Category Archives: Clinical Interviewing

Exploring Empathy — Part I

Happy Saturday. This post is the first of a three-part preview of our discussion on Empathy from Clinical Interviewing, 5th Edition.

See: http://www.amazon.com/Clinical-Interviewing-2012-2013-John-Sommers-Flanagan/dp/1118390113/ref=ntt_at_ep_dpt_1

Empathic Understanding

Empathic understanding is a central concept in counseling and psychotherapy. Rogers (1980) defined empathy as:

. . . the therapist’s sensitive ability and willingness to understand the client’s thoughts, feelings, and struggles from the client’s point of view. [It is] this ability to see completely through the client’s eyes, to adopt his frame of reference, (p. 85) . . .  It means entering the private perceptual world of the other . . . being sensitive, moment by moment, to the changing felt meanings which flow in this other person. . . . It means sensing meanings of which he or she is scarcely aware. (p. 142)

Rogers’s definition of empathy is complex. It includes several components.

  • Therapist ability or skill
  • Therapist attitude or willingness
  • A focus on client thoughts, feelings, and struggles
  • Adopting the client’s frame of reference or perspective-taking
  • Entering the client’s private perceptual world
  • Moment-to-moment sensitivity to felt meanings
  • Sensing meanings of which the client is barely aware

A Deeper Look at Empathy

As with congruence and unconditional positive regard, the complexity of Rogers’s definition has made research on empathy challenging. Many different definitions of empathy have been articulated (Batson, 2009; Clark, 2010; Duan & Hill, 1996). According to Elliott, Bohart, Watson, & Greenberg (2011), recent advances in neuroscience have helped consolidate empathy definitions into three core subprocesses:

  1. Emotional simulation: This is a process that allows one person to experientially mirror another’s emotions. Emotional simulation likely involves mirror neurons and various brain structures within the limbic system (e.g., insula).
  2. Perspective-taking: This is a more intellectual or conceptual process that appears to involve the pre-frontal and temporal cortices.
  3. Emotion regulation: This involves a process of re-appraising or soothing of one’s own emotional reactions. It appears to be a springboard for a helping response. Emotional regulation may involve the orbitofrontal cortex and prefrontal and right inferior parietal cortices.

Empathy is an interpersonal process that requires experiencing, inference, and action. In chapter 1 we noted that playing a note on one violin will cause a string on another violin to vibrate as well, albeit at a lower level. In therapy, this has been referred to as resonance. Most people have had the experience of feeling tears well up at a movie or while someone talks about pain or trauma. This is the experiential component of empathy that Elliot et al., (2011) referred to as emotional simulation).

Beyond this physical/experiential resonance, one person cannot objectively know another person’s emotions and thoughts. Consequently, at some level, empathy always involves subjective inference. This process has been referred to as perspective-taking in the scientific literature and is considered a cognitive or intellectual requirement of empathy (Stocks, Lishner, Waits, & Downum, 2011).

Empathy—at least within the context of a clinical interview—also requires action. Therapists must cope with and process the emotions that are triggered and then provide an empathic response. Most commonly this involves reflection of feeling or feeling validation, but nearly every potential interviewing response or behavior can include verbal and nonverbal components that include empathy. The action component of empathy is likely what Elliot et al., are referring to with the term emotional regulation.

Simple guides to experiencing and expressing empathy can help you develop your empathic abilities. At the same time, we don’t believe any single strategy will help you develop the complete empathy package. For example, Carkhuff (1987) referred to the intellectual or perspective-taking part of empathy as “asking the empathy question” (p. 100). He wrote:

By answering the empathy question we try to understand the feelings expressed by our helpee. We summarize the clues to the helpee’s feelings and then answer the question, How would I feel if I were Tom and saying these things? (p. 101).

Carkhuff’s empathy question is a useful tool for tuning into client feelings, but it also oversimplifies the empathic process in at least two ways. First, it assumes therapists have a perfectly calibrated internal affective barometer. Unfortunately this is not the case as clients and therapists can have such different personal experiences that the empathy question produces completely inaccurate results; just because you would feel a particular way if you were in the client’s shoes doesn’t mean the client feels the same way. Sometimes empathic responses are a projection of the therapist’s feelings onto the client. If you rely solely on Carkhuff’s empathy question, you risk projecting your own feelings onto clients.

