Special Article A Comprehensive and Individua1ized Psychiatrie Interviewing Training Program Shawn c. Shea, M.D. Juan E. Mezzich, M.D., Ph.D. Scott Bohon, M.D. Anlta Zeiders, M.S.

mhe psychiatrie interview is one of the foundations of ~ psychiatrie education and practiee. Psychiatrie educators, in two surveys conducted six years apart, supported this premise when they ranked "eonducting a psychiatrie interview" as the single most important skill for a psychiatrist (1,2). In both surveys, the majority of the remaining ten highest-rated skills were also related to interviewing, such as recognizing countertransference problems, delineating aecurate diagnoses, and assessing suicide and homicidal potential. It would seem that psychiatrie residency programs would have emphasized research on the development and efficacy of interviewing training techniques and curricula. Yet Maguire's 1982 article on the necessity of training psychiatrists in interviewing highlighted that most efforts to develop and evaluate interviewing programs had been done at the undergraduate level with medical students as subjects (3). Maguire' s assertion is supported by a review of the Journal of Medical Education between 1970 and June 1988. During that period, the journal eontained over 50 articles eoncerned with general medical interviewing for medical students. Only four articles eoncerned psychiatrie resident interviewing training. Furthermore, the Journal ofPsychiatrie Education, from its inception in 1977 through June 1988, published only four articles specifically focused on teaching interviewing skills to psychiatrie residents. Despite this relative paucity, some important articles have focused on curricula designed to teach psychiatrie interviewing skills to residents (4-12). These articles have examined topics ranging from improved methods of teaching residents engagement skills to diseussions of specifie supervision techniques. At the present time, contemporary psychiatrie educa-

Dr. Shea is director of the continuous treatment team at Monadnock Family Services, 331 Main Street, Keene, New Hampshire 03431. At the time this research was completed, all of the authors were affiliated with the Western Psychiatrie Institute and Clinie of the University oE Pittsburgh. Copyright C 1989 Aaulemic PsychiJltry.

tors appear to be facing two core challenges with regard to interviewing training. First, programs must be developed that foster the resident' s ability to handle a wide diversity of dinical interviews with flexibility. The range of interview types includes diagnostic interviews, emergency room assessments, consultation and liaison evaluations, medical and psychotherapy assessments, and other more specialized tasks, such as forensie evaluations. To accomplish this goal, programs must be developed that help residents naturally integrate a wide range of interviewing skills, such as engagement techniques, recognition of defense mechanisms and dynamic conflicts, techniques for sensitively structuring interviews, and methods of delineating diagnoses according to standard diagnostic systems such as DSM-III-R and the prospective tenth edition of the In-

ternational Classification of Diseases.

The second major task consists of developing programs that are individualized to the specific needs of the trainee, for residents vary remarkably in the skill base they bring to their training programs. In addition, it is ourexperiencethattheeffectivenessofeducational techniques may vary significantly with the resident. For instance, some residents may require modeling experiences in order to improve, whlle others may benefit more powerfully from readings or videotape supervision. We believe that individualized training helps residents more effectively seeure their newly acquired skills. This is important, as at least one study suggests that interviewing skills can easily be lost over time (13). The present article addresses the core challenges noted above and builds on the works previously mentioned. It describes an intensive training program on interviewing in which the trainees develop individualized educational goals tailored to their strengths and weaknesses. The residents' impressions of both the overall course and the effectiveness of the specific educational approaches utilized are reported.

