Reide Herndon, BS, Candidate for Master of Science, OSU Center for Health Sciences
James D. Hess, Ed.D., Professor of Healthcare Administration, OSU Center for Health Sciences
Ronald R. Thrasher, Ph.D., Professor of Forensic Science, OSU Center for Health Sciences
This article discusses the potential usefulness of law enforcement techniques in medical interviewing. A fictional patient scenario is discussed in which full and complete information was either not obtained or disclosed due to cultural and generational factors, thus ultimately resulting in the patient’s death. These law enforcement techniques may be especially useful in assisting the physician in obtaining accurate and complete information when cultural and generational factors further challenge the clinical discourse.
John, a seventy-five year old, white, male, rural farmer presents to his family physician with lower back pain. With no other symptoms John’s physician examined and aligned John’s spine recommending stretching, heat, additional water intake and over the counter pain medication. The physician scheduled a follow-up appointment that John later canceled. As a result of John’s treatment, he was able to return to his rural farm duties.
John failed to mention to his physician the blood in his urine and stool. John managed his reoccurring pain and fever with excessive aspirin. Within six months John’s bowels blocked, then perforated. John died in his home from a resulting infection and his undiagnosed Crohn’s Disease. Due to his age and the backlog at the State Coroner’s office, John was never autopsied. Without additional information and data we must presume the truth or accuracy of John’s story. The likelihood of missed information or non-disclosure however raises questions of cultural and generational factors and the need particularly for rural physicians to obtain complete diagnostic information.
Life histories from shrinking populations of Korean, World War II and Vietnam veterans can provide insight into the culture of an often silent group. During their youth, this group experienced extreme battle conditions without the technology, equipment and supplies available to today’s military. Under those conditions, survival often depended upon getting equipment fixed with whatever material was available. This get-it-done behavior exemplified a commitment to self-reliance. Much of rural America continues to embrace this culture.
Looking closer at our fictional patient, John worked hard all of his life. He hoped for a better life for his children who went to college and ultimately left the family farm. A proud man, John struggles from one season to the next, balancing debt and crop conditions.
Consistent with his generational culture, John sought out the services of his physician only when his pain reached the point he could no longer work. All John wanted was to control the pain and get back to the farm. John was reluctant to report any additional symptoms that might take him away from his life or cause him to incur additional expense or debt. Consequently, John knowingly withheld his bleeding from his physician. John died when he might have lived had his physician had complete information from which to make an accurate diagnosis.
Established methods of interviewing utilized in law enforcement settings may be applied in the clinical setting to overcome generational and cultural barriers to obtain complete and accurate information for appropriate diagnosis and treatment. Three specific interviewing techniques are described for potential application in the clinical setting. Additionally, specific questions and methods are offered to aid in the information gathering process.
Motivational interviewing techniques may be applied in the clinical setting to express empathy, develop discrepancies, recognize resistance and promote self-efficacy.1 The Reid Technique of interviewing applied to a clinical setting allows the physician to utilize suggestive statements to elicit missing information.2 Additionally, this method utilizes mild confrontation when it appears the patient may be withholding important details or symptoms. This technique is highly effective in overcoming resistance and denial, thus physicians can utilize the technique to erode patient resistance to communication and obtain needed information for appropriate diagnosis.2 The components of the PEACE methodology can function as a structured interviewing format for obtaining complete and accurate patient information for diagnosis and treatment.3 These structured interview components include preparation and planning, engage and explain, account, closure, and evaluation.3
Physicians have a number of tools available for diagnosis and treatment, and obtaining complete and accurate information from the patient is an important factor in making a useful diagnosis. Physicians are well versed in the symptom review process, often utilizing the PQRST process to determine sources and severity of pain (palliative- provocative factors, quality, radiation, severity and temporal factors).4 Similarly, a number of interviewing styles and approaches long practiced by criminal investigators may be utilized by rural physicians to obtain additional or supplemental diagnostic information from the patient.
Motivational interviewing represents a predominate form of interviewing used in both law enforcement and clinical settings. Given its long history and broad utilization, an understanding of its foundation and core principles is appropriate here. Rollnick and Miller define motivational interviewing as a “directive, client-centered counselling style for eliciting behavior change by helping clients to explore and resolve ambivalence” (p. 326).1 This type of interaction becomes useful in helping patients adhere to recommendations for treatment. A majority of the research in the efficiency of this technique is predominately performed with individuals who are seeking treatment for addiction.1 In order to be successful in using this approach, Rollnick and Miller suggest to act in accordance with the “spirit” of the theoretical principles.1 In other words, this style should be used more as a guide rather than as a rigid formula.