Consider what might happen if a therapist tends towards pessimism, while her client usually puts on a happy face. The following exchange might occur:

Client: “I don’t know why my dad wants us to come to therapy now and talk to each other. We’ve never been able to communicate. It doesn’t even bother me any more. I’ve accepted it. I wish he would accept it too.”

Therapist: “It must make you angry to have a father who can’t communicate effectively with you.”

Client: “Not at all. I’m letting go of my relationships with my parents. Really, I don’t let it bother me.”

In this case, asking the empathy question: “How would I feel if I could never communicate well with my father?” may produce angry feelings in the therapist. This process consequently results in the therapist projecting her own feelings onto the client—which turns out to be a poor fit for the client. Accurate empathic responding stays close to client word content and nonverbal messages. If this client had previously expressed anger or was looking upset or angry (e.g., angry facial expression, raised voice), the therapist might resonate with and choose to reflect anger. However, instead the therapist’s comment is inaccurate and is rejected by the client. The therapist could have stayed more closely with what her client expressed by focusing on key words. For example:

Coming into therapy now doesn’t make much sense to you. Maybe you used to have feelings about your lack of communication with your dad, but it sounds like at this point you feel pretty numb about the whole situation and just want to move on.

This second response is more accurate. It touches on how the client felt before, what she presently thinks, as well as the numbed affective response. The client may well have unresolved sadness, anger, or disappointment, but for the therapist to connect with these buried feelings requires a more interpretive intervention. Recall from Chapter 3 that interpretations and interpretive feeling reflections must be supported by adequate evidence.

To help with the intellectual process of perspective-taking, instead of focusing exclusively on what you’d feel if you were in your client’s shoes, you can expand your repertoire in at least three ways:

  1. Reflect on how other clients have felt or might feel
  2. Reflect on how your friends or family might feel and think in response to this particular experience
  3. Read and study about experiences similar to your clients’.

Based on Rogers’s writings, Clark (2010) referred to intellectual approaches to expanding your empathic understanding as objective empathy. Objective empathy involves using “theoretically informed observational data and reputable sources in the service of understanding a client” (Clark, 2010, p. 349). Objective empathy is based on the application of external knowledge to the empathic process—this can expand your empathic responding beyond your own personal experiences.

Rogers (1961) also emphasized that feeling reflections should be stated tentatively so clients can freely accept or dismiss them. Elliot et al., (2011) articulated the tentative quality of empathy very well: “Empathy should always be offered with humility and held lightly, ready to be corrected” (p. 147)

From a psychoanalytic perspective, it’s possible to show empathy not only for what clients are saying, but also for their defensive style (e.g., if they’re using defense mechanisms such as rationalization or denial, show empathy for those):

Client: “I don’t know why my dad wants us to come to therapy now. We’ve never been able to communicate. It doesn’t even bother me any more. I’ve accepted it. I wish he would.”

Therapist: “Coming into therapy now doesn’t make much sense to you. Maybe you had feelings about your lack of communication with your dad before, but it sounds like you feel pretty numb about the whole situation now.”

Client: “Yeah, I guess so. I think I’m letting go of my relationships with my parents. Really, I don’t let it bother me.”

Therapist: “Maybe one of the ways you protect yourself from feeling anything is to distance yourself from your parents. Otherwise, it could still bother you, I suppose.”

Client: “Yeah. I guess if I let myself get close to my parents again, my dad’s pathetic inability to communicate would bug me again.”

This client still has feelings about her father’s poor communication. One of the functions of accurate empathy is to facilitate the exploration of feelings or emotions (Greenberg, Watson, Elliot, & Bohart, 2001). By staying with the client’s feelings instead of projecting her own feelings onto the client, the therapist is more likely to facilitate emotional exploration.

A second way in which Carkhuff’s (1987) empathy question is simplistic is that it treats empathy as if it had to do only with accurately reflecting client feelings. Although accurate feeling reflection is an important part of empathy, as Rogers (1961) and others have discussed, empathy also involves thinking and experiencing with clients (Akhtar, 2007). Additionally, Rogers’s use of empathy with clients frequently focused less on emotions and more on meaning. Recall that in his original definition, Rogers wrote that empathy involved: “. . . being sensitive, moment by moment, to the changing felt meanings which flow in this other person. . .” (p. 142). And so empathic understanding is not simple, it involves feeling with, thinking with, sensing felt meanings, and reflecting all this and more back to the client with a humility that acknowledges deep respect for the validity of the client’s own experiences.

