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Dr. Alex Raben: [00:00:00] Hello, listeners, this is Alex here. Welcome back to Psyched for the month of July. Instead of one episode, you'll be getting five. That's because we're going to be doing a special mini series in which we cover clinical skills in psychiatry. So in the past, we've tended to cover specific disorders or illnesses, but these five episodes will focus on approaches and competencies that will help you in your training in psychiatry. We hope that you will enjoy. Okay. So we are now recording. Welcome back to Psych everyone, the psychiatry podcast for Learners by Learners. We're here today to talk to you about a very important topic, the psychiatric assessment or the psychiatric interview. Normally, our episodes focus on a particular disorder or mental illness. Today, we're going to be focusing more on skills. And this is one of our most important skills in psychiatry is the interview. And today we are joined by Dr. Juveria Zaheer, and I'm also joined by Lucy Chen, who's my PGY-5 now colleague. And I'm Alex Rabin, your host today, also PGY five here at U of T and Dr. Zaheer or as she likes to be called, Juveria, someone who is a cornerstone of our education here at U of T. And we're very lucky to have her with us today. She is a staff psychiatrist here at CAMH. And she's works in the emergency department and is also the education lead, if I have that correct in the emergency department. Juveria, would you like to share anything else about yourself? I know you also do research as well.
Dr. Juveria Zaheer: [00:01:56] Yeah, that's exactly right. So I'm a clinician scientist here at AMH. My clinical work is focussed in the emergency department and I do education in the emergency department. I get to meet all of the learners as they come through in PGY one. And I also do research largely on suicide and suicide prevention.
Dr. Alex Raben: [00:02:12] Great. Lucy, if you could just say hi to our audience.
Dr. Lucy Chen: [00:02:15] Hi guys! I'm here.
Dr. Alex Raben: [00:02:17] You guys all know Lucy. The learning objectives for this episode are that by the end of this episode, you, the listener, should have a clear understanding of number one, have a clear understanding of the goals of a complete psychiatric interview, the general structure and content that should be covered in an interview. And number two, feel comfortable to begin to use techniques that will help you conduct a professional, compassionate, empathic, efficient and accurate interview. And number three, be familiar with techniques you can use to facilitate information gathering when you're in a more challenging scenario. All right. So now that we have the learning objectives and the scope established, let's launch right into the interview itself or this topic itself. I should also say that my research for this episode I used to references, in particular the Shea- Psychiatric Interviewing, The Art of Understanding, Second Edition book, and the Carlat, The Psychiatric Interview, Fourth Edition pocket Book. We'll put the details of both these in the show notes. We don't get any kickback for talking about these books. This is not an advertisement, but these are two books I've personally found helpful. The Carlat book is short and sweet and it gets to the points and the Shea book is more in-depth and has some more advanced techniques. So, if you're interested, check those out. Okay, let's launch into the questions now. I think maybe the first question for us in this room is what is actually the purpose of the psychiatric assessment? Why do we do this in the first place?
Dr. Juveria Zaheer: [00:04:00] I think the psychiatric assessment, exactly as you said, is the most important diagnostic and therapeutic tool that we have in psychiatry. I think people are often waiting a long time to see us, and when they get into that room, they have often no idea what's about to happen or they may have had challenging experiences in the past. So in its original form, people are sitting there with you and you have a responsibility to make them feel comfortable, to build rapport, to build an alliance, and to create the space where you can get that really accurate information in a really rigorous way. The the interview can help us diagnose. They can help us formulate, we can put historical information into context. So from your chart review or any other information that you have, you can ask about it and clarify. And you can also do some work to support people emotionally, to help regulate them or to provide them with hope or some context or an explanatory model for what they're going through.
Dr. Alex Raben: [00:04:54] It seems that we would define it sort of as the most important tool in our toolbox. And obviously one of the objectives would be the diagnosis and coming up with a formulation about the person and then a plan. But it's also useful to get historical points from that person down on paper to build an alliance, because this may be the first time someone is even seeing a psychiatrist. And there's also a room for emotional support and some sort of supportive therapy work. One other thing that I thought was nice that I think is in the Shea book that he mentions, is this "installation of hope idea" which I thought also made sense and can be a nice way, particularly to end off an interview. I don't know. Lucy, did you have any other thoughts to add to that?
Dr. Lucy Chen: [00:05:47] I think it just important to emphasize that the utility of a psychiatric interview isn't strictly for data collection, that there's many opportunities for therapeutic work. And the intention behind a psychiatric interview allows us to have a clear sense of the picture of what's going on. But that therapeutic alliance also allows us to get more data and more of a sense of what's going on.
Dr. Alex Raben: [00:06:08] We'll talk more about that therapeutic alliance when we get to the process part. I've divided up this idea of the assessment into two conceptual ideas, one being content of the assessment and the other being processed. If we do focus on content, I guess it's important to have a structured way to asking your questions, having a sense of where you are in an interview. We often get taught a fairly prescribed structure to our interview, and we're going through our training. Now, this may vary by school or city, but we'll give you the Toronto version here. I'm wondering if we can review together the major components and rough order of these components for a full assessment.
Dr. Juveria Zaheer: [00:06:59] Absolutely! I would want to add to thinking about the purpose of the psychiatric interview. I also think if we're going to be suggesting a treatment plan, the psychiatric interview gives us an opportunity to better understand people's goals and people's past experiences, to co-create a plan that actually makes sense for them rather than a sort of a laundry list stemming from diagnosis only. I think Lucy's point is really well taken in terms of the psychiatric interview. I think it's important to start with a confidentiality disclaimer or a discussion of the limits of the assessment and the limits of confidentiality in the Emergency Department or in an outpatient setting or in an inpatient setting, for that matter. You want to be familiar with the reporting guidelines for your province or for your state? So in the emergency department where I work or at CAMH, we want to make sure that people know that if they disclose any information around unsafe driving, that there's a mandatory report to the Ministry of Transportation. We also let people know that if they have children and children are potentially at risk based on the content of the interview, we are mandated reporters to the Children's Aid Service. Then we also talk about if people disclose violent ideation towards someone else or thoughts of harming somebody with an intent or plan, or if they disclose suicidal thoughts that are beyond the scope of what can be managed as an outpatient, there would be a duty to follow up or potentially think about next steps. I think it's really important, though, because people can come in and they can be nervous that if they say I'm having suicidal thoughts, that they're immediately going to be, in their words, locked up or have their rights restricted. So, it's important to do a little bit of normalizing around that, that often people will have thoughts of suicide. Disclosing those today doesn't mean that we're going to end the assessment or we're going to act in ways that you're concerned with. We just want to know, we want you to feel safe and know what the limits would be.