Motivational interviewing is comprised of four basic principles, including expressing empathy, developing a discrepancy, rolling with resistance, and supporting self-efficacy.5 In order to express empathy, the medical professional must communicate that he/she understands and accepts the patient’s experience, which includes their ambivalence to change.5 The medical professional then tries to motivate the patient to change their behaviors by explaining the differences between their current behaviors and his/her personal goals, thereby allowing the patient to develop a discrepancy.5 Medical professionals utilizing this method must be able to recognize and overcome resistance, specifically by not opposing resistance on the part of the patient. Finally, the medical professional should support self-efficacy by consistently expressing they believe the patient can change and place an emphasis on the patient’s ability to choose to change their behaviors and carry out a plan.5
In order to implement these four core principles, Levensky et al. suggest the use of four methods or skills to be used in motivational interviewing that include: reflective listening, asking open-ended questions, affirming, and summarizing.5 The first skill, reflective listening, requires that the physician respond to statements made by the patient in a way that states back to the patient a specific part or the essence of the statement.5 Second, asking open-ended questions should be a free narrative on the part of the patient; the medical professional should listen and ask questions only to encourage further elaboration.5 Third, affirming is an important skill as it can help build rapport, provide support to the patient’s self-efficacy, support the patient’s efforts, and encourage exploration into the issues.5 Finally, the medical professional should reinforce information that has been discussed by using summary statements to the patient.5
A meta-analysis performed by Rubak, Sandbæk, Lauritzen, and Christensen reviewed studies in a scientific setting.6 The researchers found that in 80% of the studies reviewed, motivational interviewing helped patients change their behaviors and outpaced traditional advice giving.6 Additionally, they found that decreases in specific behavioral changes were significant to the point that they strongly encouraged the use of this technique.6 The researchers also noted that the effects of motivational interviewing can be found in brief encounters (roughly 15 minutes), and each encounter with a patient increases the possibility of these effects.6 Similarly, Rollnick and Miller found a high degree of support for the efficacy of the method in changing the behaviors of problem drinkers.1 Additionally, the researchers concluded that in order to greatly elicit change, the most effective method may be to evoke minimal resistance from the patient, rather than trying to get as many positive statements from the patient.1
Within the law enforcement setting, research indicates that motivational interviewing demonstrates efficacy with offenders in the investigative, correctional and probation settings. Mann, Ginsburg, and Weekes discussed the methods in which motivational interviewing can be incorporated with offenders.7 One suggestion was to incorporate motivational interviewing with risk assessment.7 This is currently being implemented in the Correctional Service of Canada (CSC) with its national sex offender program.7 The CSC has labeled this incorporation of motivational interviewing with risk assessment, collaborative risk assessment, since motivational interviewing principles are used in their group therapy sessions.7 During group therapy, members are informed of the risk factors and are asked to discuss how those risk factors pertain to their own cases.7 The CSC also utilizes motivational interviewing in their pre-treatment process to develop rapport, determine the offender’s applicability for treatment, and explore the key issues surrounding offender substance abuse.7
Motivational interviewing has also been utilized to alter the behaviors of offenders in the probation setting. Walters, Vader, Nguyen, and Harris sought to determine whether training probation officers in the “spirit” of motivational interviewing could improve their skills and additionally, if this training would positively impact the outcome of the individual on probation.8 The researchers discovered after a 24-hour training session on the use of motivational interviewing, the skills of the probation officers did improve and these improvements continued to be seen over the next six months.8 However, they also found that the outcomes of the individual on probation were not affected by the probation officer’s having or not having training for motivational interviewing.8
The reviews of using motivational interviewing to change problematic behaviors among offenders are varied. In some instances it appears to be a beneficial tool for certain kinds of situations throughout the criminal justice system, but not as successful in others. There is a need for further research in finding ways to implement this method, considering it does have significant effects on changing the behaviors of individuals facing health problems. Regardless of how this method affects offenders, it is widely accepted and supported throughout the medical field and is highly suggested as a tool for medical professionals attempting to help their clients recognize a change in their behaviors is necessary, particularly when the client may be ambivalent.