More to come on this tomorrow in “Exploring Empathy” Part II.

References

Akhtar, S. (Ed.). (2007). Listening to others: Developmental and clinical aspects of empathy and attunement Lanham, MD, US: Jason Aronson.

Carkhuff, R. R. (1987). The art of helping (6th ed.). Amherst, MA: Human Resource Development Press.

Clark, A. J. (2010). Empathy: An integral model in the counseling process. Journal of Counseling & Development, 88, 348-356.

Greenberg, L. S., Watson, J. C., Elliot, R., & Bohart, A. C. (2001). Empathy. Psychotherapy: Theory, Research, Practice, Training, 38(4), 380-384.

Rogers, C. R. (1961). On becoming a person. Boston: Houghton Mifflin.

Rogers, C. R. (1980). A way of being. Boston: Houghton Mifflin.

Stocks, E. L., Lishner, D. A., Waits, B. L., & Downum, E. M. (2011). I’m embarrassed for you: The effect of valuing and perspective taking on empathic embarrassment and empathic concern. Journal of Applied Social Psychology, 41(1), 1-26. doi: http://dx.doi.org/10.1111/j.1559-1816.2010.00699.x

 

What I’m Writing Today: CI5 Chapter 5

With a February 1 deadline looming, I’m in all out writing and editing mode. Today’s topic: Congruence. Below is an excerpt from the draft of the upcoming 5th edition of Clinical Interviewing. I gotta say, Congruence and Carl Rogers—good stuff—way better than any NFL playoff games:). I know, Empathy would be a little better, but you can’t always get what you want.

Here’s a glimpse of the opening of chapter 5: Evidence-Based Relationships in the Clinical Interview

In 1957, Carl Rogers made a bold declaration that has profoundly shaped research and practice in counseling and psychotherapy. He hypothesized in a Journal of Consulting Psychology article that no techniques or methods were needed, that diagnostic knowledge was “for the most part, a colossal waste of time” (1957, p. 102), and that all that was necessary and sufficient for therapeutic change to occur was a certain type of relationship between therapist and client.

Although we could go back further in time and note that Freud (of course) had originally discussed the potential value of therapeutic relationships, Rogers’s revolutionary statements refocused the profession. Until Rogers, therapy was primarily about theoretically-based methods, techniques, and interventions. After Rogers {{365 Rogers 1961; 690 Rogers 1957; 363 Rogers 1942;}}, we began thinking and talking about the possibility that it might be the relationship between client and therapist—not necessarily the methods and techniques employed—that produced therapeutic change.

For years, a great debate has fulminated within the counseling and psychotherapy disciplines {{499 Wampold 2001;}}. Norcross and Lambert (2011) refer to this debate as “The culture wars in psychotherapy” (p. 3). They describe it as a polarization or dichotomy captured by the question: “Do treatments cure disorders or do relationships heal people?” (p. 3). As academics and professional organizations have engaged in this debate, typically there has been little room for moderation and common sense. There have been assertions about the “rape” of psychotherapy as well as strong criticisms of practitioners who blithely ignore important empirical research {{4453 Baker,Timothy B. 2008; 5969 Fox, Ronald E. 1995;}}. The heat of this controversy continues, in part, because we live in a world with limited health care dollars . . . and the fight to determine which forms of therapy are included as “valid” and therefore reimbursable will likely continue.

But the focus of this chapter is about a part of the controversy that’s really no longer a controversy at all. In the past two decades excellent research and research reviews have settled at least one dimension of the argument. Evidence now overwhelming shows that therapy relationships do contribute to positive outcomes across all forms of therapy and setting {{2241 Goldfried 2007; 285 Sommers-Flanagan 2007; 4074 Norcross 2011;}}. The question is no longer a matter of whether the relationship in counseling and psychotherapy matters, but how much it matters.

This chapter focuses on what has come to be known as “evidence-based therapy relationships” {{5958 Norcross 2011;}}. Although organized around specific theories and supporting research, the chapter also provides clinical examples for how the theories and evidence translate into specific evidence-based relationship facilitating behaviors that occur in the clinical interview.

