Category Archives: Clinical Interviewing

Thoughts on the Relationship Between Cleavage and Professional Counseling and Psychotherapy

The following is a short discussion about cleavage in counseling and psychotherapy.  We’re not especially trying to be provocative (which is one reason why no photo accompanies this blog post) and so we’re interested in your thoughts on this short excerpt BEFORE we include it in the 5th edition of our Clinical Interviewing text.

[Excerpt starts here] For the first time ever in a textbook (and we’ve been writing them since 1993), we’ve decided to include a discussion on cleavage. Of course, this makes us feel exceptionally old, but we hope it also might reflect wisdom and perspective that comes with aging. 

In recent years we’ve noticed a greater tendency for female counseling and psychology students (especially younger females) to dress in ways that can be viewed as somewhat sexual. This includes, but is not limited to low necklines that show a considerable amount of cleavage. This issue was discussed on a series of postings on the Counselor Education and Supervision listserv which includes primarily participants who teach in master’s and doctoral programs in counseling. Most of the postings included some portion of the following themes.

  • Female (and male) students have the right to express themselves via how they dress
  • Commenting on how women dress and making specific recommendations may be viewed as sexist or inappropriately limiting
  • It is true that women should be able to dress any way they want
  • It is also true that specific agencies and institutions have the right to establish dress codes or otherwise dictate how their paid employees and volunteers dress
  • Despite egalitarian and feminist efforts to free women from the shackles of a patriarchal society, how women dress is still interpreted as having certain socially constructed messages that often, but not always, pertain to sex and sexuality
  • Although efforts to change socially constructed ideas about women dressing “sexy” can include activities like campus “slut-walks,” the clinical interview is probably not the appropriate venue for initiating a discourse on social and feminist change
  • For better or worse, it’s a fact that both middle-school males and middle-aged men (and many “populations” in between) are likely to be distracted—and their ability to profit from a counseling experience may be compromised—if they’re offered an opportunity for a close up view of their therapist’s breasts
  • At the very least, excessive cleavage (please don’t ask us to define this phrase) is less likely to contribute to positive therapy outcomes and more likely to stimulate sexual fantasies—which we believe is probably contrary to the goals of most therapists
  • It may be useful to have young women watch themselves on video from the viewpoint of a client (of either sex) that might feel attracted to them and then discuss how to manage sexual attraction that might occur during therapy

It’s obvious that when it comes to clinical interviewers showing cleavage, we don’t have all the perfect answers. Guidelines depend, in part, on interview setting and specific client populations. At the very least, we recommend that you take time to think about this issue and hope you might also consider discussing cleavage issuesJ with your class or your supervisor.

Info on Clinical Interviewing – the text and videos – is at:


A Wiley Website with Info about our Brand New Counseling and Psychotherapy Videos

This spring and summer Rita and I have been working with John Wiley & Sons to produce DVDs to go with our textbooks Clinical Interviewing and Counseling and Psychotherapy Theories in Context and Practice. The Clinical Interviewing DVD is out and the Theories DVD will be available soon. There’s a new website with information about this at:


John reading the new textbooks to his twin grandchildren (who look quite excited about learning how to do psychotherapy).


Favorite Quotations: Clinical Interviewing – Chapter One

These are my favorite quotations from Chapter One. Unfortunately, I didn’t find one of my own:)

It is good to have an end to journey toward;

but it is the journey that matters, in the end.

—Ursula K. Le Guin, The Left Hand of Darkness


In his 1939 book The Wisdom of the Body, Walter Cannon {{3281 Cannon 1939;}} wrote:

When we consider the extreme instability of our bodily structure, its readiness for disturbance by the slightest application of external forces . . . its persistence through so many decades seems almost miraculous. The wonder increases when we realize that the system is open, engaging in free exchange with the outer world, and that the structure itself is not permanent, but is being continuously broken down by the wear and tear of action, and as continuously built up again by processes of repair. (p. 20)


Strupp and Binder {{324 Strupp 1984;}} gave to mental health professionals three decades ago: “ . . . the therapist should resist the compulsion to do something, especially at those times when he or she feels under pressure from the patient (and himself or herself) to intervene, perform, reassure, and so on” (p. 41).