Dr. Juveria Zaheer: [00:08:51] Then moving on from the confidentiality, we always want to know who somebody is that we're interviewing. I think we always teach our clinical clerks or medical students or our first-year residents, get a really strong ID which consists of age, marital status, where the person's living, how they're supporting themselves. Do they have any children? Do they have any religious connections? I think one of the challenges, and I'm sure residents have had in medical since have had this experience is, you go in and the person is saying "Isn't it all right in front of you? Why are you asking me these questions?". Sometimes I think it's important to be transparent about what you know. So, "Mr. Smith, I see here that you're 54-years-old and that you're married, is that correct?" That way people know that you're thinking of them and that you're not just going by the book or by the list. The next piece we would want to know is the reason we have a referral and or the chief complaint. We always package those two together and sometimes in a perfect world, they're the same. The reason that the family physician or the emergency physician referred to you, is the same reason that the client feels that they're being interviewed by you. Sometimes it can be different, and I think it's really important to clarify those two pieces. So "Your family doctor sent you here because they're wondering if you have a diagnosis of depression.
Dr. Juveria Zaheer: [00:10:06] I'm wondering what you were hoping for today" or "What is most concerning for you today?". That way you can compare the two and triangulate the two. Then we move into the history of presenting illness, which is really important. I know that sometimes for learners and for experienced psychiatrists, it can be really challenging to know where to start. If somebody tells you, I've been depressed my entire life, how do you differentiate between a past psych history and a history of present illness? We can talk about that a little bit through the course of the podcast but in general, the history of present illness is the story. It's what's happening. What brings you here? How are you suffering? How is this affecting your life? When did this all start? We talk about we want to give people narrative space. They've been waiting a long time to tell you this story. They've been practising potentially in their minds what it's like to tell a psychiatrist or a psychiatry resident or a medical student their story. I think giving them some space listening actively, one of the strategies that I use during my HPI's and I tend to be a little bit impatient, I'm emergency physician, so we want to do things really quickly. I ask myself to pause and to count to three during the HPI.
Dr. Juveria Zaheer: [00:11:17] If someone says "I feel like I've been depressed for the last three months and things are just so terrible right now and I don't know what to do", it can be easy then to jump in with an empathic statement or to try to clarify or to continue with your review of symptoms. I sit there sometimes and I say, okay, Juveria one, two, three. That gives them the space to tell you more. We always want to make sure that we understand what's happening with them, but we want to very rigorously review the symptom clusters as well. I know that you have other podcasts that go over this, so I won't go over in too much detail. But you want to focus on mood and on anxiety. Sometimes the anxiety piece can be missed. We focus so much on the depression, but we also want to make sure that we screen for anxiety disorders as well in our interview. We want to screen for psychosis, potential organic causes, any medical issues, any recent TBI, seizure, safety and also want to think about addiction in this section. I think sometimes we can save that and not place it in the HPI because we will screen for it later. But I think it's important because it could be really contributing to what you're seeing now.
Dr. Juveria Zaheer: [00:12:27] If you do a quick screen there, you can ask for more details later but if alcohol use or opioid use is driving the current presentation, you don't want to miss it. You don't want to be caught out in your stressor or more importantly, clinically, by leaving it till the sort of later in your assessment under that rubric and then thinking "this really colours the HPI". You want to ask about recent stressors. People's narrative models aren't the DSM-5. They're going to say X happened, then Y happened, then my sister was sick, I lost my job and I had to go to school. People have a narrative and it's really important to honour that. If you can, even in the HPI, it's nice. We can talk about that a little bit later in terms of ways to build rapport, so I'll leave that for now. Safety. We talked about SI (Suicidal Ideation), HR (Harm Risk) but we want to think about violence more generally than that, driving children, any other risks as well as any recent treatments. "You told me that you came to your family doctor about six weeks ago, you said you've had depressive symptoms for three months, tell me what you guys have done in the last six weeks". People are always trying their best, so to reiterate that and to say "What kind of treatments have you had? What's worked? What hasn't the past?". Psychiatric history is a little bit different than the HPI.
Dr. Juveria Zaheer: [00:13:46] I think about the past psych history narratively and I try to create a timeline in my mind. I start with a service utilization history actually, and people have different approaches. For me, service utilization is something that I can really hang my hat on and then I can explore around it. If you say "when was the first time you were depressed", it gets a little bit muddy. When was the first time you saw a psychiatrist or came to a healthcare provider for mental health issues? Then did you feel well? Didn't you feel well? What happened next? "What happened next" are sort of the three best words you can use in one of these assessments, because you want to really make sure that you're really steady and clear on what's happened. You want to understand how many hospitalizations a person has had, how many emergency visits, and how those visits tend to cluster over time. So if someone's had three depressive episodes and they only really visit emerges or family doctors before that, it's really important for us to know, so we can get kind of a template.
Dr. Juveria Zaheer: [00:14:49] But the really important thing to remember is that a lot of people who have mental health issues don't get treatment and they can't access treatment. They've been suffering in silence, having issues with stigma. After you do your service utilization history, then I'll go back and say "I'm so glad that you were able to seek care" and comment on whether the experience was positive or negative and say, "I imagine, though, that there have been times where you have felt X (depressed, anxious, distressed). Have there been times where you felt that way and you haven't gotten care?". Then you can see if you can understand those periods and understand whatever functional impairment came along with that. You want to get in your past psychiatric history and a really good history of past suicidal behaviour. Some people might spread it into two different areas, but if you're in that past history, it might be a nice place to get that history of suicidal behaviour. Right afterwards I'll say "You told me what was going on in your life at any point in that narrative or story. Did you have suicidal ideation or do you have a suicidal behaviour?". We'll talk about that later for sure. A past medical history is really important and you want to make sure that you get that next.
Dr. Alex Raben: [00:15:59] I wonder if we can pause here just because these sections we've covered are a lot of the more psychiatry specific sections. There also are some of the trickier sections of the history, particularly the HPI as you were mentioning. It can be hard even for more advanced practitioners to know exactly what should go in there, and I don't think there is any right answer, so it's probably not helpful for us to completely parse it out but since we covered so much ground, I think it's helpful to kind of mull that over a little bit. One of the things you mentioned is that someone can come in and say "I've had depression my whole life". What is a strategy a learner can use that would allow them to create understand the more recent story in that scenario?
Dr. Juveria Zaheer: [00:16:49] I think that's a great question, and there are a lot of process components to it in terms of reading the person in front of you, knowing what they're going to respond to and what they're not going to respond to. In general, from a content perspective, there are several things you can do. You can say "Dr. Jones referred you to us about a month ago before you asked for that referral or before Dr. Jones put that into place. How long before that had you been having difficulty? I'm so sorry to hear you've had depression your entire life. Would you say that this is the worst it's ever been? If it is the worse that's ever been, when did things start to slide downhill?". You want to find whether they're very clear demarcations or whether they're more artificial. You want to find something to demarcate. You can also guess and test a little bit. If they say that it's probably been really bad for three months, you can get some information in your HPI. One of the questions I like to ask is "What if I had met you four months ago? What did life look like for you then?". That's a way to guess and test that you're making sure that you're actually cutting at the right place. People who have histories of trauma or people who've had longitudinal mental health issues, psychotic disorders, it might be a little bit more challenging to clear that quickly. In my experience in the Emergency Department, almost everyone can say "You know, if I look back on it, things have been really hard for X".
