The Clinical Interview Using DSM-IV
The Clinical Interview Using DSM-IV. Volume 2: The Difficult Patient
E Othmer and SC Othmer
Washington DC: American Psychiatric Press; 1994. 513 p
This book is a sequel to The Clinical Interview Using DSM-IV. Volume 1: Fundamentals. The authors recognized the need for an integrated approach to interviewing. Volume 1 came out of that recognition. It is now followed by Volume 2 The Difficult Patient.
“Clinical interviewing is a transitional process between diagnosis and treatment” according to Mel Sabshin, author of the foreword. In introducing the book, the authors identify the descriptive approach to DSM-IV, and address the special issue of difficult patients who express their distress in ways other than straightforward symptoms. They draw our attention to the differences between a diagnostic and a therapeutic interview (p. 55). The authors acknowledge the different approaches in interviewing: 1. the psychodynamic standpoint that engages open-ended, free-association interviewing aimed at uncovering conflicts; 2. the behavioral standpoint that explores the noxious stimuli leading to the maladaptive response; and 3. the descriptive standpoint that explores signs and symptoms and the diagnostic criteria. One has to agree with the authors that no one approach fits all groups of disorders. Their “New Think” approach claims to provide a different interview method. It is intended to help prepare the patient for “optimal therapeutic intervention”. I can’t help wondering if this also means cutting down the number of therapy sessions which will, in turn, result in cost cutting. If this, in fact, helps produce better-equipped physicians and specialists, so much the better.
The authors stress the significance of rapport with the patient as key to information gathering, which in turn is crucial in making a diagnosis. The authors have drawn from various schools such as the dynamic, cognitive, neuropsychiatric, and legal, hoping to provide a differential approach to interviewing.
The authors emphasize 5 steps in the therapeutic interview: listen, tag, confront, solve, and approve. With examples, they define and explain each of these steps in relation to special patient populations identified as difficult. These populations include patients with dissociation, conversion, psychosis, somatisation, cognitive impairment, delirium, dementia, and mental retardation. The authors further identify patient populations with different behavior patterns such as “self-protective and deceptive behavior”. Within the last group, they identify behaviors such as “concealing”, “falsifying and lying”, “factitious behavior”, and “self-deceptive behavior”.
What I found most useful in this book is the authors’ attempt to offer practical interventions for the interviewer in dealing with a patient who, for example, is seductive, dissociating, a victim of incest, leaves the office door partially open and asks the receptionist to check in every 10 minutes, and so on. The authors also provide step-by-step verbal and behavioral responses for both patient and therapist. They further explain the rationale behind the suggested interventions: “he (the therapist) gave her (the patient) space rather than pushing for answers”; “he combined empathy with limit setting”.
The book is refreshingly free of unnecessary jargon. A great deal of thought and experience with patients has been invested. The authors have given meaning to the defensive functioning aspect of the DSM-IV.
Most of the educators in the field follow what Mel Sabshin advocates: “integration rather than ideological segmentation of our field”. I agree with Sabshin’s conclusion that this book will add to “education and continuing learning”. It delivers what it claims to deliver. The authors do not maintain that this book is everything to everybody.
The book ends on a high note by focussing on the patients’ assets, their highest reachable GAF score, and our responsibility as caregivers to help them get there. It also provides an appendix for Qualitative Evaluation of Dementia (QED) and The Executive Interview (EXIT) for dementia, which outlines these methods.