About two decades ago, Phares (1988) concluded that the need for diagnosis before intervention is standard practice in psychology:

Intuitively, we all understand the purpose of diagnosis or assessment. Before physicians can prescribe, they must first understand the nature of the illness. Before plumbers begin banging on pipes, they must first determine the character and location of the difficulty. What is true in medicine and plumbing is equally true in clinical psychology. Aside from a few cases involving blind luck, our capacity to solve clinical problems is directly related to our skill in defining them. (p. 142)


As Strupp and Binder (1984) noted, “Recall an old Maine proverb: ‘One can seldom listen his [or her] way into trouble’ ” (p. 44).

Working on Multicultural Awareness

As I’m reviewing and editing the CI text, I’m running across topics and content that may be of more general interest and will post them here as a means of (a) distracting myself, (b) procrastinating and, if anyone is interested, (c) getting feedback. Below is an adaptation of a “Putting It In Practice” activity we cover in the text:

Talking About Skin Color

No one we know over the age of 12 is very comfortable talking about skin color. Nevertheless, because research shows that many individuals have unconscious skin color biases, we believe some discussion of this potentially emotionally charged topic should take place within the context of various educational settings, including graduate education in counseling or psychotherapy. This is why we recommend the following websites.

1.  Go to HTTPS://IMPLICIT.HARVARD.EDU/IMPLICIT/ and take some form of the Implicit Association Test. This test is designed to evaluate your underlying, possibly unconscious, attitudes toward people with various skin colors. We recommend that you take the test and then discuss your reactions to the test (and to your results) with friends, family, or colleagues.

2.  Teaching has a nice website on multicultural equality. One part of this website lists a video titled “Starting Small” that shows young children with divergent racial and ethnic backgrounds comparing their skin colors (thanks to Midge Elander for pointing this out to me; go to for the video). Watching the video and then engaging in the small group skin color activity is an appropriate way for adults to open a conversation about skin color.

Although it’s important to potentially be able to discuss skin color and other racial, ethnic, and cultural issues directly with clients, family, and friends, we recommend that doing so with caution and sensitivity. Skin color isn’t typically a topic that should be brought up by white people—because white people should work out their own skin color issues rather than dragging people of color into the issues with them. Instead, skin color, culture, and race are issues to discuss openly within safe and secure individual or group settings or when people of color show an interest in such discussions. The point is to get more comfortable at communicating directly if needed and in the appropriate time and place. The other point is to move past unconscious negative or positive stereotyping biases like those identified in the implicit association test.

Revising Clinical Interviewing — Who Wants to Help?

It’s time to put our Clinical Interviewing text into its 5th edition and so I’m just starting on my main and very exciting summer project (there’s some, but not complete sarcasm here). In the next four weeks I’ll be editing, updating, and transforming the 15 chapters with the latest thinking and research in the Clinical Interviewing domain.

That brings me to the purpose of today’s blog.

If any of you are familiar with this text and have thoughts about what needs to change and what needs to stay the same, I’d love to hear from you.

If any of you are aware of cutting edge research on clinical interviewing, I’d love it if you’d pass the information on to me.

And if any of you have special qualifications and might want to write a 1,000-1,500 word professional essay on a specific topic in one of the chapters . . . let me know and I’m open to hearing your ideas.

In the meantime, I’m hunkered down in a small cabin on the Stillwater River just West of Absarokee and will be diving into this project (and not the river) as I fend off the staggering winds (wishing for a wind turbine . . . darn it) and take breaks to weed the garden and catch skunks. I’ll try not to have too much fun and will be blogging more than usual in an effort to avoid real work:).

Webinar Reflections and a Suicide Myth Quiz

Last week I had the privilege of doing a Wiley Faculty Network Webinar on Teaching Suicide Assessment to graduate students in counseling and psychology. It was a first webinar experience for me and I have a few reflections and a suicide myth quiz from the webinar.

