# 01 - 1. History Taking & Interview Skills

# 1. History Taking & Interview Skills

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1. History Taking & Interview Skills 
The four tasks of a psychiatric interview are 1. Build a therapeutic alliance. 2. Obtain the 
demographic information required. 3. Interview for diagnosis. 4. Negotiate a treatment plan. 
Basic concepts on approaching threatening topics: 
1.Use normalizing questions to decrease a patient's sense of embarrassment about a feeling or 
behaviour. 2. Use symptom expectation and reduction of guilt to defuse the admission of 
embarrassing behaviour. 3. Use symptom exaggeration to determine the actual frequency of a 
sensitive or shameful behaviour. 4.Use familiar language when asking about behaviours. 
Nondirective 
techniques 
Use 
Example 
Comments 
Open-ended Qs 
The opening stage of the 
interview, to allow free 
narration. Non-directive 
technique 
What brings you to the 
hospital? 
Preferable when highly 
suggestible; not very 
useful to focus if overtalkative or extremely 
poor historian. Usually 
starts with ‘tell me’, 
‘describe’, etc. 
Repetition 
Repeating the exact 
words of the patient 
Pt: I was having bad 
dreams last night. 
 
Dr: So, you were having 
bad dreams last night. 
Helps patient to feel that 
doctor is listening actively 
Restatement 
Similar to repetition but 
phrases rearranged 
Pt: I was having bad 
dreams last night. 
 
Dr: So, you are getting 
disturbed by the dreams 
you have. 
Helps patient to feel that 
doctor is listening actively 
Summation 
Brief summarisation of 
what the patient has said 
up to a point in the 
interview 
 
‘So from what you have 
told so far, you are worried 
for last 4 months and not 
sleeping well, and your job 
is at risk. Right?’ 
Helps patient to check if 
he has said what he 
intended to say. Helps the 
doctor to form an idea of 
the narration so far. 
Clarification 
Doctor tries to get details 
from patients about what 
the patient has already 
said. 
 
‘You said you are feeling 
depressed ever since you 
can remember. When do 
you feel most 
depressed?’฀ 
Helps in avoiding 
misconceptions by the 
clinician. Also shows 
clinician’s interest in 
knowing more. 
Facilitation 
Helping patients continue 
the interview by 
providing both verbal and 
nonverbal 
encouragement. 
 
Approval nods, leaning 
forward slightly to express 
interest, ‘Yes. And then?’, 
‘yeah, go on…’ ‘Uh-huh’ 
etc. 
Helps patient to feel that 
doctor is listening actively. 
Encourages flow of 
information.

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Techniques when changing topics: 1. Use smooth transitions to hint at something the patient just 
said. 2. Use referred transitions to hint for something said earlier in the interview. 3. Use 
introduced transitions to pull a new topic from thin air. 
1. Non-directive techniques: These techniques are employed without focussing on a particular 
answer. 
2. Directive techniques: These are focussed on seeking a particular answer or driven by other 
motives of the doctor. Note that these are not necessarily detrimental but must be used 
judiciously. 
Directive 
techniques 
Use 
Example 
Comments 
Closed 
questions 
When, where, how many, which and 
what questions. 
Answers can only be ‘yes or no’, in 
most occasions. When clubbed with 
non-facilitative gestures, can be 
detrimental to interview process. 
Stating a presumption followed by 
tags can be very directive. 
Did you sleep well last 
night? 
 
You have lost weight. 
Haven’t you? 
Better avoided in early 
parts of the interview as 
they can produce 
prescribed answers lacking 
in detail. Also avoid in 
highly suggestible 
patients. Good technique is 
to start with open; move to 
closed by the end of the 
interview. Useful to rule 
out less likely symptoms. 
Question 
rephrasing 
Persisting with a question to seek an 
answer; so, restating the question in 
different terms for a second time. 
 
Often used when patient 
digresses from the topic of 
discussion. The motive is 
to collect the specific 
information. 
Redirection 
Gently reorienting patient towards 
the topic of discussion. 
Pt: ‘It is not good if one’s 
parents are divorced even 
before one goes to school.’ 
Doc: ‘I’d like to hear more 
about your parents, but 
first let me get a picture of 
what’s happening to you 
of late’. 
The motive is to keep the 
patient on track. 
Transition 
Moving from one to another topic – 
this is a special skill and preferably 
must be done as smoothly as possible 
to keep the patient interested. 
‘You mentioned that your 
mother is a medical 
secretary. What about 
yourself? What job do you 
do?’ 
Smooth transitions – uses 
the cue off something the 
patient just said. 
 Referred transitions – uses 
the cue off something said 
earlier in the interview. 
introduced transitions 
-uses a new topic to 
proceed.

