6. Interview Techniques

After eight months experience of psychiatric interviews with Aboriginal people, I do not consider myself accomplished. I still flounder at times, but less than when I commenced work here. Many clinicians in this field, of much greater experience, report that they too often walk away from an interview perplexed. Tolerance of uncertainty and incomplete information is important, as is the seeking of advice and help from Aboriginal people.

The interview skills which I had gained from my training in non-Aboriginal culture remained useful in my new work. But they clearly needed to be added to and modified in this very different setting where the language and cultural differences between myself and the patients are immense. These new skills were developed largely through experiential learning, observing other clinicians and discussions with AHWs. One of the challenges is to be able to pick up how Westernised or how traditional the Aboriginal patient is and be flexible enough to adjust my interview style accordingly.

There is a vast spectrum of cultural experience within the Aboriginal people of Central Australia, from those that first had contact with white society as adults to others who have lived for extended periods in Europe and have tertiary education. These extremes may occur within the one family. It was safest to err on the side of conducting an interview style that was Aboriginaloriented, as no matter what the individual's experience of different cultures, they would see their identity as Aboriginal. Over time the flexibility became a subconscious process in the same way that one makes subtle adjustments in interview style for patients of different age, gender or personality type.

Holland (34) from her work with Aboriginal people of the far west of NSW describes a 'checklist when working with Aboriginal people' which includes being aware of their history and consequent multiple losses, taking a personal inventory of any prejudices, value judgements (these may affect your body language and can be picked up by Aboriginal people who may give a 'blank wall' response as a way of coping with prejudice), maintaining a low key, non threatening approach, going slow and expecting small gains. This is a good mental preparation. The following are areas of interview technique that I believe important for psychiatric assessment of the fairly traditional Aboriginal people of the remote communities.

Initiating and Rapport

More often than not some family will be present at the interview. I greet each person with a loose handshake, with arm fully outstretched so as not to invade personal space, and only fleeting eye contact. Importantly the hand should not be withdrawn too quickly. I try to greet the elderly first as a sign of respect.

Seating arrangements or, more usually, sitting arrangements are important. For the interviews done at the patient's home, I ask the patient where they would like to sit to talk. This gives them the option of walking off to sit under a tree if they wish not to talk with family around (sometimes young men prefer this option). However the concrete verandah adjacent to the house, with the family gathered around, is the usual preference. I try to sit so that I am not directly facing anybody.

The ideal is to sit side-by-side with the patient and face in the same direction that he/she is, for example with our backs to the house and looking out over the community. This allows some closeness without intimidation, and without the patient feeling that he or she is being stared at. Too much eye contact makes the patient feel as if they are being judged, especially if there are issues relating to shame. In every day interactions between Aboriginal people there is a tendency to talk side by side rather than face to face. There is no rigid rule for eye contact though, as intuitively one can sense that a certain amount of eye contact is acceptable based on how much eye contact you are receiving from the patient, the patient's gender and the amount of shame in the content of the material being discussed. Importantly, when not making eye contact it is important to keep one's gaze fixed at one particular spot, for example on the ground or on your hands. A wandering gaze can give the impression of not being interested in what the patient is saying. The amount of personal space required is more than what one uses for Western people and especially so for a patient of the opposite gender.

To gain rapport early in the interview I generally make a lengthy and unhurried description of my role, where I am based and where I travel to. I highlight any connection I have with people they may know, for example the clinic nurse, AHW or DMO. This lengthy introduction serves firstly to reduce the patients anxiety as it takes pressure off them to start talking. Secondly, Aboriginal people need to know your relationships with others before they can decide on their relationship to you. It is not enough to say my name, qualifications and the purpose of the interview (which is all that most white people would need). Aboriginal culture is based on a complex structure of obligations and entitlements based on relationships and kinship networks. If I can show that I am not just a doctor stopping at the community for a day or two without formal connections, but that I visit all the regional communities and am closely connected to local health staff then it validates my role as a helper and a provider of a service for the local community. Similarly when I commenced my position I emphasised my close connection to my predecessor, and while my predecessor's departure was a loss to many of his patients, I was able to gain some acceptance through some transferring of the attachment they had made to him.

In explaining my role I make it clear that my aim is to provide help within the community and to lower the chance of admission to hospital in Alice Springs. Fear of admission, particularly involuntary admission has been a factor in patients and family being reticent to give a frank history. (On one occasion the grandmother of a young psychotic man denied his quite serious aggressive behaviour toward her, for fear of him being taken away forcibly to Alice Springs hospital. The incarceration and a loved one being removed from the family, understandably, bring out strong emotions in Aboriginal communities).

