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Professor of Psychiatry, Albert Einstein College of Medicine

of Yeshlva Un wersity,
Bronx, New York

Washington, DC
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Note: The authors have worked to ensure thai all information in this book is
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Library of Congress Cataloging-in-Publication Data
MacKinnon, Roger A., 1927-
The psychiatric interview in clinical practice / by Roger A. MacKinnon, Rob-
ert MIchels, Peter J. Buckley.— 2nd ed.
p.; cm.
Includes bibliographical references and index.
ISBN 1-58562-090-4 (hardcover: alk. paper)
1. Interviewing in psychiatry,
[DNLM: 1, Interview, Psychological—methods. 2. Mental Disorders—diagno-
sis, 3. Physician-Patient Relations. VVM 141 M158p 20061 1- Michels, Robert,
1936- 11. Buckley; Peter J., 1943- I I I . Title,
RC480.7.M25 2006
616.8914—dc22
2006001943
British Library Cataloguing in Publication Data
A OP record is available from the British Library.
CONTENTS

Foreword ix

Preface xiii

Acknowledgments xvii

P A R T I
General Principles

General Principles of the Interview 3

Z General Principles of Psychodynamics 79

P A R T II
Major Clinical Syndromes

3 The Obsessive-Compulsive Patient 107

4 The Histrionic Patient 137

5 The Narcissistic Patient 177

6 The Masochistic Patient 205

1 The Depressed Patient 229

8 The Anxiety Disorder Patient 281

9 The Traumatized Patient 315

I0 The Borderline Patient 325

I I The Antisocial Patient. . 353

I2 The Paranoid Patient 385

I 3 The Psychotic Patient 421

I4 The Psychosomatic Patient 447

(With the assistance of John W. Barnhill, M.D.)

\ The Cognitively Impaired Patient 461

(With the assistance of John W. Barnhill, M.D.)

P A R T III
Special Clinical Situations

I 6 The Emergency Patient 481

I1 The Hospitalized Patient 505

(With the ass/stance of John W. Barnhill, M.D.)

I 8 The Patient of Different Background 521

PART IV
Technical Factors Affecting the Interview

I 7 Note Taking and the Psychiatric Interview 551

20 Telephones, E-Mail, and the Psychiatric Interview 559

Afterword 583

Bibliography 585

Index. . .603
FOREWORD

As long ago as 1988, Reiser reflected on a shift that he noted when he

watched psychiatric residents interview their patients in his residency
program at Yale. He noted that some psychiatric residents were stop-
ping their data collection after eliciting a symptom inventory that satis-
fied a descriptive diagnostic category and that allowed for a medication
prescription. He expressed distress at what he witnessed, noting that a
descriptive DSM diagnosis was only one aspect of the diagnostic process
and that the clear lack of curiosity in some psychiatric residents about
the patient as a person was likely to be a serious obstacle to establishing
a solid therapeutic relationship. There can be little doubt that in the
ensuing years since Reiser made his observation, the situation in psychi-
atric training has become even more grave. With the breakthroughs in
neuroscience research and a plethora of new psychopharmacological
agents on the market, psychiatric residents are continuously confronted
with a psychiatry that leaves out the complexities of the human mind in
favor of one steeped in biological reductionism.
Given this disturbing trend in the training of psychiatrists, this new
edition of the classic text The Psychiatric Interview in Clinical Practice could
not have arrived at a more auspicious moment. When the first edition
appeared in 1971, psychodynamic psychiatry was in its heyday, and the
authors guided psychiatry residents and other trainees through the com-
plexities of defense mechanisms, conflicts, wishes, and fantasies as they
navigated the rough seas of clinical interviewing. In this revised and ex-
panded new edition, the authors continue to address the same chal-
lenges inherent in clinical interviewing, but they have also taken on the
formidable task of adapting their interview strategies to a new era of psy-
chiatry. Their new chapters address topics that reflect the changing inter-
ests of the mental health field as a whole, including trauma, narcissism,
and borderline conditions. In addition, their incorporation of knowledge
from neurobiology is reflected in their chapters on the psychotic patient
(Chapter 13) and the cognitively impaired patient (Chapter 15).

