BritishJournal of Psychiatry(1988),153, 819—820

Point of View

The Assessment of Psychological-Mindedness

in the Diagnostic Interview
NINA E. C. COLTART

In the last paragraph of his paper ‘¿A

defect in currently related in himself, to his own story;
training', Yorke (1988) has a sentence which serves properly - if unhappily - the product of the connective
as an excellent link to the opening of this paper —¿ aetiology of his life's circumstances. A history which
“¿For
all their importance, empathy and awareness has to be coaxed, dragged, or frequently prompted
of patients' anxieties do not in themselves amount by the assessor does not show much potential for the
to psychological understanding―. In his paper, he development of further free associative ease, and also
had made a plea for more psychoanalytical suggests severe inhibition, anxieties, or cast-iron
psychology to be included in a general postgraduate resistances. Here, there is a strong implication that
psychiatric training, and I am in complete agreement the assessor himself can effectively use a disciplined,
with his cogently-argued case. well-judged capacity to maintain quite a lot of
However, I want to concentrate on a particular silence —¿
often for longer than the patient either feels
aspect of this point. When an experienced psycho that he might want, or is socially accustomed to.
analyst is carrying out a diagnostic consultation with However, I am not referring to a stultifying, unhelpful
a view to assessing a patient's suitability for analysis silence which may be experienced by the patient as
or analytical psychotherapy, he is exercising his own frustrating to the point of sadism, and which, in
skill and psychological-mindedness in this intensive inexperienced assessors who are aping an ill-digested
exploration. The prospects of a successful treatment model, may actually be so.
will be greatly enhanced if he finds the patient is 3. The capacity to bring up memories with
‘¿psychologically-minded'
—¿
whatever the presenting appropriate affects, and some sense of how both
complaints, or however unpromising the superficial these, although perhaps not easy for the patient, may
impression. relate to his present state of suffering.
Therefore, I would like to detail some of the
qualities of this feature, with a view to offering some Developments in the interview
guidelines to colleagues who are still learning their arising from the history
technique. Because of the value of brief lists for the
4. Some awareness in the patient that he has an
purpose of consigning to accessible memory, I shall
unconscious mental life. There are people who
lay out these points in an approximate order of
cannot tolerate, and stoutly deny, that they have an
discovery, rather than of importance, under two
unconscious - especially if it may contain ‘¿outdated'
main headings. Nevertheless, it should be remembered
material which is powerfully influencing their current
that the whole may be larger than the sum of its
feelings, behaviour, and thought-processes. Such
parts.
people are unsuitable candidates for the analytical
approach. It is extremely important, therefore, to
The history assess the capacity both to allow for the existence
of these as-yet unknown powerful influences, and
The diagnostician should look for:
to hope that with skilled assistance from another,
1. The capacity to give a history which deepens, they may become known, accepted, and transformed.
acqufres more coherence, and becomes texturally S. Some capacity to step back, if only momentarily,
more substantial, as it goes on. This may happen in from self-experience, and to observe it reflectively —¿
a rambling, and not necessarily consecutive way. either spontaneously, or with the help of a simple
Indeed, a very tidy, chronologically exact history interpretation from the assessor, who should make
without diversions, or patches of apparent incon opportunity for this sort of intervention. In the
sequence, may suggest a constricted, over-anxious presence of psychological-mindedness the use of such
or very heavily-defended mind. an intervention should lead to a more mobile
2. The capacity to givesuch a history without needing recognition by the patient that he may be able to
too much prompting, and a history which gives the tolerate, even welcome, and use, a new light on the
listener an increasing awareness that the patient feels darker, more hidden side of his internal reality, with

