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Corresponding author:
Lucia Tomas-Aragones
Department of Psychology, University of Zaragoza,
Calle Pedro Cerbuna 12, 50009 Zaragoza, Spain
Email: ltomas@unizar.es
Phone: +34 606 973 090
Open Access Article
Abstract
The biopsychosocial model encompasses biological, social and
psychological processes with the aim of offering a more holistic
Keywords: therapeutic approach. Good communication skills are vital for its
application; they help to enhance the patient-physician relationship
patient-doctor and can improve health outcomes. The clinical interview is a valuable
communication,
diagnostic and therapeutic tool, but interviewing techniques are some
patient-centred
of the most difficult skills to master and implement. The therapeutic
interviewing skills,
alliance forged during the clinical encounter lays the foundations for
clinical interview
techniques, ongoing patient care and education. The interview is usually the main
motivational source of information, but it is not the only one. Assessment scales,
interviewing, if used wisely, can strengthen the therapeutic alliance and promote
the psychosomatic treatment adherence. However, when psychological assessment tools
interview, are employed, care must be taken to avoid labelling patients with
psychosocial a mental health disorder. Professionals should avoid judgemental
assessment, language and behaviour at all times.
mental health
screening,
communication skills.
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Lucia Tomas-Aragones, Cristiana Voicu, Servando E. Marron
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THE CLINICAL INTERVIEW AND ASSESSMENT: GENERAL CONSIDERATIONS
REVIEW
from either medication or more intense therapy. of satisfaction if they alter their behaviour in
However, a relationship of trust and confidence comparison with making no lifestyle changes (14).
must be established before the dermatologist One of the objectives of motivational interviewing
can recommend the patient to a mental health is to identify and mobilise the patient’s intrinsic
professional. When this occurs, it is important for values and goals in order to stimulate behavioural
the dermatologist to stay in contact with the patient change. The motivation for change is drawn from
and to offer further consultations so that the patient within the patient and not imposed from without.
does not feel abandoned. During these visits, the The patient’s belief in their ability to undertake
patient can talk about the experience with the and achieve specific goals must be reinforced.
mental health therapist and the dermatologist can Motivational interviewing can therefore be seen
offer support (12). as both a set of techniques and a therapeutic style
Patients may resent and even refuse a referral. (15).
Some will either abandon treatment or try ‘doctor
shopping’. Some may fear the social stigma iii. The psychosomatic interview
associated with psychiatric care and others may Whilst the medical interview generally focuses
not be able to afford it. For patients who refuse to on illness and a diagnosis, the psychosomatic
be referred to a psychiatrist, a pharmacological interview is a broader, patient-centred assessment
approach may be the most feasible option (11). that explores the unique elements of each patient
from biomedical, psychological and sociocultural
c. Types of interviews perspectives. The psychosomatic interview aims
Interviewing is one of the most difficult clinical at more than the attachment of a diagnostic label;
skills to master. The demands made on the it attempts to correlate various factors within
physician are both intellectual and emotional. multiple domains. The patient’s level of interest
Interviewing is often considered part of the ‘art’, in and participation in the treatment process is
contrast to the ‘science’, of medicine. An empathic, also evaluated. The empathic alliance is neither
patient-centred interview can bolster the patient’s paternalistic nor authoritarian; it seeks to be
sense of self-esteem and lessen the feelings of a partnership than can offer effective disease
helplessness that often accompany an episode management. Through the utilisation of open-
of illness. The therapeutic alliance forged during ended questions, observation of nonverbal
the clinical encounter can lay the foundations for behaviour and deliberation of illness perspectives,
ongoing patient care and education. dimensions, behaviours and life stories, the
clinician is able to form a more complete picture
i. The patient-centred interview of the patient (16).
