Questions and questioning are obviously important in obtaining information from patients. An interview may include questions but it need not. An assessor can obtain information from pure observation. However, to understand a patient’s internal state, or their motivations, or their risks in different domains, the assessor must ask something. I’ll focus on the word ‘ask’ in a while because questions are taken as ‘the thing’, in terms of asking.
[There is a ‘Fat disclaimer’ at the end of this article.]
What is a question?
It is an inquiry of some sort. In written form it usually ends with a question mark. But a question can inquire without actually asking. This is asking: “How did that make you feel?” This is inquiring without an obvious asking, “I don’t fully appreciate how you may have felt. I’m interested to learn more; how you felt about it.“
Open or closed
Closed questions are very simple. For example:
- “Do you hear voices?“
- “Do you sleep well at night?“
- “Is your appetite okay?“
- “Have you ever felt suicidal or life is not worth living?“
- “Did you think you might avoid arrest?“
- “Have you got memory problems?”
The above usually lead to ‘yes’ or ‘no’ or other binary responses like ‘good’ or ‘bad’ etc. Closed questions inherently do not explore the range or depth of an issue.
Open questions or inquiries usually have the words, ‘How‘, ‘When‘, ‘Why‘, ‘What‘, ‘Who‘, ‘Where‘, ‘Which‘. These normally do not lead to binary responses.
For example (transformed form the above closed questions):
- “Some people hear sounds when there is nothing around to make a sound – what do you think about that?” (It is an opening and open question – later on it can be closed)
- “How much sleep do you get?“
- “Tell me about your appetite for food.”
- “What do you think about suicide?” (obviously the ‘client’ could say “nothing” – which is fine because it opens a discussion).
- “Some people have tried to avoid arrest by claiming they have no knowledge of what happened. I often wonder about things like that. How relevant, if at all – might that be to you?”
- “How good is your memory? I’d like to check on that if we may.“
Questioning is about inquiring but it need not be open or closed questions. It could be statements that prompt the interviewee to make a response.
A big problem with all questions is that they must assume something in the sentence structure. “Are you suicidal?” – assumes that the patient understands what suicidal means. “Do you use illegal drugs?” – assumes a patient knows which drugs are illegal. On one occasion I heard a patient answer this as a ‘no’. I then interrupted and asked “Which of these are illegal – cocaine, heroin, cannabis?“. The response was “cocaine and heroine“. Yes – some quantities of cannabis maybe legal. However, the response then leads to a discussion of cannabis – such as “What’s your understanding about cannabis?” (which is an open question).
Good questioning must aim as much as possible not to assume too much. The interviewer is duty bound to ensure that the interviewee understands the words and concepts in the question. On one occasion, the question was “Can you walk 50 metres without stopping?” The response was “Yes”. Then when said person was asked “Can you walk the length of 3 buses without stopping” The answer was “no only about two.” Three bus-lengths is roughly 30 metres. The answers are contradictory. On further exploration, the individual had no idea what 50 metres was like, in terms of distance.
Transforming closed to open inquiries.
Almost every closed question can be transformed into an open inquiry. “Do you hear voices?” could become “Some people experience things that others cannot. What might be your experience of anything like that?” NOT – “Have you experienced anything like that?” – which leads to a ‘yes’ or ‘no’ quite quickly. The open inquiry leads to a discussion – or allows the interviewee to seek clarification e.g. “What do you mean?” The interviewer can then explain, “The sensations are taste, smell, touch, hearing and so on“. So – this gives some information about what is being looked for but does not feed the patient ‘voices’.
The skill of transforming closed into open questions does not come easily. It requires much practice and preparation. The job of this post is not to feed those interested, prepared open-inquiry prompts.
These are not truly questions but they can be considered as statements of an inquiring nature in the course of a conversation.
A list is not given here.
