Technique of the Iatrosedative Interview
Although the verbal, fact-finding interpretative aspect of the technique is discussed and exemplified below, I wish to emphasize that the separation of the verbal and non-verbal aspects is artificial. Obviously the verbal and nonverbal communications are, in reality, united and inseparable. However, looking at the techniques separately simplifies the presentation.
Once a patient responds to the opening question with a statement of anxiety or fear such as, “I’m petrified of dentists”, a simple but precise tactical design should be operative. The doctor must progress from the general statement of fear to the determination of what the patient specifically fears. Eliminating or reducing the fear level is thereby made much easier; it is virtually impossible to make a commitment of behavior if the specific fear is unknown. Once the specific fear is known, the next step is to learn the circumstances of its origin.
Graphically stated: General statement –> specific statement–> origin of fear
The most economical and expeditious technique of moving from the general to the specific to the origin is by the use of brief, highly specialized questions in responding to the patient’s statements. We will label these questions as:
- “What” questions
- “Can you tell me” questions
These “on target” questions are succinct. The doctor at this stage of the interview does a minimum of talking and a maximum of listening and responding. This will be reversed when the time comes for him to give information. Examples of these “what” and “can you tell me” questions can be illustrated briefly as follows:
Patient: “I’m petrified of dentists.” (general statement)
Doctor: “What is it that you are petrified about?”
Patient: “The drill”
Doctor: “What is it about the drill that bothers you?”
The patient may respond to this question with the specific aspect of the “drill” by stating it is the pain; that the patient had always had painful experiences. An appropriate response would be, “Can you tell me more about it?” The objective is to have the patient elaborate on the history of her experiences. Another such question is: “Can you tell me what happened?”
Example and Analysis of an Iatrosedative Interview
The doctor initiates an open-ended interview, unaware that the patient is fearful.
Doctor: “Are you having any difficulties?” The usual open-ended question; the doctor knows nothing of the patient’s feelings. This question permits the
patient to establish the priority of “difficulties.”
Patient: “Doctor, I’m terribly afraid of anything to do with my teeth.”
With this general statement of fear, the doctor signals his recognition and acceptance of the problem by responding with the first of the “what” questions. This also sets him on course to determine the specific fear.
Doctor: “What is it that you are afraid of?” The first of the basic “what” questions.
Patient: “I hate needles.” This is more specific but not specific enough. There are many reasons people fear injections, i.e. deep penetration, pain, sense of body damage, etc.
Doctor: “What is it about injections that bothers you?” Another “what” question designed to pinpoint the specifics of the fear.
Patient: “It’s the pain of the shot that bothers me.” This is the specific threat. Now the questions should be directed toward revealing the origin of the fear and the behavior of the past doctors which may be responsible for this learning.
Doctor: “Have you had painful injections in the past?” This is a precise question repeating the word “pain” (painful) to get to the origin.
Patient: “Yes, I have … many times and I’m really afraid of them.”
Sometimes the patient will continue the story, particularly if facilitation [by the doctor] is used by nodding the head. If not, then…
Doctor: “Can you tell me what happened?” This brings the patient closer to the origin.
Patient: “As a child I had shots for fillings and the needle hurt a lot … they were awful…” This pairing of pain with injections may be traumatic enough to set up a conditioned response. But if the doctor’s behavior is traumatic as well the threat increases.
Patient continues: “I cried and squirmed and they got angry which frightened me even more…” The sense of helplessness is magnified here, the danger is
intensified by the doctor; he offers this girl no protection… the distrust is compounded by his anger… in all creating a traumatic experience of considerable power.
Patient continues: “It got worse because sometimes the shots didn’t take, but he drilled anyway, it was terrible.” The fear of the unknown is added to the other fears… she did not know if she would have protection from the pain or not… again compounded by the doctor’s not caring.
At this point the strategy shifts from gathering information to giving information. The elements of the conditioning are painfully clear: the pain, the distress, the fear of helplessness and the unknown coupled with a nonprotective, angry authority figure. The counter-conditioning process begins with an emphatic statement of support followed by your interpretation of the effects of the experience on the patient and an explanation of why you believe she can relearn. Suggestion is used in conjunction with a commitment of how you will behave when both of you face the first injection together. This commitment will state:
- How you will behave
- What you will do
- How you will do it