Observation #1: When doing Webinars, keep your eyes on your content (and not the “news feed” with names of friends and colleagues making interesting comments). If you watch the comments you will sound dull and slow – sort of like people sound when they’re talking to you on the phone while watching an engaging television show or surfing the internet.

Observation #2: There are lots of faculty and graduate students out there who want to do their best to help others through suicidal crises. This is very cool. I am always a little verklempt (sp) about how many kind and helpful people there are out there in the world.

Now . . . here’s the suicide quiz. Let’s see how you do. Answer the following True or False. The answers are at the bottom.

  1. Suicide rates are typically highest in rainy and cloudy climates, like Seattle, the Northeast, and the United Kingdom.
  2. Suicide rates are typically highest in the Winter months, especially around the holidays. 
  3. Antidepressant medications (i.e., SSRIs like prozac and celexa) can REDUCE a client’s suicidal impulses.
  4. Antidepressant medications (i.e., SSRIs like prozac and celexa) can INCREASE a client’s suicidal impulses.
  5. Suicide rates in the U.S. are usually higher than homicide rates.
  6. The most common means of suicide among females is firearms.









  1. False.  In the U.S., every year the highest rates are nearly always in Montana, Alaska, Wyoming, and Nevada – and the lowest rates are in the cloudy Northeast
  2. False:  U.S. Suicide rates are nearly always highest in the Spring (April and May, in particular; Mondays have highest rates and Saturdays lowest and, surprisingly, December has the lowest rates).
  3. True:  Yes, there is evidence that antidepressant medications can REDUCE a client’s suicidal impulses.
  4. True:  Yes, there is evidence that antidepressant medications can INCREASE and even CREATE suicidal impulses. [Increased akathisia and violent thoughts]
  5. True:  U.S. Suicide rates (about 30K per year) are typically higher than U.S. homicide rates (about 20K per year).
  6. True:  Firearms constitute the most common method for completed suicides for both females and males.




Differential Activation Theory and Suicide Assessment

In anticipation of my upcoming suicide assessment interviewing webinar, I’m posting this and other suicide assessment interviewing material.

Differential Activation Theory

Differential activation theory suggests that when previously depressed and suicidal individuals experience a negative mood, they are likely to have their negative information processing biases reactivated. The original theory:

. . . stated that during a person’s learning history—and particularly during episodes of depression—low mood becomes associated with patterns of negative information processing (biases in memory, interpretations, and attitudes). Any return of the mood reactivates the pattern, and if the content of what is reactivated is global, negative, and self-referent (e.g., “I am a failure; worthless and unlovable.”), then relapse and recurrence of depression is highly likely. (Lau, Segal, & Williams, 2004, p. 422)

This theory and supporting empirical research indicates that during the course of a clinical interview, certain questioning procedures may move a previously depressed client toward a more negative mood state with an accompanying increase in negative information processing and suicide ideation. In fact, there are many studies indicating that both depressed and non-depressed clients and non-clients can be quickly and powerfully affected by mood inductions (Lau et al., 2004; Mosak, 2000; Teasdale & Dent, 1987).

For example, in a recent study, participants were divided into three groups: (a) those previously depressed with suicide ideation; (b) those previously depressed without suicide ideation; and (c) those with no history of previous depression (Lau et al., 2004). Following a mood challenge in which participants spent eight minutes listening to a depressive Russian opera at ½ speed while reading 40 negative statements such as, “There are things about me that I do not like,” participants generally experienced a worsening of mood and performed more poorly on a cognitive problem-solving test than prior to the mood challenge. Additionally, the participant group with a history of depression and suicide ideation exhibited significantly greater impairment in problem solving than the comparison groups. The authors concluded: “. . . when mood has returned to normal, cognitive variables may return to normal, but those who have been depressed and suicidal in the past are vulnerable to react differentially to changes in mood—with greater deterioration in problem-solving ability” (p. 428). This deterioration in problem solving is consistent with Edwin Shneidman’s concept of mental constriction, which we address later in this chapter.

