Week1 Advanced Practice PMHN III PDF

Introduction to the Psychiatric Interview Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2452200-dt-... Introduction to the Psychiatric Interview Speaker: OK, well, hello. Hopefully most of you remember me from Nursing 6...

Introduction to the Psychiatric Interview Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2452200-dt-... Introduction to the Psychiatric Interview Speaker: OK, well, hello. Hopefully most of you remember me from Nursing 6020, the psychopharmacology course. Now it's time to begin the discussion of making a diagnosis, developing a plan of care so that we can then decide whether or not a pharmacological approach is appropriate or not. So this is the beginning of this unit, which has a lot of information, Introduction to the Psychiatric Interview. There's a sequence of events here. First we have to talk about the comprehensive psychiatric interview, then we talk about the focused psychiatric interview. And then we will talk about the physical examination, which does occur in psychiatry in the form of the mini-mental examination. But !rst up, this slide set. This is the longest one. This is the most laborious. There's a lot of information here. Please hang in with me. Every bit of it is important. I promise I will not present to you material that doesn't have some real role in your ability to make an assessment and a diagnosis in a psychiatric mental health patient. So !rst up, we're going to talk about general elements of the history gathering. And then we do get into some speci!c issues like the di"cult patient, the patient who won't stop talking. All of that's coming. But this !rst slide set, which admittedly is longer than I would like it to be, but it's the foundation. It's the starting point. Then you will talk about a very deductive approach to developing a diagnosis. And then the last slide set in this weekly unit is about the mental status exam. I promise you, this !rst one is the most-- it's the longest, it's the most laborious. But that's because there's a lot of information here that is so important. So I invite you to sit back, get your bottle of water or your co#ee or your Red Bull or whatever it is that helps you stay awake, alert, and oriented and engaged as we talk about Introduction to the Psychiatric Interview. Now two things I want to tell you before I turn o# my video and we get down to work. The !rst thing is, remember, I will turn o# the video. I don't know about you, I really do 1 of 33 7/3/24, 4:48 PM Introduction to the Psychiatric Interview Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2452200-dt-... not like staring at myself, a little picture in the corner there, through the entire lecture process. So after this introduction slide, there will be no video. The other thing I want to tell you is that I'm having some challenges with my headset here. I have I have been traumatized by, in the past, recording entire lectures that didn't actually get recorded. So I have tested, retested-- this is like the 15th time I'm saying this. And I have noticed that one thing I can't seem to get rid of is this weird phenomenon where the !rst slide in any presentation I record, there's like a little bit of a staticky minute where the audio is lost. I'm hoping that will not happen again through this slide set. But if you had a little bit of a crackle here where you missed me, I really think that's the end of it. And I'm not really saying anything here substantive so it should be OK. So without further ado, I'm going to turn o# the video, turn on the audio for learning. And we will go to our next slide. OK, so the !rst-- there's a lot to unpack here when we talk about history taking with the psychiatric patient. And the !rst one is the comprehensive history. And the comprehensive history is really not entirely unlike what you learned about history gathering in your core advanced physical assessment course. A lot of the concepts we talk about here are similar. Of course, we have a di#erent purpose. There are di#erent things we want to look for, and it's a di#erent kind of patient. But there is a core here, and that's the !rst part of our conversation. So keeping in mind that the comprehensive history is typically what we see the !rst time around. This is our !rst approach to the patient. This is the new patient. And it is going to be very comprehensive and include all sorts of stu#. The purpose the !rst time around is to get that well-rounded history. When we talk about the problem focused exam and really trying to develop a solid diagnosis for the patient, one of the things that I will emphasize is that in the beginning, we have to be complete. We have to be well- rounded. If you don't have a good, solid, comprehensive history from which to draw from your !rst encounter with the patient, it really can make things much harder down the line. You'll notice when we talk about formulating psychiatric diagnoses that there are a couple of key things that are always there. One of them is that the symptoms are not explained by a medical condition or a medical diagnosis. 2 of 33 7/3/24, 4:48 PM Introduction to the Psychiatric Interview Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2452200-dt-... That the symptoms are not explained as the consequence of adverse e#ects of medication. And that the consequences-- or that the symptoms are not the consequences of a substance use problem. And all of that comes from that initial approach to the patient. So the purpose of that !rst patient encounter really is to develop a comprehensive assessment to ask questions that might seem like they have nothing to do with anything. I always tell the patient in that !rst interview that I'm going to ask a lot of questions that don't really seem related to what it is that they're coming to see me for. But that a well-rounded database the !rst time around makes things much more useful-- or useful is not the word. Makes things much more precise and gives us a much better impression going forward. Also, keep in mind that !rst encounter with the patient, a lot of this comprehensive history will come by way of written questionnaire before you even actually see them. By the time the patient makes it to their !rst appointment with you, they usually have !lled out lots of forms. And of course, those forms include things like demographic data, insurance information, a general medical history, a surgical history, social history, allergy history. All those things that any patient does. But there also are typically a series of questionnaires that patients are asked to !ll out the !rst time around, like things like a depression screening tool, a mood disorders, a manic screening tool, an anxiety questionnaire. All of that stu# is part of this comprehensive history, and you get it before you even see the patient. And one of the things that you do during the actual visit is to review that questionnaire with the patient to make sure it's accurate. Sometimes people just get tired of answering questions and they just start checking o# stu#. Sometimes the way that those questions are worded is a little bit odd and the patient has trouble with it. So it's an excellent starting point. You gather all those questionnaires, all that information, even the information about their history. And then an important part of what you do in comprehensive history assessment is to go over that information that you get in writing, identify anything that $ags for you as needing further explanation, anything that seems unusual. Like I'll tell you one thing I see all the time in new patients is that in the questionnaire it will say, no psychiatric history. Or it'll say they've never been on psychotropic medication. And when I ask them about that speci!cally during the interview, I !nd out that that's not true and there are things that I need to know. So getting that written 3 of 33 7/3/24, 4:48 PM Introduction to the Psychiatric Interview Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2452200-dt-... comprehensive history, it's going to be a good starting point for you and you need to do it. But de!nitely, have to go over and review it with the patient for accuracy. OK, so a couple of things speci!cally that we are going to want to pay attention to. The psychiatric history is obviously really going to be important. But here are some things you want to look for. Even going back to childhood, even if you have a 40-year-old patient sitting in front of you, you want to know anything that might be available about previous psychiatric evaluations and if they were diagnosed with anything. And they don't go hand in hand. There are some kids that the school sends them for an evaluation or whatever. The parent took them for an evaluation because maybe something happened in their lives and they never actually had treatment or took medication. And the family unit might not even know if there was a diagnosis or what it was. But anything they happen to have that can get will be helpful. If the patient was treated for a psychiatric diagnosis, remember that not all treatment is drug therapy. It might have been that the patient was in intensive therapy for, who knows, even years. But if you ask them if they were treated or they took meds, they'll say no but neglect to mention that they saw a therapist for three years for some thing. So try to !nd out whatever you can about previous treatments. If drug therapy, non-drug therapy, whatever it was. Like if it worked or not. This can really be very helpful. So let's say somebody was in therapy for two years and it was really helpful. But then they seemed better, they seemed more stable, capable of coping and decided to leave therapy. But the fact that therapy was helpful is di#erent than someone who saw a therapist and said it never helped them at all. This can help direct your treatment modalities going forward. Equally important, if the patient took medications earlier in the lifespan. Whether it was 20 years ago or last month, if they took medications, did they work or not? And for any e#ective treatments, why