NR548 Exam 2

Psychiatric interview - the process by which psychiatric assessment is conducted -primary tasks • building a therapeutic alliance between the PMHNP & client • obtaining a database of psychiatric info about the client • establishing a dx • negotiating a tx plan Therapeutic Alliance - a feeling that you should create over the course of the diagnostic interview, a sense of rapport, trust, and warmth -most important goal of the interview process -the cooperative working relationship between the therapist and client • begins during the initial or opening phase of the interview -fundamental component of successful therapy • Without trust, adherence to treatment recommendations may be compromised • interview may not elicit the information needed to formulate an appropriate dx & plan of care without rapport & trust Creating rapport: tips - -Be Yourself -Be Warm, Courteous, and Emotionally Sensitive -Actively Defuse the Strangeness of the Clinical Situation -Give Your Patient the Opening Word -Gain Your Patient's Trust by Projecting Competence How to approach threatening topics (sensitive/embarrassing material) - - Normalization -Symptom Expectation -Symptom Exaggeration -Reduction of Guilt -Use Familiar Language When Asking about Behaviors Normalization - Introducing Q with some type of normalizing statement -two principal ways to do this: 1. start the question by implying that the behavior is a normal or understandable response to a mood or situation • ex: Sometimes when people are very depressed, they think of hurting themselves. Has this been true for you? 2. Begin by describing another patient (or patients) who has engaged in the behavior, showing your patient that she is not alone • ex: I've talked to several patients who've said that their depression causes them to have strange experiences, like hearing voices or thinking that strangers are laughing at them. Has that been happening to you? Symptom Expectation - communicate that a behavior is in some way normal or expected -Phrase your Q's to imply that you already assume the patient has engaged in some behavior and that you will not be offended by a positive response -high index of suspicion of some self-destructive activity -Ex: patient is profoundly depressed and has expressed feelings of hopelessness. You suspect suicidality, but you sense that the patient may be too ashamed to admit it. Rather than gingerly asking "Have you had any thoughts that you'd be better off dead?" you might decide to use symptom expectation. "What kinds of ways to hurt yourself have you thought about?" *reserve this technique for situations in which it seems appropriate Symptom Exaggeration - suggesting a frequency of a problematic behavior that is higher than your expectation, so that the patient feels that their actual, lower frequency of the behavior will not be perceived by you as being "bad." -helpful in clarifying the severity of symptoms *reserve this technique for situations in which it seems appropriate Reduction of guilt - seeks to directly reduce a patient's guilt about a specific behavior in order to discover what they have been doing -useful in obtaining a hx of domestic violence & other antisocial behavior Domestic Violence -"Have you ever been in situations where fights occurred and you were affected?" • If patient answers "yes," you can flesh out whether role was being a witness, victim, or perpetrator According to Peplau's Theory of Interpersonal Relations, establishing early rapport allows the role of the nurse to evolve from stranger to: - resource person, teacher, leader, surrogate, technical expert, and counselor Establishing the Relationship - -Trust is essential for a therapeutic alliance -First impressions are important -PMHNP should take time to make introductions and ensure the client is comfortable -Ask general questions to arrive at an empathic understanding of how the client feels -Listen carefully and communicate an appreciation for the client's concerns -Building a trusting relationship based on respect, kindness, and acceptance will break down barriers and allow for client needs to be the center of the plan of care -Being present and openly engaged will enhance the communication experience three phases of the psychiatric interview - 1. Opening phase 2. Body of the Interview 3. Closing the Interview Opening phase - -first 5-10 minutes -establish rapport & therapeutic alliance -often most important phase • establishes the foundation -begins with PMHNP asking "what brought you in to see me today?" Body of the Interview - -30-40 minutes -Chief Complaint Established • additional Q's asked to elicit info r/t the complaint -ask about HPI, family hx, social/developmental hx, medical hx, psychiatric ROS -basis for dx and tx formulation Closing the Interview - -5-10 minutes, final phase Should include 2 components: discussion of your assessment using patient education techniques & negotiated agreement about tx or f/u plans -wrap-up statement and inquiry about missing info that may be of value -Patient education regarding working dx & recommended plan of tx • education about meds if recommended -Homework may be assigned • especially in CBT -Return visit agreed upon Four