ix
x • THE PSYCHIATRIC INTERVIEW IN CLINICAL PRACTICE

The essential humanity of their interviewing approach is beautifully

illustrated in their approach to patients with chronic schizophrenia. As
they examine delusions, they do not lose track of the fact that the psy-
chotic process is happening to a person. They note that a delusion is a
special creation—a window into the conflicts, concerns, and wishes
embedded in the patient's psyche. Like Freud's view of the dream as
"the royal road" to an understanding of the unconscious mind, they
note that delusional beliefs function similarly in persons with schizo-
phrenia. From the patient's perspective, a delusion may explain every-
thing and is clung to tenaciously for that reason.
When the first edition was written, the diagnostic nomenclature in
psychiatry was in a rather rudimentary form. In this edition, the authors
accommodate the DSM-IV-TR classification while also being forthright
in critiquing its limitations. For example, in the chapter on the anxiety
disorder patient (Chapter 8), they note that "pure" forms of most anxiety
disorders are relatively uncommon and that clinicians are more likely to
encounter two or more comorbid anxiety disorders when they are inter-
viewing an anxious patient. Hence, they suggest that the taxonomy of
DSM-IV-TR may be more illusory than real for the clinician interviewing
a patient in the real world outside the rarefied realm of academic re-
search centers. They also make a strong case for evaluating the meaning
of anxiety as a symptom rather than simply attempting to erase it as a
disorder. They value the use of medications in such patients, but they
stress that prescribing is not a psychiatric practice that is compartmen-
talized from an exploration of meanings with the patient.
The psychodynamic expertise of the authors is particularly evident
in the chapters focused on personality disorders. Here one finds clinical
pearls for trainees regarding what not to do as well as what to do with
these patients. In their discussion of the antisocial patient, for example,
the authors caution the neophyte interviewer to avoid the role of dis-
trict attorney. They point out that trying to earn the respect and trust of
the patient is of far greater value than "getting the goods" on him or her.
In their chapter on the narcissistic patient (Chapter 5), the authors mas-
terfully describe strategies to tolerate the feeling that one does not exist
as a separate person in the presence of the patient.
One of the outstanding chapters in this new edition is "The Patient
of Different Background" (Chapter 18), in which the authors provide
valuable guidance to approaching issues of difference between inter-
viewer and patient. Racial and ethnic differences are some of the most
difficult topics in psychotherapy and in psychiatric interviewing. How
our cultural differences affect the interview and the information de-
rived from it is well covered. In addition, the authors provide highly
Foreword • xi

useful suggestions about issues of sexual orientation in an interview.

The attitude of psychiatry and society at large toward homosexuality
has changed dramatically since the appearance of the first edition, and
the contemporary perspective provided in this new edition will be of
great value to clinicians.
The book's title is misleading in some ways. The scope of this text is
far greater than the clinical interview. The authors include in their chap-
ters detailed discussions of differential diagnosis that go well beyond
the descriptive characteristics on which most discussions are based.
They also incorporate vignettes that reflect psychotherapeutic strate-
gies. In this regard, the book is also useful in teaching psychotherapy to
beginning trainees.
Readers who spend time dipping into this volume will be richly re-
warded with the wealth of clinical wisdom in its pages. This second edi-
tion is equivalent to the first in its usefulness to trainees in all the mental
health professions, an impressive accomplishment in and of itself. In
their preface, the authors note that they have changed over the 35 years
since the first edition, describing themselves as more experienced, more
empathic, less certain, and more respectful of their patients' solutions to
life's dilemmas. Readers will be grateful for the simple fact that after
35 years, the authors are alive and still writing! Their longevity is our
good fortune.

Glen O. Gabbard, AID.

Brown Foundation Chair of Psychoanalysis
and Professor of Psychiatry,
Baylor College of Medicine
Houston, Texas
PREFACE

I he first edition of this book was published in 1971 with great hope but
uncertain expectations. Each chapter had been reviewed by several col-
leagues, a process that consumed 3 years. Since then we have received
many requests for a second edition that would cover topics not in-
cluded previously as well as reflect the enormous changes in psychopa-
thology and psychodynamics during this period of intense develop-
ment of psychiatric knowledge.
The first edition was successful beyond our wildest expectations.
Our primary audience was intended to be medical students and psychi-
atric residents, but we were pleased that many of the 95,000 copies that
have been sold were purchased by psychologists, social workers,
nurses, and other mental health professionals. Many have introduced
themselves to us at professional meetings and reported that they use
the book as a standard text.
For this edition, chapters have been added in Part II, "Major Clinical
Syndromes," on "The Borderline Patient" (Chapter 10), "The Narcissis-
tic Patient" (Chapter 5), "The Masochistic Patient" (Chapter 6), "The
Anxiety Disorder Patient" (Chapter 8), and "The Traumatized Patient"
(Chapter 9). In Chapter 1, "General Principles of the Interview," a sec-
tion on how to elicit psychodynamic history has been included. In Part
III, "Special Clinical Situations," the chapter "The Patient of Different
Background" (Chapter 18) expands and replaces the old "Interviewing
Through an Interpreter" chapter. Included in the new chapter is a sec-
tion on the gay or lesbian patient and/or interviewer. Chapter 18 also
covers the situation in which the interviewer and patient are from dif-
ferent backgrounds, ages, and so on. A section on elderly or retired
patients is included as well. In Part IV, "Technical Factors Affecting the
Interview," we have added a chapter on "Telephones, E-Mail, and the
Psychiatric Interview."
A new chapter on "The Cognitively Impaired Patient" (Chapter 15)
replaces the first edition's chapter on acute and chronic brain syndrome