Overall, the research clearly indicates that all individuals, depressed or not and suicidal or not, can have their mood quickly and adversely affected through rather simple experimental means. Additionally, it appears that previously depressed individuals may experience differential activation and therefore also have increases in negative cognitive biases about the self, others, and the future. Further, it appears that previously suicidal individuals may be particularly vulnerable to having their problem-solving abilities adversely affected when they experience a negative mood state.

Depressogenic Social, Cultural, and Interview Factors

In addition to the preceding research findings, there are a number of contemporary social and cultural factors that may predispose or orient individuals toward depressive and suicidal states. More than ever the United States media is involved in defining depressive states and promoting medical explanations for depression and suicidality. There are many books, magazine articles, and Internet sites encouraging individuals to examine themselves to determine if they might be suffering from depression, bipolar disorder, an anxiety disorder, AD/HD or other mental disorders. In particular, pharmaceutical advertisings encourage individuals to consult with their doctor to determine whether they might benefit from a medication designed to treat their emotional and behavioral symptoms. Unfortunately, as most of us know from personal experience and common sense, it is very easy to move into a negative mood in response to suggestions of personal defectiveness (which, over time, certainly may be as potent as eight minutes of a slow Russian opera). Consequently, it would not be surprising to find that continually rising depression rates and accompanying pharmaceutical treatments are, in part, related to increased awareness of depressive conditions.

Even more relevant to the suicide assessment interviewing process, it may be that interviewers who focus predominantly or exclusively on the presence or absence of negative mood states inadvertently increase such states. This possibility is consistent with constructive theory in that whatever we consciously focus on, be it relaxation or anxiety or depression or happiness, tends to grow. It is also consistent with anecdotal data from our students who report feeling surprisingly down and depressed after conducting and role-playing suicide assessment interviews.

Our concern is that traditional medically oriented depression and suicide assessment interviewing may sometimes inadvertently contribute to, rather than alleviate, underlying depressive cognitive and emotional processes. Consequently, in the following sections on suicide assessment interviewing, we guide you toward balancing negatively oriented depression and suicidality questions with an equal or greater number of questions and prompts designed to increase the focus on more positive client experiences and emotional states. This serves two functions. First, including positive questions and prompts may help clients focus on positive experiences and therefore improve their current mood state and problem-solving skills. Second, if clients are unable to focus on positive personal experiences or display positive affect, it may indicate a more chronic or severe depressive and suicidal condition. Overall, our primary message is that we should always pay close attention to the manner in which we use words, questions, and language when conducting depression and suicide assessment interviews.

Adopting a New Client and Suicide-Friendly Interviewer Attitude

Consistent with the CAMS approach as well as other more recent treatment perspectives (Action and Commitment Therapy (ACT); and Dialectal Behavior Therapy (DBT); we want to encourage you to adopt a fresh new attitude toward clients who may present with depressive and suicidal symptoms. Specifically, consider these attitudinal statements:

Depression and suicidality are natural conditions that arise, in part, from normal human suffering. Consequently, just because a client arrives in your office with depressive symptoms and suicidal features, this does not necessarily indicate deviance—or even a mental disorder.

Given that depressive and suicidal symptoms are natural and normal, it is acceptable for you, as an interviewer, to validate and normalize these feelings if they arise. This is especially important because many suicidal individuals feel socially disconnected, emotionally invalidated, and as if they are a burden to others (Joiner, 2005). There is no danger in accepting and validating client emotions—even self-destructive emotions.

In the spirit of the CAMS approach, we encourage you to listen to your clients’ suicidal thoughts and impulses nonjudgmentally; these thoughts and impulses represent your clients’ unique efforts to cope with their interpersonal and life problems.

Rather than continually drilling down into your clients’ depressive and suicidal symptoms, be sure to balance your clinical interview with questions that focus on the positive and your clients’ unique reasons for living. Forgetting to ask your client about positive experiences is like forgetting to go outside and breathe fresh air.

Fortunately, most people who experience depression recover, with or without treatment. Additionally, most people at least briefly consider suicide as an alternative to life, and of those who seriously contemplate—or even attempt—suicide, most end up choosing life instead of suicide.