COURSE FRAMEWORK ANDDIDACTICS The course emphasizes the use of didactic material as it is immediately applied to direct clinical experience and supervision. The training program is integrated into the threemonth rotation at the Diagnostic and Evaluation Center (DEC) at Western Psychiatric Institute and Clinic in Pittsburgh. This unit functions as both a full intake-assessment center and a psychiatric emergency room. Residents are thus required to conduct two significantly different styles of interviewing tailored to each clinical task. After the resident interviews the patient, the patient is also interviewed by a faculty psychiatrist, providing the resident a chance to observe the faculty member's interaction with the patient. During the rotation, residents attend 17 one and one-half hour elasses dedicated to interviewing technique. The first 30 minutes is devoted to lecture. In the second 30 minutes, one of the trainees interviews a patient from the DEC (or an inpatient unit if no dinie patient is available) in front of the dass. In the last 30 minutes, the group discusses the interview and provides constructive feedback to the interviewer. Classes are composed of six to 14 mental health professionals, induding psychiatric residents, clinical psychology intems, psychiatrie nurses, social work interns, family practice residents, emergency medicine residents, counselors, and medieal students. This multidisciplinary leaming cohort provides a rich arena for personal growth and leaming. Considerable attention is given to fostering this milieu, for it has long been recognized that the learning environment and social context in which educational techniques are utilized can enhance their effectiveness considerably (14). The lectures provide a theoretical overview that integrates numerous schools of thought induding descriptive psychopathology, psychoanalysis, counseling, and clinical

psyehology. Empathie skills are taught hand-in-hand with diagnostie techniques, structuring techniques, and psychodynamie approaches. Emphasis is placed on adapting skills to the specifie clinica1 task at hand. The course outline is inc1uded as an appendix to this paper, and a more detai1ed description of an earlier variant of this course has been published (15).

2.

ogy' diagnostie skills, content exploration (history of the present illness, chief eomplaint, etc.), and assessment of sensitive material. Within these broad eategories, specifie "subgoals" tend to be behavioraUy described. For instance, under "minimizing bias" the first subgoal is "avoiding phrasing bias as seen with negative questions, multiple questions, leading questions, or overly wordy questions." EventuaUy, specific behavioral goals to be performed in specific clinical situations are individuaUy prescribed. Detailed diagnosis is made of the initial

3.

of the rotation each resident is required to make a videotape of a eomplete psychiatrie assessment, resulting in a diagnostic formulation using the five axes of DSM-IIl-R. The interviews are eompleted in about 60 minutes. The instructor reviews the videotape for an hour and then reviews it with the resident. They agree upon an individuaUy prescribed set of two to five behaviorally defined areas for improvement. For the remainder of the rotation, the resident records progress in these areas on a self-monitoring form following each interview. Educational alternatives are provided

Individualized Training As residents rotate through the DEC, an attempt is made to develop an individualized training package in addition to the eore eoursework described above. The paekage is jointly designed by the trainee and the instructor, both of whom are encouraged to utilize their analytic and intuitive skills. This creative experience fosters in the residents both excitement and a sense of responsibility for their own learning and professional development. Glaser outlined the basic principles that provide a strong foundation for the sueeessful use of an individualized educational program (16). Listed below are the six operational requirements developed by Glaser and the specific techniques used in our program that correspond to each requirement.

1. The outcomes and subgoals of ltarning are specified in terms olobservable ltarner performance and the conditions under which this performance is to be exercised. Each resident in our training program is given a list of educational goals at the beginning of the course. These specific goals are grouped under the following headings: dynamic skills, basic engagement skills, basic structuring techniques, handling stylistie resistance, handling confrontational resistanee and intense affect, minimizing bias created by the interviewer, maximizing validity while probing sensitive areas, phenomenology and psychopathol-

state of a ltarner entering a particular instructional situation. At the beginning

which are adaptive to the classifications resulting from the initial student ability profiles. A variety of educational

approaches are made available to the residents. They are provided with a copy of Psychiatrie Interviewing: The Art of Understanding, whieh contains numerous interview examples, sampie questions, and specific technieal principIes that direct1y complement the didactics of the classwork (17). A file of optional readings is also available for residents for whom reading seems to be a particularly effective means of in-

4.

tegrating information. In several dasses of the rore course, role playing is routinely used for studying various methods of handling resistance and awkward patient questions. Techniques based on Ivey's microtraining also are utilized in a workshop format (18). Modeling is provided by asking the residents to view several videotapes of the instructor interviewing patients in the dink setting. They are also urged to observe interviews by faculty and colleagues. As students learn, their performance is

monitored and continuously assessed at longer or shorter intervals appropriate to what is being taught. As mentioned ear-

lier, residents continuously self-monitor their progress and periodically share this information with the instructor. Additionally, the instructor directly observes three interviews conducted by each resident and provides pertinent feedback.

