Presentation of Self and the Clinical Performance 

How the initial assessment is structured, its component parts and the order in which aspects are delivered and chosen is very important.

My opinion, however, is that the manner of delivery is more important. The way the person speaks the speed of delivery, pauses, expressions on the persons face, the non-verbal communication, the physical gestures. I would consider these more important.

I would suspect that to a significant extent, these factors are innate to the individual and serve as a form of talent. If a clinician has a presentation of self, which exists through no effort of design, and serves to deliver a calming effect and places patients at ease. Then that clinician will find it much easier to work with a patient who has a proclivity for distress.

Clinicians, who have this aptitude would be more likely to have success in the field of mental health, and are more likely to continue to work in this area. Be drawn towards it, or at least not be immediately pushed away through failure.

In essence I would suggest not having too many mannerisms, but there are some important ones to have. These are the mannerisms of a calm, measured, thoughtful, rational, attentive and kind person.

Consider the speech of a calm person. A calm person would calmly begin speaking, they would not jump in. There would be no pressure to speak. They would let the other person’s speech come to an end and then there would be a gap, then their speaking would begin. The first syllable of the first word and generally the first word as a whole would be delivered gradually and especially not suddenly, but not annoyingly slowly.

The gap after the patient has spoken is important, you can follow their sentence with an affirming nod and Mmmm. Then allow a moment of silence before you speak. This conveys the information that you have taken what the person has just said seriously, you have really listened and you are thinking about what you are about to say before you say it. You are not just going through the motions. You are not just rolling out the same thing that you say to every patient. That ‘Mmmm’ needs to be delivered as an individual response to what the person has said. If you’re delivering exactly the same ‘Mmmm’ in exactly the same way, with exactly the gap (or no gap at all) after the person had finished speaking. If you react in exactly the same way each time, then you are clearly not in the moment with the person.

Cutting the patient off, suddenly beginning what you are going to say and saying it quickly is not a good strategy. You will escalate the intensity of the situation and you will make it appear that what the other person is saying is not important. I write this knowing that I am to some degree stating the obvious, but I have seen too often clinicians do this. I have also seen many clinicians respond to the intensity of the situation and be unable to hide their own stress. The patient may be distressed and the pressure of managing this begins to get to the clinician and this begins to show in their mannerisms. Displaying this stress then escalates the stress in the patient. What you are looking for is the ability to outwardly take on the opposite display to what the patient is going through or what the situation is.

The pressure of time on the clinician can create patterns of behaviour which are negative in working with MH patients. Some patients, especially many mental health patients will talk at great length about superfluous issues and keeping the person on track while not butting in a talking quickly can be too difficult for many. You will need to weigh up what you need to do. You could calmly cut the person off and say, ‘hang -on, we’ve drifted off topic here’ some people will pre-empt this by setting this as a ground rule before the session begins. But whatever you do, don’t do it in a pressured sudden manner

A ground rule often used for sessions is to say something like ‘We have 45 minutes for the session and we we’re going to have a lot to cover, it may that sometimes I need to butt in to keep us on track, it won’t be that I don’t think what you’re saying is important but I’ll want you to get everything you need out of the appointment so it will be best to stick to the most important things and we can return to other things at a later date’. Even if you set this as a ground rule, it doesn’t mean that you can now be abrupt. It just means that you calm interjection is more likely to be successful.

Allow your moment of silence then begin speaking somewhat slowly. Choose a rate of speech which is not pressured, which is not rapid but at the same time it's not infuriatingly slow. If you are saying something very important then slow right down, this will convey that you are really thinking about each word that you say, because each word in this situation is very important and you want to get this right.

If you have with a deep voice you will naturally be calming in your tone, if you have a high-pitched voice you will not be naturally be calming. Be very careful however trying to lower the tone of your voice can appear very contrived.

Consider physical mannerisms which convey how calm and measured you are. If you go to adjust your position in your chair during the appointment because you feel uncomfortable. This may be because you are physically uncomfortable or emotionally uncomfortable, both situations would give you a sense that you need to change position. Change position slowly, initiate the movement slowly, and then slowly come to a rest, do not make sudden motions, sudden twitchy motions, stimulate the persons fight on fighter flight or fight system. So, move slowly, if you need to stand to demonstrate something to show movement. Stand slowly don't jump up don't ask a question in a hurried way. Take your time. If you need to get something from your bag, do it slowly. Don’t frantically look for it because you’re worried about losing time. If you destroy the session by agitation, then whatever time you save will be worthless.

Become comfortable with silence. If you ask a question and the person freezes while they're trying desperately to pull the information out of their mind in a panicked way. Give them time. Don't worry if there's silence just make sure any difficulty you're having with how stressful this appointment may become is not evident to the other person. You must act like a swan. Your feet may be furiously paddling under the water, but on top of the water, you are calm, elegant and serene. Inside you may be thinking at 1 million miles an hour. What should I do? What should you say? What am I going to do next? But when you go to speak your speech is delivered in a calm, slow way measured way. 

Think about gestures being done slowly, you must not be twitchy. If you are taking notes during the appointment, do it smoothly. If you need to pick something up do it slowly