Carl Rogers’s Core Conditions

Carl Rogers (1942) believed that the necessary and sufficient therapeutic relationship consisted of three core conditions: (a) congruence, (b) unconditional positive regard, and (c) empathic understanding. In his words:

Thus, the relationship which I have found helpful is characterized by a sort of transparency on my part, in which my real feelings are evident; by an acceptance of this other person as a separate person with value in his own right; and by a deep empathic understanding which enables me to see his private world through his eyes. When these conditions are achieved, I become a companion to my client, accompanying him in the frightening search for himself, which he now feels free to undertake. (Rogers, 1961, p. 34)

Congruence

Congruence means that a person’s thoughts, feelings, and behaviors match. Based on person-centered theory and therapy, congruence is less a skill and more an experience. Congruent therapists are described as genuine, authentic, and comfortable with themselves. Congruence includes spontaneity and honesty; it’s usually associated with the clinical skill of immediacy and involves some degree of self-disclosure (see Chapter 4).

Congruence is complex and has been described as “abstract and elusive” {{5961 Kolden, Gregory G. 2011;}} (p. 187). The ability to be congruent includes an internal dimension that involves clients being in touch with their inner feelings or real self plus an external or expressive dimension that involves therapists’ being able to articulate their internal experiences in ways that clients can understand. The following excerpt from Rogers’s work illustrates these internal and external dimensions of experiencing and expressing congruence:

We tend to express the outer edges of our feelings. That leaves us protected and makes the other person unsafe. We say, “This and this (which you did) hurt me.” We do not say, “This and this weakness of mine made me be hurt when you did this and this.”

To find this inward edge of my feelings, I need only ask myself, “Why?” When I find myself bored, angry, tense, hurt, at a loss, or worried, I ask myself, “Why?” Then, instead of “You bore me,” or “this makes me mad,” I find the “why” in me which makes it so. That is always more personal and positive, and much safer to express. Instead of “You bore me,” I find, “I want to hear more personally from you,” or, “You tell me what happened, but I want to hear also what it all meant to you.” (pp. 390-391)

Rogers also emphasized that congruent expression is important even if it consists of attitudes, thoughts, or feelings that don’t, on the surface, appear conducive to a good relationship. He’s suggesting that it’s acceptable—and even good—to speak about things that are difficult to talk about. However, as you can see from the preceding example, Rogers expected therapists to look inward and transform their negative feelings into more positive external expressions of congruence.

Guidelines for Using Congruence

When discussing congruence, students often wonder how this concept is manifest. Common questions include:

  • Does congruence mean I say what I’m really thinking in the session?
  • If I feel sexually attracted to a client, should I be “congruent” and share my feelings?
  • If I feel like touching a client, should I go ahead and touch?
  • What if I don’t like something a client does? Am I being incongruent if I don’t express my dislike?

These are important questions. Watson, Greenberg, & Lietaer {{4387 Greenberg,Leslie S. 1998;}} provided one way for determining the appropriateness of therapist transparency or congruence. They wrote: “. . . it is not necessary to share every aspect of [your] experience but only those that [you] feel would be facilitative of [your] clients’ work” (p. 9). This is a good initial guideline: Would the disclosure be facilitative? In fact, sometimes, too much self-disclosure—even in the service of congruence or authenticity—can muddy the assessment or therapeutic focus. Perhaps the key point is to maintain balance; the old psychoanalytic model of therapist as a blank screen can foster distrust, reluctance, and resistance, while too much self-disclosure can distort and degrade the therapeutic focus {{2454 Farber 2006;}}.

Rogers also suggested limits on congruence. He directly stated that therapy wasn’t a time for clinicians to talk about their own feelings:

Certainly the aim is not for the therapist to express or talk about his own feelings, but primarily that he should not be deceiving the client as to himself. At times he may need to talk about some of his own feelings (either to the client, or to a colleague or superior) if they are standing in the way. (pp. 133–134) {{760 Rogers 1958;}}

Let’s say you’re working with a client and you feel the impulse to congruently self-disclose in the moment. If you’re not sure your comment will be facilitative or whether it will keep the focus on the client (where the therapy focus belongs), then you shouldn’t disclose. Additionally, you should discuss ongoing struggles with self-disclosure with your peers or supervisors because by so doing, you’ll deepen your learning about how best to be congruent with clients.

Since the 1960s, feminist therapists have strongly advocated congruence or authenticity in interviewer-client relations. Brody {{331 Brody 1984;}} described the range of responses that an authentic therapist might use:

To be involved, to use myself as a variable in the process, entails using, from time to time, mimicry, provocation, joking, annoyance, analogies, or brief lectures. It also means utilizing my own and others’ physical behavior, sensations, emotional states, and reactions to me and others, and sharing a variety of intuitive responses. This is being authentic. (p. 17)

Brody is advocating many sophisticated and advanced therapeutic strategies; but keep in mind that she’s an experienced clinician. Authentic or congruent approaches to interviewing are best if combined with good clinical judgment, which is obtained, in part, through clinical experience.