xiii
xiv • THE PSYCHIATRIC INTERVIEW IN CLINICAL PRACTICE

patients. The chapters on "The Depressed Patient" (Chapter 7), "The

Obsessive-Compulsive Patient" (Chapter 3), and "The Histrionic Pa-
tient" (Chapter 4) have been expanded and revised in the context of new
knowledge. A number of new and emotionally moving clinician-patient
interchanges have been added. We are frequently asked, "How did you
know to say that, or ask that?" The answer to the question is "Experi-
ence—It can be learned but not taught."
There has been enormous growth of the mental health professions.
Much psychotherapy is now provided by psychologists, social workers,
nurses, and clergy. Institutes of the American Psychoanalytic Associa-
tion now admit nonphysician candidates. Consistent with the expected
change in our readership, most references to "doctor" or "physician"
have been replaced with the term "clinician." Exceptions are in situa-
tions where physicians still predominate, as in the chapters on "The
Hospitalized Patient" (Chapter 17), "The Psychosomatic Patient" (Chap-
ter 14), and "The Emergency Patient" (Chapter 16). Medical students,
house staff, doctors and nurses, and medical social workers will find
those chapters both psychologically enlightening and full of practical
suggestions for the management of the details. The emphasis is on un-
derstanding the patient as a person confronted by a strange and some-
what frightening environment and its many scary procedures.
Since 1971 there has been an explosion of knowledge in psychiatry.
There have been three major revisions of the psychiatric nomenclature
based on clinical phenomenology with specific operational criteria re-
quired for each diagnosis. Structured interviews and standardized
scales have supplemented the clinical skills required to take a history
and perform a mental status examination. These instruments also allow
reliable quantitative assessment of the severity of psychiatric symp-
toms. In addition, there are manuals that standardize several specific
psychotherapies, such as cognitive-behavioral therapy or interpersonal
therapy. The scientific underpinning of this approach is to facilitate re-
search comparison of these different therapies in order to determine the
most effective therapy for each psychiatric condition.
Unfortunately, one result of the additional material to be mastered
by the student mental health clinician is that less time is allotted to
learning the psychodynamic complexities of clinical interviewing. Psy-
chodynamic psychotherapy continues to play a crucial role in clinical
care.
Since the first edition, new perspectives on psychopathology and
diagnosis, symbolized by the DSMs, have emphasized descriptive phe-
nomenological approaches to psychopathology but unfortunately have
often encouraged psychiatric interviewing that is overly focused on de-
Preface • xv

scribing symptoms and establishing diagnoses rather than learning

about the patient, his problems, his illnesses, and his life. Nevertheless,
at the same time, these newer approaches have encouraged attention to
the universal presence of personality types and the importance of the
personality as a determining factor in the evolution of psychiatric dis-
orders. Along with this there has been great interest in serious person-
ality disorders—our chapters on narcissistic and borderline personality
disorders are both new to this edition.
Psychoanalytic theory has likewise undergone radical changes. In
North America, emphasis has shifted from an exclusive ego psycholog-
ical foundation. Ego psychological models continue but now coexist
with object relations, relational, self psychological, Kleinian, Lacanian,
intersubjective, constructivist, narrative, and other models. Perhaps
most important, the multiplicity of theories diminishes the authority of
theory itself, and in doing so allows the clinician to utilize contributions
from several theories in a manner that he finds most clinically useful for
each particular patient. Our theories have been redefined as useful
ways of thinking in the clinical situation rather than as basic truths
about the world. Clinical theory has grown from a one-person (the pa-
tient) to a two-person (the patient and the clinician) psychology. Psy-
choanalysis has moved away from the concept of the analysis opening
and blossoming like a flower following a preexisting program with the
analyst as a neutral observer. Chapter 2 reviews the modern psychody-
namic theories on which our pluralistic approach is based. For a more
complete discussion, the reader is referred to Gabbard's text Psychody-
namic Psychiatry in Clinical Practice.
Students learning psychoanalytic theory often ask, "But what do I
say to the patient?" We offer concrete answers to that question, using
clinical vignettes from our everyday work—what we said in a wide
variety of clinical situations and what we felt and thought that led us
to say it. As we reread the earlier edition, we realized that our clinical
style has changed. We were more confrontational with the patient then;
an additional 35 years of experience and life have led to a "softer" ap-
proach. There is more emphasis on the patient's strengths and emo-
tional assets as well as his unconscious conflicts. Often, by empathically
exploring a real-life conflict and understanding the problem the patient
experiences in acting on his decisions, the therapist becomes an ally
who can then introduce the concept of unconscious conflict. This offers
the patient a new level of understanding of the impact of unconscious
factors that had made obvious realistic solutions appear to be outside
his range of possibilities.
The revolutionary changes in biological psychiatry—genetics, cogni-
xvi • THE PSYCHIATRIC INTERVIEW IN CLINICAL PRACTICE

