Schizophrenia - Interviewing Guidelines

Psychiatric diagnosis involves use of generic clinical assessment skills, such as combining open-ended and close-ended questions, as well as specialized skills needed to address challenges associated with psychiatric impairments. In this section we discuss guidelines for interviewing people with schizophrenia, focusing on particular challenges to interviewing, and highlighting clinical communication skills in particular.

Guideline 1: Preinterview “Baggage”
Some challenges to interviewing may begin even before the interviewee has actually attended the interview or met the interviewers. These may be related to the interviewees’ feelings, expectations, and concerns generated perhaps by past experience. For instance, even before coming to the interview, the interviewee may feel threatened, expect to be harshly judged and criticized, and be concerned about the possible consequences of the interview. Such preinterview feelings may manifest themselves in a range of different ways.

For example, an interviewee who is feeling threatened may be very guarded or may be aggressive as a response to his or her perceived threat. Similarly, an interviewee who expects to be harshly judged may be hesitant and reluctant to interact or even hostile and antagonistic toward the interviewer. Finally, an interviewee who is concerned with the consequences of the interview might be busy trying to guess how he or she might “best” respond to questions asked by the interviewer, which would seriously threaten the validity of the information elicited.

Because the effectiveness and quality of all interviews depend on rapport, a starting point for the interviewer meeting an interviewee with features described earlier would be to develop empathy and understanding of the potential origins of the interviewee’s “baggage.” This may include recognizing that the interviewee may have been in several clinical settings and situations in the past that he or she perceived as threatening (e.g., being interviewed at a teaching hospital in front of trainees who were all strangers), that he or she was indeed judged harshly (e.g., for discontinuing medication against medical advice or using substances), or suffered from perceived consequences of previous interviews (e.g., forced interventions or involuntarily hospitalization). In addition, the interviewer may use his or her clinical skills to help the interviewee feel more comfortable and at ease by expressing concern and empathy, and reacting to the interviewee and his or her story in a nonjudgmental manner. It is often useful in such cases not to ignore the “elephant in the room” but rather to focus first on the interviewee’s immediate feelings and address the discomfort that he or she might be feeling (“I have a sense that you are not feeling very comfortable. I was wondering if you might be willing to share how you are feeling right now”). In addition to addressing the interpersonal context, there are several practical ways in which the interviewer might be able to help the interviewee feel more at ease.

Examples include introducing him- or herself, describing what to expect in terms of the format of the interview (its nature, rationale, and length) and what will follow. The interviewer should offer the interviewee the option to ask questions and to have his or her concerns addressed before proceeding. Forming a collaborative atmosphere in which the interviewee is viewed as an active participant rather than a passive subject of an interview is important. In addition, respecting the interviewee’s style and pacing oneself to better match his or her tempo gradually increase the interviewee’s trust and participation.

Finally, when the interviewee is uncomfortable, it is particularly useful to start the actual interview with a “warm-up” phase that includes easy-to-answer, factual questions to help the interviewee gradually become more at ease. As the interviewee feels more comfortable, follow-up questions can be particularly helpful in gathering more information about particular areas of significance.

Guideline 2: Lack of Insight into Illness
Because the interview usually takes place in a clinical setting (outpatient clinic or hospital), a typical early question is “What brought you here?” or “How did you come to be in the hospital?”. These questions are meant to provide a neutral stimulus to encourage the interviewee to reveal the sequence of events that preceded the current situation. One potential challenge is that the interviewee may lack insight into his or her behaviors, experiences or beliefs that impacted the events preceding the interview. The interviewee may deny having a problem (“I do not know. Everything was just fine”) or believe that what led to being treated is not his or her problem (“They [family] wanted me taken away, because they needed the room in the house”), or that he or she has a problem but not a mental problem (“I was feeling weak, but they wanted me to go to the psychiatrist”).

These various degrees and styles reflecting a lack of insight are common among people with schizophrenia and present a potential obstacle for the interviewer seeking to obtain an overview of the current episode and psychiatric history.

Although it may be frustrating for the interviewer, it is not useful to be confrontational or to repeat the question with the hope that the interviewee will eventually “gain insight.” It is important instead to acknowledge the potential value in the information collected rather than to get angry or anxious about failing to elicit the “required” information. There are a number of reasons why information collected “even” with an interviewee who seems to have limited insight into his or her condition may be of value: First, discrepancies between the perceptions of interviewees and mental health providers may not always indicate lack of insight (Roe, Leriya, & Fennig, 2001). Second, even if the interviewee clearly lacks insight, it is clinically useful to explore and to understand how he or she perceives and experiences different events (Roe & Kravetz, 2003). In addition, lack of insight may in some cases serve as a defense against the threat to self posed by the illness, and its social and personal meaning (Roe & Davidson, 2005). Thus, acknowledging the clinical value of the interviewee’s report, even if it is not concurrent with one’s own, may help the interviewer to convey genuine respect for the interviewee’s views rather than to become impatient, angry, or confrontational regarding the interviewee’s “lack of insight.”

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