9 Psychopathological Evaluation: The Clinical Dialogue

1. Overview

The study of psychopathological symptoms as subjective experiences has been offered a framework from phenomenology (see section 1.2.1). Phenomenology emphasizes a disciplined assessment of subjective phenomena, in particular the “suspension of judgment in the process of attending to and extracting primary experiences (Husserl, 1913, 1921|1970, 1913|1931, 1936|1954; Jasper, 1913|1963). It is recognized that a tendency in human thinking is to simultaneously grasp the primary experience and at the same time to generate secondary interpretations. It is important for the clinician to segregate secondary interpretations from primary experiences in the process of describing subjective phenomena. Phenomenology aims at a minimalist approach. It starts with the most parsimonious basic components of subjective experiences (see section 3). The approach is thus relatively free from the theories of different schools of psychology. The basic components of experience as clarified in phenomenology can later be utilized by a variety of psychological, psychotherapeutic, and neurocognitive theories downstream. However, for the psychopathological evaluation, the objective is to stay as close as possible to the primary phenomena. 

It may be counterintuitive to appreciate that it requires more effort to stay free from theoretical involvement. A metaphor can illustrate this point from the historical evolution of pottery craft in ancient China. In the evolution of the  glaze (decorative coating) in ceramics, the first glaze to emerge was not the colorless or white glaze, but the green glaze (made from selected ingredients from the soil), which was developed around 100 AD. It would take the next 400-500 years before white (or transparent) glaze was developed in the sixth century  (the “white” glaze is actually transparent, applied over a white body). In psychopathology as well as in ceramics, the technique of a colorless cover-layer requires more techniques and distillations. The information we can attain may enjoy a closer proximity to the core pathological processes and enables us to achieve better prediction of illness trajectories and intervention responses.

The clinical dialogue is an evaluative technique in psychopathology involving an iterative process (Pickering, & Garrod, 2004). Through cycles of information exchange between the patient and the clinician, the psychopathological experience is progressively clarified. The clinician has the opportunity of probing for information as the model is being developed. A well-managed clinical dialogue involves many different skills. 

The overall objectives of the clinical dialogue are 3-fold. 
(1) a psychopathological “clarification”. The “psychopathological clarification” involves detailed clarification of anomalous experiences in terms of its representational structure and content. This includes the primary experience, the contexts, and the development path of the anomalous experiences. The clinician also observes the patient’s behaviour, including how he engages with the clinical dialogue itself, as well as other signs of observable behavioural abnormalities.

(2) a detailed perspective about the patient as an evolving Person, developing through a chosen path of engagement in his Lifeworld. The anomalous experience is placed in the context of the Person by considering the basic structure of the Person, and the representations in his Lifeworld.

(3) optimal engagement of the patient so that future therapeutic interaction will be facilitated (Shea, 1998). 

2. Preparations for Clinical Dialogues
1. Engagement 
Engaging the patient and building up a working rapport is not a trivial process in mental health consultations. While in general medicine, patients are driven to seek help to relieve distress, in mental health clinical scenarios this drive is often lacking. Patients with mental health conditions often have limited appreciation of their problems (Tait, et al., 2003; Marková, 2005). Patients tend to seek help reluctantly and disengage easily, aggravated by heavy stigmatization. Clinicians have to deploy extra effort just to engage patients. The process of engagement starts from the very first contact. Often, the initial evaluation is also the beginning of a therapeutic relationship. Sufficient attention to the interactional processes is crucial to the efficient conduct of assessment, and to facilitate future therapeutic work with the patient (Shea, 1998). 

2. Clinical Etiquette
An evaluative interview is a unique encounter between two individuals. Within the approximately one-hour interview, the clinician aims to gather high quality information that allows an accurate clarification of the anomalous experiences. This is a challenging task in view of the limited time frame.

A respectful introduction, stating the location, the time as well as the context of the interview is a good start to a professional encounter. Defining a professional encounter explicitly is important as it evokes a professional-client schema rather than the schema of an informal encounter between friends. The professionalism enables explorations in areas that are inaccessible in informal friendly interaction. However, having defined this context, it is then desirable to generate an atmosphere that still enjoys the ambience of a friendly sharing. 

3. Information Quality
Clinicians should be mindful of potential sources of “noise” in psychopathological information, as they may compromise clinical decisions. The quality of the clinical dialogue depends on the processes of the interaction, as well as the individual characteristics of the clinician and the patient.

The contents covered by a psychopathological interview comprise subjective experiences of the patient. Access to subjective experiences is negotiated through a skillfully conducted dialogue. Factors such as language and differences in interpretation may constrain how the experience is communicated and received (see section 8.3 on the dialogue cycle). While it is important to recognize some limitations in access to subjective data through dialogue, it is equally important to be aware that with due attention, it is possible to clarify high quality data concerning subjective experiences (see 7.2.4 below). 

The approach currently proposed involves considering of subjective experiences as structured phenomena. They can be described as mental representations consisting of feature dimensions (see section 6). Clarifying a subjective phenomenon involves identifying which dimension are involved, as well as what contents fill the dimensions. It is also important to identify the context in which the anomalous experience took place.

“Thick description” is a method which involves making explicit the details about the experiential contents as well as the contexts. In a summary account, inevitably some data are filtered out at an early stage, thereby increasing the possibility of undiscovered bias in the selection of data. When raw data are richly represented, the context under which specific information emerged becomes available for subsequent examination. Without detailed information about the context of the observation, it becomes more difficult to evaluate, especially when contradictory information arises at different points in the interview process. 

To an experienced clinician, contradictory information is not treated with the assumption that there must be some “error” and only one account is “correct”. Discrepancies could be genuine and informative, if the contexts in which different observations are made could be explored. This may lead to a more informed grasp of the patient’s experiences. Clinical notes in psychiatry should be rich and sufficiently detailed, rather than merely like a checklist.

4. “Immersion”  in the patient’s Lifeworld
In a psychopathological interview, an interviewer aims to gain access to the psychopathological phenomena that takes place in the subject’s daily life. In order to do so adequately, it is important that the interviewer has an adequate grasp of the Lifeworld of the subject (see section 1.2.1 of Lifeworld above). While there are limits to which the interviewer could directly observe the subject experiencing his world in a real-life situation, it is important for clinicians to have extensive contact with the socio-cultural environment in which the subject lives. The meaning of the experiences can be accessed in this context through the use of empathy. (Geertz, 1973). Adequate socio-cultural contextual exposure for the clinician is crucial for understanding a patient’s experiences. The task of the clinician is to connect to the subject’s world and to empathize how this world is experienced by the subject. The access to meaning is possible via the interviewer’s own subjective experience of the world and meaning system. This way of understanding is described as “verstehen” by Jasper (1913|1963) and has been elaborated by ethnographers in anthropology. Indeed, the psychopathologist has to becomes “immersed” in the observation process.  His own system of meaning and his immersion in the world the subject inhabits, would then become processes in understanding his subject’s experiences. 

5. Active Probing and “Clinician Participation Effects”
One of the factors which affects emerging information in a clinical dialogue is the impact of the interviewer. The interviewer’s behaviour affects the emergence of subjective data. It is important to appreciate how much of this data is influenced by the interviewer’s style; and how much is the result of the primary experience of the subject. 

