Thursday, April 23, 2015

Interviewing 101

Interviewing seminars are a big part of the first year of psychiatric training.  I am not sure how it goes these days, but I can recall having to record interviews and being critiqued by the instructor and all of my peers in seminars.  I can remember not always agreeing with the critiques.  Every psychiatrist goes on to develop their own interview style around the basics.  Just about every interview is unique because it also depends on the person you are talking with.  The flow of information in the interview has always been fascinating to me.  At times you can cover all of the essential elements in 30 minutes.  At other time you can talk for 90 minutes and end up with 25% of the information.  Facilitating and directing that flow of information is one of the key elements of interviewing.  Against that backdrop I found this commentary on an interview of Robert Downey, Jr. somewhat interesting.  It seems surprisingly linear.  It reminded me of some of my media interview experiences where the predominate advice seemed to be: "No dead air.  Either I am talking over you or you are talking over me.  Got it?".  This clip has been widely broadcast for the past several days.  In it, the interview takes a bad turn and Downey politely gets up and walks out.  The discussion near the end of this brief clip suggests that there were probably just a few minutes left.

In the critique of this interview, Kathleen Kelley Reardon focuses on what is described as the human chemistry between the participants and how that potentially involves features like attractiveness, mood, timing and other features.  Reardon speculates that Downey may not have been up for the interview and the transition to personal questions may have been premature. She sees it as an excellent case study in what can go wrong with interviews.  I think that there are some good examples of what might go wrong but there are also some unknowns.  From my vantage point as a psychiatrist I have a few other observations and I have never had to worry about the tone of the interview, but then again I am never working on an interview as an infomercial.

1.  The introduction is very important, but we may have missed it.  Even though this is supposed to be the entire interview, it begins with Downey speaking.  This is an old Oral Boards style point - if you don't introduce yourself and set the context of the interview - come back and try it again next year because you have just failed the exam this year.  The interviewer could have saved himself a lot of problems by discussing the interview context ahead of time and setting ground rules for what the actor is or is not willing to discuss.  You don't have time to discover that in an 8 minute interview.

2.  Too many people in the room is never a good thing.  Because I am teacher, I still have people observing my interviews for teaching purposes and I never like it.  I have to be completely focused on the other person and how they are affecting me.  I did not see Downey as distracted or disinterested; I saw him look to his advisor several times until it got to the point he was overtly looking for advice.  I saw him make a clear announcement at one point: "Are we promoting a movie?" where he was clearly dissatisfied in the direction things were headed and that comment was directed to other people in the room.  The best way to maintain focus is to make sure that there are only two people in the room.

3.  What is the purpose of the interview?  There has to be a focus on that point and the interviewer needs to be aware of it.  In a psychiatric or medical interview the overriding agenda is that there is a mutual focus on a problem that needs to be solved for the patient.  Everything is as confidential as possible.  I heard a prominent psychiatrist and researcher say at a psychotherapy conference that some of the primary goals are: "Be nice to the patient and say something useful to them."  In a celebrity interview there are really dual agendas - publicity for both the interviewee and the interviewer.  Being a celebrity interviewer can lead to celebrity status on its own.  The interviewer is probably aware of how they want to come across to the viewers.  Where do they want to be along the famously provocative to famously uncontroversial spectrum?  Do they aspire to be a celebrity interviewer?  How focused are they on entertainment versus journalism?  I personally cannot think of a greater intrusion into the interview process.

4.  Contrary to the author's point, I don't think that the reporter (Krishnan Guru-Murthy) had a problem with transitioning or failing to read the cues of Downey. He seemed anxious to me. Downey came across as authoritative when talking about American cultural influences but then somewhat oppositional and defensive when talking about a past opinion that he gave during an embarrassing period in his life. He was aggressive when commenting on the interviewer's motor behavior and suggesting that he was running out of time to ask (what was probably going to be) a controversial question.  This would have been an entirely different interview if the focus had been maintained on superhero culture and the actors theories of where the film fits into that genre. He had a pretty good interpretation of some of the Stan Lee origins in Vietnam era America.  Just the time line of those developments and the further implications for the film would have filled the time.