Psychic Communications . . . and Cultural Differences in Mental Status

You may or may not have noticed that I haven’t posted anything on this blog in the past 10 days or so. This is because I’ve been experimenting with my telepathic (psychic) communication abilities. As it turns out, my telepathy skills aren’t as refined as I wish they were and so instead of any specific communications from me, receivers have only experienced warm and fuzzy positive sensations. And so if you experienced anything positive like that over the past ten days, it probably means I was thinking of you and trying to psychically send you some pleasant holiday wishes.

Below please find another installment in my intermittent Mental Status Examination series. This posting includes an activity you can use yourself or with a class to facilitate a discussion (with yourself or among class members) about cultural differences in mental status.

Happy New Year! and Happy Mental Statusing!!

Cultural Differences in Mental Status

Part One: Cultural norms must be considered when evaluating mental status. In the following Table, read through the MSE category, the MSE observation, and then contemplate the “invalid conclusion” along with the “explanation.” The purpose of this activity is to illustrate how cultural background and context can affect the meaning of specific client symptoms.

Category Observation Invalid Conclusion Explanation
Appearance Numerous tattoos and piercings Antisocial tendencies Comes from region or area or subculture where tattoos and piercings are the norm
Behavior/psychomotor activity Eyes downcast Depressive symptom Culturally appropriate eye-contact
Attitude toward examiner Uncooperative and hostile Oppositional-defiant or personality disorder Has had abusive experiences from dominant culture
Affect and mood No affect linked to son’s death Inappropriately constricted affect Expression of emotion about death is unaccepted in client’s culture
Speech and thought Fragmented and nearly incoherent speech Possible psychosis Speaks English as third language and is under extreme stress
Perceptual disturbances Reports visions Psychotic symptom Visions are consistent with Native culture
Orientation and consciousness Inability to recall three objects or do serial sevens Attention deficit or intoxication Misunderstands questions due to language problem
Memory and intelligence Cannot recall past presidents Memory impairment Immigrant status
Reliability, judgment, and insight Lies about personal history Poor reliability Does not trust White interviewer from dominant culture

Part Two: For each category addressed in a traditional MSE, try to think of cultures that would behave very differently but still be within “normal” parameters for their cultural or racial group. Examples include differences in cultural manifestations of grief, stress, humiliation, or trauma. In addition, persons from minority cultures who have recently been displaced may display confusion, fear, distrust, or resistance that is entirely appropriate to their situation.

Work with a partner to generate possible MSE observations, in addition to those listed in Part One of this Multicultural Highlight and using the Table below, that might lead you to an inappropriate and invalid conclusion regarding client mental status.

Category Observation Invalid Conclusion Explanation
       
       
       

This Table is adapted from the text, Clinical Interviewing, by John and Rita Sommers-Flanagan: http://www.amazon.com/Clinical-Interviewing-2012-2013-John-Sommers-Flanagan/dp/1118390113/ref=la_B0030LK6NM_1_1?ie=UTF8&qid=1357167677&sr=1-1

 

Another Sample Mental Status Examination Report

Mental Status Examination (MSE) reports can be more or less detailed. More detailed reports are necessary when patients or clients exhibit a complex array of psychiatric symptoms, affect, and behavior. Less detailed reports are more common when the situation is less complex and the patient or client displays affect and behaviors that are generally within what might be considered a broad range of normal.

In most cases MSEs are imbedded within a clinical or psychiatric interview. As a consequence, as an evaluator, sometimes you may obtain more information about certain areas of functioning than others. This may or may not be intentional and it may or may not be reflected in your report. For example, in the example below, the purpose of the interview was to screen an individual for advanced placement in a Job Corps setting. Because Job Corps is a social and vocational setting, you may notice the MSE report writer emphasizes social functioning. You may also notice that the writer is EXPLICITLY clearly giving the client a “clean” mental status.

Keep in mind that like all MSE reports, this report is designed as a relatively objective appraisal of mental functioning. Nevertheless, subjective judgment and inference is always a part of MSEs and MSE reports.