In a psychopathology evaluation, the interviewer himself is not just a passive observer, but an active participant in a process of dialogue in which psychopathological experiences are clarified. It is important for the clinician to be mindful that he has an impact on the phenomena under observation. (Oswald et al., 2014; Robins, et al., 1996). 

This situation, where the observation process impacts on the observed phenomena is often encountered in scientific studies. For example, in the observation of protein structures, crystallography has been a major approach. Protein “crystals” are analyzed by x-ray. The crystallization however extracts protein from its natural environment, which is a fluid medium. Different domains of science devise their own methods to tackle these kind of problems. In the study of psychopathological phenomena, this involves a disciplined attempt to dissect the various additional embedded layers of information resulting from the observation processes.

When the interviewer is aware of the dual-role of being an observer and a participant, these two roles can be complementary rather than compromise each other. The observer actually can make a more in-depth observation through the use of active exploration processes. This approach has been discussed in the section on empathic explication. (see section 5.1.2). 

Is it possible to “distill” primary subjective experience from the product of interactional processes? Some insight can be facilitated by repeated approach to the same experience through different dialogue perspectives. When the same content is approached from different angles, the resultant dialogues have overlapping and non-overlapping contents. The interviewer can tease out how much consistency there is in the core expression and how much variations are dependent on the different conversational contexts. In a previous discussion (Section 6.4.2), we have seen how the previous SOMs affect the current SOM. If we attempt to address the current SOM from a number of different pathways {i.e. each time through a different SOM pathway), it may be possible to compare the different final SOM we obtain and extract the core that is consistent. This exploration is similar to manual exploration of an object by touch from different angles (see section 5.1.2 on empathic explication). 

Adequate probing is mandatory for unveiling complex subjective phenomena. Probing refers to the process in which the interviewer actively interacts with the subject in an attempt to facilitate the description of the phenomena. This requires the subject to actively retrieve and explore his own inner experiences in ways beyond what he has offered in the first place. Active probing offers a good opportunity to observe how the patient comes up with responses. Situations in which the subject has to give a forced-choice response are considered more vulnerable to the tendency of ad hoc response instead of genuine reflection of inner experiences. 

A single phenomenon could be probed from different angles using different lines of approach. This may yield different results. Having a grasp of the different descriptions that emerge from different probes enables a more in-depth appreciation of the phenomena under observation (see section 5.1.2 on emphatic explication above).

It is also important to consider whether the subject has reasons to intentionally conceal information or to mislead the interviewer. It is acknowledged that deception and concealment can take place in clinical interviews. Intentional deception may be difficult to unveil, and it would take time and effort to detect inconsistency that is attributable to deception. There is no substitute for adequate probing. Deception and concealment, apart from leading to a distortion of the information, could themselves be significant signals for psychopathology. 

6. Behavioural Observations
At the same time as the clinician immerses himself in the clinical dialogue, he also takes up the role as an observer on a patient’s verbal and non-verbal behaviour, including the ongoing interactional dialogue processes in the interview.Though the observation takes place in the clinical dialogue, information obtained in this way includes clinical signs (rather than subjective accounts) which falls under the premise of the Natural Sciences (see section 1.1.1).  One example is observation of the patient’s speech, in order to decide whether language disorganization occurs. Language disorganization is an important clinical sign. Pragmatic procedures to observe and describe language disorganization have been detailed (e.g. Chen, 1996). 

It is important to recognize that attention to context is also important in behavioural observations. For example, language disorganization is more observable in some content areas than in others (for example when discussing more abstract topics, or topics related to the content of psychotic experiences).

7. Perspective Switching
One of the basic skills for clinicians involves a switching among three perspectives: a first-person perspective, a patient’s perspective, and a third-person perspective on the part of the interviewer. In a first-person perspective, the interviewer is fully engaged in the interview process as a participant in a conversation. Therefore, the immediate experience of the interviewer is as a person experiencing a conversational process with the subject. In empathic understanding ieshe clinicians try to see things from the patients point of view. In addition, the clinician “literally” scans the visual environment from the subject’s perceptual viewpoint (see below, section 6.1 on visual environment). On other occasions, the interviewer switches to a “third-person perspective” from time to time (Libby, Shaeffer, & Eibach, 2009). In the third-person perspective, the interviewer inspects the interview process as if through the eyes of someone observing the interview from the outside. This third-person perspective enables the interviewer to reflect on the interactional processes taking place between himself and the subject. Intentional and regular switching between these perspectives is a discipline the clinician develops with practice.

3. The Clinical Dialogue Cycle 

The Clinical Dialogue involves a transfer of experiential information from the patient’s mind to the clinician. The aim of the clinical dialogue is to build as accurate as possible a representation of the patient’s psychopathological experience as a mental model (representation) in the clinician’s mind. A visualization of the steps involved in the dialogue cycle (below) is a tool that clinicians can utilize during real-time monitoring of the interview process (see figure 9.1).

8. Components of the Clinical Dialogue cycle
There are four basic modules involved in the dialogue cycle, consisting of an experience module (M) and a communication module (I) for each of the clinician (C) and the patient (P). Within the clinician there are two modules. One module is set aside for constructing a representation of the patient’s symptoms (CM). Another module is responsible for communication with the patient (CI).   Similarly, in the patients’ mind that there are two modules. One module is where the patient experiences the psychopathology (PM). The other module is involved in communication with the clinician (PI). These modules are relating to one another as described in the basic structure of the “atomic representation of experience” (see Figure 9.1 above).

The communication module in the patient and the clinicians are engaged in iterative cycles of conversation. If the communication module in the patient is itself directly affected by illness (such as via language disorganization), the dialogue cycle can be significantly compromised. 

9. Processes in the dialogue cycle
1. Process 1 Initiation of the Clinical Dialogue Cycle
The dialogue cycle starts when the patient begins to give an account of the symptoms that he has been experiencing. The clinician aims not to constrain the dialogue. The patient is allowed freedom to choose how to approach the area or experience that concerns him most.

2. Process 2 Patient accesses his own experience
The patient refers to the part of his mind where the anomalous experience took place (his experience module). This process of self observation on the patient’s part assumes that the patient can relate to his experience as an observer from one part of his mind that could make observations on another part of his mind (see section 4.2 on phenomenology). Sometimes, the phenomenon being observed is in the past and memory processes are involved (see section 4.3 on phenomenology). When the target processes accessed are in the Present, a self-reflective process is implicated. These processes enable the grasping of an internal experience that can then be communicated. The phenomena that is grasped can be specified with the structure of a representation, with dimensions that could be filled. It is important to recognize that the capacity for reflection may not be always entirely intact. It could be impaired for instance, during an acute psychotic state. In psychosis, the cognitive space for reflective processes may be compromised by the immediacy of the psychotic phenomena. 

3. Process 3 Patients communicates his experience
The success of communication depends on the integrity of a number of factors. First, the communication module in the patient has to be competent and willing to engage. Secondly, the patient has to be able to encode the relevant experience in terms of linguistic expressions available in his language. 

To the extent that the semantic network is culturally shared between different individuals, experiential states could potentially be communicated between individuals. Experiential information is transferred to linguistic expressions. It is important to recognize that linguistic representation of experience is a processed representation of the experiences rather than the raw experience itself. Proper communication of experience depends on the richness of the subject’s linguistic resources as well as the availability of relevant vocabulary within the shared language itself. For instance, it is well known that different languages vary in their richness for descriptors of emotions (Russell, 1991). 