Tasks of the Diagnostic Interview - 1. Build a therapeutic alliance 2. Obtain the psychiatric database 3. Interview for diagnosis 4. Negotiate a tx plan with your patient Obtain the Psychiatric Database - Also known as the psychiatric history -includes historical information relevant to the current clinical presentation • history of present illness, psychiatric history, medical history, family psychiatric history, and aspects of the social and developmental history Tricks for Improving Patient Recall - -Anchor Questions to Memorable Events • major transitions (graduations and birthdays), holidays, accidents or illnesses, major purchases (a house or a car), seasonal events ("hurricane Katrina"), or public events (such as 9/11 or President Obama's election) -Tag Questions with Specific Examples • similar to posing multiple-choice questions, specifically for areas in which your patient is having trouble with recall -Define Technical Terms • patient's vague recall may be a lack of understanding of terms How to Change Topics with Style - -Smooth Transition • cue off something the patient just said to introduce a new topic -Referred Transition • refer to something the patient said earlier in the interview to move to a new topic -Introduced Transition • introduce the next topic or series of topics before actually launching into it Techniques for the Reluctant Patient - -Open-Ended Questions and Commands • increase the flow of information -Continuation Techniques, keep the flow coming: • Go on. • Uh huh. • Continue with what you were saying about... • Really? • Wow -Neutral Ground • changing the subject to something nonpsychiatric, with the intention of sidling back into your territory once you've gained the patient's trust. -Second Interview • When all else fails *must feel comfortable that the patient is not at imminent risk of suicide or other dangerous behaviors Techniques for the Overly Talkative Patient - -Closed-ended and multiple-choice questions -Redirecting questions to another topic • The Art of the Gentle Interruption • redirecting statement • empathic interruption, you add an empathic statement to soften the blow • educating interruption incorporates a structuring statement in which you educate the patient about the sorts of questions you have yet to ask and the time constraints you're both working under -Structuring statements regarding information required and/or clinical procedures -brisk, highly controlling style therapeutic or nontherapeutic communication & communication technique it represents: Why are you so anxious? - Nontherapeutic communication technique: Asking for Explanations therapeutic or nontherapeutic communication & communication technique it represents: Why don't you and John get married? - Nontherapeutic communication technique: Asking Personal Questions therapeutic or nontherapeutic communication & communication technique it represents: What would you like to talk about today? - Therapeutic communication technique: Broad Openings therapeutic or nontherapeutic communication & communication technique it represents: What do you think you should do about it? - Therapeutic communication technique: Reflecting therapeutic or nontherapeutic communication: Older adults are always confused. - Nontherapeutic therapeutic or nontherapeutic communication & communication technique it represents: I don't see anyone else in the room. - Therapeutic communication technique: Presenting Reality therapeutic or nontherapeutic communication & communication technique it represents: If I was you, I'd take a break from school. - Nontherapeutic communication technique: Giving Advice therapeutic or nontherapeutic communication & communication technique it represents: I'm so sorry about your mastectomy; it must be terrible to lose a breast. - Therapeutic communication technique: Sympathy therapeutic or nontherapeutic communication & communication technique it represents: Today we have talked about a plan for you to manage feelings of anger. - Therapeutic communication technique: Summarizing therapeutic or nontherapeutic communication & communication technique it represents: You shouldn't even think about assisted suicide; it's not right. - Nontherapeutic communication technique: Disapproval therapeutic or nontherapeutic communication & communication technique it represents: You seem upset about something. - Therapeutic communication technique: Making an Observation therapeutic or nontherapeutic communication & communication technique it represents: No one here would intentionally lie to you. - Nontherapeutic communication technique: Defensive Responses therapeutic or nontherapeutic communication & communication technique it represents: Don't worry, everything will be all right. - Nontherapeutic communication technique: False Reassurance Translating emotions: - Sharing observations Sharing empathy Sharing hope Sharing humor Sharing feelings Non-verbal communication: - Active listening Using touch Using silence Information verification/dissemination: - Providing information Clarifying Focusing Paraphrasing Validation Asking relevant questions Psychiatric Interview versus the Medical Interview - most notable difference is that the psychiatric