Dr. Alex Raben: [00:18:15] I know in my own going through residency I learned the importance of getting a duration on the chief complaint early on. Then you know that's that demarcation point if someone's able to give that to you.
Dr. Juveria Zaheer: [00:18:36] Absolutely. I think it should be one of the first things you do in an empathic way. But to get that at HPI and demarcation early allows you to link it to the chief complaint and it allows you not to get lost in the weeds. I think if you're working clinically and you have some time as a resident, if you have someone an hour and a half booked for your assessment versus 15 minutes, these things can be a little bit less urgent. I think always clinically, it's really good to have that demarcation and especially if you're going into a testing situation and into an observed interview, you really want to show your interviewer that you are pretty clearly dealing with a certain time period. I think clients appreciate that structure because otherwise you can imagine if someone asks you to recount your own social history or your own work history, you'd really like to know where they'd like you to start. I think people tend to appreciate that structure.
Dr. Alex Raben: [00:19:32] As you say, it allows you to tailor what comes next and which we were talking about the review of symptoms such as the mood symptoms, anxiety, psychosis, organic stuff like drugs and TBI, seizure and then safety of course. I think certainly one strategy is just to go through that entire checklist. But I think with time and experience, we tend to actually tailor that a bit more towards the chief complaint. And we may leave out things that are a bit extraneous or may not allow us to be as efficient. How does one move through that review of systems because you could really get lost in every anxiety disorder? Is there a way of touching on things without going too in-depth?
Dr. Juveria Zaheer: [00:20:23] Absolutely. I think when you're starting, you want to really make sure that if pressed, you would know exactly which questions to ask, if you had to do a very thorough screen of X, Y and Z. I really like your point that the more experience you get, the more you know what you can adapt and what you can leave out. You have your screener, then you have the follow-up questions. I think that's a really good approach to think what is my screener and what are the questions that I ask afterwards? If I would encourage all learners to have a look at a skid, a structured clinical assessment to see what screeners are used even in a research context, because that can really help you figure out what to ask and how not to get lost in the weeds. The other thing I really stressed to my learners is really pay attention to free information. Free information, paying attention to it, coding it and filing it in saves you so much time and it actually is experienced really positively by the client. If I'm giving you my HPI and I said "the last three months have been impossible, I haven't been able to sleep, I haven't been eating. It's really tough to get out of bed to go to work". When you're screening you might not want to say "how is your appetite?".
Dr. Juveria Zaheer: [00:21:38] I learned so much from my learners and I really appreciate the opportunity to watch them interview. I always take things from my learners to the one thing that I always pay attention to is the look on the patient's face when the person is asked like "Oh, well, tell me, have you had any changes in appetite?" after they said they spent 5 minutes describing how they used to love to cook and they're a chef. I think you're nervous, right? You want to make sure you don't miss anything. But if you have something in front of you where you can file and tick off, it's also a great way to show the patient you're listening. So that way when you get to the mood to screen, you've told me that in the last few months you're not really enjoying anything, you're not eating, you're not sleeping, I'm wondering about if you've had any feelings of guilt. Then when you move to anxiety, I always ask "Would you say that you're an anxious person? Has anyone ever told you you're an anxious person? Has your anxiety been worse or better in the last three months? Has it been worse or has it been about the same?", if it's been worse "What symptoms of anxiety do you have? Do you have panic attacks? Are you generally a worrier?". You can do these things really quickly and conversationally the more experience you get. With psychosis, if somebody has a very well-organized mental status and they're presenting for depression and anxiety, I always ask about psychosis. But you might not want to go through every single cardinal symptom of psychosis because people can also experience that as pretty stressful if you want to go through each and every single one. So, you want to be careful there. I think there's a couple of places where I stack questions, we always tell you guys don't stack, don't stack, but I always stack for my mania screen only because, a lot of people say "have you ever had the opposite of depressed or whatever?" but it's not super diagnostic. There's mixed episodes and people have a variety of emotions. But to pair sleep with energy "Have you ever had periods of time where X and then that" saves you that whole screen. OCD you can stack as well "recurrent intrusive thoughts of X, Y or Z", that saves you that piece, too.
Dr. Alex Raben: [00:23:46] Right. The idea being that, if you have these screener questions, then if you get negatives on the screens, so someone is saying "no, actually my mood is fine and I'm still enjoying life", then by virtue of that, depression is no longer something you really need to delve into as much. So that might save you some time and similar with other types of diagnoses.
Dr. Juveria Zaheer: [00:24:11] You don't want to go hunting. Someone's telling you what their chief complaint is and you want to really focus on that piece. You also want to make sure that they don't have a psychotic disorder that you're missing. You want to make sure that you screen and pay attention to mental status. Ggain, you don't want to necessarily get lost in the weeds.
Dr. Lucy Chen: [00:24:27] It sounds like for HPI, how I've done it is that I focus a big chunk of time on the recent context of their chief complaint. Again, that's getting a story of why they came in the first place in terms of the assessment. For me , how I've prepared for STACERs which are clinical exams where you have to do a 50-minute psychiatric interview, that's comprehensive and then create a formulation and plan on the spot. What I've done is, I've also created six horizontal boxes and each of those boxes I've just had just to remind myself, I have a mood, depression, mania, a psychosis screener, anxiety, substances, and then safety. Then I usually leave the organic stuff actually for the medical history, but I can include that there if it's very relevant. If you have those titles kind of written in these boxes, you won't forget. That's kind of a way to kind of organize yourself when you're approaching HPI. So the first part is just the story, the context, and then those six boxes to screen for and then that could transition into the past medical, the past psychiatric history where you're asking about recent treatments or what's been helpful in the past or past episodes. Maybe they're presenting with a depressive episode now, but they've had a manic episode in the past. But just for the HPI and having a visualization on the paper could really help you with an approach when you're kind of feeling nervous.
Dr. Juveria Zaheer: [00:25:59] I will say that I still do that in the emerge. If I see someone instead of writing down every word they tell me evenwhen I'm listening to the HPI, I have my boxes or my rubrics and if I hear "I went to a work and then I felt like I wanted to hide under my desk because my heart was beating so quickly", I can make a flag for myself of "panic". If I say "I've been drinking a lot more and my friends are really worried about me and I feel so socially awkward all the time", I can make those notes in the little boxes and that way when I come back to do my screens, I already have the information there and the scaffold and I can follow up on it. I really like that approach too, it's great.
Dr. Alex Raben: [00:26:37] We've went back to HPI there because it tends to be the biggest struggle for learners. I think it's important for us to really flesh that out. We had just finished up past psychiatric history, why don't we get back to the rest of the content of the interview?