5.  Sometimes the person being interviewed drops a gift at your feet and you have to go with it. As an example, if I am interviewing a person who has been incarcerated I rarely go directly after that information.  I can probably get the historical details elsewhere and it is a threat to the interview process.  I don't want the interviewee to develop the "cop transference" and start to experience it as a police interrogation.  And I usually have an hour compared to this less than 10 minutes session.  The  interviewer needs to be aware of the fact that he is not doing psychoanalysis and that all of those Barbara Walters interviews where there was a key emotional disclosure occurred after hours of interviewing and heavy editing.  In this case Downey talks about how he portrays the character and how his interpretation of the character had changed over time.  That leaves him talking to a small part of the audience for this interview - the people interested in art and acting but that would have ended a lot better.

6.  As I watched the interview, I had the question about whether there were any journalistic biases operating.  It becomes clear that Guru-Murthy wants Downey to answer questions that have nothing to do with the movie and were from a very difficult time in the actor's career.  It is clear that the reporter's anxiety level is building as he tries to force those questions.  And, it is clear that he is trying to force them into the smallest possible window in this interview - the final minutes.  It was anxiety provoking for me to watch that section of the interview.

7.  There is often a lot of focus on the process aspects of the interview.  It seems that the emphasis on the communication aspects of the interview are very linear - pick up this cue and make this intervention.  Interviews (at least the way I see them) are non-linear,  There are a lot of parallel processes going on and interviewers tend to elicit much different information based on their biases and techniques.   There may be times where I slow the interview way down to get at specifics and at other times I am looking for global markers and whether they are present or not.  

8.  Based on my past experience,  I also had to wonder if the gotcha dynamic was operative.  I have been called in for media interviews where the reporter has some preconceived notion of how the world works.  A good example is the fallacy that the Christmas Holiday season is the peak time of the year for suicides.  After I had spent some time explaining to the reporter over the phone that this is really not true, during the interview I was pummeled with comments and anecdotes about how people naturally get depressed and kill themselves more often during Christmas.  This has happened to me more than once and it is a good reason to avoid reporters.

The way this interview ended seemed quite civil to me.  It is not surprising to me that the media is making a big deal of it in spite of the fact that really catastrophic interview endings tend to occur with people who are accusatory, demanding, threatening and/or aggressive.  In an interview with an actor that is not likely to happen.

Despite all of our focus on interviewing in psychiatry, we seem to be loathe to look into the science of it all.  For the past 30 years we have been operating under the illusion that in order to make a DSM diagnosis, all it takes is getting the answers to the right questions.  Those questions were typically structured interviews using DSM or the precursor RDC criteria.  It gave way to the Diagnostic Interview Schedule (DIS) for early epidemiological work followed by the Schedule for Affective Disorders and Schizophrenia (SADS).  This work seems to have led to brief diagnostic checklists based on  the DSM criteria.   I read an article in the Journal of Clinical Psychiatry once that suggested if all of the clinicians in a clinic used the SADS as their diagnostic interview they would have better outcomes.  The idea that a structured interview or checklist elicits better or more useful information than an experienced psychiatrist interviewing the patient is another great fallacy in the field.  I would actually put that at the top of the list and rate it higher than needing a head to head comparison of antipsychotics based on time to discontinuation or whatever the Cochrane Collaboration has to say about "limitations of methodology / need more study" for practically any drug trial.  The evidence that I am right is replicated tens of thousands of times every day by psychiatrists out there doing the same work.  If you interview the same patient twice it is very unlikely that they will give  you the same history.  I have a standard flashcard that lists about 100 medications of all classes and they will not consistently endorse the same medications on this list.  We interview people about their subjective experience and that experience is always plastic.  That is much more interesting than storing the encyclopedia on computer chips.

In some cases we might put a metric like test-retest reliability on an interview metric or the global result of a structured interview.  Given that we are measuring something that reflects the functioning of a highly plastic organ, I don't know why we would expect reliability to be high.

That brings me back to this interview.  Our interview technology is a holdover from the 1950s.  We have evolved subtle modifications over the years but currently we are constrained to a small fraction of the conscious state and we do not know how to optimize the flow of relevant information.  This is a major limitation.  There have been some theorists who have looked at mapping diagrams of the interview process but none have gained any widespread acceptance.

The only good news for psychiatrists now is that we are not operating at the level of reporters.

George Dawson, MD, DFAPA

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