were they stopped? Were they stopped for side e#ects? Were they stopped because of cost? Sometimes people !nally land on a medication that's really helpful, and then their insurance changes and they won't pay for it and they can't a#ord it. So all of this stu#. One of the things that you don't need to do is reinvent the wheel. If the patient has a diagnosis and they've been treated for in the past and the treatment was helpful and they stopped it because they no longer had access to it, whether it was geography or money or whatever, well, shoot, I mean, now if you need to treat the 4 of 33 7/3/24, 4:48 PM Introduction to the Psychiatric Interview Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2452200-dt-... same condition, obviously the place to start is with the treatment that helped before. Is there a way now that we can help them get access to it? Maybe something that was a branded drug that cost a lot of money !ve years ago is now available generic and it's a#ordable. Or maybe if they had a branded drug and can't a#ord it, you can identify a generic drug in class. That's the same drug class that might be helpful. So there's lots of reasons that this is helpful. But you really do want to drill down into that psychiatric history, even if they never had a diagnosis. That they had evaluations, what for? And if they were treated, how so? And did it work or not? I mean, by the same token, if they were treated for something and the treatment didn't work, then obviously going forward, there's no point to try the thing that didn't work. Many times when we're treating diagnoses, what didn't help is just as useful as what did help. Now I mean the speci!cs, If somebody says, yep, yep. That was the one. It was called-- it was called Lamictal. And yes, it did help. Of course, if the patient knows the dose, great. But that's like the least of it. I mean, not everybody could remember that 10 years ago, they took 100 milligrams of Lamictal BID. But they might remember Lamictal, and that could be very helpful for you. And then, of course-- well, yeah. I already mentioned about any reasons for stopping, like were things successful or not. OK, so that's that. Next up, personal medical history. Like I said when I introduced the topic, medical conditions always need to be ruled out as a cause of any psychiatric symptoms. There are things. Like COPD is notorious for causing anxiety, for instance. The classic like hypothyroidism is commonly linked to depressive symptoms or $at a#ect. Hypothyroidism commonly mimics anxiety disorders. So you need to know the medical history. Medical conditions always need to be considered and ruled out as the cause of symptoms before you make any psychiatric diagnoses or treatment decisions. Similar principle with the medications. Sometimes patients are started on a new medication for a medical condition and an adverse e#ect of that medication is a symptom that might be mimicking a psychiatric condition. Again, some of the obvious suspects are things like beta blockers. Beta blockers for a migraine headache or for coronary artery disease or whatever we use beta blockers for, because there are many, they also can produce what appears to be a depressive a#ect. Sometimes patients that have just started being treated for asthma will use or overuse 5 of 33 7/3/24, 4:48 PM Introduction to the Psychiatric Interview Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2452200-dt-... their albuterol inhaler, which is a stimulant and can lead to tremulous and tachycardia, et cetera. So I think you get the idea. There's a lot more to it than that, but these are just examples of why this stu# really matters. So that !rst comprehensive visit with the patient, very often, an hour long and the patient's thinking, why are you asking me all these questions? This is why. Because the more information you have now, the more precise your diagnosis is going to be and the better your treatment options are going to be. The family history also. And I mean, we are focusing on psychiatric diagnoses here because some do have a clear genetic tendency and others do not. Even those that have a genetic tendency, it's usually a combination of genetic predisposition and then some sort of environmental circumstance and trigger. I mean, I don't think there is any psychiatric diagnosis that has 100% concordance with monozygotic twins. So even people that share DNA-- people that have the same DNA, one may develop a diagnosis and the other one doesn't. So clearly it's not just about the gene pool, but there certainly are things that have a genetic predisposition. And so if they have been diagnosed in the family previously, that's helpful to know. And then also keep in mind that going back generations, like the patient's parents or even older siblings, many times, they may have had a psychiatric diagnosis but they never saw a mental health provider. They never actually had a diagnosis made. So if you say something like-- if you're evaluating a patient for generalized anxiety disorder, which does have a clear psychiatric-- or rather a clear genetic history and you say, well, did your mom or dad or brothers or sisters ever have a diagnosis of anxiety disorder? If you leave it at that, the patient might say no because maybe the family was never diagnosed. But then if you expand your discussion to say, well, but did they ever just seem always worried about stu#, have panic attacks? The focus really should be both on the presence of diagnoses. If there is available, that's great. But even if diagnoses aren't available, sometimes there is a clear history of characteristics that would have been a psychiatric diagnosis if the patient ever saw a mental health provider. Now the social history is important for so many reasons. I mean, number one, like I just said in the last slide, most times, I think, there is a combination of genetic predisposition and then environmental trigger. Some environmental thing that spawns 6 of 33 7/3/24, 4:48 PM Introduction to the Psychiatric Interview Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2452200-dt-... that genetic tendency. So the social history really is very important. Right o# the bat, we always want to know speci!cally about substances of abuse and history of addiction. And they are two di#erent things. Substances of abuse may be prescription medications that the patient uses inappropriately. It may be over the counter things that the patient uses inappropriately. I mean, abuse just means that you are using it for some reason other than it's intended or-- and we'll talk more about this. We have a whole substance abuse unit to talk about. But a substance of abuse may be something that's readily available over the counter, but the patient's using it inappropriately, disproportionately. Whereas addiction isn't necessarily about substances. People can be addicted to food. People can be addicted to behaviors. They can be addicted to gambling. They can be addicted to sex. They can be addicted to shopping. So they're two di#erent things, and we want to peruse both of them. Personal and family relationships, this can often be the thing that triggers an underlying genetic tendency. Or if there's a relationship issue currently, it may be that the patient is having an adjustment disorder. Lots of psychiatric diagnoses can mimic di#erent things. And of course, part of my job in this course is to help you begin to recognize that. But major depressive disorder is a very particular type of disorder. We'll talk about it next week. Adjustment disorder is di#erent, but there is certainly such a phenomenon as adjustment disorder with depressive a#ect. And it's the depressed mood that makes the patient come in for the appointment. And when you pursue the relationships, you !nd out that they don't really have depression. What they have is an adjustment disorder. And the reason that matters is because the treatment modalities are di#erent. Major depressive disorder, major depressive episodes, very typically, medication is an important part of that treatment. Whereas with adjustment disorders, therapy is the most important part of treatment. So that is just one of many examples about how this matters. The patient's occupation, what they do for a living. It's so interesting that sometimes-- it seems obvious to us as the professionals, but to laypeople, they don't understand that their occupation is the problem. Whether it's a job of long standing that they have become disillusioned and depressed by. I have a patient who is a dentist. And he was being-- he came in to be seen for a depression. And it had all the classic lack of motivation, no energy, disinterest, not 7 of 33 7/3/24, 4:48 PM Introduction to the Psychiatric Interview Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2452200-dt-... looking forward to anything. A lot of class of depressive symptoms. But as we got into the discussion, it was very clear that-- he was a dentist, he became a dentist because his father was a dentist and so they were going to like they were in business together. And now, he's got all these years of education in it and he just doesn't want to be a dentist. He feels trapped between the years of education. He now has a family to support and loans to repay. He feels like he's living in his father's shadow. He realizes is not what he really wants to do. I mean, there's a lot to handle there. And it doesn't necessarily mean jumping into a di#erent profession. I mean, maybe that's not something that he could do right now. That's a whole di#erent conversation. But my point being that the occupation truly is at the root of his symptoms. And so it will help us in terms of managing his symptoms and trying to get the best quality of life. We will have to address this in some way. Doesn't always mean they can make a change. But recognizing their problem is half the battle. Then we !gure out the best way to treat it. Interactions with law enforcement are helpful because there are some conditions like bipolar I. Patients that have true manic episodes, very often, they !rst are diagnosed