Applying the motivational interviewing technique to our case study patient, John, the specific behaviors needing alteration would include lack of hydration, excessive work habits and failure to recognize changes in health status. The specific actions for the healthcare provider would begin with expressing empathy to John for the realities of his life situation, recognizing the demands of his farm business and the pressures of providing for his family. The second phase would include assisting John in recognizing the discrepancy of his current behaviors with his ultimate goal. Specifically, the provider should point out that the lack of attention to his health status and not taking responsibility for that status ultimately work against his goals over the long term. The discrepancy is established by communicating to John that if the intent is to keep his farm viable for the longest time possible, then his ability to maintain his health status and manage his over exertion are the most important variables in achieving that goal. During this process the provider must be prepared to deal with resistance by expressing compassion but continually reinforce the notion of the discrepancy between the current and desired state. Finally, the provider would promote self-efficacy by reinforcing in John that he is capable of making the appropriate changes in his behavior and expressing consistently the importance of developing an action plan to make those behavioral changes. Continued demonstration of confidence in the patient is vital to the process of behavioral change.
Motivational interviewing is applicable to patients in a variety of settings. While this study focuses on its use in assisting diagnosis and treatment for a rural patient, the core principles are equally effective in overcoming cultural and communication barriers with patients in an urban environment.
Developed during the 1940s and 1950s, the Reid Technique has become a widely used interviewing technique throughout law enforcement agencies in the United States and is considered the most effective interviewing and interrogation technique available.2 While the original authors make a specific distinctions between the two terms interviewing and interrogating, these terms are often used interchangeably by officers. The use of one term over another depends on the circumstances and whether the officer is interacting with a witness or a suspect.
Buckley lays a foundation for the differences between an interview and interrogation.2 Primarily, an interview is not accusatory in nature where an interrogation is accusatory and actively uses persuasion.2 Secondarily, interviews and interrogations have different purposes in that the goal of an interview is to simply gather as much information as possible, while an interrogation is meant to learn the truth from a suspect or person of interest.2 It is also suggested that during an interview an officer take written notes throughout the encounter, but during an interrogation it is suggested to only take notes once the individual has told the truth and is consistent in his/her story.2
The Reid Technique generally consists of nine steps of interrogation.2 These include direct confrontations, methods of shifting responsibility/blame, minimizing denials, the use of sincerity and suggesting alternatives for committing the crime.2 The technique assumes either guilt or the withholding of information and provides alternatives to make the truth more palatable for the subject.
Applying this technique to a clinical setting, the physician would utilize suggestive techniques to elicit additional or missing information and mild, but caring, confrontation when it appears that the patient may be withholding important details or symptoms. This technique is highly effective in breaking down resistance and denial; thus physicians can utilize the technique to erode patient resistance to communication and obtain needed information for appropriate diagnosis.
It is worth noting the application of the Reid technique is not without risk. Given that the patient-physician relationship is based upon the notion of trust, the processes utilized to gain additional information must be approached with sensitivity and empathy so as to further and protect that trust. To put it simply, it is the compassionate application of the process that matters most.
While the Reid Technique is widely used throughout the United States, in the United Kingdom and other countries the PEACE model of interviewing is being utilized with great success. According to Snook, Eastwood, Stinson, Tedeschini, and House, the PEACE model was created in response to the realization that during the interviewing process coercive and highly manipulative strategies were contributing greatly to wrongful conviction cases in the United Kingdom.9 Thus, the British implemented reforms that included training officers to use the PEACE model of interviewing rather than the Reid Technique. The acronym PEACE stands for the steps of this model; Preparation and Planning, Engage and Explain, Account, Closure, and Evaluation.9 This model can be used not only for suspect interviews, but also for witness and victim interviews.9
The preparation and planning step consists of several items that should be completed prior to the start of the interview. These steps include developing a timeline, creating an outline of how they will proceed with the interview, prepare both opening and subsequent questions, and plan for all eventualities. The next step requires the officer to engage the interviewee in conversation and then explain what will transpire during the interview. According to Snook et al., this step is intended to establish an environment in which the interviewee will be more willing to communicate.9 While the account phase is more dependent on the individual being interviewed, the purpose of this step is simply to obtain all the information about what occurred at the event from the interviewee.9 The account phase should initially utilize open-ended questioning, then shifting to a type of questioning that gets more exact and specific information about items noted during the open-ended questioning9. Finally, the closure and evaluation phase is designed to allow the officer to determine when to end an interview and to maintain the rapport that was built during the interview.9 Evaluations can be conducted by the officer who conducted the interview (i.e., a self-evaluation) or a supervisor.