Dr. Lucy Chen: [00:26:53] I just want to highlight, though, for past psychiatric interview, it's also including all past admissions. It includes past psychotherapy. If we ask "have you ever finished a course of CBT", some patients will say "I've done CBT in the past, but it's like I missed half of all of my sessions". So getting a sense of completion of the psychotherapy that they've pursued, any sort of past history of medication trials, a sense of what the dose was and how long they were on the medication some patients will try medication for about a week and then they'll discontinue. So it's not really considered a full course of medication, and that's informative in terms of your formulation and plan for medication options for this patient. Also asking about neurostimulation or past psychiatric treatments in the domain of rTMS or ECT.
Dr. Alex Raben: [00:27:45] So, treatment is defined quite broadly.
Dr. Juveria Zaheer: [00:27:48] I think exactly that. In the past psych history, one of the things that you want to do is also get someone's opinion on what happens. If someone said "I did CBT", then first of all "what did you actually do? Tell me more about that", because some people's experiences of CBT might not be what you might consider to be CBT; "I did talk therapy" "what did that look like for you?". I always ask people what helped and what didn't, and asking people why they stopped treatment or medication is really important if they say "I did 16 sessions of IPT and I felt really great afterwards", that's very different than "I did 8 and I felt worse when I stopped then when I was doing it". Or before around the medication piece, I really liked how you put it. You want to know when they started what the dose was, what benefit did they have, if any, what side effects that they have? You really want to ask about adherence as well.
Dr. Juveria Zaheer: [00:28:47] Everybody says "I took it regularly", but to say things like in a typical week "how many doses would you miss" or "would you have to refill? Would you always on time and refilling your prescriptions or was there always some left over?", those are really useful questions to understand. The other thing I would suggest for is that you think about your assessment is going to be someone's past psych history sometime in the future, right? So,the use of skills is really important. If someone had a past psych history and you can find the chart, you see that they have a bunch of nines on the chart, it's really useful. People might argue, but I think about scales as part of the HPI, having people do a GAD-7 or PHQ-9 is really important as well to understand the HPI.
Dr. Lucy Chen: [00:29:36] Then with regards to also past admissions, some patients will have several admissions. You can just get a sense of how many admissions in total. At what age were you first admitted? When was the last admission? What was the worst admission and how approximately how many of those admissions were for If the chief complaints relate to depression? Or perhaps if they've had a past history of mania, how many of those admissions were related to mania?
Dr. Juveria Zaheer: [00:30:01] Awesome! And what was your worst admission? What was your best admission? What worked really useful?
Dr. Alex Raben: [00:30:05] Then we get into some the part of the assessment that is less specific to psychiatry, the past, medical history there. Are there things in psychiatry were particularly interested in from this perspective, from the past medical history?
Dr. Juveria Zaheer: [00:30:21] As a person who does a lot of suicide research, there are certain conditions that are linked with suicide and these same conditions are linked with mental health concerns. To ask about head injury and any post-concussive syndrome symptoms, I ask about seizure as well. It's important to ask a very general review of system, you want to make sure that someone doesn't have a history of hypothyroidism that's undertreated generally physically how are you feeling for women. I always like to ask about their menstrual cycle. I think it's really important as well as contraception, thinking about planning for medications or family planning in the future. I think these are pieces that you probably don't want to miss. Then you think about the medication you want to have an eye on, the medications you might prescribe. A history of diabetes, a history of insulin resistance, these things can be really important as well. Then in your HPI, too, you're going to be asking about what's happening. If someone identifies particular physical changes and physical symptoms, you want to think about that too. If you're working with older people, you want to think about cognition.
Dr. Alex Raben: [00:31:27] I've put it separately here on my page, the substance use history. Now, we already said that we would often already have screened for this in the HPI. However, here this is more like a past psychiatric history, but for their substance use, I have to be honest that I usually will clump my "substance use history" in with my "past psychiatric history" and just ask about addictions treatments in the past, whether they've been involved in AA (Alcoholics Anonymous) or something similar. Then get an idea of when their use first started and when it became a problem for them as defined by them. Then getting into the details of how much they're using and what that actually looks like. Do you guys have other comments on that? I know I'm not being terribly specific, but those are some of the highlights that I would ask around for sure.
Dr. Lucy Chen: [00:32:22] I think also critical aspects of the substance use sort of history and context is a history of withdrawal and whether or not there's been any complicated withdrawal with seizures, delirium tremens or have they ever been hospitalized in the context of intoxication or withdrawal.
Dr. Juveria Zaheer: [00:32:36] I agree. I think you want to take the care with a substance, use history as Alex said, exactly as you would with the psychiatric history. And there are going to be particular things that you really want to be concerned with. I often will ask people "when did you first start using alcohol? Has your alcohol use changed over the course of your life". People will sometimes say "when I'm feeling more anxious and down", "I try not to drink", "I'm not drinking right now". I ask people "when was your use the heaviest", and even people who don't have heavy criteria for substance use disorder will say "when I was in university, I binge drink or X or Y" . Then you always want to ask about other substances even sometimes people are a bit taken aback "But cannabis is legal". I always ask about cannabis specific. Quickly "do you use cannabis, how often". People sometimes forget, they won't consider it to be a drug. You want to ask about cocaine and you really especially now want to ask about opioids. Have you ever used opioids that were prescribed or not prescribed to you? It's a really important question. Then thinking about, as Lucy said, tolerance and withdrawal. The dependence right here is super important. You also want to ask, if you do end up treating this person substance use disorder or referring on "have you ever been on agonist therapy? Have you ever had anti-craving medication? Have you ever required residential treatment?". I think those are pretty important questions to you. Then asking about what people's goals are, especially if they're coming to you for mental health reasons. You want to know when you're taking this history in the past "Has this been something that you need a treatment for? Where are you at right now?".
Dr. Alex Raben: [00:34:12] Right. Moving to medications. This would be similar to any other medical assessment, although we obviously pay special attention to psychiatric medications. But I don't think we need to spend too long on that section. You would obviously just want to know dose and timing and all of that. If there aren't any naturopathic medications and then of course allergies are important in our field to know about. Now we move on to family history. What do we want to know from a psychiatric perspective in terms of family history?
Dr. Juveria Zaheer: [00:34:53] It's interesting cause I think the family history, we think of it as something that's a little bit separate, but the family history and the social history and the developmental history are so tightly linked. If someone has a parent with serious major depressive disorder or history of suicidal behaviour, that's going to affect how they live their lives growing up. Then sometimes it can feel a little bit invalidating or you might end up wasting time, might be a little bit less efficient. For the family history, sometimes I will use that to segue way into the developmental and social history. "Tell me about your family. Who's in your family? Who's in your immediate family? Did anyone in your family ever have mental health issues? Did and has anyone in your family ever been hospitalized?" Sometimes, I'll remind people meaning siblings, your parents, your cousins, your aunt's or uncles. Because mental illness has been so stigmatized, you often get a history of an aunt or grandma. And it's a little bit unclear.