when they come to the attention of law enforcement because classic of true mania is that it will often land people in a position where they're getting arrested. And then as a function-- I mean, I could give you a patient example for everything we're discussing here because this is all so classic. I have a patient who, as a condition of his probation, had to be seen by mental health. And it became crystal clear that his o#ense was driven by a manic episode. So there's that. And then that's not the only example. People sometimes have delusions or hallucinations that cause them to act in such a way that they wind up getting arrested. There's many, many disorders that could lead to an arrest. And so we don't need to know all the details of it, but it is helpful to know if there have been arrests. We want to try to !nd out, not the charge or the punishment, but the nature of the activity that led to the arrest because that can help us !gure out what is going on too. What else? Let's see. Sexual and gender assessment. So just a good part of basic comprehensive history taking in this day and age is to identify the patient's gender identity and preferred pronouns. And this is typically part of that initial questionnaire that the patient completes before you ever actually even see them. But do make sure 8 of 33 7/3/24, 4:48 PM Introduction to the Psychiatric Interview Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2452200-dt-... you con!rm that. Keeping in mind that sexual orientation is di#erent than gender identity. And so we want to make sure that we are clear and respectful of the patient-- where the patient is and the patient's orientation and identity. Sometimes we just need that information so that we can address the patient appropriately and respectfully. And sometimes it is part of the reason that they're there. I mean, obviously-- I think it's obvious, or at least it always has been to me, that someone who is struggling with a gender that is not consistent with their physical habitus and their genitalia, obviously, there has to be-- there have to be some issues in coping and accepting and working this out. And sometimes, that's the reason that they make the appointment. Other times, patients have worked that out, I mean, very well and that is not the nature of their problem. And it's just about being respectful. And we also want to ask about-- and again, this will be on the questionnaire, but this is something you always want to con!rm. Their current relationships and do they feel safe in it. And believe me. Intimate partner violence happens in every, every type of relationship, not just the classic male female relationship where the male is the aggressor. We have male-female relationships where the female is the aggressor or the o#ender, is probably the better word. We certainly have same sex relationships that are characterized by abuse. And so there's no stereotype there. You don't want to make any assumptions. Every patient that we take into our practice, we want to have an understanding of their relationships and whether or not they feel safe in it. Developmental history. So I mean, depending on the patient that you have, if you're seeing a child, it is certainly important to know if things like vaccines are up to date. Excuse me. If developmental milestones were met. If you have records from a pediatrician, of course, that's very awesome. But also remember development in terms of psychosocial development. And we will talk a whole lot about these-- depending on where you are in the program, we will have several lectures talking about psychosocial development because that can help explain, not only some of the nature of the patient symptoms, but also how we best approach the patient. Where the patient is in the life span actually can help inform us with respect to the best nonpharmacologic therapeutic treatment modality. So just by way of example, consider 9 of 33 7/3/24, 4:48 PM Introduction to the Psychiatric Interview Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2452200-dt-... Eric Erikson. I'm sure you've heard the name in some developmental undergrad psych class. Eric Erikson was a child psychologist who described the whole life span in terms of developmental con$icts. You know he's a child psychologist because he described the entire life cycle in terms of eight stages. And I think the !rst six of them are before the age of 21 or something. As if from 22 till death, there's only two more developmental con$icts to address. And that's probably a little bit generalized. But anyway, the point of Erikson's developmental con$icts is that Eric Erikson described a series of con$icts that occur-- emotional con$icts that occur through the life span. And that if you successfully-- we will all experience them. And if you successfully resolve the con$ict, then that helps to strengthen positive personality characteristics and helps you to become a strong productive citizen, person, whatever in society. Whereas if you do not successfully resolve those developmental con$icts, it can lead to both di"culties of personality and mental health diagnoses later in the lifespan. Just for instance, just to remind you what I'm talking about here, Eric Erikson describes the !rst year of life as trust versus mistrust. That every infant through the !rst year of life is developed with having to-- is presented with having to develop a trust relationship with their primary caregiver, typically the maternal !gure, but whoever it that is their primary caregiver. That every infant has to address that. And if the infant is able to trust the caregiver, if their needs are met, if they are fed and they are given hydration and they are their physical needs, they are clean they are fed, they are kept safe, they develop a bond to that primary caregiver. If they develop a sense that they can trust the primary caregiver, then that is successful resolution of that trust versus mistrust. And that helps to maintain-- or to strengthen, develop, maintain a stronger, more trusting person through the rest of the lifespan. Whereas, if in that !rst year of life, the infant cannot trust the primary caregiver, if their basic needs are not met, if they are not fed, if they are not changed, if they are not made to feel safe, if they don't develop a bond with a primary caregiver, then they don't successfully resolve that con$ict. They develop a sense of mistrust in infancy that can go on to help shape who they become through the rest of the lifespan. And children that don't successfully-- infants that don't successfully resolve this and-- I guess, resolve it in the way of mistrust are at much greater risk for certain mental 10 of 33 7/3/24, 4:48 PM Introduction to the Psychiatric Interview Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2452200-dt-... health disorders going forward, including psychosis. Erikson's second stage of development is what we call the stage of the toddler, like from one to three years old. And the developmental con$ict is autonomy versus shame and doubt. So at this point, the toddler is ambulatory. So they can get around on two feet. They can walk around, they can explore, they can begin to develop some primitive level of autonomy. They don't rely on the caregiver to carry them from point A to point B. They can sit up. They can lie down. They can pick up something to eat. They can carry around their own-- I was going to say bottle, but we really don't want that at that age. We want their sippy cup or a drinking implement. They can explore. So in this toddlerhood stage of autonomy versus shame and doubt, if they are encouraged to be autonomous, they are encouraged to explore and do for themselves and pick up their own food and have their sippy cup and things like that, they're encouraged to become autonomous. And this helps develop positive characteristics as they progress through the lifespan. On the $ip side, if they don't successfully resolve this, if they are made to feel ashamed when they try to be autonomous, if they are berated and told not to do things and punished for it and yelled, this is-- you see sometimes the overaggressive parent. If they develop a sense of doubt as they try to learn and explore, then shame and doubt, the unsuccessful resolution of that con$ict, can lead to certain mental health symptoms and diagnoses as they progress through the lifespan. And a classic one is obsessive compulsive disorder. So I'm not going to go through the whole list because then that would be a whole lecture in another course. But to get the idea here. So the developmental history, I mean, not that the patient's going to know where they were in Erikson's stage or being able to give you any information. But the developmental history, if you !nd that perhaps in the !rst year of life, they were removed from the parent caregiver, you'll have patients where they were taken away from the parents because of typhus and drug use or something like that. And maybe they were bounced around from foster home. Or even worse, they weren't in a foster home. They stayed home with a parent who had drug issues and abandoned them, stu# like that, then you can see where it might lead to certain diagnoses down the line. So that was more than I wanted to say about developmental history. But you'll hear it again, I promise. Almost everything I'm saying here you will hear again at some point. 