5. Instruction and learning proceed in an interrelated fashion, tracking the performance and selections of the student. Once

6.

a resident has mastered a new skill, as evidenced on the self-monitoring form, new objectives are chosen and subsequently monitored. Guided role playing with the instructor is used when residents appear to be having difficulty mastering a particular skill. The instructional system collects informa-

tion in order to improve itself, and inherent in the system's design is its capability for doing this. Written tests and video-

tapes are routinely gathered at the beginning and the end of the DEC rotation. At the end of the course, residents complete a detailed evaluation form. The course has been continuously evolving over its five-year history, and has been conducted more than 25 times. The most recent trainee evaluation forms are the main sources of data for this paper.

In our experience with this individualized learning program, we have found that one of the most important elements in helping trainees comprehend and integrate interviewing techniques is to provide them with a concrete language with which to describe interviewing process. Some areas of interviewing a1ready have a weIl developed language, such as the concepts of defense mechanisms and transference; other areas are less weIl defined. In particular, the techniques involved in sensitively structuring interviews and making smooth transitions between topics have never been weIl delineated or operationalized, although Sullivan directed some attention toward a description of interviewer transitions (19). Consequently, we have developed a descriptive system known as facilics, based on the Latin root "facilis," meaning ease of movement (15,17). This language defines seven different methods of transition in interviewing and also addresses concrete styles of structuring and utilizing time constraints. Specific symbols, developed for ease of understanding, also provide a method of recording structuring style for the purpose of supervision and dass discussion. A programmed manual is used by the trainees to rapidly familiarize themselves with the principles of facilics.

Program Evaluation We examined resident response to this overall program and to its specific techniques as a first step toward determining which methods are preferentially effective and with whom. At the end of the course, each trainee was asked to complete a threesection evaluation of the program. The first section asks questions about the trainee' s impression of the overall effectiveness of the training program and about specific educational techniques, such as role playing, selfmonitoring, and direct supervision. Each question is answered using a five-point scale ranging from zero, meaning poor learning

TABLE L Trainees' evaluation of spedfic educational techniques, by number of trainees Evaluation 0

Rank

1 2 3 4 5 6 7 8 9 10

Technique Videotar: supervision Textboo on interviewing Didactics+ Live interviews with peerobservation++ Role playing Wrap-up discussion +++ Direct supervision Supplemental reading Self-monitoring Pretest Overall rating of course quality

Poor

Below average

Average

3 Above average

0 0 0

0 0 1

2 2 2

4 5 6

0 0 0 1 0 0 3

1 1 0 0 0 1 4

1 2 4 3 5 8 8

0

0

1

1

2

4

Excellent

Mean

13 12

3.6 3.5 3.4

8 7 8 6 4 6 4

10 10 8 9

2 2 0

3.4 3.3 3.2 3.2 2.7 2.5 1.7

4

15

3.7

11

+ru-st 30 minutes of class ++Second 30 minutes of dass +++nnaI 30 minutes of dass

experience, to 4, meaning excellent learning experience. Following each question is space for written comments. This section ends with a request for specific recommendations for improvement. The second section of the evaluation lists 13 specific skills mentioned as objectives on the list of educational goals given to residents at the beginning of the course. Each skill is followed by a five-point scale on which the respondent rated the course' s effect on their ability. Responses were zero, indicating the course led to a significant decrease in ability; 1, for no change in ability; 2, for slight increase in ability; 3, for moderate increase in ability; and 4, strong improvement in ability. A fourteenth question relates to overall increase in skill. A final question addresses the trainee's feeling of seH-confidence and represents an attempt to understand the training program' s impact on trainees' self-image. In the third section, trainees are asked to identify the four educational techniques of the 12listed that they perceived as the most powerful in enhancing their interviewing ability. This forced-choice answer format attempts to delineate the trainees' perceptions

of the techniques that are most critical for successfullearning. The course was given four times over a 12-month period. Twenty trainees participated in the full training program, and numerous others audited only the classroom section. Only responses of trainees who participated in the full training program were included in the evaluation. Thirteen of the 20 participants were PGY-1 or PGY-2 psychiatrie residents. Four participants were clinical psychology interns at the master's level or above. Two participants were psychiatrie nurses enrolled in master' s programs, and the final participant was a social work intern. The 20 participants in the study completed all evaluations.

