Toward a conceptual scheme for teaching clinical psychiatric evaluation.

Summary We presented the physician as the instrument of clinical psychiatrie evaluation and (1) observation, (2) evocative listening, (3) empathy-intuition-introspection as his primary functions. His evaluative work consists of a descriptive and an interpretive synthesis of the intra- and extra-interview data. Though in actuality all of the work occurs simultaneously, with the different evaluative functions intermingled, for the sake of clarity and convenience we dealt with them separately. We have seen the patient bring to the diagnostic situation his (a) behavior, (b) experiences, and (c) somatic phenomena, as modes of expressing his way of reaching out to the doctor and overtly or covertly communicating his wishes and expectations of him (Fig. 1). When the patient reaches out and the doctor responds so that meaningful communication is established between them to the extent that their individual idiosyncratic barriers permit, a two-person system is established. This is essential for obtaining the kind of data we need for a comprehensive psychiatric evaluation. Such intra-interview data, supplemented by extra-interview data, permit a descriptive synthesis leading to (1) clinical diagnosis and an interpretive synthesis, leading to (2) dynamics and (3) genetics of the patient's behavior and symptoms; a formation of (4) the patient's idiosyncratic response to and barrier against the communication with the physician; and, finally, a formulation of (5) the physician's idiosyncratic response to, and barrier against, the patient. These data should permit specific statements about (6) treatment possibilities. This is essentially Levine's six-point diagnosis (Fig. 2). We then presented a didactic model of the mental apparatus with its three subsystems (Fig. 3) in order to enable us to understand clinical-descriptive data in meaningful functional relationships to each other. We described briefly and only in general terms the three subsystems, their relationship to the stimuli impinging upon them, the resultant behavioral responses, and then their relationship to each other. The cognitive-intellectual functions listed are more or less individually “testable” in addition to an overall assessment in an ordinary conversation. The affective-emotional responses are not in the same sense “testable,” but primarily perceived through observation, empathy and introspection, and at times by inference, in the context of the ordinary conversation. The interpersonal adaptive-defensive behavior requires the same modes of perception and inference. The intrapsychic adaptive-defensive mechanisms, however, representing theoretical concepts of internal events, are formulated primarily by inference. A descriptive synthesis aims at presenting the data obtained so as to indicate how the observed “functions” (by necessity viewed as if truly separate or separable) coalesce into a coherent personality. Such a descriptive synthesis, documenting the form and content of what transpired in the interview, serves as the basis for a clinical diagnostic label and also provides the “raw data” for the interpretive synthesis. An interpretive synthesis aims at identifying the interpersonal and intrapsychic forces at work (dynamics); their early innate or experiential precursors (genetics); the manner in which the patient treats the doctor (transference and other feelings); and finally the manner in which the doctor treats the patient (countertransference and other feelings). The interpretive process was delineated from the process of interpreting. Understanding and explaining were presented as two consecutive and interrelated steps in arriving at an interpretation. The latter may either be diagnostic or therapeutic in intent and use. This will depend upon the needs of the immediate situation, and the doctor may keep the interpretation to himself (diagnostic interpretation) or communicate it to the patient (therapeutic interpretation). The models that best condense interpretively the clinical material are those of the focal conflict and nuclear conflict. Their use enables us to express our understanding more precisely and in such a fashion that our diagnostic formulations contain definite guidelines for treatment. The focal conflict represents the problem and its attempted solution that is foremost in the patient's mind and explains most of the data at any one time. Crucial to such formulation is a knowledge of the precipitating circumstances that brought the problem to the fore. Identification of the focal conflict permits the diagnostician to get hold of the red thread of the doctor-patient transactions, which he needs in order to listen and intervene more skillfully. His listening and his interventions are also aided by his formulation of the nuclear conflict (which is a formulation of the deeper roots of his conflicts) by putting current problems into “genetic” context.