11 of 33 7/3/24, 4:48 PM Introduction to the Psychiatric Interview Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2452200-dt-... Safety. So this is the equivalent of-- if you are a family nurse practitioner or an adult primary care nurse practitioner, when the patient comes in complaining of chest pain, you have to make sure it's not a heart attack. It might just be re$ux, but you have to make sure it's not a heart attack. So safety !rst. And we have some safety issues in the psychiatric assessment as well. Obviously, we're talking about suicidality here. The suicidal patient in our o"ce is like the patient having an MI in a primary care provider's o"ce. And it's not just adequate to say, are you suicidal? Yes or no? So when you're considering suicidality, especially in that initial comprehensive history, is the patient suicidal now? That's !rst up now. Because if they are suicidal right now, they are unsafe and they need to be-- their safety needs to be assured. So this might be somebody that has to go to an inpatient facility. Keeping in mind that not all suicidal thought is acute suicidal ideation. If the patient is suicidal now, they have been hoarding medications, they're planning to swallow them all when they go home. Or the patient is planning to shoot themselves. And yes, the patient does have access to a weapon. Like that kind of stu#, that just needs to go to a 72-hour inpatient involuntary assessment. And that's pretty much the end of that. You can stop this conversation right there. But that may not be the case. You may have the patient who attempted suicide in the past, but they're not suicidal right now. You might have someone who has never attempted suicide, but they just are-- they think a lot about, it would be better if I was dead. It would be easier if I was dead. That kind of thing. That doesn't require an immediate inpatient admission, but it is a part of the history that you want to be aware of as you go forward. So is the patient suicidal now? If not, has there ever been a suicide attempt? So what you want to know about this is what it was and how it was aborted. How come it was not successful? If the patient made an attempt and then the patient themselves stopped the attempt or they reached out for help or they knew somebody was coming-- like if the patient really drove the fact that it wasn't truly successful, I'm not suggesting it's not a concern. But that is less concerning than the patient who really would have been successful, except for some totally unplanned serendipitous event, like perhaps the patient's signi!cant other planned to be away for a weekend. They had to go out of state for a work job. So the patient knew that their signi!cant other would be gone for the 12 of 33 7/3/24, 4:48 PM Introduction to the Psychiatric Interview Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2452200-dt-... weekend, that they would be alone in the house for Saturday and Sunday. So the patient makes a suicide attempt, whether it's pills or a hanging or whatever. They go through with an attempt on Saturday having truly every reasonable expectation that nobody will be home until Sunday night. But something unexpected happens. Maybe the signi!cant other misses the $ight and winds up coming home. Just like something like that. So I think you understand what I'm trying to say here. If the patient really would have died, but for an unanticipated, unexpected intervention, that's much more concerning than the patient who actually, in the end, stopped it themselves or really didn't intend for it to go through. And again, I will reiterate here. I'm not saying that !rst one isn't a concern. It's just these are-- they're di#erent. So it really is helpful to know how it was aborted. You also want to evaluate their protective factors. And there's checklists and forms for this. We'll go through them at some point in some course. But it's, yes, the patient may be thinking about death or have reasons to be dead. But what are the reasons they would want to stay alive? Things like, if they have close bond, a close support system, things to live for. Whether it's their job, their dog, their cat, their grandchildren. So there is an assessment of both risk and protective factors. And we will talk more about this another time. I want to be very clear that one protective factor doesn't outweigh a risk factor. If you genuinely think that there is a risk today of suicidality, nothing else matters. And for that, the patient does need to be referred. In addition to suicidality as a safety issue, we've alluded to this before too. Does the patient feel safe at home or do they feel as though they are at risk for intimate partner violence of some sort? I mean, these are just the elements of a comprehensive history. As I say, most of this is on a questionnaire or a checklist. But it's your job to go through it for any speci!cs, anything that $ags you going forward. Now another piece of that general initial comprehensive history is that we want to think speci!cally about some issues in cultural competence. Cultural competence, I mean, it's a topic that has become recognized as very important in the health care world in general. And for us in the psych mental health world, there are some elements that, for both patient and us provider, we really want to do-- we do want to take some time to review. So let's look at the cultural competency for a moment. Cultural competency and the psychiatric interview. Obviously, I already said, it's an essential part of any health care 13 of 33 7/3/24, 4:48 PM Introduction to the Psychiatric Interview Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2452200-dt-... interaction. But in psychiatry especially, cultural values, et cetera, may have a huge impact on patients. Second bullet point, cultural values and beliefs may render patients vulnerable to mental health symptoms due to internal con$ict and maladaptive coping. Many times, patients who have identi!ed strongly with a certain culture and then perhaps grown, matured, trans-- why can't I think of the words I want today? Transitioned from childhood through adolescence to adulthood. And !nally, they !nd that the adult they are becoming is inconsistent with some of the cultural values that maybe the family-- are very strong to the family unit. You know what I'm trying to say here. I mean, someone who is raised perhaps in a very strong religious or ethnic home where there are certain beliefs, and then the patient, him or herself, !nds that as an adult, they feel very di#erently can be extremely con$icted by this. And that can be what leads to depressive symptoms or anxiety symptoms and withdrawal. So that's just one piece of cultural competency. It may be, or cultural issues may be the reason that the patient comes in the door in the !rst place. For us to develop some level of cultural competency or cultural sensitivity, lots of di#erent words out there, we really want to ensure that as best we can, we demonstrate cultural sensitivity to the patient. Because that's one of the things that's going to help them to trust us. We can completely annihilate any chance of a trust relationship-- which obviously is essential to mental health-- we can completely annihilate that by just being totally oblivious to cultural issues that are stunningly important to the patient. So what are some of the key concepts in cultural competency? Well, I knew you would ask. And that's what we have slides for. First up, what is it? So cultural competency, oh, my gosh, this is a term that has so many di#erent de!nitions, I can hardly even stand it. So I just tried to pull together some common themes and present them here to you. So for sure, no matter whose de!nition of cultural competence you ascribe to, one thing that is for sure is it is not static. It's not like we're like, OK, we read up all about these religious values or we read up all about-- oh, I don't pick your poison. And then say, OK, I got it. I am now culturally competent. Just saying that implies that you're not because none of us-- cultural competency, it is a goal. It's an ongoing goal. The more aware and the more sensitive we become, the more we realize that we're not there yet. We are not competent and that we have more to learn. Cultural competence 14 of 33 7/3/24, 4:48 PM Introduction to the Psychiatric Interview Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2452200-dt-... is the ability really to understand and interact e#ectively with people from other cultures. And so what does that mean? Even like what is the word culture? Cultural competence, like I said, this phrase is widely used. There's all sorts of di#erent de!nitions, elements. People have steps to achieving cultural competency. And I don't profess to be any particular expert. I think my strength in cultural competency is that I just recognize it is ongoing, that you just always have to be aware that there is more to learn. So some of the common themes in the world of cultural competency is that cultural competency is really comprises a set of behaviors, attitudes. Even policies that come together in a system or an agency, like whatever environment you're working among really any professionals that enable us-- ourselves as individual providers within the system or agency with which we work, it enables us to work e#ectively and cross cultural situations recognizing that culture by de!nition is a set of behaviors and attitudes. So culture doesn't just mean that someone is a certain religion or a certain race or a certain ethnicity. It means that they have a set of beliefs and attitudes or behaviors that, from our place in the world, can impact what brings them to care, how they respond to care, what treatment modalities that they are comfortable using or not. Cultural competence in health care really describes the ability of us as individual providers, as well as bigger systems to be able to provide care to patients that have diverse beliefs, diverse behaviors. And that we are able to, as best we can, tailor delivery of those treatments to meet those needs. Really whether it comes down to something like a religious value system or perhaps a gender identity-- the culture of gender identity or sexual orientation, it's an enormous-- it's an enormous concept. We demonstrate this by demonstrating an awareness in the integration of a few di#erent issues. Health related beliefs, health related beliefs, health related cultural values. Even disease incidence and prevalence. There are certain disorders that are more prevalent in certain cultures. Maybe it's because they're more open to assessment and diagnosis or maybe it's because there's something in that belief or value system in which the patient is raised and developed that leads to certain symptoms down the line. There really is a lot to unpack here. But cultural competence, by de!nition, I mean, most simply put, is the level of knowledge-based skills that we need to have to provide e#ective clinical care to patients from any particular cultural group. 