One of the complaints regarding the use of the PEACE model is that it is difficult to implement due to time constraints. According to Clark and Milne, most officers did not see the need to use the planning and preparation stage and felt pressured to complete their interviews quickly, even though their supervisors reported that no time constraints were implemented for the interview.3 However, Clark et al. also mention that certain types of officers are more than willing to adapt the PEACE model given that it provides them with useful, reliable information from the interviewee.3
Even though most officers feel that the PEACE model of interviewing is time consuming, when it is implemented there is still a vastly beneficial result.3 When even part of this model is used the officers receive more accurate and truthful information from whomever they are interviewing.3 Additionally, when this model is used rather than others that are considered more coercive, there is no decrease shown in the number of confessions obtained by suspects.3 Thus, the PEACE model is just as effective as other techniques without the potential of having their statements deemed inadmissible in court or resulting in a false confession.3
Application to Clinical Practice
The application of the PEACE method in the clinical setting suggests that physicians may obtain more complete information by preparing and planning for patient encounters. Given that every patient encounter is unique, the development of a prepared structured format for collecting information is beneficial. Engaging the patient on their level is more likely to elicit better information than exhibiting disengagement. The account component of interviewing is best applied by allowing the patient to tell their story without interruption and making notes for follow-up questions. Physicians can apply the closure component by waiting for appropriate cues from the patient that all of the appropriate information has been garnered and the patient is not exhibiting behaviors consistent with withholding. Finally, the evaluation component suggests that physicians should seek the guidance of other physicians or nurses to determine if their interviewing skills are eliciting complete and accurate information from patients.
In order to properly diagnose, physicians need complete and factual information. This information comes by way of diagnostic tests, examinations, interviews, and observation. The simplest way to obtain all the information is by asking their patients questions and listening to their responses. However, this is not necessarily the most accurate and complete way to obtain diagnostic information. Therefore, it could be beneficial for physicians to incorporate long practiced and thoroughly studied interviewing styles, or portions of these styles. Various aspects of motivational interviewing have been taught and utilized in the medical profession. This article suggests that additional research and application of other interview and interviewing techniques may prove helpful in obtaining all the information needed to properly diagnose and treat those patients reluctant to provide “the rest of the story.”
1. Rollnick, S., & Miller, W.R. What is motivational interviewing? Behavioural and Cognitive Psychotherapy. 1995;23:325-334. https://doi.org/10.1017/S135246580001643X
2. Buckley, J.P. (2005). The Reid Technique of interviewing and interrogation. In T. Williamson eds. Investigative interviewing: Rights, research, regulation. Burlington, Massachusetts: Taylor & Francis Group; 2005:190-206.
3. Clarke, C., & Milne, R. National evaluation of the PEACE investigative interviewing course. April 2001. Retrieved from https://so-fi.org/wp-content/uploads/peaceinterviewcourse.pdf
4. Gray, J. A pain in the neck - and shoulder. Pain Topics. 1977;I, No. 3, 6.
5. Levensky, E.R., Forcehimes, A., O’Donohue, W.T., & Beitz, K. Motivational interviewing: An evidence-based approach to counseling patients follow treatment recommendations. American Journal of Nursing, 2007;107(10):50-58. doi: 10.1097/01.NAJ.0000292202.06571.24
6. Rubak, S., Sandbæk, A., Lauritzen, T., & Christensen, B. Motivational interviewing: A systematic review and meta-analysis. British Journal of General Practice. 2005;55(513): 305-312.
7. Mann, R.E., Ginsburg, J.I.D., & Weekes, J.R. Motivational interviewing with offenders. In M. McMurran eds. Motivating offenders to change: A guide to enhancing engagement in therapy West Sussex, England: John Wiley & Sons, Ltd.; 2002:87-102.
8. Walters, S.T., Vader, A.M., Nguyen, N., & Harris, T.R. Motivational interviewing as a supervision strategy in probation: A randomized effectiveness trial. Journal of Offender Rehabilitation, 2010;49:309-323. doi: 10.1080/10509674.2010.489455
9. Snook, B., Eastwood, J., Stinson, M., Tedeschini, J., & House, J.C.Reforming investigative interviewing in Canada. Canadian Journal of Criminology and Criminal Justice. 2010;52(3):215-229. doi: 10.3138/cjccj.52.2.215