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Limit setting 
Useful to manage time pressure, 
especially in garrulous patients. 
‘I am going to interrupt 
you as there are few 
important things we need 
to cover today’. 
To be used cautiously, 
overuse may detach 
patient from the doctor. 
The motive is to use time 
effectively.

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Other methods to elicit information: 
 
 
Technique 
Description 
Example 
Comments 
Confrontation 
Point out to a patient 
something to which 
the doctor thinks the 
patient is missing or 
denying. 
 
‘You seem not to have gained any 
weight in last 6 months. Is it possible 
that your eating has been poor again?’ 
Must be done in a 
respectful way. The aim is 
to help patients face a 
difficult aspect rather than 
dismissing patients by 
showing a negative aspect. 
Interpretation 
Clarifying certain 
associations or 
relationships that the 
patient may not see. 
 
You seem very anxious when talking 
about your job. Are you having any 
problems at workplace? 
Sophisticated technique 
and should generally be 
used only after the doctor 
has established some 
rapport. Should be stated 
as a hypothesis after 
sufficient collection of 
evidence from the 
interview. 
Self-revelation 
Limited, discreet selfdisclosure by 
physicians 
 
‘Do you like Shakespeare? I was a mad 
fan when I was at school.’ 
Helps physician feel atease sometimes. Excessive 
self-revelation is a 
boundary violation. 
Silence 
Silence can be used 
either to facilitate 
discourse or to 
indicate disapproval 
or disinterest. 
Sometimes useful and 
allows free emotional 
expression. 
 
Relieves patient’s pressure 
and he/she may fell relaxed 
that not every moment 
must be spent talking. 
Symptom 
expectation 
 
Without a formal 
admission from the 
patient, asking about 
details of problem 
behaviour. Doctor 
assumes (rightly) that 
the patient is involved 
in the act. 
What sorts of drugs do you usually use 
when you're drinking? 
(Assuming that the patient uses drugs) 
 
Defuse the admission of 
embarrassing behaviour. 
May help in reduction of 
guilt. But must be used 
with experience and 
according to the context. 
Symptom 
exaggeration 
When deception or 
minimisation is 
expected, overstating a 
guessed frequency in 
order to elicit a true 
answer. 
How many times have you taken 
overdoses since your last 
hospitalization? Four? Five? 
Also helpful in reducing 
guilt to certain extent as 
the patient feels that the 
doctor has expected a 
higher amount of problem 
that what she/he actually 
has brought.

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Supportive techniques – not aimed at eliciting information: 
Supportive technique 
Use 
Example 
Reassurance 
Used to instil positive hope and 
avoid or reduce despair. Must not 
be falsely reassuring. 
‘The depression may be very difficult for you. 
I think it is very likely with the proper 
treatment you can get back to your job’. 
 
Advice 
Many patients seek advice directly; 
it is acceptable to provide advice 
but based on sound understanding 
of the context. Premature advice can 
be obstructive than facilitative. 
 
‘I think it is best for you to consider ECT at 
this time. If I am you, I will give this a serious 
thought.' 
Postponement 
Conscious and deliberate 
postponement of delicate issues; but 
must be opened at an appropriate 
time. 
‘I can see that you are uneasy to tell me about 
your relationships. That’s OK, we can come 
back to this when you feel ready to discuss 
with me.’ 
Validation / normalisation 
Helps to decrease a patient's sense 
of embarrassment about a feeling or 
behaviour. Generally done by 
quoting how it is normal for people 
to have different emotions/ 
reactions/ behaviours, etc. 
‘Sometimes when people are very depressed, 
they think of hurting themselves. Has this 
been true for you?’ 
 
Acknowledgement of 
affect 
Making a remark about patient’s 
affect can facilitate disclosure. 
I can see that you look anxious when talking 
about those voices. 
 