15 of 33 7/3/24, 4:48 PM Introduction to the Psychiatric Interview Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2452200-dt-... Common themes for the culturally competent clinician. So like I said, we don't go through some lectures, take a test and go, OK, I'm culturally competent now. But these are some of the things that you can-- that will help us strive toward it. That will help us always be in step trying to improve our cultural competence. Number one, recognize the term culture refers to any group with a shared belief and value system. That it is not used just for race, religion, or ethnicity. And we also need to understand that those beliefs and values can have an enormous impact on presenting to health care, opening up to the provider, trusting and interacting with the provider and acceptance of certain treatment modalities. Another interesting thing to consider when we look at this cultural competency as a phenomenon. Remember that not all members of a culture necessarily ascribe to or live a belief that is commonly associated with that culture. So we need to remain aware, but we also need to avoid stereotypes. Honestly, I mean, I !nd-- and like I said, I don't suggest that I have any great-- I'm not a cultural competence expert. I don't believe that my cultural competency is at the top of Maslow's hierarchy there where I've achieved the ultimate and can't get any better. But one thing I do to an absolute certainty is that a critical piece of cultural competency is always remaining open minded. Always remaining open minded to the fact that A, there's culture everywhere. That it's not just those things we might think are obvious or those things we can see. There's culture everywhere that we always need to remain open minded that we can learn something new about that culture's beliefs and values and behaviors as they interact with the health care system. And just be open to learning more about it. But there's always a but. But remember that we don't want to stereotype. So sometimes we strive so hard to be culturally competent that we will stereotype. It's all with the best of intentions, but again, it can be the thing that drives a patient away. I mean, let's be honest, nowadays, it is not easy to balance the skill of cultural competency versus stereotyping. If we think we're doing the right thing and we think, oh, in that culture, this happens. So then we make the assumption of that culture. And then that patient is like, oh, why does everybody think that just because I'm this, I'm going to feel that way. Sometimes we try so hard to be culturally sensitive that we run the risk of insulting people. Listen, I didn't say it was going to be easy. I never promised you a rose garden. 16 of 33 7/3/24, 4:48 PM Introduction to the Psychiatric Interview Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2452200-dt-... I mean, there are, of course, some things that we can do to try to mitigate this and do the best that we can. But it's a balance, just like anything else. This is of my favorite phrases in the world of health care is that health in general is usually a steady state somewhere in the middle of extremes. We have those who are on the extreme of not accepting any other culture except their own. Like, oh, that can't be right because I don't believe it. And then we have those that sometimes try so hard to be culturally competent that they learn everything about every culture and then just zip people into those pockets. And so basically, are stereotyping. And that can be insulting to the patient. The best place is a balance somewhere in the middle. Recognizing, yes, there are some commonly held things that we could be aware of and that's helpful. But then most importantly is being open minded. Asking questions and recognizing really that there's a lot we don't know. That there's always going to be more to learn and being open to learning it. And asking the question in just a general open-minded non-judgmental way. You can virtually never go wrong by asking a question relative to culture. Does this person-- do they have any cultural values that we should know about? You can almost never go wrong by just being open minded and asking the question in a respectful and non- judgmental way. OK, so here's-- I like this at all. I made it up. I'm so not creative that I'm so proud that I made this little thing. Not the concepts. I didn't make that up. But putting it on this graphic here because I'm so like not creative. It took me forever to !nd the ability to do this on PowerPoint. So I hope you're very appreciative. But what it really is just here to imply that cultural competency, like I said, it's dynamic, it is not static. So the reason that I think this is useful is that it shows you here how it's very circular and ongoing. And it begins with cultural awareness. Like, I said, !rst up, we just have to know that there are things that we don't. Be aware to the fact that there are aspects of culture that really drive how people seek and respond to care that we are not aware of. So like I said, ask the questions. Just ask the questions if you don't know. Being aware leads us obviously to the place where we're going to learn something. And this is what increases our cultural knowledge. Sometimes you just don't know until you're open minded, you're aware, you !nd out something. And boom, at least then it going forward. So the next time that you see 17 of 33 7/3/24, 4:48 PM Introduction to the Psychiatric Interview Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2452200-dt-... somebody of a similar culture, you can at least ask if this x is something that applies to you. And I'll give you an example in a minute. But then cultural knowledge, this is what leads you to the ability to develop some sensitivity. Just be aware that in a certain culture, x concept is something that you may approach a little bit di#erently. And that's when you begin to achieve some level of cultural competence in certain circumstances. Of course, being culturally competent should reinforce your awareness that there are things you don't know. And that's why it's so circular. And that's why it was so atypical of me to be creative in this slide set. Because we just keep going on and on and on. In terms of being aware, an important concept in being culturally aware is understanding implicit bias and identifying it in yourselves. Among the !rst things that any of us should be doing in our quest for cultural competence is identifying and understanding our own implicit biases. And everyone has them. Everyone has them, they are implicit. And implicit bias is the phrase that's used in the world of implicit bias and cultural sensitivity, et cetera. I didn't coin the phrase. I just have to work with it, but I don't like it. I really think-- and I didn't make this up either, I borrowed it from somebody else who's smarter than me. But I really think we'd be better o# referring to this as implicit tendency. Because implicit-- the word bias, it sounds negative. If you say if you suggest that somebody is bias, it sounds like you are making a negative accusation. Like, oh, I'm not biased. This isn't what we're talking about. In fact, the phrase implicit bias is a true paradox. Implicit is like you don't know. You didn't do it. You didn't develop it on purpose. It's just that as a consequence of early life, childhood, upbringing, repeated exposures, environment, we tend to develop certain thought processes or tendencies or approaches to life of which we are not even aware. The thing that's relevant here is these implicit tendencies really do impact how we address people, how we prioritize things. And sometimes, if it's not consistent with some beliefs or values of another culture, it can really be a thorn in the side of that trust relationship. Remember, we're talking about developing a relationship with a patient here. That's what the psychiatric !rst interview is all about. Our !rst interview with a patient, that comprehensive assessment, one of the most important things that happens there is trust building. And not recognizing and working with our implicit biases really can 18 of 33 7/3/24, 4:48 PM Introduction to the Psychiatric Interview Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2452200-dt-... just shoot our attempts to develop a trusting relationship right in the foot. So I do want to take a minute to talk with you about implicit tendencies or implicit bias. A couple of critical points here. We are not aware that they exist. We don't know. So anybody who says, I don't have any implicit biases, right o# the bat, they're wrong. They do and they're in trouble because they can't recognize it in themselves. You have them. I have them. Anybody listening to me has them. And one of the biggest mistakes we make is not acknowledging that, just not even acknowledging they exist. Because we don't know they exist, we can't do anything about it. Everybody right now listening to this has to acknowledge that we have implicit biases. The next step then is trying to !gure out what they are. And then how we can best use them to create a trusting relationship and a positive relationship with our patients. So I already alluded to this a little bit in the earlier slide. Implicit biases typically do begin in those formative years of childhood. We don't know we're developing them. I can't say that enough. These are unconscious. These are implicit. Some of the things that are characteristic of implicit bias, associating women with family and men with work or career. I mean, it sounds ludicrous on the-- I mean, any woman I work with-- any professional will say, aha, that's ridiculous. Absolutely not. And yet, guess what? Some of you do. If you were raised in a world where the women manage the family and stayed home and the men went out and did the job, it is very likely that there is some element of that implicit bias in you. How can that impact you as a psychiatric mental health provider? What we see-- because there's a lot of study of this. I didn't make this up. I'm just sharing with you here some of the important points of a body of knowledge. In some circumstances, what has happened is if a woman comes in for mental health care, she's having symptoms. I keep saying depression and anxiety because they're so common and they are also very sensitive to environmental issues. If a woman is having those sorts of issues related to job and career, there are providers who just approach it di#erently than they would with men. Similarly, the men who are the stay at home dad, if they come in and they are having symptoms as a consequence of managing children, balancing home life that kind of things, it just may be approached and prioritized di#erently by a provider. 