Dr. Juveria Zaheer: [00:35:58] But if you ask "anyone who seemed a bit different or had some challenges", then always ask about substance, family history of substance use too, don't forget that one. Then family history of any suicidal behaviour is really important because that in itself is an independent risk factor for suicide. Then you want to take that information and not just not do anything with it. So finish your family history and use that and make sure you remember that when you're taking your social history "you told me that your mom was hospitalized for depression, what was that like for you?" The last thing I just wanted to say for family history that's really important is if someone tells you "my brother and my mom had bipolar disorder", you want to ask what medications people have been on and what's worked for them. That can guide your own treatment if you know that "my mom had had bipolar disorder, she was in and out of hospital, but she did so beautifully on Lithium and she has been out of hospital since". That can be important to know.
Dr. Alex Raben: [00:36:54] Now we come to the social and developmental histories, which is another area that is very important to the psychiatric assessment and larger in terms of number of questions than perhaps any other area of medicine.
Dr. Juveria Zaheer: [00:37:09] I think about this a lot as an emergency psychiatrist, "if you've ever been to the doctor, if anyone listening or if you guys have ever seen a physician", it can be really tough if you're in an emerge or seeing your family doctor and you feel like they don't know you like they're asking. I'm sure people who are listening often work in health care. Tthat feeling when you go to the doctor and you say "Do I tell them I'm a resident? Do I tell them I'm a medical student?". It's kind of a weird feeling and especially with mental health, if people want to come and they do want to tell you their story, but they also may be feeling a bit nervous to take up your time. This developmental social piece is such a lovely time to actually engage with someone and to understand them and to take what you've learned about them and make sure and show your work. Show them that you remember the things that they've told you so far. I have combined my developmental and social history, so I don't have to go over both separately. My bias is as a general psychiatrist, people who are developmental, who are child models and psychiatrist are going to do a much more thorough developmental history than I would.
Dr. Juveria Zaheer: [00:38:12] This is the approach that I take. I keep myself to a short period of time and I hit my high points. I start with "tell me where you were born. Tell me a little bit about the people in your family. What was your mom like? What was your dad like? You have siblings, are you close to any of them? What are they like? Did you do you know if your mom had any problems with you when she was pregnant or if she's any substances? Did anyone ever tell you if you walked on time, if you talked on time? Did anyone ever say what kind of baby you were?" Often people will say "I was like a great baby" or "I was so angry and my sister was so calm" This is important information in terms of temperament. "What are your earliest memories of school? Tell me about school. Did you like school? Didn't you? What was tough for you if you didn't like school? Was it the social aspect or was it the educational aspect?". This is a great place to screen for ADHD, developmental disability, cognitive disability. "Were you ever in a special classroom? Did school come easy? Did it come hard? Was your childhood pretty happy? Was there any trauma? Was there any bad things that happened in that way?" You're getting a more organic trauma history than has anything ever had.
Dr. Juveria Zaheer: [00:39:27] "Is anything bad ever happened to you? Have you ever had physical, sexual or emotional trauma? What was the toughest thing that happened to you when you were high school? Tell me about high school. Tell me about university". Then I go from there to. "When was the first time you had a romantic relationship? What break-ups been like for you? Tell me about your current partner so you can sort of take it through time? Are you doing now what you thought you would be doing?". Then getting a sense of what work is like for them sometimes as people. "How do people see you at work?". Because people come in and they're telling you about really hard stuff and they might think "if they saw me elsewhere, this is kind of what I'm like" or "what and how do you see yourself? What if I had met you before you got sick? Are you pretty similar? Pretty different?".
Dr. Juveria Zaheer: [00:40:13] Then I ask. So making sure I get a work history "who are the most important people in your life?" is really important for safety planning and really important for understanding people's perspectives of mental illness. I ask, does that person know you're here? How do they understand what's happening to you? How do they show support? What do you wish that they could know? Because if they say to you "my partner thinks that I need to buck up and medication isn't real" then that's very different than "my partner's sister had panic disorder and did well on Cipralex". So it's going to really guide how much work you're going to do for psycho-education. It's going to guide your treatment plan. I ask people "What are your goals? Where do you see yourself? I know that this is really hard right now, but what do you believe in? What do you hope for? What were you hoping for today". These are really important questions. So it's like a very whirlwind tour through someone's history. If you're engaged and you use the free information you've given beforehand and you have a structured life history approach, you can get it done really quickly and effectively.
Dr. Alex Raben: [00:41:22] I guess that's really helpful too. I think you took us a really nicely right through from like the beginning to the end of a social history. It seems you take a chronological approach in terms of starting with birth and moving from there chronologically, conceptually. One way that can that I find helpful to think about it is sort of the categories; development, work and school and relationships. So how do they function in these different domains of life? These are the domains I want to make sure I'm covering as well so that domain approach mixed in with the chronological approach can ensure you're sort of triangulating and not missing anything important.
Dr. Lucy Chen: [00:42:08] I think in terms of a focus for a social history, I will sometimes derive it from the HPI in terms of the stressors that they presented with. A lot of the times the trigger or the stressor was a relationship, break-Up or some family conflict. I'll flesh that out a little bit more in the social history, but I'll sometimes keep on track and I'll flag that it was something that they had mentioned. Then I'll elaborate it on further in the social history.
Dr. Juveria Zaheer: [00:42:32] There you can almost even work backwards. So I know that you came in because you've had a really difficult time in your romantic relationship. Tell me more about your partner. How are things beforehand? Is this your first romantic partner? Then you can even work backward within that domain and you want to you're not going to focus the same weight on each domain. If someone in the HPI is really challenged by work stress, if they're a resident who has been really traumatized at work, if there's somebody who lost their job and is now or is retired, you want to in your social history focus a lot on that work and identity piece. If they talk about trauma, that's the piece you want to focus on. So, you want to get all of it but different pieces are going to have different weight. It's just like if you met one of your friends or you met someone on a blind date you wouldn't necessarily want, you want to make sure that you talk to them, feel connected, and ask the right questions about why they're there.
Dr. Alex Raben: [00:43:22] Then I did put the category of "past legal" here right at the end. I have to be honest, I don't have a good spot for this in my own interview. I tend to put it actually right after my HPI, just to remind myself.
Dr. Lucy Chen: [00:43:36] Sorry, Alex, before we go and dive into the legal, one more aspect of the social history, which is important because I think we didn't talk about trauma specifically and sometimes the trauma for me will come out actually in the social history. I'll ask "is there anything salient that happened in your life" or "was there ever something that was that you consider traumatic in an emotional or mental or physical context or sexual context that was really important, that it really affected you". Then if that's actually flagged, you might have to delve deep into sort of a PTSD screen but sometimes that comes up for me in the social history and I just want to flag that it's something that could be considered.
Dr. Alex Raben: [00:44:14] I think you flagged something else. That's an important point that you can always go back if you find something in social history that's clearly really important to that person's presentation, you can always go back to your HPI. It does take a bit more time, but if it's crucial, you really should do that.