Two examples –
“I don’t follow why you thought that the police were plotting – as you said – with prison officers, to poison you. Help me to truly understand that.“
“I’m trying to work out if the voice you heard was as loud as my voice and located at a distance, like from where I’m sitting or further out.“
You could spend your life defining what an interview is, delineating types, purposes etc. I’m not going to do that. For medical purposes interviews are some sort of conversation aimed at:
- understanding a patient’s situation.
- performing a mental state examination.
- assessing risk and risk controls.
Sometimes people see an interview as simply questions and answers. In reality it is a conversation, which could involve questions but it can also be about making statements to elicit a response. Therefore it is possible to inquire without asking a question, though of course questions are very important.
Forensic specialists are not required by any standard to accept everything a patient says. Often times questions should test the robustness of a belief system. Doing that may cause a degree of discomfort for some patients. The idea is not to cause harm. By comparison when a doctor in ‘physical medicine’ – with care – palpates a site that causes some pain, the intention is not to cause suffering or trauma.
I am not going to fully ‘explain’ what preparation means. I take it to mean the following (not a full list):
- Ensuring that the interview is well setup, has sufficient time, there is appropriate interview room/space, the client is notified, interpreter arranged (where necessary, obviously).
- Security arrangements are in place.
- All relevant materials are obtained and studied in advance.
- Identifying the core issues to be explored.
- Some pre-planning about questions or the types of questions. [This does not mean that one has to have a rigid format]
Busy and fussy
Unfortunately some interviewers/assessors are busy and take shortcuts – but never openly admit that. Busy interviewers or those who don’t really care, tend to do the ‘quick job’ by asking many closed questions. The author has seen this happen. Defensive, incompetent assessors simply need to say, “Well I asked him if he was suicidal and he told me he wasn’t. What more could I do? I’m sorry he’s dead. Some people do not tell you if they’re suicidal.” [The author has heard those words very similar to that said behind closed doors.]
‘Fussy’ patients – especially in custodial settings tend not to like open inquiries. They often say things in response like, “I don’t know. You’re confusing me. Nobody has ever asked questions like that before.” This tends to put novice interviewers on the back foot. Expert interviewers will have the experience in keeping the inquiring conversation going. This expertise comes only with practice. Fussy patients like closed questions, like “Do you hear voices?” because if they can just answer ‘yes’. That then affords them a better chance of getting treatment which then signposts that they need ‘better or more generous’ privileges. This dynamic is quite common, especially in prisons.
Managing the interview
All interviews should have some sort of structure. In psychiatric interviews, it is often difficult to set a structure and one has to have some flexibility. But that doesn’t mean that structure should be abandoned. When interviewing a patient who is highly pressured in speech, abusive, tangential, circumstantial or thought disordered a structure can still be maintained even if it is loosened to be accommodative. The author has observed interviewers to fail to maintain some sort of structure. What happened in those interviews is that patients rambled on aimlessly and the objectives of the interview were not achieved. Some interviewers are naturally afraid to interrupt a patient due to fears of conduct complaints. Interrupting a patient is not by definition rudeness. At times to get a word in, an interviewer will need to be assertive. Some patients may become aggressive or potentially violent if interrupted. Managing that depends on skill.
Aborting an interview is not bound to be a ‘last resort’. Interviewers should abort an interview if there are signs of hostility, frustration or aggression that are not manageable and likely to materialise in violence. It is not wrong to say something such as, “This interview will be terminated shortly, as I fear you are likely to become more abusive or you are likely to become violent.“
If saying the above is likely to trigger aggression, the assessor(s) can call for short break or assert that they need a short break. It gets difficult sometimes, with hostile patients refusing to leave the interview room. In that case the assessor(s) would be within their rights to depart with kind words.
Most healthcare settings do no readily allow for voice recordings of interviews, even when the interviewee fully consents to it. Certainly in prisons it is near impossible. In private work this can happen more readily (with consent), and it is a very good idea. [Procedures for that are not explored here. This is not a tutorial.]
