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Psychiatric Interviewing: the Art of Understanding A Practical Guide for Psychiatrists, Psychologists, Counselors, Social Workers, Nurses, and Other Mental Health Professionals ReviewShawn Christopher Shea does not quite measure up to Irwin Yalom as a poet/philosopher in the realm of psychiatry and mental health. And yet, like Dr. Yalom, the master of group psychotherapy, Dr. Shea is very good in his own published niche, the art and science of psychiatric assessment. Unlike Yalom's specialty, Shea's work contains the elements of life and death. A superficial or faulty diagnosis can result at worst in suicide, homicide, or fatal medication reaction. Thus, while Shea is a funny and thoughtful man in his own right, his book is of necessity grave. Coupled with thoroughness, this gravity makes the work a standard referral source that should enjoy a long shelf life.
It is hard to imagine a better work than Shea's for psychiatric orientation. His working setting appears to be the emergency clinic of a major hospital in which the assessor must do a lot of things in a sixty minute time frame, though Part I [pp. 3-224] deals with such issues as subtle nonverbal behavior that seem more accessible in a leisured, office setting. With a somewhat undisguised distaste for present managed care practices, Shea assumes the worst of all worlds as to working conditions: a cold client, resistance, multiple diagnoses, soft signs, need for medication and follow-up treatment, and development of a working relationship or engagement with the client-all inside of sixty minutes and assuming the assessor has leisure to dictate later in the day.
There are several features of his teaching style that merit attention. The first is adherence to the DSM-IV. The publishers of this work purchased to right to reproduce those familiar "symptom boxes" verbatim and incorporate them into the text at appropriate points. The ease of use of these cross references in the text, and the author's lucid commentary on how to verbally elicit indications of the symptomatology call for special note. Second, Shea is a master of risk management. He leaves no stones unturned in his interviews in his efforts to determine suicidal or homicidal risk; or, in another vein, he garners from clients a near exact tally of daily drinking. Since reading the work, I have found myself asking patients about suicide as often as three different times in an interview, in various guises. [Shea `s "Far Side" sense of humor comes to the fore in his treatment of suicidal assessments; noting that psychiatrists and mental health professionals are all too human, he observes that assessors are less likely to probe for suicide and severe psychotic warnings at the end of their work shifts.]
A third characteristic worth noting is Shea's attention to the "soft signs" of an emerging psychosis. It occurred to me that, given the pressure of time upon psychiatrists, the non-physician practitioner [eg. psychotherapist, social worker] might actually have more exposure to the little indicators and trends than their harried colleagues: preoccupation with an incident in the distant past, infrequent loosenings of thought associations, inappropriate affect, etc. [p. 317]. This is an excellent work for non-physician providers who wish to collaborate with psychiatrists more succinctly and Shea's reflections upon the writing of clinical notes bears special attention.
As this is a second edition of an original work, there are a few additions that might prove valuable in future editions. One is an acknowledgment that many [most?] psychiatric evaluations for diagnosis and medication are not being done by psychiatrists. In my own setting, the client's primary care physician is the gatekeeper, and one can assume reasonably competent risk management skills among MD's in regular practice. But as one progresses further down the medical service food chain, it is not unusual to see bachelor's level personnel in public receiving facilities performing the very duties outlined by Dr. Shea in this text. As state funding of services becomes more acute, there will no doubt continue to be a "dumbing down" trend, with less qualified personnel being authorized to perform more delicate psychological services, such as assessments. Consequently, although Dr. Shea's present work is unquestionably thorough, it may be that future editions will need to assume less technical background and include more basic information, given that his target audience is the entire mental health community.
Along these lines, the construct of this work assumes a one-hour psychiatric assessment. One wonders if this is an optimistic time frame. In this corner of Florida, a 30-minute office assessment is the gold card of psychiatric care among private practitioners, Medicaid, and the better health care plans. The hour assessment appears to be the domain of the inpatient residential/involuntary population, sort of a closing of the barn door after the horses have gone round the bend. If indeed one must assess in a thirty-minute window, it would be interesting to get Dr. Shea's pecking order of urgencies from those cited in this work. But I don't want to be the one to ask him.
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