Dr. Juveria Zaheer: [00:44:31] The last point about things that we may miss, you want to ask about people's "sexual function and health" too, especially with the medications we prescribe. It's a symptom of depression, side effect of medication. So when you're do something in the social history of my kind of screeners "do you have any concerns with your sexuality right now, with desire or with your sexual experiences?" and that's kind of an open place for people can feel safe to talk about it. With respect to the legal history, I think you're right. It doesn't seem to fit naturally anywhere, and it sometimes comes out of the blue for people. I think we also need to be confident in the questions that we ask. When you're seeing somebody on medicine and you're asking about they're presenting with cardiac and you ask about GI(gastrointestinal), you don't feel shy about it. Of course, this is much more serious and an emotional potentially traumatizing, but if I don't get the sense that it's an issue within the HPI. Sometimes people say "I have these charges" and if someone talks about relationship conflict in the HPI, I'll ask about "intimate partner violence" because that's really relevant for the legal, the violence history I do as part of my suicide risk assessment. So because it's risk, I tack it on after that we can talk about that in the next session and then the legal sometimes comes up in the social history. If it doesn't, I'll say "have you ever had any difficulties or challenges with legal charges". It almost always comes up if you're taking a not a super thorough but a pretty comprehensive social history. But if it doesn't, "have you ever had any challenges with legal charges", and people will tell you.
Dr. Alex Raben: [00:46:06] So, in the time that we have left, I would like to shift our focus now to process being basically how we actually conduct the interview itself, the ways we are in the room and before we even go in the room, that can set us up for success and ensure we're meeting all the goals of a psychiatric assessment. I guess my first question then would be what would we advise learners do before they even go into the interview room that can set them up for success? If you guys have tips around that or things that you find helpful yourselves.
Dr. Juveria Zaheer: [00:46:45] I think anyone who's ever worked with me knows that I really believe in the value of a thorough chart review for lots of reasons. One, it makes you more efficient because you have a sense of what's happened before. You don't have to feel like you're in the woods when you're asking the questions. When you're taking the past history, you can make sure that things match up. I think it's really important to review whatever information you have and if there are ways to get more information to get it ahead of time. That's my big thing. I think we talked a little bit about templates. I think templates are really important. Just like in any industry, there are checklists. Like a pilot doesn't say, I'm so experienced that "I don't need a checklist", experienced surgical nurses don't say "I don't need a checklist". I think having a template and there's some pretty good evidence in suicide risk assessment that shows that a template is particularly useful, especially for junior learners, I think you want to get a sense you want to sort of sit with it, get a sense of what you think is going to happen.
Dr. Juveria Zaheer: [00:47:50] Sometimes I take notes to myself of what I think I'm going to offer, what I think the diagnosis is. And you always want to see it as just a hypothesis. There's some nice research that shows that being empathic and being a good listener is the best way to avoid cognitive errors in medicine and to be open-minded and to give people narrative space. You also want to say "is there anything in here that makes me nervous or makes me feel a bit strange". I always tell my learners a story "when I was a medical student, I did an elective at CHEO, in the Child and Adolescent Inpatient unit there, which is the Children's Hospital of Eastern Ontario and Ottawa. I knew I was going to do adult general psychiatry, but I wanted to see what it was like. I was maybe 22 or 23 and my brother and sister were 13 and 11, and my cousins were around that age. I dreaded going into work every day because it made me so sad. I think that it was just because it reminded me of my siblings.
Dr. Juveria Zaheer: [00:48:51] I think that's not unusual as I've become a parent, I have a six-year-old and an 18-month-old. So my experience is of as my daughter calls them, "cool teens" has changed a little bit and I feel like very maternal. So to know where you're at, if there's anything, if you see someone from the same ethnic minority group or if you see someone who is the same age as you, to think a little bit about how you're going to feel when you go into that interview to reflect. Then, that's around boundaries, but it's also around checking on yourself and also, it feels very different to do your first consultation on a Tuesday morning when you've had a week off and you're caught up with your paperwork. When you've been on call all night and you're doing it at 3 am in the morning and you've seen 12 people to be kind to yourself and to kind of reflect to know that you can't be perfect all the time and to maybe take a time, take some time to like have a coffee or to centre yourself. I think can be really useful.
Dr. Alex Raben: [00:49:46] For sure. When you said call, I immediately thought of myself at 4 am in the morning and I'm not my best or most empathic self. Being aware of that alone is so helpful because you can stop yourself and really check-in around that, so you're doing the best you can at that moment. You also mentioned "feeling of nervousness" and that made me think of the "issue of safety" as well. Maybe we should just quickly touch on that. From my perspective and I'd love to hear you guys recite those, basically, I don't think there's any question that's more important than your personal safety. If you're in the room and you feel unsafe, you just should leave. If it's an imminent risk, press a panic strip or a panic alarm. There's no need to be a hero, stay and try to get an interview when it's not going to happen in your safety is at risk for sure.
Dr. Lucy Chen: [00:50:38] Stay tuned for the episode with Dr. Orlowski about managing aggression in your own personal safety during an assessment.
Dr. Alex Raben: [00:50:45] Context, excellent plug.
Dr. Juveria Zaheer: [00:50:47] I think about my own sort of role models in this department, whether it's Dr. Lofgren or Mark Goldstein, when I was a trainee and they both said whether it was one on one or formal in a formal teaching session, listen to your body. If the hairs stand up on the back of your neck, if you feel nervous in a room and obviously, sometimes heuristics can be a function of sort of prejudice or oppression, we don't want to get too carried away with it. On an individual level, if you're in a room and you don't feel safe, you end it because you can always re-group, right? You can, if you start to have that feeling. I always say to my learners, just leave the room politely to say, I'm just going to take a second. Go touch base with your team, maybe come up with a strategy. If you're a trainee, you shouldn't sit with that feeling alone. You can go to your supervisor and say "I'm sitting with Ron and I'm doing an assessment and I feel like he's responding to stimuli and he's he seems a little bit paranoid" and it's your supervisor's responsibility to come into the room with you, to maybe change up your approach, to maybe move the location of the interview. But your safety is the most important thing to every staff member and to your clients as well. Your clients don't want their doctors to not feel safe and they want to feel safe and supported. We would say the same thing to clients. If you're in a room with a person in a position of power and you feel uncomfortable or you feel unsafe, you always have the right to stop things and to get up and to take a break, too.
Dr. Alex Raben: [00:52:12] I think that's an important point that we have to make here today, and I'm glad we touched on it. I want to shift now to what actually happens in the room. We talked about the idea of a therapeutic alliance or therapeutic rapport being crucial in the interview process as a goal in and of itself, but also as a lubricant. Let's say, for moving an interview along, getting answers to questions you might not otherwise get if someone doesn't trust you. That's a big part of why it is so important. How so? How do we actually build rapport with people? What are some strategies we can use?