rive neuroscience, psychopharmacology, brain imaging, and the neuro-

sciences in general—have influenced the culture of psychiatry. The wars
between psychological and biological determinism are largely over;
both sides have won! The newly emergent questions are much more
interesting—no longer asking "Which is the cause?" but rather "How
did this theme become a part of the picture?" and "How has the patient
made sense of it all?" The interviewer is less troubled by concerns about
the validity of his scientific model and is freer to explore how he might
contribute to a richer, more textured, and more useful understanding of
the patient.
We ourselves have changed over 35 years as well. We are more ex-
perienced and, we hope, more empathic, but we are less self-certain and
more respectful of the solutions to the dilemmas that our patients have
forged. Our patients, and our own lives, have taught us a great deal. In
some ways our individual perspectives have diverged, but far more in
our views of the theoretical foundations of psychodynamic theory than
in clinical practice. We remain convinced of the central role of the inter-
viewer in clinical psychiatry and of the immense value of psychody-
namic understanding in the conduct of the interview.
Our greatest hope is that our audience will enjoy reading this book
as much as we have enjoyed writing it.

Roger A. MacKinnon, M.D.

Robert Michels, M.D.
Peter J. Buckley, M.D.
ACKNOWLEDGMENTS

In the first edition of this book, we thanked our teachers, students, col-
leagues, patients, editorial assistants, and publishers. We are again in-
debted to each of these groups, now with greater recognition that our
students and patients have been among our finest teachers. Many of our
colleagues have again been helpful, but we would like to single out
Maxine Antell, Ph.D., for her careful review of "The Narcissistic Pa-
tient" and "The Borderline Patient"; Susan Vaughan, M.D., for her help
in planning the organization of the book and assistance in writing "The
Patient of Different Background"; Lisa Dixon, M.D., for her close read-
ing of "The Psychotic Patient"; and John Barnhill, M.D., for his role in
the rewriting of "The Cognitively Impaired Patient," "The Hospitalized
Patient," and "The Psychosomatic Patient."
Sonia Laurent and Russell Scholl were most helpful in preparing the
manuscript, and Mr. Scholl played a special role in organizing its com-
pletion and submission to the publisher.
Bob Hales and his staff at American Psychiatric Publishing, Inc.,
have been spectacular, from the initial negotiations through the inevi-
table modifications and delays to the completion of the work. He has
been an exemplary publisher, colleague, and friend.
We decided that in addition to our group acknowledgments we
would each like to express our feelings of appreciation as individual
members of the team, as follows.
Roger says, "The first edition of The Psychiatric Interview in Clinical
Practice was a major educational event. Bob and I were relatively young
and lacking experience so that we relied heavily on critiques from
numerous colleagues. At our current stage of life, with 35 years of addi-
tional experience, we most needed a new member of the team who
could share the burden and the credit for a second edition and who
would be interested in maintaining the book when a third edition is in
order. Our selection of Peter J. Buckley, M.D., was a stroke of good for-
tune for us, because working with Peter has been a delightful and edu-

xvii
xviii • THE PSYCHIATRIC INTERVIEW IN CLINICAL PRACTICE

cational journey. Working with Bob has, as always, been a fun educa-
tional adventure. Undertaking this 3-year task subsequent to my aca-
demic retirement has been a splendid opportunity for continuity and
renewal. To Cynthia: thank you for being there, for your warmth and
patience with the many hours I have devoted to this project. Thank you
also for reading it and making suggestions and for being my link with
the computer/e-mail technological world of communications."
Bob says, "I hope that this volume is rewarding to readers in the
future. For me, the greatest reward has been during its creation—the
hours of discussion with Roger and Peter, clarifying my own ideas in
internal dialogue with imagined readers of the future, and as in the first
edition and in the intervening years, Verena's continuing support, affec-
tion, and encouragement."
Peter says, "Engaging in this work with Roger and Bob has been,
for me, analogous to stepping into a psychiatric version of what Plato
described in The Symposium. Bob provided the Socratic genius, Roger
the laser-like analysis of clinical material. The process has been one of
the most illuminating of my professional career. Maxine gave indis-
pensable affection, encouragement, and critical reading to my parts of
the manuscript."
When the first edition was being endlessly rewritten, our marvelous
publisher, John Dusseau of W.B. Saunders, helped us set it free by sug-
gesting that we think of it as the "first edition." It helped, and he was
right. Today we again offer not the finished work, but rather the second
edition.
P A R T I

GENERAL PRINCIPLES
L