Abstract
In what is likely to become a famous description of the pleasures of reading, Greg Denning [1], arguably Australia's foremost historian states: ‘Reading. The erotics of reading for me – its moment of trembling pleasure – lie in those times when I realise that what I am reading is just what I was about to say. It is a moment of jealousy and disappointment, as if the occasion has been stolen from me, but it is a moment of excitement, too – because I think I would like to try and say it better, because now the monologue in my mind has become dialogue.’ While I did not get the same erotic pleasure on reading Shea (one wonders what Denning was reading), Shea does say many of the things that need to be said about the art of interviewing and moreover says them well. The vicissitudes of the process are not only described, but he provides illustrative examples of dialogue, most of which are interesting and some of which are quite enthralling.
It is not overstating matters to assert that there is a crisis in educating about psychiatric interviewing and, moreover, about the process of formulation. Standardised interview schedules, which are undoubtedly of importance as research tools, have found their way into clinical practice and, indeed, have replaced the psychiatric interview in its traditional form in some settings. Diagnoses are made by ticking off boxes and the DSM-IV multi-axis diagnosis is offered as if a great intellectual problem has been solved. One sees psychiatric reports where pages of DSM-IV or some interview schedules are reproduced verbatim so as to establish a diagnosis.
It is hardly surprising that those training to be psychiatrists and attempting to learn about inter-viewing are preoccupied with memorising what is the right question to ask. The nuances of how a patient reacted to the question, the affective state at the time and the interviewer's feelings and reactions are all but ignored, not to mention observation of bodily posture and so on. In an effort to gather the data in a reliable fashion, even the mental state examination is sometimes ignored. What is forgotten in structured or semi-structured interviews is that the psychiatric interview creates its own data and, moreover, that it requires particular skills and a particular attitude of mind to discern the data and make use of it.
Shea's book, which is now in its second edition, is a valuable counter-weight to the ‘one size fits all’ approach to interviewing and eliciting of data. It is an invaluable book for those training in psychiatry or other mental health professions and indeed for practising clinicians. Yet Shea does not eschew structure nor indeed the discipline of using agreed categories and criteria in making diagnostic statements. Indeed, the strength of the book is the way Shea blends the phenomenology of the interview and the psycho-dynamics of the process with a need to diagnose along agreed categories as per DSM-IV. He does this without actually telling us he is doing so, and consequently gets away with it by hooking us into understanding the complex process of interaction between doctor and patient in creative ways. His approach is both open-ended and structured, free-wheeling and controlled, intuitive and scientific depending on the nature of the clinical situation and the needs and characteristics of the individual patient.
Importantly, Shea resurrects the importance of the formulation. His approach goes beyond the mere listing of predisposing, precipitating, perpetuating and protective factors within a biopsychosocial grid, which can be very irritating to listen to in a supervision or exam setting. Rather, he stresses the inte-grative functions of the formulation. However, his approach to formulation, as with the interview, is not without discipline and structure, and it is certainly not content-free or atheoretical.
The new edition contains sections on assessment of suicide and violence risk. These sections are particularly valuable as are the sections on interviewing psychotic patients. The only major quibble I have is that the book claims to be intended for a range of mental health professionals in their training. Yet Shea's approach to interviewing and formulation clearly requires a deep structure of knowledge, not to mention the issue of experience and context. Surely the way a psychiatrist interviews and formulates is different to the approach of a social worker? This is not to say one is superior to the other, but rather that the knowledge base and intention of the interviewer is different. After all, the formulation of a case can only be defined by the nature of the problem. There can be no formula for a formulation.
Returning to Denning, would I say it better? Highly unlikely, and I will not try. What I did do was to return to an older book on interviewing by MacKinnon and Michels [2]. This is arguably one of the best books on psychiatric interviewing but the modern, young trainee will probably find the language archaic and the concepts perhaps strangely written as it comes from a strongly psychoanalytical view point. The older book requires a re-write and there is no better person to do it than Shea.