Dr. Juveria Zaheer: [00:52:49] I think I would start by saying, I have a question for each of you guys, I would start by saying that sometimes we think about the ability to build rapport or to be present or to be empathic as a binary trait. It's either you have it or you don't. It doesn't grow or be that it's not relationship specific. I think it's important to take a step back and remind ourselves that these skills can be honed over time and they're all different things in your toolbox. What works beautifully for one person, for one client may work terribly for another client. What works really well when you're awake at 3 pm., works terribly at 4 am in the morning. We would say that I think about rapport as little different techniques and tools that you use, that you have in your bag, that you try out, you guess and test them. Sometimes it works and then you might want to do more in that kind of vein. Sometimes it doesn't. You want to try something else. I think, it's not like someone is an 80% rapport person and someone is a 30% rapport clinician, is a lot of it is fit. There are some universal pieces for sure. But my question for you guys is, do you think that your interview style has changed in five years? Do you think that you've gotten better or do you think that you've become more flexible or what has changed for you in this field?
Dr. Lucy Chen: [00:54:05] Yeah, for sure. I think as PGY-5s, now we are doing a lot of reflective work in terms of our changes, in our approaches and being mindful of what's been helpful and what hasn't. I've noticed that I feel a lot more relaxed with knowing some of these sort of components of a psychiatric interview and relying on my own clinical knowledge. So now I tap into more of just my general curiosity, I think that when this innate ability that everyone has, if you tap into your curiosity, you can get a lot of information and the patients actually really genuinely feel heard and then you elaborate from there. So, I think over the course of time, a lot of these things will become more innate. A lot of these things were really sink and they'll become second nature. And then you can relax and take in all the information and just use your curiosity to generate the momentum in the interview for sure.
Dr. Alex Raben: [00:55:05] I think I would agree with you, Lucy. I feel a lot more confident myself as well and more comfortable in the rooms now. I think it's hard to pin down all the ways in which experience has changed the way I've done interviewing. But one that's relevant, I think, to what we're talking about in terms of the alliance is that I definitely use a lot more empathic statements and reflection, and I blend that in a more seamless way with my interview. I really have recognized the importance of doing that because it just once you have that rapport, you have so much more leeway not only in your questions but also in building that management plan as we were talking about earlier, which is one of the goals of the interview. That is something I place a lot more emphasis on now than I used to. I agree with what you were saying, Juveria that it's not that I was innately not a empathic person before, and now suddenly I've gained that ability. I think it's learning those that skill of how to to use your natural empathy and testing it out that hypothesis testing. So one thing I know, I read in say a while ago and I've I was rereading it recently and I think it's important is the use of empathic statements. These are things where you're trying to guess at someone's essentially subjective experience of what they're going through either in the past or in the moment. You can do that in a way that you convey. You really think you know what's happening or you can do it in a less certain way. You could do it in a complex or a basic way. I think that's an important concept that Shea mentions. As an example, I could just ask someone, what's their experience like if I see they're crying, "why? What's going on for you? I see that you're upset". That's not very presumptuous because I'm actually just wondering what's going on for them. Or I could say "your mother was very important and these tears are signifying that she was the most important person in your life". Now, that might be very empathic, but I may have that wrong. If I have that wrong, it could backfire. So it is about this sort of testing and maybe in the beginning not being too presumptuous and more asking questions.
Dr. Juveria Zaheer: [00:57:26] I think that second piece you mentioned is a great interpretation for when you're engaged in dynamic therapy. Sometimes we do a little bit of psychotherapeutic work even in the individual assessment. I think the piece that you mentioned about being authentic and I love that combination that you both mentioned of like curiosity and confidence that when you're feeling more confident, things feel more seamless, and when you're feeling more confident in your skills, you can have the space to be more curious. I think I would say that we're so hard on our trainees and we're so hard on ourselves, sometimes we expect you to be to learn all of these skills and to be perfectly empathic at the same time. What I would say is that most people who choose psychiatry care about people, and they are empathic and they're interested in people's personal experiences, but then they're also learning like a ton of skills. So for our more junior colleagues to know that you're still a person, but you need to learn the technical stuff. Sometimes it'll feel like you're getting further away from being a human person, but eventually it will integrate and you'll get there. One of the things that I really do and it stems from the curiosity with my clients, is I try to come from a place of transparency. I think about the two lines that you mentioned, Alex, you can either be very kind of to the ground.
Dr. Juveria Zaheer: [00:58:45] "I see that you're crying. I'm very sorry. How are you feeling right now?" Or we can go to the other place of interpretation of "when I'm talking to you, you're thinking about your mother and how she wasn't supportive of you". There's also a third way, which is to be just really transparent. I do this a lot, and it's something that I think so important in psychiatry is to sit there and say "when I'm sitting with you, it's so it's hard for me to see you so upset. I can't imagine what it's what it feels like for you to be carrying this. I'm wondering when I was listening to your talk, when you started to cry, I'm reminded of when you said this about your mom earlier. I wonder if they're linked. I'm not sure. What do you think?". That's a curious middle ground. Even that transparency can be so useful when they're structural pieces that you can't really control. When someone is annoyed that you're doing this assessment and you're not a staff psychiatrist, and then they're going to have to come back and talk to the staff psychiatrist, to be able to own it and say "I know I'm the third person you talk to. It can't be easy and I don't love coming in knowing that you've been waiting here for 6 hours for me.
Dr. Juveria Zaheer: [00:59:59] How are you feeling right now?" If I'm certifying someone to say that "I know that no matter what you said, this was going to happen based on other information that I had I know that sucks. I'm really sorry, I wish it didn't have to be like this". To be pretty transparent about what you're doing and why. Often if someone says "am I scaring you" or if they swear, a lot of learners ask what to do in that moment and I think be transparent. Like, "it makes me really nervous when you talk to me like that and I'm not really sure what's happening here" and that I think to be honest, warm and set limits in that sense by being transparent is really useful. One of the things that I read about parenting that I love, that I think applies to all interpersonal relationships, including the physician patient relationship, "don't tell me what I'm thinking" and "don't tell me what I'm feeling". I think that works super well with clients to I think to be curious and to make interpretations, to be there and be present is so great. As Alex said, to not "don't tell me what I'm thinking, don't tell me what I'm feeling", I think that's really great.
Dr. Lucy Chen: [01:01:09] Yeah, that's such an excellent thing to highlight and put the spotlight on this idea of transparency, because I think any individual or any patient going through this interview with some of the questions was weird, or they're sort of caught off guard like "why are you asking me about that?", I'll often explain to them if I note that if there is sort of like an affective change or there's something that signifying that they're uncertain about or they seem a little bit awkward. About what you're asking. I'll often elaborate and explain why I'm asking about these medications, side effects and the length of time and the trial, because it informs us on how adequate the trial was and gives us a suggestions on what might be potential options for you that are more optimal.