4. Process 4 Clinician receives the communication
When the clinician receives verbal utterances communicated by the patient, he decodes the patient’s messages and uses the information to construct a model of the patient’s experience. The clinician allocates a cognitive space in his own mind for building up such a mental representation with data communicated by the patient. In the building up of the representation, information may not be complete. In the absence of specific information, the clinician may utilize contextual information to fill the gaps. It is important for the clinician to be aware of such processes in his own mind. Excessive “top-down” filling in of gaps may overshadow “bottom-up” information from the patient. In this situation the stereotypic expectations of the clinician may override the primary experiential details provided by the patients. Such biases could lead to a model that does not accurately reflect the patient’s experience. 

Complex processes takes place in the clinician’s mind to evaluate the model that is being built up. This reflective process involves the ability to distinguish between internally-anticipated information and externally-received information (a form of source memory for the clinician). The reflection will discriminate between what is already known from what is still not yet ascertained. The ability of the clinician to evaluate the emerging model is extremely important in guiding the clinician to generate further questions in the dialogue cycle. 

5. Process 5 Clinician constructs model of the patient’s experience
The psychopathological experience is initially private to the patient (see section 5.2.3 on the limits of empathy). The clinician can only access the information through the process of an empathic dialogue, using linguistic concepts inherited in a shared culture as a tool for clarifying the psychopathological experience. With these caveats, a limited but valid model of a patient’s experience can be constructed.
 
We note that the representational structure of the psychopathological experience in the clinician’s model may not be the same as the representational structure of the primary experience in the patient. The representation of primary experience is embedded in layers of further processing (see figure 9.2). The clinician may have to use information from these additional layers to disambiguate and reverse estimate information in the primary representation. Various active probing possibilities can be deployed to further clarify the primary experience in a process of explication.

Clinicians could also be vulnerable to premature closure in the model construction process, when excessive top-down information is employed in the clinician’s mind to “fill in” what the patient has not communicated. To minimize these tendencies, attention to the phenomenological practice of “suspension of judgment” is a particularly important discipline for the clinician. Ability to keep close to the primary experiences of patients is important for the validity of the psychopathological observations. In developing a model for the patients psychopathological experience through clinical dialogue, the congruence between the patients and the clinicians linguistic representations will affect the extent to which an accurate model can be effected. Skillful Linguistic alignment in the clinical dialogue is therefore also an important prerequisite.

6. Process 6 Evaluation of the model leading to new exploration in the next iteration
In the process of constructing the model of the psychopathological experience, the clinician seeks the most efficient way of exploring in order to obtain discerning information that can help discriminate between the different possibilities in the remaining part of the model. From an information perspective, a partially filled model still contains parts in which several possible options remain viable. Further information is required to distinguish between these options (see section B3 on information). To gain information for this purpose requires clinicians to anticipate the kind of questioning which would lead to the most discriminating information. Ineffective questioning would generate responses that do not adequately distinguish between the remaining possibilities.

The processes of acquiring information that take place in a clinician’s mind can be illustrated by the “animal guessing game”. In the game, the host identifies a target animal in his own mind, say “elephant”, but does not disclose this to the participant. The participant has to guess what the animal is by asking questions that the host has to answer truthfully. Examples of questions are “Does it has fur?”, “can it fly?” etc. The participant aims to arrive at the correct animal in the shortest possible time. Let us consider a step in the middle of the game, where the participant already has some information about that animal.  His task is to generate his next question so that a response to that question would carry maximal information. From the information perspective, the game involves starting with the whole set of “all animals” at baseline (low information). Each question and response generate information by eliminating some possibilities. For example, “lives on land” would remove sea animals and narrow down the remaining number of possibilities. A statement that specifies only a few possibilities would be highly informative if confirmed. However, their chances of being confirmed is also smaller. The use of such a question approximate random “guessing”. The converse is also true: The asking of a condition that contains a large number of possibilities  (e.g. does it have legs), is likely to be answered affirmatively, but does not narrow down possibilities in a powerful way. Some questions would be redundant if they do not narrow down further possibilities effectively. Ideal questions should reduce the possibilities, approximately by half. In this case “luck” is involved to a lesser extent, no matter whether guessing was correct or not, and the remaining possibilities are reduced. The clinician in a clinical dialogue has a similar task. What is the question that would be the most effective in giving most information in ruling out more alternatives? Generating this question requires considerable knowledge about the universe of anomalous mental experiences. 

9.3.2.7 Clinician’s reflection on the Clinical Dialogue
During the Clinical Dialogue, an experienced clinician can often judge reflectively the quality of the model being constructed. When difficulty is experienced, the clinician could be aware that he is not achieving an adequate clarification of the patient's symptoms. On this occasion, it may be helpful to identify the source of the limitation by reviewing the steps involved in the iterative clinical dialogue (figure 9.1). The Clinical Dialogue cycle is designed as a pragmatic tool to facilitate such a review, even in real-time within the interview. Obstacles can arise in any of the steps of information transfer highlighted in this model. Smooth information flow in all steps contributes to the quality of the final model. 
9.3.2.8 A Model of the Clinical Dialogue
A model of the Clinical Dialogue is presented utilizing ideas that have been developed in the previous sections (see figure 9.1). The model incorporates the use of representations in the patient’s and the clinician’s mind, and attempts to describe the process of transfer of psychopathology information between the different components. 

The key components of the model are described here. In the patients there are two compartments, the “I” that is communicating with the clinician (PI), and the “me” that experiences the potential psychopathology (PM). In the clinician there is the “I” that communicates with the patient (CI), and the part in the clinician that is assigned for phenomenological understanding of the patients “anomalous experience” (CM). The aim of the Clinical Dialogue process is to extract as much information as possible, and as accurately as possible from the patient’s “anomalous experience” (PM), to be represented in the clinician’s model (CM). CI and PI are involved in the explicit Clinical Dialogue for this purpose. PI and PM; as well as CI and CM are involved in internal information exchanges. We use a constraint satisfaction (CS) process in a parallel representation to denote the content in each of the PM, PI, CI, CM components. The constraint satisfaction process allows pattern completion from memory. The goal of the Clinical Dialogue is then to generate in CM a model that approximates the informational content of PM as far as possible. Yet, CM does not have direct access to PM, and explicit information transfer can only take place via PI and CI.

Suppose PM contains a representation for a subjective phenomenon (e.g. an auditory hallucinatory experience). The structure of the PM representation contains a number of dimensions relevant to an auditory hallucination (e.g. intensity, frequency, acoustic clarity, control, semantic content, number and identities of interlocutors, second or third person, spatial information, emotional response etc.). The patient's experience of hallucination fills these dimensions by specifying  each dimension. It is possible that some experiences are less well formed and fill only some of the dimensions (e.g. sometimes dimensions might be missing e.g. spatial information, or personal identity information). In these situations, identification of the missing dimensions in the representation is just as important, as it contributes towards characterizing the structure of the representation (i.e. some specific dimensions are not represented). Previous studies have suggested that some feature dimensions of hallucination may map to brain states (e.g. spatial locations) and may have diagnostic and prognostic significance. It is important to appreciate that when primary experience took place in PM(t0) (say, 24 hours ago), top-down and bottom-up processing may have already occurred. Subsequent to the primary experience, memory consolidation processes may also have taken place (for example, incorporation of secondary ideas to make sense of the hallucinatory experience). These layers of initial processes have already ensheathed the primary experience before it is further accessed as PM(t1). It is important to recognize that unlike PM(t0), which is a primordial experience, PM(t1) is a memory representation. PM(t1) may contain more dimensions than PM(t0). In addition, some unfilled dimensions in PM(t0) may be filled in PM (t1). Thus PM(t1)= PM(t0) + PMc(t1), where PMc denotes memory consolidation in PM. 