interview is the primary diagnostic tool used to identify psychiatric conditions. -Unlike the diagnostic process in physical medicine, psychiatric diagnoses are not generally established or validated by physical examinations, laboratory tests, or other diagnostic procedures • such processes may be used to rule out physical causes for psychiatric symptoms -need for privacy and confidentiality may be heightened in psychiatric interviewing due to the sensitive nature of the information shared • mental health diagnoses are associated with stigma in certain cultures • Safeguarding privacy is critical for building trust and protecting the client from adverse outcomes Preparing for the Psychiatric Interview - consideration of the setting and timing of the interview, as well as the unique needs of the client. -secure a space -protect your time secure a space - -Schedule the same time every week -Make your room your own in some way -Arrange the seating so that you can see a clock protect your time - -Arrive Earlier than the Patient -Prevent Interruptions -Don't Overbook Patients -Leave Plenty of Time for Notes and Paperwork Psychiatric interview setting - typically in either the inpatient or outpatient setting -inpatient interviews in the emergency department, psychiatric unit, or any unit in the hospital, often serving in a consultation-liaison role -Outpatient care: clinics, community mental health centers, residential care facilities, private practice, primary care, homeless shelters, or homecare • may self-refer or be referred by another provider for support, guidance, and medication management, or court-ordered therapy interview environment - -comfortable, clean space to put provider & client at ease -a visible clock to monitor time -access to alarms or other safety measures -provider access to the door for safe exiting -removal of sharp objects such as scissors or letter openers -a noise-canceling device for privacy interview: Time Considerations - Be on time. -Don't be late! -Schedule appointments thoughtfully to ensure promptness. Stay on time. -builds trust and communicates that respect for the client. Discuss follow-up visits in the closure phase of the interview -The timing of subsequent visits is informed by the client's unique circumstances, diagnosis and treatment, and medication regimens. Therapeutic Communication - Verbal -Active Listening: listening attentively to insure understanding -Broad Openings: allow clients to take initiative -Accepting: indicate you heard the client without judgment -Clarifying: make vague topics clear -Exploring: examine topics deeper -Focusing: putting attention into a single topic -Reflecting: direct the client's thoughts and feelings back to the client -Restating: repeat the client's words in a different way to make more clear Nonverbal -Positive techniques • relaxed movements • open arm gestures • smiles • respect for personal space • eye contact • nods when clients talk can communicate agreement or understanding -negative body language • finger-pointing • crossed arms • looking at a watch Psychiatric Interview Long Form - adapted from the one used by Anthony Erdmann, an attending psychiatrist at MGH. He takes notes on it while talking to patients and puts it in his chart Advantages -ensures a thorough data evaluation and saves time, because notes can be placed directly into the chart Disadvantages -patients may be alienated if you seem more interested in completing a form than in getting to know them Psychiatric Interview Short Form - can be used for rough notes -when you are going to dictate the evaluation or write it up in a longer version later. Advantages -presents less of a barrier between clinician and patient -easy to refer to while dictating. Disadvantages -may lead to a less thorough evaluation Psychiatric Interview Pocket Card - used to remind you of all the topics to cover -jot rough notes on a blank piece of paper or not take notes at all Advantages -card allows maximum interaction between clinician and patient Disadvantages -Required information not fully spelled out on pocket card • more use of memory is required Patient Questionnaire - decrease the time needed to acquire basic information Advantages -allows more time during the first session to focus on issues of immediate concern to the patient -may heighten patient's sense they're actively participating in their care Disadvantages -invalid information may be collected -Some patients may view filling out the questionnaire as a burden Patient Handouts - written information about disorder Advantages -increase patients' understanding of their diagnosis -sense that they are collaborating in their tx Disadvantages -may present more info than some patients can handle -Info may be misinterpreted Active Listening - involves preparing to be fully attentive to the interaction -note verbal and non-verbal cues • including what is said and how it is said -indicate attentiveness through their feedback and body language Observation - may include client presentation, grooming, and facial expressions -Observation skills are also used to collect objective data Advanced communication skills - critical listening critical questioning critical thinking