CLINICAL HANDBOOK OF SCHIZOPHRENIA

120 II. ASSESSMENT AND DIAGNOSISto develop empathy and understanding of the potential origins of the interviewee’s “baggage.”This may include recognizing that the interviewee may have been in several clinicalsettings and situations in the past that he or she perceived as threatening (e.g., beinginterviewed at a teaching hospital in front of trainees who were all strangers), that he orshe was indeed judged harshly (e.g., for discontinuing medication against medical adviceor using substances), or suffered from perceived consequences of previous interviews(e.g., forced interventions or involuntarily hospitalization). In addition, the interviewermay use his or her clinical skills to help the interviewee feel more comfortable and at easeby expressing concern and empathy, and reacting to the interviewee and his or her storyin a nonjudgmental manner. It is often useful in such cases not to ignore the “elephant inthe room” but rather to focus first on the interviewee’s immediate feelings and addressthe discomfort that he or she might be feeling (“I have a sense that you are not feelingvery comfortable. I was wondering if you might be willing to share how you are feelingright now”). In addition to addressing the interpersonal context, there are several practicalways in which the interviewer might be able to help the interviewee feel more at ease.Examples include introducing him- or herself, describing what to expect in terms of theformat of the interview (its nature, rationale, and length) and what will follow. The interviewershould offer the interviewee the option to ask questions and to have his or herconcerns addressed before proceeding. Forming a collaborative atmosphere in which theinterviewee is viewed as an active participant rather than a passive subject of an interviewis important. In addition, respecting the interviewee’s style and pacing oneself to bettermatch his or her tempo gradually increase the interviewee’s trust and participation.Finally, when the interviewee is uncomfortable, it is particularly useful to start the actualinterview with a “warm-up” phase that includes easy-to-answer, factual questions to helpthe interviewee gradually become more at ease. As the interviewee feels more comfortable,follow-up questions can be particularly helpful in gathering more information aboutparticular areas of significance.Guideline 2: Lack of Insight into IllnessBecause the interview usually takes place in a clinical setting (outpatient clinic or hospital),a typical early question is “What brought you here?” or “How did you come to be inthe hospital?”. These questions are meant to provide a neutral stimulus to encourage theinterviewee to reveal the sequence of events that preceded the current situation. One potentialchallenge is that the interviewee may lack insight into his or her behaviors, experiencesor beliefs that impacted the events preceding the interview. The interviewee maydeny having a problem (“I do not know. Everything was just fine”) or believe that whatled to being treated is not his or her problem (“They [family] wanted me taken away, becausethey needed the room in the house”), or that he or she has a problem but not amental problem (“I was feeling weak, but they wanted me to go to the psychiatrist”).These various degrees and styles reflecting a lack of insight are common among peoplewith schizophrenia and present a potential obstacle for the interviewer seeking to obtainan overview of the current episode and psychiatric history.Although it may be frustrating for the interviewer, it is not useful to be confrontationalor to repeat the question with the hope that the interviewee will eventually “gaininsight.” It is important instead to acknowledge the potential value in the informationcollected rather than to get angry or anxious about failing to elicit the “required” information.There are a number of reasons why information collected “even” with an intervieweewho seems to have limited insight into his or her condition may be of value: First,discrepancies between the perceptions of interviewees and mental health providers may