In response to the communication with the clinician (CI), the PI(t1) component of the patient accesses the PM(t1) representation in search of information in specific dimensions. This is carried out iteratively over individual dimensions one at a time. That is, CI may explicitly request PI to inquire about one feature “n” in PM(t1). After feature “n” is clarified, CI may enquire about the next feature, “n+1”. This process is repeated until CI is satisfied with the model being built in CM(t1). The CM space is initially blank, incoming information from PI via CI is used to specify dimensions in CM(t1). In the communication between PI and CI, linguistic symbols are aligned so that information can be conveyed as accurately as possible (e.g. a word used by PI should map onto similar meaning in CI). However, in the information transfer from PI to CI, PI tries to make sense of PM(t1), this process may add information to PM(t+1) in order to match constraints consistent with PI interpretation of PM. We can express this component as PIu(t1) (PI unique contribution to PI(t1)). Thus PI(t1) = PM(t1) + PIu(t1).  If we consider further processes leading to PM(t1) i.e. PM(t1)= PM(t0) + PMc(t1), we have the following relationships:
PI(t1) = PM(t1) + PIu(t1);
PM(t1)= PM(t0) + PMc(t1);
PI(t1) = PM(t0) + PMc(t1) + PIu(t1)

In other words, the patient’s awareness of psychopathology is a result of the primary experience, memory consolidation, as well as alignments with his own subjective viewpoints.

This information is what is conveyed to the clinician at CI(t1). When the clinician receives the information, the information is interpreted within a context of the clinical dialogue, and, depending on the level of alignment the clinician may fill the information to some extent with his own ideas as a result of communication gaps (e.g. what the clinician and the patient understand by “just before sleep” may be different). 

Likewise, when the clinician places the information in CM, existing contents may affect the interpretation of the arriving contents. Such priming is exacerbated by a closed and inflexible mindset. An open, reflective, empathic attitude in the clinician may reduce such biases in the CM component.

Thus the information that is finally communicated to the clinician is 
CM(t1) = PM(t0) + PMc(t1) + PIu(t1)+ CIu(t1) +CM(t1)
CM(t1) is the actual information that is available. From CM(t1), the clinician intends to access PM(t0) as much as possible. The task for the clinician is then to have some estimation of the other components PMc(t1) + PIu(t1)+ CIu(t1) +CM(t1). If more information about each component is available, these might be used to estimate the extent of their contribution to CM(t1). By subtracting these from CM(t1), we could potentially enhance the information about the original PM(t0) representation. 
PM(t0) = CM(t1) – (PMc(t1) + PIu(t1)+ CIu(t1) +CM(t1))

CIu(t1) +CM(t1) are accessible to the clinician. With training and reflective practice, the clinician can learn to be more aware of this component. In estimating PMc and PIu, the clinician often has to retain a broad range of information about the context of communication in order to have more ideas about the contributions of Plu. It is therefore important that the clinician, in the process of communication, takes in the wider dialogue context as he deploys his empathy towards grasping the primary experience in the patient. The grasp is necessarily complex and not primordial. What is aimed at is information about PM(t0) that is embedded in PI(t1). As the Clinical Dialogue unfolds, the clinician has the opportunity to actively probe for information in an explication process. The probe could be about PM(t1) or one of the sub-components therein (e.g PMc(t1), or PIu(t1)). For instance, how likely is this patient adding interpretations into his own primary experience? If so, in what direction?. How suggestible is the patient in the interview process? How consistent is the information reported when approached from different perspectives? How motivated is the patient to communicate a particular version of his narrative? Have direct questions been used to obtain certain information? With some ideas about the overlaid layers of information, is it possible to parse the current information to “peel off” the overlaid layers, in order to gain a better sense of the information in the  original experience in PM(t0).

4. Handling Clinical Categories
In the clinical dialogue, after the major clarification of WHAT the patient is suffering from, the clinician has to decide upon how best to help the patient. At this, there is a point of transition from phenomenology to psychiatry. 

In trying to decide about management, Clinicians may follow “heuristics” to decide on the best approach. A large number of objects and situations are grouped together into a smaller number of categories on the assumptions that situations belonging to the same category require similar responses. There is thus a correspondence between the number of perceptual categories and the number of actionable responses. The number of categories is inherently related to the number of possible different responses. For instance, when there are many different possible responses, classification into a larger number of categories is necessary. Likewise, when the number of responses is limited, the number of perceptual categories will be smaller (Zwaan, & Radvansky, 1998). 

In mental health scenarios, this situation becomes challenging because the number of responses differs according to approaches taken by each practitioner. Different ways of conceiving and describing mental disorders have been attempted. They are not necessarily mutually exclusive. For instance, the categories that could be used to guide psychotherapeutic interventions may be different from those that are used to guide psychopharmacology interventions. Integrated consideration of both may be complementary and enriching.

Making a “diagnosis” involves mapping the patient’s condition into a category within a system of classification.  One important level of categorization is the “symptom classification” process. We note that symptom classification is used differently from phenomenological clarification. In the latter we characterize the individual details without assumptions. In symptom classification, we assume that the experience will map onto one of the known symptom prototypes, and the task is to make this mapping. e.g. whether this patient has experienced a third person auditory hallucination. This process is crucial to diagnosis; once symptom classification has been accomplished, diagnosis follows explicit, man-made rules according to the latest version of the classification system.

The symptom classification process involves comparing details of the anomalous psychopathology experience in the patient with those reported in other patients. As such, symptom classification reduces the complexity of the clinical information into membership of symptom categories. Categorization is widely used in human endeavors (Neisser, 1989). Often, membership in a category implies that similar outcomes are expected. A typical example involves diagnosis in internal medicine. Signs and symptoms are first identified. They lead to a diagnosis. Given a diagnosis, a management pathway follows (see figure 9.3). 

In this process, a large amount of clinical information is funneled into a categorical diagnostic formulation (Elstein, & Schwarz, 2002). Given the same diagnostic categories, similar management pathways follow. Detailed information at the level of symptoms is used only in arriving at this category and is then discarded; and it may not participate further in determining the management plan. 

In psychopathology, comprehensive formulation often calls for more individualized considerations. Symptom clarification is only one source of information that leads to a multi-faceted management plan. Information about biographical details, social circumstances, personalities, and the Lifeworld inhabited by the patient, are also important data that will inform the management plan. The “funneling” of information is less steep in mental health formulations. 

In decisions about clinical intervention for patients, we have to utilize the best possible existing empirical knowledge, however incomplete it is. In this situation, the clinician will construct a clinical formulation for the patient, linking the individual patient to existing knowledge about aetiology and treatment of the condition. The formulation can be suggested by three pragmatic clinical questions: (1) why has this patient (and not others) developed anomalous experiences. (2) Why does he suffer from these particular mental experiences (rather than others)? (3) Why do these develop at this time in the course of his or her life development (and not earlier)? The responses to these questions involve applying knowledge about the condition to the individual patient. We formulate hypotheses about why this clinical condition has arisen, given the constitutional and developmental features of that individual. Constructing a clinical formulation compels us to think about factors that may underlie the subject’s condition and thereby identify key foci for intervention.