19 of 33 7/3/24, 4:48 PM Introduction to the Psychiatric Interview Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2452200-dt-... Other implicit biases, just by way of example, associating the elderly with ill health disease and depression. Just assuming that these are more likely in the elderly. An older patient with depression, if we have an implicit bias-- not biases. If we have an implicit tendency to just assume that the elderly are more likely to be ill, maybe we're looking for a physical cause of their depression that's not there. Also there is implicit bias among many to associate disability, whether mental or physical disability, with a sense of dependency, weakness in terms of personality and low intelligence. And again, the thing that is just so important to understand here, this is not conscious. This is not purposeful. People that identify these implicit biases in themselves are usually horri!ed when they do. These are unconscious tendencies that can have an unconscious or subconscious impact on how we approach the patient. So then of course, you're saying to yourself, self, oh, my gosh. How can I !gure this out? Well, I'm so glad you asked. There is this project that is being run by Harvard University. It's called Project Implicit, aptly named. I mean, it's a study, so there's a huge arms to this. But you can go online, google Project Implicit. And there's all sorts of subscales. And you can answer these questions and just answer them honestly. Good scales. Like you can't you can't beat it by giving the answer that you think it wants. And of course, that defeats the whole purpose of the thing anyway. Just answer the questions honestly. You won't even, in most cases, realize what the interpretation of that answer is. But there are a ton of subscales. So it can help evaluate your potential implicit biases towards some of the things that are listed here. Disability, sexuality, et cetera, skin tone, politics, and blah. I mean, the list is endless. There's numerous subscales here. And then it will help you to identify your-- I mean, I say I'm so impressed by this thing because I had an implicit bias about the woman family, husband breadwinner thing, which is really just ludicrous if you happened to know my whole history, even going back to childhood. I was stunned by that revelation. I was stunned by that implicit bias. I would have never ever expected it. So I would encourage you. In fact, I might not even encourage you, it might actually be an assignment in this unit. I don't remember. But anyway, it's just something that's really interesting. And if you go do the subscales online, you're learning things about yourselves and you are contributing to the data collection of this. So it's really, really, really cool actually. 20 of 33 7/3/24, 4:48 PM Introduction to the Psychiatric Interview Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2452200-dt-... That's implicit bias. That's not the same as explicit biases. Explicit biases are biases. These are things that we are aware of that are purposeful. These are things like discrimination, prejudice, hate speech, et cetera. Implicit biases are not-- and it's a hugely important thing to thing to be aware of. So when you identify-- I was going to say if, but it's not if, it's when. When you identify your implicit biases, don't hate yourself. Don't be appalled. You didn't know. These are unconscious attitudes. But these unconscious attitudes can absolutely have an impact on how we approach the patient. And so it can have an impact on patient care, optimal care and patient satisfaction with care. So I can't encourage you enough to develop an awareness of them. Project Implicit, just google it. So let's see. What are the implications? Well, because these things are unconscious and unintended and unknown to you, they can have an impact on your ability to be aware. Which then impacts your ability to develop cultural knowledge, et cetera, et cetera. I don't think I have to say any more about it. But it's a really stunningly interesting concept, this whole business of implicit bias. And how it can-- and that's like some of the implicit biases might be things that we could use positively to optimize our patient relationship. So it's not all about negativity necessarily, but I hugely encourage you to check that out. All righty, folks. As is often the case, I have typically gone on longer than I intended to here. But you know that from 6026. We are winding down here. There's just a few other things that are important to talk about with the psychiatric interview and speci!c challenges. So I think these things are kind of interesting. But it's funny that when you read about in a textbook how to do an assessment, you would just think that the patient is perfect and you're perfect. And you ask questions and they answer it. And everything is beautiful. And then you have real life where you have some challenges that are unfortunately not uncommon in the psychiatric patient. It kind of depends on where you practice. But some of these things you will encounter with greater or lesser degrees of frequency. And so let's talk about, as we wind down the last few slides here, the trust relationship and speci!c challenges. OK, so !rst up is building trust. I was going to say this is the easy part. But believe you 21 of 33 7/3/24, 4:48 PM Introduction to the Psychiatric Interview Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2452200-dt-... me, it's not. It's just easier than this speci!c challenges part of this discussion. But all joking aside, building trust is enormously important, especially in this specialty. There are specialties in health care where it's not as overt. I mean, like for instance, in a surgical practice. If you go to see a surgeon, probably what's most important to you is that the surgeon is an excellent surgeon. That the surgeon-- and you can research stu# like this. You can see how many times they've done a certain procedure. You can !nd out what their complication rate is, number of days hospitalized on average for that procedure. You can !nd out a lot. But really what's-- at least, what's most important to me is the person's speci!c expertise with that procedure. Whether or not I feel warm and fuzzy or can talk or open up my deepest, darkest, not so much. But in psychiatry, that is the most important thing. So building trust and developing an alliance with the patient, these are enormously important. And this doesn't always mean that the patient likes you. It means that they trust you. They can trust you and trust your abilities. I mean, I will also share with you-- I mean, I say this in all seriousness. I'm not being funny or trying to have you say, oh, so nice. I am not always perceived as the nicest person. There are people that don't especially like me. I know, shocker. Whether it's patients or people that have worked for me in managerial positions. But believe it or not, it's true. There are those that don't necessarily love me or wouldn't tell you how nice I am. But they will tell you that they trust me. I mean, I've had patients say to me, look, I don't like what you're saying, but I believe that what you're doing and so I will trust you to go forward with this thing. So I'm not suggesting that you want your patients to not-- you don't care if they like you. Of course, I mean, it's always easier if everybody gets along. But the trust piece is not necessarily the same as the like piece. It is very common for people to like their provider but not necessarily trust their integrity or their skill. In a perfect world, you have all three. But if you have to prioritize here, building trust is enormously important. Because you want them to be able to share everything with you. Don't want them to feel like you're going to be judgmental or whatever. So trust is important. OK, I guess I made that point. 