Positive reinforcement 
Gently uplifting self-esteem by 
statements of praise (but at a 
realistic extent) 
‘I've never been good at expressing my 
problems’. 
 ‘Well, I think you've described the situation 
in a way that helped me understand what you 
have been going through’. 
Statement of respect 
Affirmative statements (must be 
genuine and appropriate) indicating 
respect and dignity along with 
positive reinforcement 
“You have been through a lot.” “I’m 
impressed at how you have hung in there.” 
“You must be a very strong person.” 
Partnering 
The interviewer encourages the 
patient to ask questions and to 
express any concerns, encouraging 
team working 
“I’m here to help.” “Let’s plan on working on 
this together.”

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Obstructive techniques that may hamper the progress of information sharing: 
Obstructive techniques Use 
Example 
Suggestive questions 
Answers are contained in the question 
itself. Misleads both the patient and the 
doctor. The patient is left with little 
choice. 
These voices are not from your head. Am I 
right? 
Why questions 
These questions ask the patient to 
discover their own problems, in a way. 
Not useful when used to elicit 
information from a distressed patient. 
Why do you keep waking up so early in 
the morning? 
Compound questions 
Adding two or more questions in a single 
statement. This confuses the patient and 
will lead to either a vague response or 
non-response. 
Do you take a vacation every year, and are 
you able to relax? 
Negative Nonverbal 
gestures 
Facial expression, body posture, and 
behaviour that indicate lack of interest or 
inattentiveness, 
The doctor is yawning or repeatedly 
checking his/her watch, other repetitive 
gestures like tapping the table, etc. 
Disapproval 
Expressing unhappiness with a topic that 
the patient wants to discuss; may lead to 
withdrawal and not revealing the 
important problem faced b y the patient. 
‘Over the last month I have had trouble 
with sex’. ฀ 
 ‘Dr: We are here to talk about your 
sleep.' 
Setting traps 
Tricking the patient using his own words. 
Often seen as doctor’s attempt to negate 
patient’s problems. 
You wanted to see me as nothing had 
gone well for you, but you just said that 
you have got a new job and keeping a 
good shape. 
Adapted from Kay J & Tasman A. Essentials of Psychiatry, 2nd edition, 2006. John Wiley & Sons, Ltd.

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Open-Ended vs. Closed-Ended Questions 
Open-Ended Questions 
 Closed-Ended Questions 
Highly informative answers 
They produce spontaneous formulations. 
Low yield answers 
They lead the patient. 
Low reliability of answers. 
Non-reproducible at a later date, or by a different 
doctor. 
High reliability. 
Low precision – do not focus on target symptoms. 
 
The intent of the question is clear, and so precise, focused 
answers elicited. 
Not very time efficient. My lead to circumstantial 
elaborations. 
High time efficiency. 
 
Low diagnostic coverage as patient selects the 
content revealed. 
Good diagnostic coverage as doctor selects interested 
content. 
Adapted from Othmer E, Othmer SC. The Clinical Interview Using DSM-IV. Washington, DC: American Psychiatric Press; 1994. 
Techniques for a poor historian 
 
Use open-ended questions and commands to increase the flow of information. 
 
Use continuation techniques to keep the flow coming. 
 
The Shift to the neutral ground when necessary. 
 
Schedule a second interview when all else fails. 
Techniques for over-talkative garrulous historian 
 
Use closed-ended and multiple-choice questions to limit the flow. 
 
Perfect the art of the gentle interruption. 
 
Educate the patient about the need to move along in the interview. 
Ancillary methods of gathering information: 
Behavioural observation methods: 
 Observing and recording behavioural events, to study mental state or plan intervention. 
Often used when patients are in seclusion. 
 Event sampling: e.g. every fifth or tenth event is coded in detail 
 Time sampling: observations may be made only every 5 or 10 mins 
 ‘Functional analysis' refers to attempts to explain and predict the functions of a 
phenomenon by examining any relationships to the outcome. It is a special variant of 
behavioural observation methods, where the sequence of antecedent environmental 
events, target behaviour and concurrent events and consequent outcomes are observed. 
This is also called ABC analysis. Often used in LD setting, dementia care, and challenging 
behaviour services.

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Using an interpreter: 
 Explain the goals of the interview to the interpreter 
 Explain structure and content of interview 
 Explain the need for literal translation – not interpreted translation in the Mental Status 
Examination 
 Ask for feedback when something is hard to translate 
 Offer to debrief the interpreter to address any of their own emotional concerns following 
the interpretation 
 Ask interpreter about the patient’s degree of openness or disclosure 
 Preferably work with same interpreter/culture-broker for the same case whenever possible