In this process too, the patient has to be understood as a person who is a developing agent, interacting actively with the environment (see section D1a on person development). It is also recognized that an individual does not exist in isolation but exists in relation to other individuals (see section C5a on relating). Adequate assessments therefore include both a longitudinal and a cross-sectional perspective, according to the model of the person developed in the previous sections. In the longitudinal perspective, developmental changes over time are highlighted. Key processes involved in shaping the life course of the patient are identified. We note that these are similar domains as we have covered in the phenomenological understanding of the patient, but this time the viewpoint is not from the patient’s “insider” perspective, but from an “outsider’s” perspective, looking at objective environmental and developmental factors that are associated with the illness.

The clinician’s application of clinical categories is an inherent process in a clinical interview, where action is expected as an outcome. However, premature application of these categories may mislead the psychopathological phenomenological evaluation. It is conceivable that under pressure of time constraints and cognitive constraints (e.g. with excessive case-loads), these important clinical processes may be compromised. Explicit articulation of the processes involved in psychopathological assessment may allow us to estimate the limits to which psychiatric assessments can be compressed without compromising its informational quality.

5. Unpacking patient’s accounts
During a clinical interview, the patient develops an account of psychopathological experiences in the context of his life histories. The patient produces this account through verbal language. This process involves some re-organization of the primary subjective experiences. 

Such accounts are sometimes referred to as “narratives”, to emphasize they are not always only concerned with depicting “objective facts”. When he is narrating, he acknowledges his intentions, and describes how he reacts to the perceived reality. For example, in a narrative medical account, the patient is often predominantly considered as an object of pathology and treatment, but less often as an active agent responding to illness. As a result, there is a risk of under-recognizing the patient’s choices and actions. The consequences of ignoring this domain is particularly undesirable in mental illness, where the patient’s action often could play a crucial role.

10. Interpretations (Verstehen)
1. Etic and Emic descriptions
Psychopathology could be enriched by concepts from ethnography (a discipline developed to study human experiences in different populations and contexts). Ethnography has developed useful conceptual tools to facilitate empathic understanding of people’s experience in unfamiliar contexts. Two basic approaches of understanding have been designated as “etic” and “emic” approaches. The Etic approach investigates a social group from within, using shared concepts from within the group; the emic approach is to study the group from the perspective of an outsider, using the framework of the outsider’s meaning structure. In the study of psychopathology, it is assumed that the clinician shares socio-cultural background with the patients, and when this is not the case, special care needs to be taken to stay with the etic approach as much as possible. 

2. Thick descriptions 
In ethnography, “thick description” has been employed in the study of human cultures (Geertz, 1973). Thick description includes not only an account of a behaviour itself, but importantly also its context. When context is included, the behaviour becomes culturally meaningful (see above section 8.5 on context).

When an investigator (whether an anthropologist or a clinician) tries to understand his subjects’ experiences, it is important to realize that the investigator should not uncritically assume that he could grasp the contextual information in the same way as his subject has experienced it (see above Section of Clinical Interpretation of Patients Context). For the clinician it is desirable to try first to understand the subject’s experience through concrete examples of shared meanings. In the process, the clinician will need to grasp the contexts in which the subject encounters his individual subjective experiences, not assuming that it will have perfect alignment with the clinician’s own experiences. This process of understanding may involve identifying key terms used by the subject to describe experience, and to grasp the meaning of such terms as used by the subject through exploring the Lifeworld contexts in which these terms have been used.

3. Accounts of psychopathological experiences as Illness narratives
As a psychopathologist, the clinician takes into account the structural characteristics of illness stories and their relationships to individual life histories. Illness narratives are stories unfolding in time (Riceour, 1981), working towards resolutions. Receivers of illness stories receive them by re-composing the stories through their own representations (reader response theory, Iser, 1978). These processes are also embedded in the clinical dialogue and cannot be ignored. The psychopathologist needs to have an awareness of how the narrative structure has contributed to and infiltrated the account of the primary illness experience.

Is the primary experience accessible in a form immune from secondary elaborations (as in story telling)? Raw pre-narrated experiences are sometimes seen as fleeting, formless, ungraspable, and inaccessible. This is the realm of primary raw subjective experience which the psychopathologist attempts to access. However, our minds are also programmed to organize these raw experiences to generate some order through a narrative structure. Primary experiences are not immune from this process of making sense. To the person, meaning lies in the relationships amongst semantic elements involved in the narrative structure (Good, 1993). To the psychopathologist, the narrative overlaid upon the patient’s account should be disentangled as far as possible from the account of the primary illness experience. 

6. Techniques in the Clinical Dialogue
1. Ambience of the Clinical Dialogue

In this section, it will be demonstrated that, like any clinical examination, a thoughtful arrangement of essential items involved in the Clinical Dialogue process is important for the proper conduct of the psychopathological interview. Physical details often determine the psychological ambience. 

The minimum set of items involved in the interview involves a small room, in which at least two chairs are placed, one for the subject and one for the interviewer. It can be considered how their arrangements could already have an impact on the interview process itself. Spatial arrangement of the two chairs involves alignment and distance. Two chairs placed too far apart would impede communication, as hearing becomes effortful. Two chairs placed too close together will impose an uncomfortable psychological proximity between the subject and the interviewer, and could lead to a compensatory increase of psychological distance.
Alignment of the orientation between the two chairs in relation to one other is also a critical determinant of the psychological ambience for the clinical dialogue. 

Two chairs that face one another in opposite directions will impose a direct face-to-face confrontation between the patient and the interviewer (see figure 8.4). In this manner, the subject and the interviewer will have to make a deliberate effort in order not to look directly at one another. Participants in conservation often find this position uncomfortable. Studies have revealed that participants engaged in eye contact only part of the time during a natural conversational process (Argyle, 1975). For example, eye-contact is made more often during “turn-taking” points in the dialogue process. Eye contact decreases after a turn-taking transition when participants are fully engaged in the contents of the verbal discourse. This naturalistic pattern of eye contact in the conversation could be disrupted by psychopathological processes. Therefore the level of eye-contact has conventionally been regarded as important in a clinical observation. Seating positions in which the subject and the interviewer have to make deliberate efforts either to engage or to disengage eye contact compromises the sensitivity of this observation. It is therefore desirable in the naturalistic observational process that the chairs are aligned in a way that participants do not have to make exaggerated efforts, either to engage or to disengage from eye contact. 

4. Chairs arrangements A 
This arrangement reduces the eye contact (see figure 9.5). The two persons look ahead of them with little eye contact. In this situation, the two persons have to make extra effort to make eye contact. This arrangement leads to increased psychological distance between the participants in an interview. While in general, such distance makes the interview more impersonal, it may be a helpful feature for an extremely anxious patient talking about a sensitive topic. 

The ideal alignment is between 90 and 180 degrees: the principle is that The participants should not need to make much extra effort in order either to look at or not to look at the other person (see figure 9.6). The sensitivity for clinical observations on eye contact is higher if the persons have maximum freedom to choose whether or not  to engage or not to engaged in eye contact. 

6. Positioning of the table
The psychological effect of introducing a table in the room is that it represents a physical barrier. The barrier could signify an unequal relationship. Before we introduce the table, the space in the room is largely symmetrical. The table imposes an asymmetry which places the clinician and the patient into an unequal relationship (see figure 9.7). Within this asymmetrical space, the clinician could view more of the patient while the patient could view less of the clinician. This creates an unequal “observer-versus-observed” relationship. The table also suggests a protective barrier, creating a sense that one person is being protected more from the other. It is important to be aware that these spatial cues may influence the psychological ambience for the participants.

