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
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
