Communication

Approach
in Psychiatry

Dr. Lely Setyawati, SpKJ(K).

Psychiatry Department
FK. UNUD/RSUP Sanglah Denpasar.
 Outline
1. INTERVIEW - TO BE AN EFFECTIVE DOCTOR
2. SPECIAL PATIENT POPULATIONS
3. MODELS OF INTERACTION
BETWEEN DOCTOR & PATIENT
4. DOCTOR - PATIENT RELATIONSHIP
5. SPECIAL EMOTION CONDITION

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 What are you thinking about
Psychiatric Patient?

• Is he or she a difficult patient?

• What kind of the patient?

• Why are the people afraid of them?

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 ARE YOU AN EFFECTIVE
DOCTOR?
• To be an effective clinician in any field,
a physician must understand both :
 The science
 The art of medicine
• With all of the technological advances in
medicine, successful care-giving still relies on
the very basic, and deceptively simple,
relationship between doctor and patient.

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 Interviewing Effectively
• The most important aids is ability to interview
effectively
• Skilled interview
 gather the data
understanding the patient
 treat the patient
 increase the understanding of the patient
 compliance
• Personalities & character style, telephone
interruptions, interpreter, note taking ~ influence.
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 What is your comment?
Dr : Why do you come to this clinic?
Px : Doctor….. when I woke up this
morning, I showered and dressed,
something happened with my pet. My
former neighbor had stole my idea…..
Dr : Hhhhh…… (Oh, my God! Hurry up!
What’s happen with you?)
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 Special Patient Populations
1. Patients with psychiatric symptoms
2. Patients from different cultural backgrounds
– Un-assimilated
– Cannot communicate well with others
– Difficulties with the English language

3. Patients whose personality problems make

them difficult, demanding, uncooperative, or
likely to engage in power struggles.

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 PSYCHOTIC PATIENTS
• They have poor or absent reality testing
abilities (RTA)
• Doctor must focus more and provide more
structure
• Closed-ended questions are better
• Short questions are easier for the patients
• The communication may be impaired because
of thought disorders, hallucinations, illusions,
delusions, etc.
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 SUSPICIOUS PATIENTS
• Usually those with a paranoid-
personality
• They often misinterpret neutral events as
evidence of conspiracy against them
• They are critical & evasive, tend to blame
other people for everything bad in their lives
• Extremely mistrustful & may question
everything the doctor says or does.
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 DEPRESSED & POTENTIALLY
SUICIDAL PATIENTS
• They have difficulty concentrating, thinking
clearly and speaking spontaneously
• All patients must be asked about suicidal
thoughts
• Asking about suicide does not
increase the risk.
• Specific detailed questions are
essential for prevention.
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 SOMATIZING PATIENTS
• Make the patients frustrated (and also the doctor)
• Some patients experience and describe emotional
distress in terms of physical symptoms
• Many somatizing patients live with
the fear that their symptoms are
not being taken seriously
• It is essential that somatizing
patients feel that their physical
complaints are not being dismissed.
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 AGITATED & POTENTIALLY
VIOLENT PATIENTS
Several steps to minimize the agitation and potential
risk:
• The interview should be conducted in a quiet, non
stimulating environment
• Sufficient space for the comfort to the doctor and
the patient
• Avoid any behavior that
could be misconstrued as
menacing: standing over,
staring or touching the patient.
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SEDUCTIVE PATIENTS
• Manifest in a patient’s dress,
behavior and speech
• When the behavior is mild
and indirect, it may be best
to ignore it.
• Avoid precipitating
seductive behavior.

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 EMPATHETIC LISTENING
• Empathy is a way of increasing rapport.
• It can be focused and deepened through
training, observation and self-reflection
• It manifest in clinical work in a variety of
ways
• It is not necessary to have people’s literal
experiences to understand them.
• The shared experience of human being is often
sufficient
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 MODELS OF INTERACTION
BETWEEN DOCTOR & PATIENT
• The interactions between doctor & patient can
take different forms.
• Think about the relationship to formulate
‘models’ of interaction.
• These are fluid concepts
• Different approaches with different patients,
Different approaches with the same patients as
time and medical circumstances vary.
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 MODELS OF INTERACTION
BETWEEN DOCTOR & PATIENT

1. Paternalistic model
2. The informative model
3. The interpretive model
4. The deliberate model

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 PATERNALISTIC MODEL
= PARENTAL ROLE
– The doctor always know the best
– He / She prescribes treatment, the patient is
expected to comply without questioning
– The doctor may decide to withhold information
when it is believed to be in the patient’s best
interests.
– Autocratic model, the doctor generally dominates
the interview
– In emergency situations, But in another situations?
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 THE INFORMATIVE MODEL
• The doctor dispenses information
• All available data are freely given, but the
choice is left wholly up to the patient.
• No established relationship exists
• Places the patient in an unrealistically
autonomous role and leaves him / her
feeling that the doctor is cold and
uncaring.
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 THE INTERPRETIVE MODEL
• Doctors who have come to know their
patients better, understand of their lives, their
family, their values, hopes & aspirations
• They make the decision and discuss well
• Doctor does not abrogate the responsibility
for making decision, but is flexible, willing to
consider question and alternative suggestions.

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 THE DELIBERATE MODEL
• The doctor behaves as a friend or counselor
• Actively advocating a particular course of
action
• The deliberate approach is commonly used by
the doctor, hoping to modify injurious
behavior, for example
– Trying to get their patients to stop smoking
– Or to lose weight.