RESULTS Table 1 presents participants' mean ratings oE specific aspects oE the course. Seven of the ten individual components were rated as above average or higher (scores of 3.0 and above). The top four-rated aspects incIuded videotape supervision, the interviewing textbook, the didactic sessions, and the live interviews conducted in front of peers.

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T ABLE 2. Trainees" perceptions of se1f-improvement in specific tedmiques, by number of trainees Degree of self-improvement

Rank Technique

2 3 4 5 6 7 8 9 10 11 12 13 14 15

0

1

Worsened

No Change

Theoretical understanding Suicide assessment Facilitate a Nshutdown" patient Overall confidence Overall improvement inskill Structuring "wandering" patient Arriving at an Axis n diagnosis Flexibly varying interview structure Understanding patient's world Engaging patient Derailing patient's rehearsed story Arriving at an Axis 1 diagnosis Eliciting sensitive material Conveying empathy Psychotherapy assessment

2 3 4 Slight Moderate Substantial Mean implOvement improvement improvement response

0 0

0 1

2 2

5 5

13 12

3.5 3.4

0 0

0 0

3 1

8 12

9 7

3.3 3.3

0

0

2

10

8

3.3

0

0

2

11

7

3.2

0

2

4

4

10

3.1

0

0

4

10

6

3.1

0 0

2 2

4 3

8 10

6 5

29 2.9

0

0

6

11

3

28

0

2

6

6

6

28

0 0

2 4

7 6

6 8

5 2

27 24

0

3

6

10

Table 2 displays mean ratings of trainees' perceptions of improvement on specific educational objectives. Six objectives were rated above 3 (moderate improvementor higher); the best-met objectives were theoretical understanding of interviewing techniques, suicide assessment, facilitating "shut-down" patients, and focusing "wandering" patients.ln addition, the two ratings that dealt with global feelings of achievement (overall improvement in skill and overall increase in confidence) were both rated above a 3. Table 3 shows the frequencies with which 12 educational techniques were identified as one of the four favorite techniques. The top techniques, identified in the top four by 11 to 13 of the trainees, were facilics (the supervision language dealing with structuring techniques), the didactic sessions, the direct supervision, and the live interviews

24

conducted in front of peers. Observing the instructorvideos and the pre-test were never chosen in the top four. DISCUSSION

Trainee opinion and measurement of whether course objectives and skills have been leamed and maintained are the two major avenues available to educators for evaluating course effectiveness. Rather than being antagonistic, these two approaches represent complementarymethods of evaluation. A systematic approach to curriculum design based on trainee attitudes can lead to striking improvements in trainee satisfaction.ln Cassata et al.'s study, a medical interviewing course that was redesigned in response to student feedback was transformed from an experience that none of the students rated as excellent to one that 43%

TABLE 3. Trainees' prefeJmces for educational techniques Technique

1 2 3 4

5 6 7 8

9

10 11 12

Facilics-

Frequency·

Didactics+ Direct supervision Live interviews with peer observation ++ Videotape supervision Textbook on interviewing Wrap-up discussion+++ Role playing Self-monitoring Supplementalreading Observing instructor video ~t