819
820 COLTART

its wishes and conflicts. The intervention, in Pitfalls

other words, is a subtle directive towards the Our own trained capacity for creative silence needs
unconscious, and contrasts with interventions on to be kept in context:
other levels and with other aims, which come
under the heading of advice, counseffing, or guidance The accurate forecast of the patient's behaviour before
therapy has begun is a challenge to the diagnostician who
to behavioural change. These belong more to the nevertheless has the means of eliciting evidence of the
realms of the already conscious ego, and of patient's capacity to move freely within his own psyche.
external reality: cognitive therapy is more of this But he will do this only if he is prepared to movefreely
nature. within the interview situation, so that he can induce fluid
6. A capacity, or more strongly a wish, to accept and responses in the interviewee. The silent and inactive
handle increased responsibility for the self- the evaluatorwhoclingsfaithfullyto the psycho-analyticmodel
whole realm of the unconscious, its affects and of behaviour (i.e. behaviour during the course of a long
effects, and the ‘¿maturational'processes (Winnicott, psychoanalysis) will obtain only a partial, if not distorted,
1965.) This is also a crucial factor; psychoanalysis pictureof whathe is meantto be observing(Limentani,1972).
has little to offer to the patient who only desires An interviewer should not behave like a caricature of
to be rid of his own irrational suffering through an analyst. This ‘¿model'
hardly speaks, does not make
the work of another person. A passage in an interventions, makes no clarifying comments or state
assessment interview arising from some tiny inter ments toward the end, may deliver himself only of a
pretation or enlightening, new-angle comment from weighty interpretation directed at adeeper unconscious,
the assessor, in which the patient experiences a tiny which mystifies the already frustrated and probably
insight, some relief, a movement; or in which a link, frightened patient, and never varies this ‘¿technique',
however tenuous, is made between a slight easing of whoever he is with. One of the excuses for this type of
psychic pain and a fractional increase in self behaviour is that it ‘¿brings
out the patient's anxieties'.
knowledge —¿these are reliable pointers to the Of course it does. This ‘¿goal'is wheeled out as if it
existence of psychological-mindedness. Moreover, were some Aristotelian cathartic ideal in its own right,
they are promising signs for the development of true but it is nothing of the sort. Aristotle was referring to
dynamic work in treatment, and the establishment the art of dramatic tragedy, enshrined in a whole
of the therapeutic alliance. play. There is no drama if the consultant does not
7. Imagination. A totally unimaginative person may speak or work; the only tragedy will be a traumatised
find it hard to dream, to use or understand metaphor, patient (I see several in subsequent consultations
to elaborate —¿
or even to have —¿
a fantasy. every year) whose last state is worse than his first.
8. Some capacity for achievement, and some realistic The work required of the interviewer entails drawing
self-esteem; he who fails at everything fails at on all his own skills and talents, in fact his whole
analysis. The sort of achievement I refer to here personality, insofar as he trusts in its unselfconscious
does not necessarily include anything very great; value to serve his professional aims in a creative,
areas in which to look are those of work, and/or an flexible way. He does not have to make the patient
important good relationship somewhere along the too comfortable, dispel all his anxieties, or offer
line. solace or exaggerated hopes; these are the dangers
9. Overall impression. This has to be the last when the interviewer only has “¿empathy
and
ingredient. The presence of several, and preferably awareness― at his service (Yorke, 1988). It is his job
all, of the foregoing criteria tells the assessor that to create and consolidate an ever-deepening rapport,
he is with someone who is psychologically-minded. and keep it going. In other words, to deploy as
Absence of them will add up to an overall impression extensively as he can the structure he has created on
of a character who may be socially and intellectually the foundations of his own psychological-mindedness.
sophisticated, and a competent personality (although
probably with some alien-seeming symptoms), who References
nevertheless does not show and is not likely to LIMENTANI,A. (1972) The assessment of analysability: a major
develop psychological-mindedness. There is something hazardin selectionfor psychoanalysis.InternationalJournal of
deeply recognisable, but ultimately not fully defmable, Psychoanalysis, 53, 351—361.
Wir@ancorr,D. (1965) The Maturational Prcc@ and the Facilitating
about the assessor's experience of a thorough, Environment. London: Hogarth and Institute of Psychoanalysis.
intense, working consultation with a pyschologically Yoiucst,C. (1988)A defect in training. British Journal of Psychiatry,
minded person. 151, 159—163.

Nina E. C. Coltart, MA,MB,BS, Training Analyst, Institute of Psychoanalysis; Past Dfrector (1972—1982)
of London Clinic of Psychoanalysis; Ia, Well Road, London NW3 lU
The assessment of psychological-mindedness in the diagnostic
interview.
N E Coltart
BJP 1988, 153:819-820.
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