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 THE FRIENDSHIP MODEL
• This model generally
considered dysfunctional
• Can lead to un-ethical
behavior
• It is most often prompted
by an underlying psycho-
logical problem of the
physician.

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 Checklist for Clinicians
(Kaplan, tabel 1-1)
Yes No N/A
1. I put the patients at ease
2. I recognized the patients state
of mind
3. I addressed the patients distress
4. I helped the patient warm up
5. I helped the patient overcome
suspiciousness
6. I curbed the patients intrusiveness
7. Etc…
Table 1-7 Character & Qualities of the Physician
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DOCTOR - PATIENT RELATIONSHIP

1. The active-passive model

2. The teacher-student model
3. The mutual participant model
4. The friendship model

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 THE ACTIVE-PASSIVE MODEL
• Implies passivity on the part of the
patient
• Patients assume no responsibility for their
own care and play no active role in
treatment.
• The model is appropriate when a patient
is unconscious, immobilized, or delirious

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 THE TEACHER-STUDENT MODEL

• The physician’s dominance is assumed

and emphasized

• The physician is paternalistic

• The patient is essentially

depending & accepting

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THE MUTUAL PARTICIPANT MODEL

• Implies equality between the physician

and the patient: both participants in the
relationship require and depend on each
other’s input.
• Very useful in chronic illness, in which
patient’s knowledge and acceptance to
treatment is critical to success.

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 THE FRIENDSHIP MODEL
• This model generally considered
dysfunctional
• Can lead to un-ethical
behavior
• It is most often prompted
by an underlying psycho-
logical problem of the
physician.
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 Usual Patient-doctor relationship

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 Rapport
• Rapport is the spontaneous, conscious feeling of
harmonious responsiveness that promotes the
development of a constructive therapeutic
alliance.
• Rapport implies an understanding and trust
between the doctor and the patient
• Most patients trust their doctors to keep secrets
and this confidence must not be betrayed.
• An effective relationship is characterized by good
rapport.
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 Establishing Rapport : 6 strategies
1. Putting patients and interviewers at ease
2. Finding patients’ pain and expressing
compassion
3. Evaluating patients’ insight and becoming an
ally
4. Showing expertise
5. Establishing authority as physicians
6. Balancing the roles of emphatic listener, expert
and authority.

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 Empathy
• Empathy is a way of increasing rapport
• Empathy is not a universal human capacity
• An in-capacity for normal understanding of what
other people are feeling appears to be central to
certain personality disturbances, such as antisocial
and narcissistic personality disorders.
• Empathy can not be created, but it can be focused
and deepened through training, observation, and
self-reflection.
• It manifest in clinical work in a variety of ways.

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  Mental health problems are one of the leading causes
of illness and disability worldwide*

 Although effective solutions for mental disorders are

available, only 20 to 30 percent of the people identified
in epidemiologic surveys as having a mental disorder
had their needs for care met**

*The World Health Report 2001: Mental Health, New Understanding, New Hope.
Geneva, World Health Organization, 2001
** Bijl RV, Ravelli A: Psychiatric morbidity, service uses, and need for care in the general population: results from the
Netherlands mental health survey and incidence study. American Journal of Public Health 90:602–607, 2000
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 2001 : Burden of diseases worldwide -
Disability adjusted life years (DALYs)

Neuropsychiatric
disorders : 13 %
Injuries : 12 %

HIV/AIDS : 6 %

Cardiovascular
diseases : 10 %
others : 41 %

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 Gangguan jiwa berat (Riskesdas 2007)

Jumlah >1 jt

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 Prevalensi Gangguan Mental Emosional
Riskesdas, 2007)
25

Depresi & Cemas usia ≥15 th: 11,6%

20

20  ± 19 juta orang
16.5
16
14.5
14.5
14.1
14.1
13.9
13.7
13.2
15 12.8
12.3

11.5
11.4
11.3
12

10.7
10.3
10.2
9.8
9.7
9.6
10 11,6%

9
7.8
7.7
7.5
7.3
7.1
6.9
6.9
6.8
6.3
5.1
5

46
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 Learning Task
1. Describe the strategy approach to interview a
weep patient?
2. Describe the strategy approach to interview a
silent / quite patient?
3. How can we establish a good rapport while
interviewing angry patient?
4. How can we communicate and establish a good
rapport with aggressive patient?
5. How can we manage the dispute patient in front
of you in your room?

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 Case 1 : Ibu Ani
• Mrs. Ani is really sad to face the fact her
husband's affair, she felt headache since
yesterday. There have been countless
headache medication she took. Today he
came to the your clinic and intend to ask for
the better one medication. When she was
called into your room, she could not hold her
tears, crying and crying.

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 What’s the doctor answer?
A. Saya mengerti perasaan ibu
B. Tenang bu, jangan menangis terus, semua
masalah pasti dapat kita atasi.
C. Silahkan ibu menangis keras-keras sepuasnya.
D. Mari kita bicarakan apa yang masih bisa kita
kerjakan sekarang.
E. Bu, berhenti menangis dulu karena saya ingin
bertanya sesuatu yang sangat penting
F. Saya mengerti perasaan ibu, suami ibu memang
laki-laki yang tidak tahu diri.

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 Case 2 : Budi’s Sister
• Budi was really surprised to face his sister’s
behavior named Harum. His sister stays and
lays down in her room almost all the day. She
refuses to talk and avoid all of her friends. She
become very angry without any reasons. She
threw out some of furniture equipments and
broke them. Today Budi decided to visit your
clinic to consult and check her health.

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 Be talented and good physicians!

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