these final moments patients frequently

reveal some matter of great importance to them. Previously anxiety

prevented their reaching these subjects, but as they see the interview closing,
they often decide to risk the exposure. Usually time does not then permit a

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full discussion, but the psychiatrist can defer this until the next interview.

Much of the best work of interviews occurs after psychiatrist and

patient have separated. The patient (and a good psychiatrist also) goes on

thinking about the subjects of the interview. New associations and often new

emotions come to the surface and provide additional material at the next

interview. The psychiatrist can usefully ask patients on parting to think

further about the things discussed and to note these additional thoughts. Such

instructions often stimulate patients who have shown marked resistance to

psychological explorations. In the interview itself their great anxiety

frequently prevents their talking or even thinking freely, and they often

present defensive and obviously incorrect denials of symptoms and attitudes

for which abundant evidence exists in other signs. After the interview and
away from the psychiatrist, many of these patients relax and then begin to

think constructively about the topics discussed. At the same time the image of

the psychiatrist becomes less awesome. After a few hours or days of

rumination the patient may eagerly welcome a second interview and may talk

much more freely.

At the end of any initial interview the psychiatrist should discuss with
the patient plans for further interviews or for treatment. Often the patient

will press him for an immediate diagnostic opinion. The psychiatrist may then
have to explain that he will need further interviews and perhaps other

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examinations and tests before offering an evaluation of the patient’s illness.
He can usually include some initial reassurance covering what he knows up to

that point. He should avoid blanket reassurance that he may afterward have

to revise, and he should avoid offering prematurely a diagnostic opinion or

recommendations for treatment. But always he should tell the patient what

he plans to do next. Attention to such details of courtesy and cooperation

greatly aids the transition from initial and diagnostic interviews to treatment.

Few single interviews sufficiently reveal the patient’s difficulties for the

purposes of the thorough evaluation that sound practice requires. Not many

healthy people can pass from strangership to intimacy with another person in

any hour, or even in several. So we should not expect this of anxious or

otherwise troubled patients. Therefore, we must turn to additional interviews

and to additional informants, both of which are nearly always desirable. With

the patient’s consent (rare exceptions to this occurring in the cases of

irrational, psychotic patients or young children ) we should interview

important relatives of the patient, so that we may benefit from their often

quite different perceptions of the patient and his illness. The discrepancies
between the patient’s account of himself and that of a relative frequently

astonish us and also show us how differently people appear to different

observers. Our psychiatric interviews can improve if we frequently remind

ourselves of their significant limitations in giving us the information we need.

American Handbook of Psychiatry - Volume 1 51

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