Hal 30

goal is to overcome her neighbors hostility; your therapeutic goal is to cradicate the delusional thinking.
The patient is barred from this insight and would be hostile or unresponsive to your goal.

For patients with partial insight, one goal of reatment is to try to bring them to full insight and prevent
relapse. For Rose, with treatment she will recognize the delusional nature of her beliefs. Then the
treatment of the delusion itself becomes the overt goal. After remission, the prevention of a relapse
becomes a new oveit goal. At this time, the overt and therzapeutic goals have merged.

As the delusion melts away, the patient may start to challenge you and ask:

"Do you think my neighbors are really against me, or do you think I'm crazy?"

In reply, ask her what she thinks, and tell her i: this is more important that you understand her distress
rather than worry about how much her neightbors really harassed her. When a patient reaches full
insight, she may remark that you probably knew all along that her ideas were nonsense. Counter her
statement with a question:

"What would you have said if I told you that 6 weeks ago?"

For Richard and Mr. Combs (no insight), the overt goal is to take neuroleptic medication "so that the
intruders bother them less." The therapeutic goal is to abolish their delusions.

Restating the overt goal with the patient's growing insight is often a painstakingly slow process. Avoid
provocative confrontations and interpretations that may offend them. Give them time to see through
their problems and have the overt goal merge with your therapeutic one.

Both overt and therapeutic goals remain elusive if you do not show the patient that you will help him.
The more he distorts reality, that is, the more the overt and therapeutic goals differ from each other, the
more support he needs, Make him feel that you accept him "unconditionally." As Truax and Mitchell
(1971) called it. In the research on the effective therapist-the one who initiates change in his client-they
isolated three ingredients: empathy for the patient's suffering, genuineness in the patient-interviewer
interaction (see above), and unconditionally positive regard for the patient as a person. These
ingredients are not restricted to therapy but also apply to the psychodiagnostic interviewer to create an
alliance for both

Hal 31

Interview goal directed at the patient's self-disclosure and the more remote goal of the patient's
improvement

4. SHOW EXPERTISE
Empathy goes a long way, but empathy is not enough. It tells the patient that you care but it tells
nothing about your competence to care. Research has suggested that people rank competence highly in
choosing a physician. In the study cited earlier, 205 adults chese "expertise" (seems Knowledge able in
the field, ask me appropriate questions about my problem) as their first and fifth criterion for Choosing a
physician (Hill 1991).

To establish your expertise, you need to show the patient that you are competent to handle his
problems. Use three techniques to convince him that you understand his disorder:

1. Make aware that he is not alone with his problem, put his illness into social perspective

2. Communicate to him that you are familiar with his illness-show knowledge

3 Address his doubt about your professional skills. Your expertise sets you above well-meaning family
members or friends and distinguishes you as a professional.

4. Instill hope about his furure

Put the Illness Into Perspective

When the patient describes his problems, you may interject:

"Have you known anyone with a problem like yours?."

He may tell you about family members and friends, movies and books concermed with mental illness.
Ask him how his own problems fic in. Correct his misconceptions if he has any.

Another patient may claim that he has never heard about a problem like his. Tell him that it is common
to hide psychiatric disorders. Ask him what he thinks about his disorder. Discuss with him which
features of his illness are common, and which ones are specific to him. Reassure him that many people
have similar problems and has gotten well with treatment.

A patient may panic when you mention other patients to him and fear

Hal 32

Cxpress that his symptoms may be similar to others but his personality to deal with tiem is unique. that
you will file him away as just another "case." Put his wories at ease and Show Knowledge Demonstrate
expertise to your patient by probing for specific symptoms of his disorder. A patient is sometimes
amazed by targeted questions abour his condition, wondering: "Howv did you know that" Then, he
beaune more inclined to trust you and reveal secret concems such 2s ruminations obsessions, or
compulsions-since you know anyway. Another way to establish expertise is to stir up the patient's
curiosity about psychology and mental illness that he has read about or seen discussed on television.
Discuss famous examples, such as President Lincoln or television personalities for depression (also King
Saul if the patient has a religious background). Point out how they relate to him. Use phrases such as
"You've got a problem about which we have learned quite a bit recendy. Your probiem is common to
middie-aged people. "Recendy, we have made some progress in treaing a problem such as yours.

Leam from the patient's response what aspects of his problems interests him. Answer his questions in a
concise manner; explain heredicy, receptor theories, and psychological formulations, or system theory.
Your knowledge is reassuring for the intellectual, obsessive, or educated patient who bases his trust in
you more on how much you know than how much you ca (for him) What do you do if you do not know
the answer to a question Admi your ignorance freely. Tell him whether the answer is known, but you
don't know it, or whether it is not known at all. Admitting to the limits of your knowledge usually
increases the patient's confidence in your honesty. Most patients do not expect you to be omnilegent or
omniscient, but if one patient does, discuss his false expectations with him. Deal With Doubt Whenever
you encounter doubt about your expertise, decide how to deal with it (see Chapter 3: Techniques; also
compare Ochmer and Othme 104)

Hal 33

What caused you to ask dhis question at this time? -Do you lave concem whedier I really undersand
your problems? "Use openness, counterquestioning, and consider even interpretation if you sense a
deeper-seated doubt. If you handle the patient well, he will experience you as an expert. Most patients
respect skillful management f their difficulties We will talk more about this in Chapter 3. Instiil Hope
Often psychiatric patients have suffered from their symptoms, signs, and failures for months or even
years before they seek or find effective help. have tried unsuccessfully or their ovn to cut back on their
use or quit the habit altogether Patients with major depressive disorder have a negative oudook on the
furure due to the nature of their disorder.Therefore, it is essential to address their view of the future and
to instill hope Tell them what they can expect if they cooperate with your diagnostic assessment and the
treatment based on it Most patients are better off with an diagnosis d treaument than without it, a
point: to be cmphasized, without raising unrealistic expeciations.