7. Visual environment in the Dialogue
8. Points of attention
When a person enters a room, the room presents itself as the visual environment for the person. We normally do not pay much conscious attention to all the details of a visual environment. Instead we filter out irrelevant details and focus on the significant details. In a patient with a mental disorder often the capacity for attentional filtering is impaired. The patients may not be able to focus on key items but may instead become aware of a larger number of less relevant items in the room. In this paradoxical situation the patient may become more aware of certain aspects of the visual environment than the interviewer. This is because the interviewer has filtered out irrelevant features in the environment but the patient has not. This creates an interesting situation where the patient actually takes in some information from the immediate visual environment of the room that the clinician is not aware of. If the patient subsequently utilizes that information in the dialogue, the clinician may end up not being aware of this link. It would be advisable that a deliberate survey over the visual details in the room is made before the start of an interview. 
 
9. Accessories: Tissues and notes
A box of tissues placed on the table is an effective symbol. In an interview, patients may be in touch with distressing emotions. Communication during these moments are often of high information value. However, at these moments, the patient often chooses to control his emotions out of embarrassment, by moving away from the topics that cause distress. In a supportive environment the patient should feel safe to experience the distress. If a box of tissue is available, the interviewer has the choice of offering the tissue in a graceful gesture of support. 

Offering the patient a box of tissues signifies the clinician’s readiness to go into emotional issues. Indeed, having the tissues ready, from the beginning gives a visible signal that emotions are not to be shunted in the interview.  

10. Personal items (Habitus)
Personal accessories are visible items we carry with us, like jewellery or watches. Accessories are Habitus that we have chosen, therefore they contain information about ourselves. They are visible and informational to the patient. It is important to recognize that the clinical dialogue involves two interacting people. In this two-way process, the patient is also “assessing” the clinician. Information from the clinician will to some extent determine the patient’s behaviour. Through accessories, clinician’s preference and values are perceived by the patient and influence the patient’s communication with the clinician.

Personal items give information about the values, aesthetics and choices of the clinician. This information could dichotomize patients into two groups: one group consists of patients who align with the clinician in their expressed values and the other group does not align with him. If the patient perceives that the clinician does not share the same values, then the patient will have less anticipation that the clinician can be empathic over his problems. Therefore, in general, a clinician should not unnecessarily draw attention to his personal values. 

2. Directing the Clinical Dialogue

A repertoire of different interview styles is required to engage different patients. It is useful to consider two contrasting dialogue styles as reference poles. They are the check-list approach and the responsive approach (see figure 9.8).

11. Perception of control
Control is a key concept in the clinical dialogue. “Control” refers to the extent to which each participant determines the direction of the dialogue. The amount of clinician control within a particular interview requires to be managed carefully. Inadequate control from the clinician results in an ineffective interview. In an interview lacking in direction, the patient may not feel reassured with the professionalism of the interviewer. On the other hand, excessive control may result in a passive, disengaged, or even defensive patient. Control can be regulated by the skillful clinician through the use of implicit transition gates between different topics in the interview (see below, section 9.7.2 on gate)

12. Check-list approach
The check-list approach covers a comprehensive list of questions in a predetermined order. Regardless of what the patient’s response to the previous questions is, the next question follows in the same sequence. The check-list approach is used in a structured research interview. Coverage of the listed area is assured. However, the flexibility to explore specific areas in greater depth in response to unfolding information is limited. 

13. Responsive approach
In the Responsive approach, the questions raised by the clinicians are not predetermined. As in everyday dialogue, the next question is formulated based on the patient’s previous response. The responsive approach results in a more natural flow of conversation. It allows for a more flexible exploration that can be adjusted in real-time to be proportionate to the informational content of particular domains for the particular patient. 

During the interview, the clinician regularly monitors rapport with the patient. The degree of rapport can be indicated by the alignment at verbal and nonverbal levels between the clinician and the patient. Indicators of rapport include the amount of verbal response, the engagement of shared attention in the dialogue, as well as various non-verbal indicators of dialogue alignment (see below, also section 8.6.3 on conversation alignment). A well-aligned dialogue proceeds in a smooth conversational flow with the relevant contents. The amount of elaboration is appropriately regulated, with participants giving just enough, but no more, information so that they can be understood (i.e. compliance to the Grice maxim). Non-verbal communication, as indicated by the level of eye contact as well as bodily gestures (e.g. inclination of the upper body when seated), also exhibits convergence between participants. Regular monitoring of these indicators enables the clinician to gauge whether rapport had increased or decreased during different stages of the interview.

3. Alignments in Dialogues 

In the clinical dialogue cycle (see 9.3 above), interactive processes between the interviewer and the subject transfer information at different linguistic levels. 

In the dialogue one person initiates the conversation by activating a context for the communication. Linguistic information expressed by the first participant sets up anticipatory activation of a cognitive structure in the second participant. This cognitive structure in the second participant is used to determine the response, which in turn activates a revision of the cognitive structure in the first participant. Thus in iterations of conversations, the cognitive structures in the participants undergo a process of alignment. This interactive effect occurs at multiple linguistic levels. They include basic acoustic and phonemic levels, as well as higher levels of syntax, semantics, and discourse. 

At the phonetic level, the participants activate the cognitive structures that take into account the individual voice characteristics in order to decode the physical sound waves. This is a process of extracting information from a complex mixture of a background and foreground sounds. Background information is relatively invariant (such as the background noises in the environment). Foreground information are phonemes that are rapidly changing and carry the informational contents. Embedded in the sound stream is also the relatively stable voice characteristics of the speaker.  

Incoming physical sound waves are segregated automatically into streams. The assignment of sound characteristics into relatively invariant channels enables the decoding and more accurate extraction of information in the target phonemic channels (refer to different-same comparison in section 5.3). In addition to the foreground informational content, the listener sets up a representation of the background information, which enables more efficient extraction of foreground information in subsequent processes. 

The process of setting up background (contextual) information constitutes part of the mechanisms for “alignment” (Pickering, & Garrod, 2004; Garrod, & Pickering, 2009). Setting up representations for the invariant background information in a conversation results in an alignment of these representations for the participants as the conversation proceeds.  Alignment occurs at different psycholinguistic levels. Apart from the phonetic level, similar processes occur at the syntactic, thematic and discourse levels. At the syntactic levels aligned participants tend to use similar grammatical structure (referring to the order of the nouns, objects and phrases within the sentence). The availability of this shared pattern is helpful for resolving syntactic ambiguity in the conversation (e.g. whether a particular word is being used as a verb or a noun). Similarly, at the semantic level, alignment occurs in word meanings. As many linguistic symbols have multiple interpretative possibilities, every instance in the use of a word involves some judgment as to the specific meaning that word conveys in that particular context. During a dialogue cycle, contextual information is set up and shared between the participants. Alignment in the semantic context allows efficient communication between the participants with minimum redundancy. During the process of semantic alignment, participants are familiarized with the other person’s choice of words and their associated meanings. A well-aligned conversation conveys complex information parsimoniously between the two participants. This phenomenon is summarized in the Grice maxim (1975). In specific psychopathological processes of situation alignment processes may be affected, leading to difficulty in grasping the context of the conversation. 