13 12 12 11 9 8 6 5

3

1 0 0

'Number of times this technique was selected on a forced-choice questionnaire as one of the four mgst valuable techniques Supervisory language dea1ing with structuring techniques +rust 30 minutes of dass ++Second 30 minutes of dass +++Puw 30 minutes of dass

rated as excellent (20). There is also evidence of a strong positive correlation between student ratings of instructors and actual student achievement (21). With these ideas in mind it was feIt that any study of an educational program designed to teach a complex skill such as interviewing should inc1ude a detailed analysis of trainee attitudes. Glaser's sixth principle calls for an ongoing evaluation of course effectiveness. Furthermore, because of the powerful demands for cost-effectiveness in the use of instructor time at the professional level, it is importantthat individual methods of instruction be separately evaluated in an attempt to determine the methods that may be most cost-efficient, especially in programs with limited resources. Trainee satisfaction with our comprehensive course was very high, as evidenced by the overall mean rating of 3.7. It is important to note that those forms of supervision in which the trainee was directly observed (videotape supervision, performing an interview in front of the entire dass, and being directly observed by the supervisor during

clinica1 work) were all highly rated for quality, despite the fact that they represent a potential invasion of clinician privacy (22). The textbook and the didactic section were highly rated. 80th of these educational techniques emphasized an integrated approach to studying interviewing based on advances from various mental hea1th disciplines, while simultaneously exploring different skills such as engagement techniques, differential diagnosis by DSM-III-R criteria, structuring techniques, and psychodynamic understanding. The trainees feIt that their theoretical understanding of interviewing principles had improved strikingly, as indicated by an average rating of 3.5. The majority of trainees feIt that moderate to strong improvement had occurred in their ability to facilitate a "shut-down" patient (a complex skill in which a premium is placed on engagement skills and empathy) and in structuring a "wandering" patient (an equally complex task in which engagement skills playa major role in conjunction with structuring techniques and diagnostic data base management). Many residents enter the course with the misperception that data gathering and empathic understanding are at opposite ends of a continuum. Such cliniclans, some of whom may possess considerable engagement skills, are frequently inadequate at managing time constraints or developing sound diagnostic formulations. Inadvertently, interviewing courses sometimes support this damaging misconception by primarily emphasizing the development of engagement skills in an isolated fashion rather than in direct conjunction with reallife clinical tasks, such as suicide assessment or differential diagnosis (4,5,7,9,1 n To help trainees comprehend and integrate sensitive structuring techniques, a supervision language was developed that is concise, easily remembered, and behaviorally specific. It is seldom effective to simply tell a student, flUse your time better." Instead the student' s interviewing transitions, time-management approaches, and engage-

ment techniques must be clearly pointed out utilizing a well-defined language. This principle was given strong support by the fact that facilic analysis was identified as a popular educational technique more frequently than any other in the forced-choice preference questionnaire. The forced-choice questionnaire was also enlightening with regard to the concept of individualized education. Nine different techniques were chosen by at least 20% of the trainees as favorite techniques. This highlights the fact that trainees may respond differently to educational techniques and that, when possible, it is important to match individuals to specific techniques. For example, experiential techniques such as videotape and direct supervision appear to be popular with the majority of trainees and, therefore, merit a high priority in course design. On the other hand, over the five years that we have given the interviewing training program in the DEC, there have been three trainees (one of whom participated in this study) who strongly disliked one or both of these approaches and for whom they may have been counterproductive. In our experience, a small percentage of trainees demonstrate considerable performance anxiety that may reach disabling proportions. For these trainees, anticipatory fear may outweigh the potential benefits of direct supervisory techniques (22). It may be of value to attempt to identify such individuals early and provide alternative approaches. On the Other hand, most trainees feel that such anxiety is manageable, as reflected by the great popularity of the direct supervision techniques. It is critical not to mistake normal anxiety as cause for avoiding direct supervision techniques. Indeed, it can beargued that learning to move through such developmental anxieties may be an important part of professional development. A comparison of the evaluation of each educational technique by perceptions of their quality (Table 1) versus identification as favorite techniques (Table 3) suggests the