In the patient-centred interview, the patient
is encouraged to take the conversational lead, The clinical interview
initiating discussion in the areas of their experience The clinical interview does not simply comprise
and expertise: symptoms, worries, preferences, the task of collecting background information
and values. This type of interview operationalizes on the patient; it is the process of identifying the
the biopsychosocial model and is associated with illness and understanding how the individual has
numerous positive outcomes for both patients and been affected by it. Interviews can make up a large
physicians (13). part, if not all, of a treatment process. Attention
Data gathering for diagnosis and treatment must be paid to the general behaviour of the
almost exclusively consists of eliciting information patient, the content of the explanation and the
on symptoms, biomedical history and diagnostic manner in which the explanation is delivered.
tests. However, a full analysis of health or illness
requires the additional consideration of the social d. Taking a history
and psychological dimensions of human existence. In the first consultation, the objectives are: i) to
This necessitates the ability to ascertain personal understand the patient’s problem; and ii) to obtain
or psychosocial data from patients, competent information on how they cope with their condition.
interviewing techniques and relationship-building Take a psychomatically-oriented history. Try to
capacities that nurture confidence and human draw out the patient’s explanations and beliefs
understanding. The practical application of these regarding the disease and ask about subjective
skills is known as patient-centred interviewing (13). experiences; help to express the emotions
associated with the illness. The physicians’ role
ii. The motivational interview is to accept the patient’s story, including the
This patient-centred approach has generated somatic and non-somatic problems. Sympathy for
great interest in health care contexts: the main the patient’s suffering (even if it is exaggerated
focus being the facilitation of behavioural change. or without foundation) must be shown (17).
An empathetic style is crucial and the underlying Demonstrate empathy and give the patient
attitude must be one of acceptance. Patients are complete attention: they should feel sure that they
encouraged to contemplate their current state of are being listened to. In some cases, the setting
happiness and to speculate on their future levels of limits is recommended as the patient may have
8 R O M A N I A N J O U R N A L o f C L I N I CA L a n d E X P E R I M E N TA L D E R M ATO LO GY
Lucia Tomas-Aragones, Cristiana Voicu, Servando E. Marron
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REVIEW THE CLINICAL INTERVIEW AND ASSESSMENT: GENERAL CONSIDERATIONS
However, prior to their use, the following questions studies have reported a high number of traumatic
should be considered: experiences during childhood, particularly sexual
- In what way is the information obtained from and physical abuse (22). Successful psychological
these self-report questionnaires going to prove assessment and treatment typically involves a
helpful or improve the attention and treatment strong patient-therapist alliance. Unfortunately,
offered to the patient? victims of traumas such as child abuse, rape,
- Are the chosen tools user-friendly, as well as torture, or partner violence may interpret any
easy to correct and interpret? relationship with an authority figure as potentially
- What information will be given to the patient dangerous (23). The health professional should
prior to the completion of the tests? In other always show compassion and respond with
words, how are we going to justify their use? empathy. If possible, put the experiences into
- What type of feedback is the patient going perspective and instil feelings of hope.
to receive after the evaluation? Mental health Some common psychopathologies underlying
issues need to be dealt delicately and professio- dermatological disorders are anxiety, depression,
nally, care must be taken to avoid pejorative delusion, and obsession-compulsion. For example,
diagnoses. poor self-confidence and obsessive traits may
Most of the information obtained from a be risk factors for self-excoriative behaviours in
psychometric evaluation can be asked directly patients with facial acne vulgaris.
during the interview. However, tests – if used In some cases, patients can be asked to keep
wisely - can prove useful, valuable information can a record of certain behaviours, for example: the
be ascertained in a short time frame, for example, frequency and the intensity of the problematic
screening for mood disorders; measurement of behaviour (mirror checking, self-excoriating,
treatment outcomes; assessment of the impact of picking, cutting, etc.); the distress caused by or
the disease on the patient; questions on delicate associated with the problem; the degree to which
or sensitive issues. the problem interrupts or prevents more preferable
While structured interviews are still considered activities; the extent to which the problem disturbs
to be the standard methodology for the satisfactory personal relationships. This valuable
classification for mental health problems, it must be information can motivate patients to set realistic
remembered that individuals with dermatological treatment goals with the help of the health
problems often deny or hide their mental health professional.
symptoms. In such situations it may be easier for
patients to acknowledge symptoms by means of g. The use of mental health assessment tools
self-rating scales than in a personal interview (1). As already mentioned, the use of assessment
Screening tests used routinely in the clinic can tools should be clearly explained to the patients.