Where voice recordings are not possible, it is absolutely important that interviewers record a close approximation to what was actually said. That could be limited depending on whether they are allowed a laptop or other device to type as patients talk, or on the speed of their handwriting in a notebook of some sort.
There is a natural human tendency to interpret and summarise what is said. This is something of a mistake. Any sort of ‘interpretation’ and summarisation means that the interviewer is at risk of introducing (unconsciously) biases in their own minds.
A sound mental state examination which accurately captures thought disorders and symptoms such as hallucinations, need to record exactly what was said in exactly the way it was said. Here is an example. Patient: “When I hear a noise from outside in the corridor, I hear voices in my head.” Interviewer (novice) records: “The experiences internal hallucinations.” The latter interpretation, leads to a missed opportunity to to dig deeper into whether the experience was a reflex hallucination, a functional hallucination or synaesthesia. (These are defined in ‘Fish’s psychopathology‘.)
The discipline of observing and recording psychopathology ought not to be limited by time constraints. The job of an expert assessor is to truly understand the psychopathology.
Attention to non-verbal responses
Whatever sort of inquiry that is made, it is absolutely important that interviewers have the time and means to record non-verbal responses. It naturally difficult to jot down in an interview non-verbal responses. Some sort of ‘short-hand’ notes (abbreviations) can be used to capture this and aid memory in write up of reports or records.
Descriptions such as “Patient A was aggressive in manner.” say little about the substance of what was happening. A description of the same patient such as, “Patient A rose to his feet suddenly, walked over to within 1 foot of us, was waving his arms about wildly, grimacing and breathing heavily whilst shouting at us.” – gives a very different picture.
Another example: “Patient B was totally paranoid and suspicious about our presence.” – gives no substance. This does: “Patient B was looking around the room rapidly. He looked at us from the corner of his eyes. He was staring at us. His brow was furrowed. He was moving his body side to side in the chair. He answered questions only in the most economical way with one or two words. He repeatedly questioned if we had genuine motives or were sent by the police. He could not be reassured that we had no connections to the police, though we should him our health service name badges.“
The obvious difference in the above two examples, is that recording non-verbal behaviours are more wordy. I is not suggested that flowing prose be written during an interview. Telegraphic style notes can be made and expanded upon later on. The point is that attention to non-verbals is terribly important, and often times time-consuming.
Use of interpreters
Identification of the need for an interpreter is the first step. It is not uncommon from the author’s long experience to be told, “He speaks in English well. We understand him and he understands us.” – then to start the interview and discover that the patient is quite deficient in communication in English.
The issue stems from the level of communication. For simple everyday things communication in English (for a person with a different first language), may be sufficient.
When expert assessors interview they ask things of a different nature e.g. in exploring insight, perceptions of risk, understanding and benefit of therapies etc. Those issues are rather abstract and require a real command of English.
When an interpreter is present, the interviewer(s) should establish that the patient understands the interpreter and the dialect is matched. Serious problems arise from mismatch of dialect.
Quality of interpreting is also a big issue. If interviewers are not satisfied they should say so early on, and try to work with the interpreter. This could mean having a break to brief the interpreter. If after that, an interpreter is so problematic, it could mean that the interview needs to be reconvened. That’s a matter for professional judgement. The downside is ‘soldiering on’, then on reflection discovering that the findings from the interview are too unreliable. That would mean having to spend more time (travelling) and interviewing.
This article started off with questions, inquiring statements and prompts. Those are some of the ingredients of an interview. An interviewer can get a lot more understanding and information by not asking closed questions at the outset. Closed questions are not bad in themselves. Generally, in mental health assessments it is a good idea to keep closed questions as a last resort, when definite clarity is needed after a broader exploration has happened, or when a particular disclosure has already been elicited.
Several aspects of the interview itself were explored. The quality and extent of record-keeping was emphasised. Attention was given to recording of non-verbal responses.
The use of interpreters is an important area.
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