In the process of alignment, it is important to recognize that ideas can be conveyed from one individual to another without full explicit description (e.g. in the use of metaphors). In these situations, the recipient of the information is susceptible to influences based on his own inferred understanding.  Misalignment as well as erroneous construal of representations can occur. 

In everyday life, human communications occur with profound economy (e.g. Grice maxim). However this economy may cause specific difficulties in the assessment of psychopathology, as well as in the longitudinal “acculturation” of the patients to medical terminology. Communication using a technical term without clear definition could have profound implications for patients.  Similarly, the clinicians may be tempted to uncritically accept a technical term used by the patient without clarifying the primary phenomena. For instance, when a patient reports a particular experience as a “dream”, it would be prudent for a clinician to go into further details to clarify that the relevant phenomena is indeed an experience that occur in the dream state rather than, for instance, a hypnagogic state, or, metaphorically, of a pleasant hope for the future. 

Importantly, difficulty in alignment may actually provide information for the clinician as to the level of the disorganization in the cognitive psycholinguistic structures in patients. As a result of mutual alignments, the clinician, immediately after talking to a patient with language disorganization, could experience subtle difficulty in organizing his own speech. If he is aware of this change, he could use this observation to increase his sensitivity in detecting subtle language disorganization in the patient.

Under some circumstances, responses in the preceding part of the interview could have an impact on immediately following part of the interviews. The way that a person responds to the same questions could vary according to the previous questions because of the different contexts that have been setup by the previous questions (see section 8.3). This leads to an important recognition that the “line of approach: leading to the current questions may have a profound effect on the responses. Therefore in the assessment of a psychopathological phenomenon, it would be important for the clinicians to use different lines of approach in order to capture different perspectives from which a symptom can be explored. A reliance of on a single “line of approach” could result in information that is narrow and at times misleading. These realizations bring us back to an appreciation of the principle of the uncertainty in which the act of the observation itself could have an impact on the phenomena being observed.

7. Structure of the Clinical Dialogue
1. Parallel levels in the Clinical Dialogue 
At any time during the interview information flows at a number of different levels. Three major levels are firstly a “factual” level in which an account is elaborated about the history and the circumstances of the client. This information is historical-factual in nature, and is considered in the context of a clinical dialogue with a narrative structure (see below section 8.5 on narrative). At the same time there is a second level of “psychopathology” in which primary raw experience of potential symptoms is communicated by patients. When the focus of the interview focuses on this level, clinician and patient engage in “iterative clinical dialogue cycles” to clarify the symptoms (see 8.3 above). At the same time as subjective experiences are clarified, observation of behaviour during the dialogue interaction also takes place (section 1.2) . A third level in the interview is the “interpersonal” level. This refers to the interactional processes between the clinician and the patient. Engagement, empathic responses, dialogue alignments, negotiation of control etc. are processes that belong to this level. The clinician should be able to monitor key alignment variables in the interactional dimension as the interview proceeds. A particular dialogue could be located more at one level than another, and the response of the clinician can also focus the dialogue on a particular plane. E.g. patients could be talking about an experience of auditory hallucinations on a particular evening, the clinician then has to decide whether to engage the dialogue at the historical-narrative level, in which case the follow-up question could be “what happened before that, or how did you respond to that experience?”. Alternatively, the clinician could chose to locate the dialogue at a symptom elaboration cycle, in which case, the following question could be “can you tell me more about those voices, what were they like exactly?” 

2. Stages in a Clinical Dialogue

It is useful to conceptualize distinct stages for an interview in order that different tasks could be the focus in different stages (see figure 8.10, Shea, 1998). A thoughtful clinician carefully considers the timing for each task in the interview and weighs up the pros and cons for the different sequence in which the components could be completed. Skillful interviewers are also able to adjust and modify the sequence in real-time according to needs. Awareness of the structure of the interview is important for strategic management of the interview (see 9.7.1 below). Most interviews should contain at least three distinct sections: a beginning, a body and an ending section. 

14. Processes in the Clinical Dialogue
15. Beginning
Initiating the clinical interview is a crucial process that is often not adequately managed. It is important for the clinician to set aside designated attention for the task in the first few minutes of the interview. Successful engagement in this stage enhances the effectiveness of the entire interview.

1. Sharing the context
A proper introduction to the context of the interview is of utmost importance. Introducing the situation (for example, specifying the duration and purpose of the interview) clearly in the introductory phase enables the clinician and the patient to be engaged in a spirit of openness and equity. Equity in information exchange allows the patient to become an active participant in the process of the interview. This equity cannot be taken for granted because of the unequal power roles between the clinician and the patient in many cultures (Nimmon, & Stenfors-Hayes, 2016). Implied in a competent introduction process is the signal that the patient will be respected as an active participant in the clinical dialogue. A proper initiation avoids a coercive atmosphere in the interview. In an asymmetrical relationship, a defensive attitude in the patient may arise and impinge on the validity of the data obtained. The more the clinician shares control with the subject, the better the clinician can engage the patient. If the patient is participate in a half-hearted manner, the validity of the emerging data will be compromised. This is particularly important for the anxious or defensive subjects. In these instances, it is even more important to ensure the subject experiences a sense of control over the interview process. Sometimes, it is worth making an explicit statement to the effect that “Although this interview may touch on something distressing, I would like you to know that you can stop the interview at any time. If you feel uncomfortable or there are areas that you don’t wish to talk about, please let me know and I will respect that”. Giving this reassurance sometimes helps anxious patients to become more at ease and less defensive. 

2. Initial observation
One important task for the first few minutes in the interview is the making of initial observations about the appearances and behaviours of the patient. It is worthwhile setting aside several minutes in the beginning of the interview to accomplish this observation. This observation should be conducted at the beginning of the interview rather than at the end of the interview for several reasons.  In the beginning of the interview, the interviewer is still relatively sensitive to any unusual features in the patient’s physical presentation. After the interview has been in progress for some time, the clinician becomes heavily engaged in the verbal content of the dialogue and can spare less attention on the visual details. In addition, if an equivocal observation is made only at a later stage in the interview, there is only limited time left for re-confirming the observation. In contrast, if the observation is made in the beginning of the interview, there is still opportunity for further monitoring and further observation.

3. Screening for potential interview impasse
Another important task in the beginning of the interview is a screening for potential interview impasse. The first few minutes could be used as an exploration of the anticipated pattern of the clinical dialogue. In this exploration, the clinician engages the patient in a casual dialogue on a range of neutral, non-threatening topics. The clinician observes the nature of this communication in order to generate some anticipation about how the interview is likely to unfold subsequently. Tendencies towards difficult communication patterns observed at this stage (such as a “shut-down” interview, Shea, 1998; Roter, & Hall, 2006) will enable an adjustment of interview style at an early stage in the interview to address some of the anticipated difficulties.

4. Engagement
Engagement of the patient in the sense of building up a relationship in which both participants work towards an aligned goal (i.e. a therapeutic alliance) is another important objective for the initial stage of the interview. This involves aligning mutual understanding in arriving at common objectives both the patient and the clinician seeks. This process, taken for granted in other medical consultations, often requires substantial skills and efforts in psychiatric scenarios. During this process, the clinician and the patient become aligned in the various psycholinguistic levels (e.g. phonetic, syntactic, semantic levels) as dialogue participants. Successful engagement is a prerequisite for a successful interview. 