save time in detecting difficulties that can be Instruments, such as quality of life questionnaires
discussed in greater depth at a later date. For or screening scales for anxiety and depression
example, if a patient screens positively for anxiety symptoms are used on a regular basis by some
or depression symptoms, further questioning can clinicians. If they are used for research, signed
help determine the possibility of a referral or other informed consent is obligatory. Patients should
treatment options, depending on the level of also be offered feedback on the results. With
suffering and willingness to accept help. children and adolescents, parents should be kept
informed at every stage of the assessment and
f. Data collection treatment.
An assessment of the various aspects of the All assessment instruments employed must
life of a person with skin-inflicted lesions involves have suitable psychometric properties, such as
consideration of a number of dimensions of their reliability and validity. Tests should be translated,
experience, using multiple sources of information culturally adapted, and standardised (24).
and types of analyses. A complete assessment Ideally, the instrument should be simple and
should include comprehensive interviews, quick to implement. The instructions must be
psychological tests and behavioural observations. adhered to and if there is doubt with regards to
It should always be remembered that people interpretation, expert opinion should be sought
come from diverse backgrounds and have different (24).
personal resources and characteristics; these When offering feedback on psychological asses-
unique traits influence attitudes toward illness. sment, adopt an optimistic approach towards
Illness changes our sense of self and identity. In a the patient and in addition to explaining the
society that places value on achievement and self- difficulties, try to highlight and emphasise the
reliance, those that suffer illnesses can also suffer positive aspects.
feelings of inadequacy. In most cases, patients will
only talk about their feelings if the doctor shows Final considerations
empathy, understanding, and acceptance. Enduring psychological characteristics associ-
Several studies have examined associations ated with self-harm include hopelessness and poor
with traumatic events in childhood, particularly in problem-solving abilities. Repeated self-harm is
cases of borderline personality disorder. These also associated with difficulties of emotional and
12 R O M A N I A N J O U R N A L o f C L I N I CA L a n d E X P E R I M E N TA L D E R M ATO LO GY
Lucia Tomas-Aragones, Cristiana Voicu, Servando E. Marron
behavioural control. Self-harmers typically suffer Psychological tests alone cannot determine a
low self-esteem, lack confidence, feel inadequate diagnosis, but they can reveal important infor-
and are socially withdrawn. They may present mation about many aspects of a person: self-image,
disorganized and confused thinking, unstable self-esteem, motivation, values, relationships etc.
and inappropriate emotions, bizarre behaviour Before implementing a test, the clinician needs to
and impaired judgement. Subjective feelings advise the patient on its purpose and the type of
of irritability or anger are also common. These information it provides.
patients are usually emotionally fragile and must The process of learning to manage illness can
be treated with warmth and respect (25). be overwhelming; the support and understanding
Having a positive outlook and being optimistic of family and friends has a significant influence on
appear to benefit the process of adjusting to illness. the response. The condition is more manageable
The importance of a health care professional who when the sufferer knows that they are supported
is willing to listen and show respect for the needs and understood by significant others.
and wishes of the person cannot be understated. Health problems cause worry and distress. The
The perception that the patient is working together stressfulness of an illness depends on the patient’s
with the health care professional seems to facilitate perception of that illness. People react and cope
the process of adapting to the illness. in different ways, but given time, most develop
Problems in the interview often result from adaptive methods to confront the challenges of
the patient’s reactions to illness and the medical their conditions.
consultation. Most people experience anxiety when
they are ill and have to see a doctor, some harbour Conflicts of interest: none declared.
feelings of anger or helplessness. Responses Financial support: none declared.
vary in accordance with the severity of illness,
past experiences, personality, stress and support.
The patient who appears reticent to talk may
need emotional support. Active, non-judgmental
listening demonstrates the physician’s interest and
concern and encourages the patient to talk.