22 of 33 7/3/24, 4:48 PM Introduction to the Psychiatric Interview Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2452200-dt-... How do you develop it? I mean, if I had the way, I would write a book and be a millionaire and probably retire from work. But there is not a the way. But there are a couple of things that you can do to support the process. Number one, just be who you are. Inject your own personality. Don't try to be something you're not. Patients will pick up on that immediately. If you try to be all the expert, but you don't really feel that way, they're going to know it. If you try to come o# as really down to Earth and really bonding, maybe using some of the same like language slang or something, but that's not you, they're going to know it right away. So just be yourself. Inject your own personality. This implicit biases, !nd out what they are. Be who you are. Optimize your strengths. Try to minimize your not so strengths in relating to the patient. But really most important, just be yourself. Don't try to be something you're not because patients will know it immediately. And of course, they won't trust you. Who would? Do you trust people that are faking it? There's nothing worse than when I meet somebody and I don't know if they're trying to sell me something or we're having to have a professional relationship and they're all trying to be all friendly and my best friend or trying to be something. And I know right away they're not. That just turns me o# right away. Much better that you and I would never be best friends, but I trust that you are being yourself. So be who you are. Project con!dence and competence. Now I don't mean to try to make up that don't-- I don't mean to make up that you have what you don't. But do project a sense of con!dence. Even if you are con!dently saying, your diagnosis is not clear, but I do have a way to proceed. I mean, I have precept students. And I have a student working with me right now and we were just having this conversation about projecting con!dence even when you don't know what to do. Because not every patient is a textbook and you're not going to !gure out everything right away. But you do want the patient to know that you are con!dent, that you are competent. That even if the diagnosis is not immediately clear, you have a plan, you have a trajectory going forward and you are con!dent in it. So projecting con!dence and competence is not the same as acting like everything or acting like something that you don't. So think about what the di#erences are. Gee, that would be a good discussion board. Too bad I didn't think of it earlier. But yeah, I mean, be yourself. But do act con!dent. A 23 of 33 7/3/24, 4:48 PM Introduction to the Psychiatric Interview Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2452200-dt-... patient never feels good about a provider who's like, well, I'm not really sure. We could try this. Sometimes it works. You don't want to go there. You can say the same thing in a di#erent way. You can say, you know what, Mrs. Jones? Your symptoms are not textbook. They are not clear. Unfortunately, sometimes a patient's diagnosis is very clear and sometimes it is not. However, we know that you're safe. We know that this is your primary concern. So I would suggest that we try this. And if this approach works for you, that will be great. And if it doesn't work for you, well, then that will give me even more information to reevaluate. Do you see the di#erence between those two things? In both cases, I'm not sure what to do. But I'm going to give it my best shot. In both scenarios, I'm going to do that. But being that way sounds a lot better. Like, well, I'm not really sure. This isn't a typical whatever, but let's try this. OK, so you get that? Also another way to build that trust and develop that therapeutic alliance right o# the bat, yes, be sincere, et cetera, but don't overdo it. I was just involved in this exercise in developing a course. We were looking at di#erent providers and di#erent-- well, without going into all this detail, I just had a particular reason to be looking at this very, very thing. And there was this one person who was like, oh, my gosh. Every other sentence was, yeah, this happened to me. This happened to my mother and my father. Yeah, happened to my sister and my cousin. My aunts, uncles, son. Like every other word was, oh, yeah. That happened to me too. Don't overdo it. Nobody believes it. And you're not there to talk to the patient about your history, you're here to get theirs. So yes, be yourself. Be con!dent. Be courteous. And be empathic, but just don't go nuts about it. I'm telling you people, patients, especially just have a sixth sense for that stu#. It is always helpful to ask the patient for the preferred mechanism of address. We might make assumptions with which they are not con!dent-- not not con!dent. With which they are not comfortable. If the patient's name is Robert Jones, ask the patient, do you prefer-- perhaps it's Dr. Robert Jones or Pastor Robert Jones or whatever. You might say, so I see on your intake work that you are Pastor Robert Jones. How do you prefer that I address you? Do you prefer Pastor Jones or Mr. Jones or Robert or Rob or Bob or Bobby? Ask the patient what they want. It conveys respect. 24 of 33 7/3/24, 4:48 PM Introduction to the Psychiatric Interview Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2452200-dt-... Establish expectations. This is like the thing. If you don't remember anything else about anything you learned in this course or any other-- if you only remember one thing in this entire program, this entire psych mental health program, it should be to establish expectations for you and the patient. I've probably said it before because I say it all the time. One of the biggest reasons that patients do not have successful outcomes, one of the biggest reasons we lose them to follow up is that they didn't know what to expect and their expectations were di#erent than yours. And they think they're not getting better. Maybe they're too sick, maybe you don't know what you're doing. There's 100 reasons where you can lose a patient because you have not clearly established expectations. So right o# the bat, set the expectations. Make sure that you and the patient are on the same page and that their expectations are reasonable and achievable. Sometimes their expectations are too low. Sometimes they are too high. And sometimes theirs are just !ne, but they're di#erent than what you would expect. So you want to make sure you and they are on the same page, and that everybody's got realistic expectations. And yep, give the patient the opportunity to tell you why they are there and to !nish the thought. It is unfortunately all too common for us to just !ll in the blanks for people when they're taking too long to say it. And in fact, I'm grateful that I just get to dictate this and not have to wait for responses. Because I do this all the time. I anticipate what somebody's going to say and answer it before they even have a chance to. And I have to work on that. When I am actually having an interactive dialogue, that's something I totally have to work on because I'm not very good at it. But people that are struggling for the words or struggling to !nd what they really want to say, sometimes it takes them several seconds and we have to give them a chance to !nish it. OK, what else do we have here about trust and the challenging patient? Yes. I mean, a lot of this can be threatening for patients because some people just don't like the idea that they need to be in a psychiatric mental health care provider's o"ce. It's easy for us to forget that because for us, it's just all in a day's work. But some people are really troubled by that. And then even if they get past the fact that they're there, maybe they're there because they want to be there. Maybe they're there because they were forced into it. A husband, a wife, whatever, somebody like a signi!cant other. Somebody basically said, 25 of 33 7/3/24, 4:48 PM Introduction to the Psychiatric Interview Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2452200-dt-... if you don't go see somebody, I'm leaving or you're leaving. So then they have to be able to get out the problem if they would have talked to you about it. And this can be threatening to people. Sometimes people are there because of what they think might be embarrassing sexual interests, embarrassing sexual practices. I mean, pedophilia is a whole di#erent thing and we'll talk about that later. And that's not what I'm talking about here. But it might be. I mean, it might be that a major piece of marital discord is that one partner must have anal sex experience and the other one says, absolutely not. Absolutely not. And listen, if you keep bringing it up, I'm leaving or you're leaving or something. And the patient might have trouble actually talking to you about that being-- you can get through a whole hour long interview and !nd out at the end that the reason they're there is they're going to lose their relationship because they want anal sex and their signi!cant other doesn't or vise versa. Sometimes it's about they're aroused by inanimate objects, like a shoe or underwear or whatever. And for us, it could be all in a day's work. But the patient has a real hard time talking about it. Of course, substance use, abuse, relapse. I mean, this can be threatening to people. Those who didn't stick with their treatment in the past. You will see patients who they fell out of care before because they stopped taking their meds, they stopped going to a therapist. And they're embarrassed to tell you because they think that you're going to judge them or you think they're not going to treat them. Really anything that the patient thinks you might disapprove of, this is considered a threatening topic. And of course, if they can't actually talk to you about it, you're not going to get anywhere. So what do you do for the patient who has to talk with you about what they think are threatening topics? Well, we have a couple techniques. You know how it is. We have techniques for everything in the world of health care. So there are a couple. One of them is the process of normalization. Imply that the patient's behaviors or thoughts are a normal response. Even if they're not normal for you. And if you're really having trouble with it then you probably shouldn't see the patient or it's time to do another specialty of mental health or refer the patient to somebody else. If somebody is just like enormously aroused by shoes, they have a profound shoe fetish, if you can't handle it, it's time to refer the patient out. Even if shoes aren't your thing, and it may not be "normal for you", don't have it you 26 of 33 7/3/24, 4:48 PM Introduction to the Psychiatric Interview Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2452200-dt-... don't have the same response to shoes, imply this to the patient. Listen, one of the best things that helps people feel better is knowing that they're not the only one. So if you have somebody who after 15 minutes of stammering, !nally tells you that it's a real issue in their relationship, they can't respond sexually to their partner because they are so embarrassed to tell them about their arousal by stiletto heels, it can be really helpful to share just general discussions about patients with other circumstances. You