There has been a change in my demeanour in interviews in this setting. In the urban white community a professional distance and a calm controlled air of authority will often give optimal results. This is simply not culturally appropriate in remote Aboriginal communities, where there maybe a distrust of authority figures. Credibility is earned by your acceptance of Aboriginality, willingness to learn Aboriginal ways and humility. In fact, use of humour, often at one's own expense, can be disarming and promoting of trust. In one community I became known as the 'superman doctor' because of my alleged resemblance to Clark Kent (American popular culture knows no boundaries), which would give ample opportunity for jokes especially with the youth of the community. Being able to laugh with the people and at myself was a vehicle for acceptance. It became clear that in order to provide a service for Aboriginal people one must develop a relationship first and to show who you are not just what you are.

This is initially a confronting challenge, because of fear of rejection and discomfort with altered boundaries, but is ultimately exhilarating.

Another boost to my acceptance came when I was given a 'skin name' by Maisie, the Aboriginal mental health worker. This included me in an integrated kinship network whereby everyone in the community has one of eight skin names. Your skin name is usually derived from your father's skin name (unless you are an outsider and given a skin name de nova), and your skin name defines who is your first or second choice spouse (see Appendix 4). The same skin names apply for most of the language groups across Central Australia (though Arrante and the Eastern Northern Territory have different skin names). My skin name Japljarri implied that my father is Jungarai and my first choice wife Nakamarra. In the beginning of an interview I would often discuss skin names as a way of 'breaking the ice'. If my patient was a Jungarai of an older age than me, I would make it clear to him that I understood my need to be deferential to him like a son to a father. Or if she was a Napljarri I would point out the connection that we were like brother and sister. It would show that I was attempting to understand their culture and help the members of the community to relate to me. There maybe some extreme reactions though: an elderly female patient with dementia cackled with unrestrained mirth on learning that, as a Japljarri, I was her first choice husband. It was not clear if this was a sign of frontal disinhibition or not.

Language

Language is of enormous importance in understanding mental health problems in Aboriginal people. This was highlighted in a controlled comparative study by Kiloh and Cawte (35) in which groups of children at Yuendumu were instructed either in English or in their own Warlpiri language to draw a picture of the local country side containing a fruit tree. When instructed in English they drew pictures of paddocks surrounded by barbed wire and studded with apple trees, a form of vegetation they had never seen. When instructed in their own language they drew the local rounded sandstone hills and foregrounds of hakea and mulga. Hence interviews done 'in language', even where the patient has a good grasp of English, are likely to produce a more accurate picture of affects, beliefs and internal phenomena.

It is of regret that I have not had sufficient time to learn more language. Most of my remote area patients are fluent in their own Aboriginal language and have a variable degree of English. Only about half to two thirds of the time do I have access to an AHW or AMHW who can help interpret (and even then, the interpreting skills are variable). But even the few words of language I do know are very useful. Through contact with AHWs and linguists from the Aboriginal Institute of Development, I have developed some basic interview questions in some of the major languages of Central Australia (see Appendix 5). They have worked quite well in that often the patient can answer in English as long as the question is given in language. The information given seems more accurate when the Aboriginal language questions are used, and it has meant that in those interviews where there has been no access to interpreters I have been able to get reasonable information from patients with poor English skills.

The work of Morice (24-26) is inspiring. As a psychiatrist who worked extensively with the Pintubi and Luritja people of the Western Desert area of the NT and Western Australia, he developed a lexicon of Pintubi words for an incredible variety of affect states and behaviours (see Appendix 6). Significantly there are words for five different types of anxiety (including a word for panic and thanatophobia), the physiological effects of anxiety, several types of sadness and symptoms of depression including early morning wakening, lack of emotional reactivity plus shame/guilt and several types of anger including justified and unjustified anger. This lexicon would not only be useful clinically but it helps to understand the mental health experiences of the people as a whole. If the epidemiological surveys of the 1960s and 70s had such lexicons available it is interesting to hypothesise whether anxiety disorders would have still been recorded as being so scarce.

