Psychiatric Interview as Therapeutic Intervention
M. BOTBOL
THE IDEA THAT PSYCHIATRIC INTERVIEW IS A THERAPEUTIC INTERVENTION
• A banal statement, or a controversial issue? • Has a history that is strongly linked with the history of the representations of psychiatric nosography and of models of psychiatric practices.
Brief history of a not so common idea
• In the beginning of the 19th century: “Mental Alienation” : Psychiatric interview is a therapeutic intervention and nothing else • In the middle of the 19th century: definition of many different entities each of them seen as a natural. Psychiatric interview is nothing else but a diagnostic process
• during the middle part of the 20th century: the main concern is therapeutic: to understand the patient. The only remaining nosographic concern is to differentiate between neurosis and psychosis • In the next historical step differenciation is again a main issue. It is not that psychiatric interview cannot be seen as a therapeutic tool , it is that this is not the main concern because most of the therapeutic hopes are put on medical approaches
A new psychiatric era? Psychotherapeutic effects of psychiatric interview are widely recognized • Psychotherapy plus medication is not the addition of two scientific approaches, it is a completely new object we have to study as such. • Much stress put on therapeutic alliance, subjective experience of disease and holistic global approach of the person
History of the question shows us anyway that
T - Therapeutic value of psychiatric interview is strongly dependant of the nosographic principles of the moment • - In its history, psychiatric interview swings between two poles:diagnostic and therapeutic • - Current tendency seems to look for an exception in this overall swinging pattern of evolution • - This may affect our current nosographic paradigm.
How psychiatric interview can get a therapeutic value in the current psychiatry?
• In our current model, psychiatric interview has at least three main objectives: • Diagnosis (including differential diagnosis) • Prognosis (relying greatly on diagnosis ) • Therapeutic indication
• Description of symptoms in every day life • History of the symptoms and personal and familial anamnese • Consequence of the disorder on personal functioning and social or familial context • Experience of the disease in the patient and in his environment
The psychiatrist will then have to adress:
• The whole process means that the psychiatrist will have to enter in the private life of the patient • This is possible only because the specificity of the patient doctor relation gives to the doctor a special place in the patient’s intimacy
• Is not only a side effect of the diagnostic process ( something an objective diagnostic process should reduce as much as possible to have a scientific value). • Also one of its values that has to be used by all psychiatrist to improve therapeutic alliance, therapeutic effectiveness of all type of treatment and, therefore, therapeutic outcomes of patients.
The intimate and subjective dimension of patient-doctor relation
• The problem is that, if the psychiatrist gives attention to the role he is taking in the patient affective life, he is also to develops his empathic capacities, that is to say , he increases his chances to be exposed to affective effects in his own affective life
• A psychiatric theory that would limit itself to descriptive diagnosis of clinical categories leaves the psychiatrist alone to deal with his mixed feelings induced by his empathic exposure • This has important consequences, even in the more evidence-based part of our field: example of SSRI meta-analysis
• To help psychiatrists to deal with the (at least implicit) therapeutic dimension of psychiatric interview is then one of the current major stakes for psychiatry. • Through its focus on insight and the transference and conter transference, psychoanalysis is a tool to face this stake, • Further it may, in some cases, help increase the therapeutic value of psychiatric interview