complementary value of both types of survey. For example, the majority of trainees rated the book very high with regard to quality, but it was not selected by the majority as one of the four most preferred techniques. This suggests that a textbook is probably not as important as direct ''hands-on'' supervision of trainees, a concept that seems to parallel common sense, considering the significant challenges of transforming theoretical knowledge of complex skills into practice. The value of utilizing both an attitudinal survey toward quality and a forced-choice preference survey is also apparent when evaluating the effectiveness of the self-monitoring form. This educational technique received a relatively low mean rating for quality (2.5), but three of the trainees ranked it as one of their four favorite techniques. This finding suggests that self-monitoring may be an effective technique for a subgroup of trainees. In exploring why this technique had been relatively ineffective with many trainees, we determined that regular feedback about the form from supervisors was necessary. Without such supervision, most trainees completed the self-monitoring form infrequently and subsequently lost interest in it. The course appeared to have a significant impact on the trainees' attitudes toward themselves as professionals. This outcome was reflected in Table 2 by the mean rating of 3.3 for overall confidence. We have observed that these attitudinal changes appear to translate into important behavioral changes concerning rapport with patients. As the residents become more comfortable with their knowledge base and skill level, they convey a higher sense of competence and greater calmness, resulting in a more reassuring alliance with the patient. As shown by Table 2, skills such as conveying empathy and engaging patients were given relatively lower scores, despite the deliberate emphasis placed on them throughout the course in an effort to reduce

emotional distance. One possible explanation is that the course was not particu1arly effective in these areas despite our concerted efforts. An alternative explanation involves the design of the questionnaire, which asks the trainee to judge the amount of change from baseline. Most mental health professionals, as part of the self-selection process for entering the field, consider themselves already adroit at engaging people. Consequently, their baseline attitude toward their engagement skills and ability to convey empathy may be high at the outset, and one would not expect a major shift in reported confidence. Even more revealing is the fact that when relatively nebulous concepts such as empathy and engagement are expressed in explidt terms, such as "fadlitating a shutdown patient," the trainees frequently reported strong improvement. The residents' perceptions of relatively little change in psychotherapy assessment skills appears to be related to the fact that the course did not emphasize that area; these skills are concentrated on in a separate course, Introduction to Psychodynamic Psychotherapy, offered at our institute. Elidting sensitive material, understanding the patient's world, and arriving at an Axis I diagnosis were also feit to have improved less substantially. The complex nature of these skill areas may require relatively more clinical experience before residents feel confident about them. CONCLUSIONS Dobbs and Carek provide an avenue for understanding both the marked popularity and reported effectiveness of the integrated program outlined above (23). They make the point that medical interviewing represents a complex matrix that includes not only obvious skills, such as engagement behaviors and empathic verbalizations, but also a complicated set of internal thought processes and dedsion trees. These processes include understanding the data base requirements

and selecting the information areas that are mostimportant considering time constraints and clinical task. Other complex thought processes include an ability to compare incoming data with the previous knowledge base, an ability to synthesize knowledge on the spot, and hypothesis testing (as seen in differential diagnosis). Finally, the interviewer must also have an ability to utilize this material in an effective manner in the ongoing interview and an ability to flexibly adapt to the defenses of the patient. Unlike many medical and psychiatrie interviewing courses reported in the literature, our course assumes from the start that all of the above skills must be given in-depth attention and emphasizes theirinterrelationship in actual clinical practice. Engagement skills are taught hand-in-hand with structuring techniques, and emphasis is placed on helping trainees understand the patient's core psychological pain at the same time diagnostic interviewing is explored.1n addition, trainees are taught to flexibly alter their styles to suit the clinical task. For example, in one class the instructor demonstrates a relatively structured emergency room evaluation, and in another class, the same instructor demonstrates a relatively unstructured psychodynamic assessment from which the students jointly create a psychogenetic formulation. The integrated approach is complemented by the individualization of instruction, which is one of the leading reasons for trainee satisfaction. The individualization begins with the videotape session in which the instructor finds out the trainee's strengths and weaknesses and continues through the use of direct supervision and self-monitoring. In our opinion, the experiential emphasis of the program and the use of direct and videotape supervision are the most powerful agents for change. The following principles summarize what we have learned about developing an interviewing curriculum design for psychiatrie residents:

1.

2

3.

4.

5. 6.

7.

8.