5. Probing for hidden agenda
In the process of engagement and alignment, it is important for clinicians to recognize that patients’ main concerns might be different from the clinicians’ objectives. This is often referred to as the “hidden agenda”. Some exploration and probing will be required for the clinicians to come to an understanding of what lies at the core of the patients’ concerns and tries to align those objectives with the clinician’s own objectives in order to ensure successful therapeutic alliance with the patient.

6. Identifying an effective feedback channel
One key objective for the first few minutes is to identify an effective feedback channel with the patient. In particular, this involves deciding on the relative role of the visual and verbal channels. The channel is for communicating feedback in the interview. It is important for the dialogue process that regular feedback from the clinician is provided while the patient is communicating his or her account. Deliberate attention to this process is important as some channels might be compromised. For instance, if the level of eye contact in the patient is limited, then the visual feedback channel could be compromised, and non-verbal gestures such as nodding may not provide effective feedback. In this circumstance, more deliberate use of verbal feedback may be required.

16. Regions and gates

The body of the interview can be conceptualized according to the key concepts of Regions and Gates (Shea, 1998). Regions refer to a coherent body of information whose parts are related to one another, such as “mood states” or the “family history”. Gates refer to points at the interview in which there is a transition from one region to another. We can conceptualize the interview as consisting of a linear progression through a number of regions, with the transition from one region to another being conducted by gates (see figure 9.11). It is important to realize that the dialogue process within one region tends to be natural and less explicit control is required to direct the conversation. However, in transition between one region and another, a clear change of direction is often required. At this point, the issue of how control is negotiated between the clinician and the patient becomes a focus. (see above, section 8.5 on control)

In a clinician-directed interview, the clinician imposes a gate transition in an explicit manner. For instance, the clinician might state “We have finished talking about this area, let us change the topic to another area”. In this situation, the interview will acquire an ambience that is dominated by the clinician. The result is that the patient feels that his participation in the interview is less active. This may limit the free flow of information from the patient. A less directive interview style may encourage the patient to participate more in determining the content of the interview. In this case, the patient is allowed to take the lead to change to different areas in the interview and the clinician will follow. This style will encourage the patient to be an active participant in the processes and allows discussion in areas that the patient is concerned about. However, in some circumstances, for instance, in patients with disorganized communication, this style becomes less effective. In these scenarios the clinician will need to steer the dialogue more proactively. An experienced clinician can provide direction without being explicitly domineering. Gate negotiation provides an excellent opportunity. If a clinician can pay attention to the process of transition from one region to another, he can often direct the transition in a way that feels less controlling. One notable way to achieve this is to link the first region with the second region with a bridging question. The bridging question provides a semantic link between the first and second regions. The clinician identifies the last area of exploration and then considers how these areas could be meaningfully linked to potential areas in the target region towards which he is seeking to move. After identifying the potential link, the clinician then formulates a question that provides a bridge in a natural manner. For example, the first area that has been explored is “mood state”, and the second region that the clinician wishes to direct the interview may be to “personality”: The clinician can search the second region for a topic that is relatively close to the previous topic in the first region. For example, in this case an enquiry about drinking habit may become a possible point of entry. The clinician then tries to link the first region (mood state) with drinking, perhaps with a bridging question such as “A lot of people will resort to drinking when they feel unhappy, I wonder what you think about this?” In this way, the patient will be guided to a conversation about drinking habits and then from drinking habit, an exploration of the rest of his lifestyle and personalities could be launched. Gate negotiation using a bridging question could be less explicitly directive and yet still focuses on a direction guided by the clinician.

Another general principle about regions and gates is that while the conversation stays in a region, the clinician should endeavor to explore the region fully before trying to move on to another region. Unnecessary moves between regions create the need for more gates as there is a need to return to the “not-yet-fully-explored” first region at some points in the future. This unnecessarily increases the number of gates required in the interview session. The practice of fully exploring a region before moving on minimizes the number of gates in an interview session (Figure 9.11). 

In fostering an empathic ambience for the interview, it is important to consider the provision of the right amount of psychological space. The issue with psychological space has already been discussed alongside physical spaces for the interview process (see above, section 9.4.1 on space). During the clinical dialogue, psychological space is important, particularly when considering the amount of empathic feedback the clinician gives to the subject. On one hand, the interviewer may give very little feedback, thereby increasing the psychological distance. On the other hand, the interviewer can be offering too many feedback statements of empathy. This may result in intrusiveness and reduce the psychological space for patients. It is important to achieve the right balance between these positions. 

7. Empathic statements
The explicit communication of empathy is important in the interview process. From time to time, the clinician gives signals to indicate that he has understood and empathizes with the patient’s sharing. Such feedback could be simply acknowledging communication as discussed in the section on visual and verbal feedback (see 5.3 above, on feedback channels[a]). At other times, a more explicit statement of understanding, called “empathic statement”, is called for. Empathic statement is a verbal expression to the effect that the interviewer understands and appreciates what the patient has communicated. Empathic statements do not need to be made too often and should be made only after particularly significant sharing. An empathic statement could refer to factual content of what the patient had expressed, or it could reflect on the emotional implications of a communication. Usually, empathic statements are qualified with varying degrees of certainty with phases such as, “it sounds like”, “it feels as if”, or “it must be”. It is important to recognize that for patients with psychotic symptoms, empathic statements could sometimes be interpreted as intrusive access to his mental state, and as such could be perceived as threatening and may reinforce psychotic experiences (such as mind reading). The level of certainty to which empathic statement is stated therefore needs to be qualified sensitively. 
8. Here-and-now reflection
The “Here-and-now” reflection is a technique that brings the focus of the clinical dialogue to the present process of the interview itself. Often the content of an interview dialogue refers to events and experiences that have happened in the past outside the interview room. This external focus of the conversations is necessary to explore comprehensively what a person has experienced outside the interview setting. However, when the interview process itself becomes an important focus of attention, for example, when information flow is impeded in the interview, it may be necessary deliberately to focus on “here-and now”. When it is necessary to bring the dialogue to the “here-and-now”, the psychological distance changes and the transition may be difficult for both the interviewer and the subject. In particular, the interviewer himself may feel threatened when the attention is turned to the interview process itself, as he needs to step forwards from a more hidden “observer” position to come directly into view for possible discussion in the dialogue. The interviewer needs to overcome this reservation in order that the interview can freely proceed from the safer focus on “there-and-then” to the more challenging focus on the “here-and-now”. Notably, “Here-and-now” reflection is used as a technique to address some interview difficulties (such as the shut-down interview, Shea, 1998). 

8. Authenticity and openness
The clinical dialogue is a unique encounter between two Persons. To be effective, it requires the participants to be open to relate to the other person empathically. This purpose is best served with an open mind, with patience and attention to details, minimizing assumptions. It allows the other person to go beyond one’s expectations and to surprise. It allows the other person to be creative in one’s mind.  

In this mode, the clinician is open to the possibility that the representational structure in his own mind can be changed by the encounter. The interview process becomes a creative interaction. Instead of being a closed one-way process, accommodation of new information is anticipated. This openness in authenticity will prevent a closure to new observations. This will address a significant neglect over an area that could potentially yield useful information for advance in the understanding, recognition, and management of mental conditions.

A serious attempt to understand the distressing experiences of another person through empathy not only paves the way for better healing efforts, but the encounter itself should make the suffering patient at least feel less isolated.