Dr. Alex Raben: [01:01:52] I think we've all mentioned something multiple times here, but I'll just make it more explicit for the learners is picking up on that affect in the room. If there is an affect change, particularly a strong affect change like someone is breaking down into tears, we want to pause on our checklist and our content and we want to address where that affect change has come from for I think, a couple of reasons. One, because it's often very helpful for our assessment and understanding the person, but also it does show a true human understanding and an empathic understanding that then feeds back and builds that rapport as well. I think that's something that sometimes I when I'm observing junior learners, I do notice that particularly with the subtle affect changes, they may not pick up on that. Then maybe down the road they do, but it's an opportunity that should be taken advantage of for sure.
Dr. Juveria Zaheer: [01:02:56] There's a really lovely paper from a million years ago that talked about priests, and they were trying to measure how goodness or reciprocity or altruism. The idea was that if a person pretended to fall in front of a religious clergyperson, then they would be more likely to help than a random passer-by. I think what the study found is that it wasn't about if someone was a random passer-by or a clergyperson, it was about whether they had time or how they were feeling in that moment. I think for our junior learners, I love Alex's point. You know, it's harder early and it's not because it's because you haven't sat with so many people to see these subtle changes. You're learning. It's also because you have a million things in your head that you're trying to keep track of, and you're also trying to be a grown up and trying to be a doctor. And it's really hard to juggle all of these things. It's like we're teaching you how to ride a bike and juggle and we want you to be nice too. So just to know that it gets better and those skills are there and they're going to grow. I like that point.
Dr. Alex Raben: [01:03:57] Right, maybe. Transitioning from that to kind of our last topic, we could talk about things that we find challenging or things that we generally categorize as maybe more challenging in an interview and how we might deal with that. I don't think we have time to go through all of our scenarios that we have here. But one scenario that is true or that I find particularly difficult. So maybe I'll highlight that one is the patient or the person or the client who is who we're interviewing, who is talking quite a lot. Maybe they're tangential, they're not necessarily answering our questions and it's difficult for us to get out our questions. What do you guys do in those scenarios to help move that interview along?
Dr. Lucy Chen: [01:04:50] I've actually found that generally people are not offended if you redirect them and say "Hey, Mr. Smith, I noticed that you're very passionate or you're really excited about topping up this topic. But I've got some questions I need to cover in order to better understand the context and serve you better and figure out what's going on. So is it okay if we re-align ourselves with with with the interview?"
Dr. Juveria Zaheer: [01:05:16] Yeah, I love that. I do that, too. And sometimes I'll even be even more explicit like "I need to ask you these questions. I have six questions. Can I ask you those six questions". Then people will smile and they'll say, "Well, can we come back to this" and I'll say, "I promise we're going to devote whatever time we have left to chatting with this, because I'm really interested". If I am interested, yes. Usually it's always pretty interesting. It's like "I'm really interested. I wish we had more time. Let's do this first and we'll see what time we have left". In that way, it's kind of a more fair, reciprocal thing. The other thing that I try to do is that transparency really helps too "I wish we had more time because I'm in emergency, I have a bunch of people waiting. I do have to get through these pieces because I just need to figure out how there's some things I need to know for us to know where we go next. Do you mind if we move to those pieces?". I noticed you can try the gentle interruption stuff and sometimes it works, sometimes it doesn't.
Dr. Juveria Zaheer: [01:06:14] Then I think you can get a little bit more assertive. It's like you need to if you smile and you're friendly, it is like you need to stop and then we can go from there. But if someone is experiencing your interrupting as quite invalidating, then I think then there's always room to explore it. So, if it's someone who is maybe not as pleased to be redirected or experiences that or has past experiences of being silenced or has a trauma history or as a marginalized person or had a very different idea of what was going to happen, then I will explore it. Then I'll say "I know right now you're experiencing me as interrupting you and that's exactly what I'm doing" and "I'm so sorry, and I know it sucks. What do you think? How can we sort of move past this?". And so there's times where it works. If it doesn't, then I would say take the time to explore it for a few minutes because exploring it is actually going to help you finish the interview.
Dr. Alex Raben: [01:07:12] Right. It sounds like framing the timing, what you're trying to accomplish, explaining that can be helpful. If that fails, maybe some gentle interruptions. If that's not working out, then you may have to be more assertive and just sort of keep asking your questions. I also find if I can do my questions more rapid fire, so there's less sort of pauses in an assessment that can also be helpful. Then there is the risk, however, that people might be might feel invalidated by your interruptions. And in those cases, you can always kind of circle back and check in with them.
Dr. Juveria Zaheer: [01:07:47] I think own it. You know, you are interrupting them and you aren't letting them tell their story and just own it. Yeah. And apologize and say "these assessments are hard because you want to talk about what's bothering you and you've gone through so much" and it's the dialectical behavioural therapy and it's not a "but" and there's so much that's so important here. We also need to get through the assessment, so we can figure out what comes next. Then you can sort of leave it there and let the person take ownership or responsibility of what happens next.
Dr. Alex Raben: [01:08:20] For sure. I think we we will wrap up. We've covered a lot of ground here in terms of content and in terms of process. Does anyone have any parting thoughts for learners who are going to be doing these assessments on their own?
Dr. Lucy Chen: [01:08:34] I think it's just about practice, right? I mean, it was a lot of content, guys. It's this stuff. The more that you practice it and emerge context and the outpatient context, the inpatient context, you'll have to get practice. This will become ingrained. It'll become really natural, it'll become just intuitive. And then when you're in the space, you can really relax and all of this content will stick.
Dr. Alex Raben: [01:08:59] So use our structure as a lattice on which to build your interviews.
Dr. Juveria Zaheer: [01:09:05] Yeah, I agree completely with Lucy. I think what I would say is that you can't be unstructured if you don't know the structure. The most important thing early is learning the content. Read as much as you can. Read the DSM, read the diagnostic criteria, read a sked practice. Have as many observed interviews as you can see as many patients as you can and always be as empathic as you can. And to know that empathy isn't binary and it's always going to grow and your clients deserve the best of you and they'll get it. But these things take time.
Dr. Alex Raben: [01:09:39] Great! Thank you both for joining me and with that, we will sign off. Thank you guys for listening!
Dr. Lucy Chen: [01:09:46] See you next time!
Speaker4: [01:09:47] PsychED is a resident-driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not meant to be representative of either organization. This episode is part of our mini-series on psychiatric skills, which are intended to provide you residents with content directly related to the in trustable professional activities or EPAs in our curriculum. Since EPAs are designed to capture core professional psychiatric competencies, we trust our listeners outside what will still find them entertaining and educational. This episode was produced and hosted by Alex Raben and Lucy Chen, audio editing by Jordan Bawks. Our theme song is Working Solutions by All Live Music, a special thanks to Dr. Juveria Zaheer for serving as our expert this episode. You can contact us at info@psychedpodcast.com or visit us at psychedpodcast.org.
[01:10:39] Thank you so much for listening. Catch you next time!