don't want it to be you. Leave you out of it. Whether it's not true and you're just trying to bond or it is true, patients don't need to know about you. And you're not their peer. You are the professional. But it could be helpful to share other generals. Now obviously, you're not going to share any speci!cs about another patient. Nothing that could be identifying. But you can say, you know what? Patient x, you know what Robert Jones, I mean, I totally understand that this might seem something that's uncomfortable for you to talk about. But I can tell you that I probably-- 30% of the people that I see have a similar preference. I mean this is not unusual. It's not unusual and they !nd it very arousing. It's not it's not hurting anybody. It's legal. And you know what? You might !nd that your spouse actually enjoys that-- or your signi!cant other or your partner actually enjoys that. But the idea is to share generalities so that people don't feel like they're the only one. Normalize it. You're normalizing their behavior without giving away anybody else's personal information. But I do want to emphasize that normalization, you don't want to-- nothing to do with you. Nothing to do with you or another professional. You want to normalize it throughout the population. Also use language that a patient understands. Sometimes when providers feel uncomfortable, they slip into professional jargon, half of which the patient has no idea what you're talking about. Now I'm not saying fake it and use like language or jargon or local slang that you think is going to put you on the same level as the patient. But I'm saying use words that they understand. And most importantly, be clear that you are not judgmental, that you are just getting information. Patients really want to hear that what you're saying is just-- it's just info. And that you've heard other things that are similar from other people and that you're not judging at all. Just good eye contact and a relaxed body posture and facial expression. That can go a very long way. Because it's true. Guilt and shame are common reasons 27 of 33 7/3/24, 4:48 PM Introduction to the Psychiatric Interview Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2452200-dt-... that patients don't share information with us. And if they won't share information with us, you're just not going to get anywhere. Then some of the other interesting circumstances we have to manage are the patient that just doesn't want to be there. I mean, some people just $at out don't want to be there. Here are some examples. Mental health care as a condition of probation. They got arrested. They're in front of the court. The judge says, hey, you can either go to the county jail for 30 days or you can go home, but you must see a mental health care provider. What's the patient going to say? Of course, they're going to go to a mental health care provider. But it doesn't mean they want to be there, especially if the patient's still manic, they really don't think they've done anything wrong. Another reason people are in your o"ce and they don't want to be is an ultimatum from someone that they are afraid of losing. You must see somebody or-- right? Or the requirements of another health care provider. There's a couple here. The example I gave you is pain management. Pain management says, I will not treat you unless you go see mental health. Because we in the professional world know that chronic pain or intractable pain or pain with no obvious organic origin is very often a consequence of a mental health diagnoses. And it doesn't mean that they're not having pain and it doesn't mean that they don't need help. But it means that they need mental health help. And so the patient doesn't want to hear that either. So threat, coercion, the judge, these are all reasons that patients are there when they don't want to be. And if somebody doesn't want to be there, it's very di#erent than someone who seeks you out for help. So what do you do? What do you do when you have the person sitting in front of you, they don't want to be there. They just feel forced. If it's a patient on probation, I mean, they just want you to sign their forms so they can go back to the judge and get o# the hook. But I mean, you want this to be productive. So there are some techniques that you can use to try to help draw in the patient that doesn't want to be there. Number one, allow them to tell you why and validate their opinion. That doesn't mean that you agree with it. It doesn't mean you think it's right. When the patient says, listen, I don't need to be here. I'm not the one who's crazy. My signi!cant other, she's the one that threw me out of the house or he's the one that threw all my stu# out. And the only reason I got mad was because that person threw all my stu# out on the lawn. I don't 28 of 33 7/3/24, 4:48 PM Introduction to the Psychiatric Interview Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2452200-dt-... need to be here. They do. I'm not suggesting you should say, yep, you know what? You're probably right. You seem normal to me. But you do want to validate their opinion without being like, oh, yes, tell me more. Or why do you feel that way? But I mean, you can say things like, well, I mean, listen, I understand what you're saying. I totally get why you think that. So tell me more about x. Why did they get that mad to throw everything out? Or so they got that mad and threw everything out, but it's your response to it that got you arrested. So let's talk about how you respond to that kind of stu#. So you can validate their opinion without necessarily agreeing with it. But if they don't want to be there, I mean, you virtually have to at least allow them to tell you why. Don't jump in. Don't do that body language where they cross the arm sit back go, hmph. And make it clear that you think they're like not valid. Validate their-- let them tell you why and validate the opinion. Starting with neutral ground. It's never about taking sides. It's never about you're right, they're wrong, they're right, you're wrong. They don't want to be there anyway so you got nothing to lose by just that generic, neutral, open-ended phenomenon. Also this is the time for open-ended questions. Even in basic nursing education, we learn about open-ended questions and closed- ended questions. And we're usually taught not to use closed-ended questions. You want to let the patient tell the story. Listen, there's a time for each technique. But this is the time for open-ended questions. And if you're thinking like, but oh, my God. I only have an hour. I'm not going to get anywhere if I keep going open ended. With this patient, you're not going to get anywhere anyway because they don't want to be there and they don't want to talk to you and they want to tell you anything. So any information is good information. So if you're trying to !nd a way to engage the patient that doesn't want to be there, do use neutral open-ended questions. And then sometimes when all else fails, I mean, if it's just completely unproductive on this day, they are just so angry, so resistant, so whatever, end it. I mean, you don't want to feed into their-- you don't want them to think that they're leading you and that they can just have you on. So you use the tools you have and when they don't work, it's time to end the interview. Again, it doesn't have to be confrontational. It doesn't have to be unpleasant. It's just 29 of 33 7/3/24, 4:48 PM Introduction to the Psychiatric Interview Transcript https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2452200-dt-... time to end. You might just want to say, look, I mean, I understand that we're probably not going to accomplish anything today. So I'm going to say goodbye. Maybe think about some of the things that you might want to talk about. And when you come back on x date-- and there will be a comeback because whoever coerced them the !rst time is not going to let them o# the hook that easy. And when you come back, think about things you might want to talk about. It's true, for whatever reason, patients sometimes they're more willing to talk at the second interview because you didn't force their hand on the !rst one. You didn't make them sit there and endure it for an hour and push them into things they didn't want to talk about. So sometimes, it's just time to end it. Give them a few things to think about and let them know that when they come back the conversation will start where they want it to start. That's one challenge. Another one is the malingerer. Patients are faking symptoms. So malingering is usually about secondary gain. The patient's got something to get out of this. Disability claims is one common example. Controlled substance prescribing is another one. They're there because pain management told them they had to be there. So what they want to get through this business with you so they can go back and get their pain drugs. And listen, sometimes there are substance abusers and sometimes they genuinely need their pain management drugs. But whatever. When people are there for some sort of secondary gain, that can be a real lost cause unless you recognize it and try to work with it. So some of the red $ags from malingering are listed here on your handbook. This is the textbook perfect patient. So if I am looking for a disability claim and I want you to !ll out my disability form, if I'm smart, what am I going to do? I'm going to google it. I'm going to get on disability and !nd out what has to be there for disability to be approved, and I'm going to learn it. And when I come to you, I'm going to recite everything you ask me. I'm going to have a perfect presentation. Same thing with the controlled substance prescribing. Thank God for google now. All the malingering patients can !nd out exactly what they need to say. Red $ags for the malingering patient, number one, is when symptoms are absolutely textbook perfect. But then anything else you ask-- like once you get past that textbook perfect answer, responses to your questions tend to be vague. You just can't commit 30 of 33 7/3/24,