A note of caution is in order. People often hesitate to ask directly about suicidal ideation out of a fear that they will somehow cause a sad person to suddenly think of suicide as an option. Asking about suicidal thoughts or impulses is not the same as dwelling on negative and depressing thoughts and feelings. Balancing the focus between negative and more positive, solution-focused material can be both wise and helpful. Failing to ask about suicide is neither.

Good Ideas about Multicultural Counseling and Psychotherapy – Part II

Three More Ideas About Multicultural Counseling

4.  Developing your Self-Awareness is Central

Both the American Counseling Association and the American Psychological Association place self-awareness of the therapist as a central factor in developing multicultural competency. This is a great, but tricky idea. It’s tricky because of the nature of awareness is such that it’s all too easy for us to remain unaware to very significant multicultural issues. If you’re interested in exploring your multicultural awareness further, you should check out the Implicit Association Test at:

I have a friend who often claimed: “I’m not insensitive, I’m just oblivious!” Of course this was offered in humor, but obliviousness—especially if you’re aware of it—is no good excuse for being insensitive to diversity issues. I’m also reminded of the insensitive and oblivious response of many White Montana students to multicultural discussions. It’s not unusual for some of them to say things like, “I just haven’t had much contact with people from other cultures because we don’t have many minorities in Montana.” When I hear this I try not to gasp aloud as I, or a Native or First Nations Person points out that, in fact, 6.8% of Montana’s population is Native American and that several people IN THE ROOM are Native American.

The initial splash of multicultural awareness is often accompanied by an emotional response . . . and occasionally a bit or a bundle of defensiveness.

5.  As you Work Towards Multicultural Competence, Remember the Concept of Multicultural Humility

Although it’s standard procedure in the counseling and psychotherapy literature to refer to multicultural competence, one major problem with the term multicultural competence is that it implies that there’s an endpoint in the multicultural awareness, knowledge, and skill acquisition process. For this reason, I prefer the terms multicultural humility or multicultural sensitivity.

Similar to awareness, I think humility is central to good multicultural work. Unfortunately, within the dominant cultural media-based messages humility is typically viewed as being weak and confidence, swagger, and even arrogance is seen as more desirable. Thomas Merton (quoted in part I of this blog series) has a quotation that speaks to the tendency for entire countries to engage in self-superiority. He wrote:

“The greatest sin of the European-Russian-American complex which we call the West (and this sin has spread its own way to China) is not only greed and cruelty, not only moral dishonesty and infidelity to the truth, but above all its unmitigated arrogance toward the rest of the human race.”

It’s crucial for multicultural counselor and psychotherapists to move beyond thinking in terms of competence and tolerance (both of which speak to Merton’s ideas of arrogance). Instead, we need to embrace our fallibilities and humility and approach cultural and individual differences with what Marcia Linehan might call radical acceptance and what Carl Rogers would have referred to as unconditional positive regard.

6.  Keep Making Efforts to Understand a Collectivist Cultural Perspective.

In collectivist cultures, values and norms are shared. The self and the personality are defined in terms of group memberships, and the group needs and values are more central than those of the individual. Some people with collectivist perspectives avoid the whole idea of the concept of self or self-esteem or self-image. Instead, Collectivists tend to evaluate themselves based on attaining group goals.

For lots of us folks who have been deeply involved in American individualism, the idea of collectivism can feel odd and repeatedly difficult to grasp. This is where exposure, discussion, and real listening to others becomes so important. Rather than trample on the idea of collectivist being, we need to persistently take extra steps to maintain awareness of this concept that can be so slippery for individualists to grasp.

To close this blog, in 1975 Robert Hogan wrote,

A central theme in Western European history for about 800 years has been the decline of the medieval synthesis or, alternatively, the emergence of individualism. Two hundred years ago individualism was a moral and religious ideal capable of legitimizing revolutions and inspiriting sober and thoughtful minds. Sometimes in the last century, however, social thinkers began to regard individualism in more ambivalent terms, even in some cases as a possible indicator of social decay. (p. 533)

This is interesting stuff, even if it’s sometimes difficult to completely and consistently understand.