Residents respond enthusiastically to a program rooted in a broadly based theoretical understanding. (The presence of different disciplines among the trainees can enhance this process but is not necessary.) It is valuable to focus on methods of helping the resident integrate numerous skills, such as engagement techniques, DSM-III-R diagnosis, structuring techniques, and psychodynamic understanding, as they appear in actual clinical practice. The course should occur in a setting in which the principles are immediately clinically applicable and experiential learning is emphasized. Individualized training, in which the weaknesses and strengths of the resident are delineated, is perceived as very helpful by most trainees. Specific goals for the individual should be defined with a concise and clarifying supervisory language. Progress should be monitored continuously. It is valuable to provide access to a range of educational techniques such as a core textbook, supplemental readings, didactics, and various forms of direct and indirect supervision. Feedback from residents, including their attitudes toward the quality of specific techniques and their preference for specific techniques, should be carefullyevaluated.

Further research is needed to determine which educational techniques may be most cost effective. Depending on the availability

of resources, the above principles can be implemented in a flexible fashion. For instance, our program meets the need for a wellgrounded theoretical foundation through the use of didactics, a textbook dedicated to interviewing process, and supplemental readings. This same principle could be achieved without the use of lecture material using a small group seminar and a textbook. Future areas for research include the following: outcome studies with control groups to determine the overall effectiveness of interviewing courses as weil as the efficacy of specific educational techniques; the development of methods for rapidly matching trainees with the educational techniques that best suit their individual needs; improved systems for delineating specific trainee weaknesses; longitudinal studies of the long-term impact of the training; and further studies on the impact of training programs on the trainee's attitudes toward learning itself and toward the supervision process. In the long run, one of the major goals of interviewing programs such as ours is to stimulate intellectual excitement about the interviewing process. It is hoped that this excitement will involve residents in an ongoing evaluation of their interviewing styles. Only if this openness for future learning has been achieved can a training program fulfill its promise. As Sir William Osler astutely observed, "The hardest conviction to get into the mind of a beginner is that the education upon which he is engaged is not a college course, not a medical course, but a life course, for which the work of a few years under teachers is but a preparation" (24).

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APPENDIX: Core Course Outline SECI'lON1: Principles olInterviewing Oass 1: Introduction: The Language of Interviewing Key Topics: Goals of c1inical interviewing; engagement; blending; unconditional positive regard (Carl Rogers); behavioral inddent (Gerald Pascal); facilic analysis; type A and B validity errors Oass 2: The Strudure of the Interview

Key Topics: Five phases of the interview; scouting phase; c1inidan analysis during opening minutes of the interview; Harry Stack Sullivan and "the self system"; issues during the introduction and closing phase; initial resistance

Oass 3: Handling the "Shut-Down Interview"

Key topics: The Degree of Open-Ended Response Scale (DORS); open-ended questions; gentle commands; swing questions; qualitative questions; empathic statements; statements of inquiry; facil-

itative statements; closed questions; closed statements; interview typologies; specific methods for engaging reticent patients Oass 4: Nonverbal Behavior Key topics: Proxemics (Edward Hall); kinesics (Ray Birdwhistell); paralanguage and tone of voice; fadal expression; eye contact; clues to deceit; seating arrangement; note taking; displacement activities; postural echoing; workshop on role playing with shut-down patients Oass 5: Sensitively Structuring Wandering Patient Key Topics: Use of closed-ended techniques; appropriate use of cut-offs; cross-sectional facilic analysis; "the dead zone"; effective use of time as related to c1inical tasks

SECI'lON2: Psychop"thology Ilnd the Interview Process Oass 6: Exploring Depression and Mania

Oass 9: Exploring Personality Dysfunction

Key Topics: Phenomenology of mood disturbance;

Key Topics: The role of the sodal history; Axis 11 of

critical data for DSM-III-R diagnosis; techniques for elidting data about depression

the DSM-Ill-R;defense mechanisms; signal signs; signal symptoms; probe questions; techniques for eliciting sensitive material (shame reversal, symptom amplification, gentle assumption); video workshop on personallty dysfunction

Oass 7: Exploring Anxiety Symptoms

Key Topics: Phenomenologyof anxiety symptoms; critical data for DSM-Ill-R diagnosis; techniques for elidting data about anxiety symptoms Oass 8: Exploring Psychotic Process