If psychological assessment tools are used, care This work is licensed under a Creative Commons Attribution 4 .0 Unported
must be taken to avoid labelling patients with License. The images or other third party material in this article are included in the
article’s Creative Commons license, unless indicated otherwise in the credit line; if
a mental health disorder. Positive aspects and the material is not included under the Creative Commons license, users will need to
personal skills should be emphasised and coping obtain permission from the license holder to reproduce the material. To view a copy
strategies reinforced. of this license, visit http://creativecommons.org/licenses/by-nc/4.0/
Bibliography
1. Tomas-Aragones L, Marron SE. Body dysmorphic disorder in adolescents. In: 14. Britt E, Hudson SM, Blampied NM. Motivational interviewing in health settings:
Pediatric psychodermatology. Tareen RS, Greydanus DE, Jafferany M, Patel DR, a review. Patient Education and Counselling 2004;53:147-155.
Merrick J. Berlin, De Gruyter, 2012. 15. Rubak S, Sandbaeck A, Christensen L, Christensen B. Motivational interviewing:
2. Papadopoulos L, Bor R. Psychological approaches to dermatology. Leicester: The a systematic review and meta-analysis. British Journal of General Practice
British Psychological Society, 1999. 2005;513:305-312.
3. Rachman S, De Silva P. Obsessive compulsive disorder. Oxford: Oxford University 16. Fava GA, Sonino N, Wise TN. The psychosomatic assessment. Basel: Karger AG,
Press, 2009. 2012.
4. Back A, Arnold R, Tulsky J. Mastering communication with seriously ill patients. 17. Hart W, Gieler U, Kusnir D, Tausk FA. Clinical management in Psychodermatology.
New York: Cambridge University Press, 2010. Berlin: Springer-Verlag, 2009.
5. Ong LM, de Haes JC, Hoos AM, Lammes FB. Doctors-patient communication: a 18. Poot F, Sampogna F, Onnis L. Basis knowledge in Psychodermatology. JEADV
review of the literature. Soc Sci Med 1995;7:903-918. 2007;21:227-234.
6. Teutsch C. Patient-doctor communication. Med Clin North Am 2002;5:1115-1145. 19. Ulnik J. Skin in psychoanalysis. London: Karnac Books ltd, 2008.
7. Poot F. Doctor-patient relations in dermatology: obligations and rights for a 20. Othmer E, Othmer SC. The clinical interview using DSM-IV. Vol. 1: Fundamentals.
mutual satisfaction. JEADV 2009;23:1233-1239. Washington: American Psychiatric Press, Inc, 1994.
8. Hinshelwood RD. The difficult patient. British Journal of Psychiatry 1999;174:187- 21. Ventiling CD. Body psychotherapy in progressive and chronic disorders. Basel:
190. Karger AG, 2002.
9. Koekkoek B, van Meijel B, Hutschemaekers G. ‘Difficult patients’ in mental health 22. Dhossche DM, Shevitz, SA. Assessment and importance of personality disorders
care: a review. Psychiatric Services 2006;57:795–802. in medical patients: An update. Southern Medical Journal 1999;6:546-556.
10. Koo JYM. Psychodermatology: a practical manual for clinicians. Curr Prob 23. Briere J, Scott C. Principles of trauma therapy. A guide to symptoms, evaluation
Dermatol 1995;6:199-234. and treatment. Thousand Oaks: Sage Publications, Inc, 2006.
11. Koo JYM, Lee CS. Psychocutaneous medicine. New York: Marcel Deckker, Inc, 24. Tomas-Aragones L, Castillo-Amores AB, Marron SE. Sistemas de medida.
2003. Evaluación psicométrica. [Systems of measurement. Psychometric evaluation]. In:
12. Poot F. What a dermatologist needs to know to transfer dermatological patients Fundamentos básicos en psicodermatología [Basic principles of psychodermatology].
to the psychiatrist or psychologist. Dermatol Psychosom 2002;3:34-37. Rodriguez-Cerdeira C. La Coruña: TresCetres Edit, 2010.
13. Lyles JS, Dwamena FC, Lein C, Smith RC. Evidence-based patient-centered 25. Self-harm: Longer-term management. UK: NICE clinical guideline 133, 2011.
interviewing. JCOM 2001;7:29-34.
1 / M a rc h / 2 0 1 7 13