Psychiatric intake as a mystery story

Abstract

The psychiatric intake process is a form of negotiated interaction, where patient presentations are affected by referral source, the illness itself, and illness behavior. At the same time, staff understanding of patient presentations is affected by institutional structures of the clinic, desire to control the clinical interaction, and broad developments in the psychiatric fields (especially the dominance of biopsychiatry). Much of the interplay involves patients withholding or reinterpreting information, staff imputations about both the withheld and the proffered information, and the resultant bargaining over what is at stake. Patients may simply be telling a story, but therapists are listening to it as a mystery story. They thus look for cues as to how things are signified and intended, and clues as to how this material fits together as a mystery. This leads to excessive reliance on a question-and-answer mode of engaging, staff interpretation of patient behavior and motivation, and control by staff of information. For patients, too, the clinical intake is a mystery in terms of what is wrong with them, what will be done for them, and how to conduct themselves in the intake.