Key Topics: Phenomenology of psychotic process; critical data for DSM-Ill-R diagnosis; soft signs of psychosis; engagement techniques for elidting data pertinent to psychotic symptoms

Oass 10: The Cognitive Mental Exam as Related to Delirium and Dementia Key Topics: Orientation techniques; digit spans; vigilance test; trails test; four-object recall; constructions; humanistic concerns during the cognitiveexam

SECI'lON3: Advllnced Interoiewing Techniques Ilnd Psychodynllmic Interoiewing Perspectives Oass 11: Vantage Points: Bridges to Psychotherapy Key Topics: Attentional vantage points; use of fantasy and clinidan countertransference; Harry Stack Sullivan and "partidpant observation"; ob\l

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serving ego and "self-remembering"; conceptual vantage points Oass 12: Assessment of Suicide and Homicide Key Topics: Phenomenology of suidde; statistical '

approach; interviewing techniques for probing "dangerous material"; three-step approach; triad of lethality

and response to interpretive questions; use of reflecting statements; the uncovering techniques of Grinder and Bandler

aus 13: Role-play on Handling Resistance and Video Workshop on Eliciting Sensitive Material

aus 16: Introduction to the Role of the Psy-

aass 14: Family Assessment

Key Topics: Importance of family dynamiCSi sorting out triangles, cross-generational alliances, unfinished business, and family mythology

aus 15: Assessment for Dynamic Psychother-

apy

Key Topics: Desirable patient characteristicsi understanding the "process" of patient behavior

chodynamic Formulation and Objed Relations During Initial Assessment Key Topics: Psychogenetic history; brief overview of ego psychology and object relations; defense mechanismsi identifying unconsdous conflicti identification; introjection; incorporation aass 17: Psychology of the Seit u Related to the Initial Interview Key Topics: Normaland abnormal deve1opmentof the self; split affectsi Otto Kemberg; Heinz Kohuti the bipolar self; structural interviewing

References 1. Langsley OC, Hollender MH: The definition of a psychiatrist. Am] Psychiatry 1982; 139: 81415 2. Langsley OC, Yager]: The definition of a psychiatrist: eightyears later. Am] Psychiatry 1988; 145:469475 3. Maguire P: Psychiatrists also need interview training. Br] Psychiatry 1982; 141:423-424 4. Ward NC, Stein L: Reducing emotional distance: a new method to teach interviewing sldlls. JMed Educ 1975; 50:605-613 5. Benedek EP, Bieniek CM: Interpersonal process reca11: an innovative technique. ] Med Edue 1977; 52:939-941 6. Willmuth LR, McI
student acquisition and retention of communi~tion and interviewing skills. Journal of Medica1 Education 1981; 56:572-579 14. Resnik LB: The Science and Art of Curriculum Design. Leaming Research and Deve10pment Center, University of Pittsburgh, 1975 15. Shea SC, Mezzich JE: Contemporary psychiatrie interviewing: new directions for training. Psychiatry Interpersonal and Biological Processes 1988; 51:38&397 16. Glaser R: Individual Differences in Leaming (Reprint 63). Leaming Research and Development Center, University of Pittsburgh, 1970 17. Shea SC: Psychiatrie Interviewing: The Art ofUnderstanding. Philadelphia, Saunders, 1988 18. Ivey AE: Microcounse1ing: Innovations in Interviewing Training. Springfield, ill, Thomas, 1971 19. Sullivan HS: The Psychiatrie Interview. New York, Norton, 1954 20. Cassata DM, Harns ffi, Bland G, et a1: A systematie approach to curriculum design in a medical school interview course. ] Med Edue 1976; 51 :939-942 21. Cohen PA: Student ratings of instruction and student achievement: a meta-analysis of multisection validity studies. Review of Educational Research 1981; 51:281-309 22. Betcher RW, Zinberg NE: Supervision and privacy in psychotherapy training. Am] Psychiatry 1988; 145:796-803 23. Dobbs HI, Carek D]: The conceptua1ization and teaching of medica1 interviewing. ] Med Edue 1972; 47:272-276 24. Osler W: Aequanimitas, 3rd ed. Philadelphia, B1akiston, 1945