Not having been able to become fluent in any of the Aboriginal languages, the most useful skill that I have been able to develop is Aboriginal English. This is the form of English used by many of the Aboriginal people in the remote communities and is characterised by a restricted vocabulary and some idiosyncratic word usage and syntax. The following are some useful terms used in the psychiatric interview:

fella	- man
mob	- a group of people or organization, for example, 'I am from mental health mob'
rubbish one	- a useless item, for example, 'Is this medication a rubbish one?'
long time	- months, years
stopping	- staying, for example, 'You been stopping here long time?'
walking round	- agitation
running wild	- impulsivity
grog	- alcohol
ganja, mardi	- marijuana
spirit weak	- depressed mood
spirit strong	- euthymic, sense of well being
tucker	- food
shame job	- something that would bring shame to the person
talking rubbish	- thought disorder or floridly delusional
thinking backwards	- ? subjective description of though disorder
humbug	- to pester with inane or repetitive requests

It is crucial to develop an understanding of which English words are likely to be in the vocabulary and which are not. Throwing in too many difficult words at the beginning of an interview can lose the patient's interest. One patient corrected me by saying 'You gotta talk black fella English', and other patients could just clam up possibly through shame of not knowing more English. An example of inappropriate English would be: 'I am a psychiatry registrar from the remote mental health team and you have been referred by the DMO who wanted me to interview you about how you are coping with your family problems'.

This could be paraphrased to: 'I am the doctor from mental health mob. I am stopping here for two days in the community. The clinic doctor is worried for you, he thinks your spirit is weak. Maybe we can have a talk about your worries'.

It is best to start with Aboriginal English in the interviews even though some of the patients are quite fluent in conventional English. Naturally there is a spectrum of English ability and once you get to know a patient you may find that he or she is comfortable with 'white fella' English. Often it may still be optional to stay in Aboriginal English for the benefit of family members that may be present.

Taking a History

Consulting a standard text such as the Companion to Psychiatric Studies (1993), by Kendall and Zealey reveals that history taking in the psychiatric interview should start with some open ended questions about the presenting problems. It is hoped that the patient will then give a rich account in their own words of the presenting problem but may need direction to stop them from drifting onto past issues or material not pertaining to the history of presenting illness. Later in the interview some more directed questioning can occur to clarify certain points and once the history of presenting illness is dealt with then other areas such as social and personal history, family history and so on can be focused on. This schema has served me well through my training, but failed dismally in remote Aboriginal communities because:

1. Starting with open ended questions puts too much pressure on the patient to start opening up. More ease is gained by the interviewer doing most of the talking early on. The result of too many open ended questions early will often be silence or a shrug of the shoulders.
2. Once the open ended questions have failed, the frustrated clinician will resort to a battery of close ended questions which only serve to intimidate the patient who may object to 'too much worry questions' or may simply say 'yes' to the questions to please the doctor (making the clinician either mislead or more frustrated or both).
3. Asking about the history of presenting illness first will be baffling to most Aboriginal people who feel that their problems cannot be understood by anyone unless their relationships within their community and spirituality are understood. Probing for familiar symptoms like early morning wakening, appetite disturbance, weight loss and so on before exploring the patients family network and what spiritual beliefs he or she may have about the presenting problem, will lose the patient's confidence in the interview process.
4. Asking multiple choice questions in a last ditch effort to prevent 'yes bias' of the totally close ended question, will also be fruitless. This is because the Aboriginal language does not have multiple choice questions in the way that the English language does, for example, 'Is it A or B?'

Thus a typical frustrating sequence of questions may be:

Interviewer: How is your sleep? (Open ended question)

Patient. Yes

Interviewer: is your sleep good or bad? (Multiple choice question)

Patient: (baffled) Yes

Interviewer: Is you sleep bad? (Close ended question with yes bias)

Patient: Yes

While it is now easy for me to see the mistakes I have made, and the problems with the traditional history taking, it is more difficult to find a simple schema to replace our traditional models. My understanding of appropriate questioning is still evolving and I expect advances will only be made by very close collaboration with AMHWs over a lengthy period of time. The following are techniques that I have found useful:

1. Talk slowly and wait for considerable time for the patient to consider the question/statement before he/she may reply. It is the Aboriginal way to consider questions at length before replying. Quick replies can be seen as impolite.
2. Commence not with questions but with non threatening statements for example, about things that I have noticed about the community, how long it has been since I was last in the community, etc. This can then lead smoothly into getting some social history. For example, 'I saw some footballers on the oval today. I heard the team here is good. Do you play football?'
3. After establishing some social history regarding what interests the patient has, it is relatively easy to inquire about family relationships, skin names and marital history. This is also an opportunity for the family to become involved in the interview.
4. If family are present then gather a simultaneous corroborative history from them. In fact there may be little distinction between what is 'corroborative history' and what is history from the patient, as the family may answer for the patient and some answers seem to be the result of family discussion. This concept was difficult for me at first and my efforts to get the patient to talk for him or herself were fruitless. Over time I realised that my Westernised emphasis on the individual was impeding progress. The 'illness' in a sense may be shared by the whole family and the boundaries between individuals within an Aboriginal family are looser. Eastwell (14) has carefully documented many cases of 'associated' psychiatric illness in Arnhem Land Aboriginals where a depressive illness in one clan member has resulted in other clan members having depressive symptoms (he theorises a similar mechanism to folie a deux but that there is an absence of dominant and submissive individuals, but rather there is a belief that sorcery has caused the illness and that when sorcery effects an individual it may also effect the other family members. There is the belief that mental experiences in general are not private but shared by close relatives).

So although some clarity of the 'true' subjective experience is lost when family answer for the patient, the patient's subjective experience is modified greatly by the family. The illness becomes in effect a family illness in terms of the perceived origins and the expected goals of management. This does not supersede the need for diagnosis of the individual.

Also if there seems to be some discrepancy between the family's version of the psychopathology and information from the mental state examination, then it is worth pointing out the discrepancy to the family who are usually willing to discuss amongst themselves and come to a new understanding of how their relative may be affected. For example a young man who appeared to be responding to auditory hallucinations in my interview was described by the family as being quiet but they denied any other symptoms of mental illness. When I pointed out to them that he appeared to be responding to some distracting experiences the family were able to give more information and were able to report that the patient had been talking to himself.

5. As previously described in the section on interview setting, often one or two family members have a special role as a carer or 'looking out for' the individual who has been referred. These carers usually give the most valuable history and will often act as a spokesperson for the patient.
6. Delay the questions about history of presenting illness until well into the interview. Try to use open ended questions, and if this does not produce a response then ask the question in different ways using as much Aboriginal English or Aboriginal language as possible. Try to avoid closed ended questions unless I am sure that the patient's answers are not the result of a 'yes bias'.
7. If there is an AHW present, then involve him or her as much as possible especially if there is an impasse in the interview.
8. When little information is being obtained due to apparent shyness or shame, then story telling can be tried. This technique involves telling a story to the patient about someone else you have seen that reminds you of the patient. This third person is usually a fictitious person that one can construct to have similar issues as the patient in the interview. By telling the patient that this other person reminds you of the patient, it often can overcome any shyness or shame and allows the patient to talk more freely without feeling that he or she is going to be judged. This technique can also be used in management and psychoeducation as will be discussed later. Story telling is an important part of Aboriginal culture. Successful attempts at psychoeducation for drug and alcohol abuse have been carried out by inventing a 'dreaming story' consisting of Ancient Greek and contemporary Australian themes. (Personal communication from Dr L Petchkovsky).
9. Try to understand the cultural significance of any events in the history for example a middle aged woman who had caused great alarm within the community when she walked up a hill. At first this seemed like an insignificant event but in fact it transpired that she had walked into a men's area and this was a flagrant violation of traditional law and reflected what was a gross impairment in judgement. She had a psychotic depressive illness. It is important for me not to be afraid of showing ignorance, by asking questions about such cultural factors, and it is much appreciated by the family when the interviewer asks for help in trying to understand the cultural factors.
10. Endeavour to understand the emic view of the illness as well as the etic view as will be discussed later. The history will include information about predisposing and precipitating factors as well as retrospective attributions and culturally accepted explanations of the illness and its origins, and it is important to delineate each of these.
11. It is important to revisit the social history later in the interview in some detail and this may include quite sensitive areas which are discussed in the next chapter. But it will be important to try to establish whether the individual has been, for example, fully initiated in traditional adulthood, what their status is like in the community, and what interests they may have such as hunting, playing cards, art work, etc. Developmental history is usually fairly coarse and one difficulty is that most families will report that their mentally ill relative had a history of head injury as a child. This information is not very useful because head injury is so common in the communities and it is a culturally accepted belief that mental illness is caused by blows to the head (the other explanation is often one of sorcery, and it is interesting to note that there should be both physical and spiritual explanations for mental illness in Aboriginal culture as there is in Western culture). The drug and alcohol history may be difficult to attain because of a sense of shame and it is also important to note that the quantity of substance that the person states is used is often the quantity that is shared by the patient and his group of friends rather than being purely the quantity for personal use.
12. It is important to be patient in these interviews. Often it is the last thing said that is the most important and I can remember one example of a young Aboriginal man who denied any symptoms of emotional distress or any symptoms of mental illness. But on getting up to leave and saying good bye to the patient he admitted quietly that he had been hearing voices for several weeks.

Australian Academy of Medicine and Surgery