MSE Sample Report: Example of Positive Functioning

Lucia Rodriguez, a 24-year-old Latino female, was open, pleasant, and cooperative during our meeting. She was well-groomed and looked somewhat younger than her stated age. She was fully oriented and alert. Her speech was clear, coherent, and of normal rate and volume. Her affect was euthymic and stable. She rated her mood as an “8” on a 0-10 scale, with 0 being completely down and depressed and 10 being as happy as possible. She further indicated that she is typically in a “positive mood.” Lucia has no current obsessional thoughts or psychotic symptoms. She has no significant mental health history. Her intellectual ability is probably at least in the above average range. She completed serial sevens and other concentration tasks without difficulty. Her cognitive skills, including memory and abstract thinking were intact. Her responses to questions pertaining to social judgment were positive and well-developed. Overall she appeared forthright and reliable. Her insight and judgment were good.

The WACES Conference in Portland — Presentation I — The Mental Status Exam and Suicide Assessment

This post includes the powerpoint slides from my presentation on Teaching the Mental Status Examination and Suicide Assessment at the Western Association of Counselor Educators and Supervisors. It was a very nice conference organized and attended by some awesome Counselor Educators. WACES MSE

Practicing Humility When Conducting Mental Status Examinations

Perhaps more than any other assessment task, conducting a balanced mental status examination requires that professionals resist the natural temptation to make sweeping judgments about clients on the basis of appearance, specific behaviors, or single symptoms. For example, in a recently published book titled The mental status examination and brief social history in clinical psychology, Smith {{5681 III 2011;}} stated:

A Fu-Manchu mustache suggests the wearer doesn’t mind being thought of as “bad,” whereas a handlebar mustache tells you the person may be somewhat of a dandy or narcissist. (p. 4)

After reading the preceding excerpt, I decided to conduct a small research study by surveying men in Montana with Fu-Manchu mustaches. Whenever I saw men sporting a Fu-Manchu, I asked them to rate (on a seven-point Likert scale) whether they minded being thought of as “bad.” In contrast to Smith’s (2011) observations, I found that most men with Fu-Manchu’s actually thought they looked good and reported wearing the mustache in an effort to look attractive. Of course I didn’t really conduct this survey, but the fact that I thought about doing it and imagined the results carries approximately the same validity as the wild assumption that a mental status examiner can quickly “get into the head of” all clients with Fu-Manchu (or handlebar) mustaches and interpret their underlying personal beliefs or intentions, or even worse, extrapolate from a physical feature to a personality disorder diagnosis.

Although I’m poking fun at the sweeping generalizations that Smith (2011) made in his text, my intent is to point out how easy it is to grow overconfident when conducting MSEs. Like Smith, I’ve sometimes found myself making wild and highly personalized assumptions about the psychopathological meaning of very specific behaviors (some years ago I had my own personal theory about “tanning” behaviors being linked to narcissism).

The key to dealing with this natural tendency towards overconfidence is to use Stanley Sue’s (2006) concept of scientific mindedness. A single symptom should be viewed as a sign that the sensitive and ethical mental status examiner considers a hypothesis to explore. Another example from Smith (2011) may be helpful as another caution of the dangers of over-interpreting single symptoms. He stated: “If the person is unshaven, this may be a sign of depression, alcoholism, or other poor ability at social adaptation” (p. 4).

Smith may be correct in his hypotheses about unshaven clients. In fact, if a research study were conducted on diagnoses or symptoms commonly associated with unshaven-ness, it might show a small correlation with depressive symptoms, partly because poor hygiene can be a feature of some depressive disorders. However, in the absence of additional confirming evidence, an unshaven client is just an unshaven client. And when it comes to social adaptation, I should note that I know many young men (as well as a variety of movie stars) who consider the unshaven look as either desirable, sexy, or both. This could lead to an equally likely hypothesis that an unshaven client is particularly cool or has an especially high level of social adaptation.

In your own MSE work I encourage you to adopt the following three guidelines to help you avoid what might be called the overconfident clinician syndrome:

  1. When you spot a single symptom or client feature of particular interest, you should begin the scientific mindedness process.
  2. Remember that hypotheses are hypotheses and not conclusions; this is why hypotheses require additional supporting evidence.
  3. Don’t make wild inferential leaps without first consulting with colleagues and/or supervisors; it’s often easier to become overconfident and subsequently make inappropriate judgments when working in isolation.

Keep these preceding guidelines in minds as you conduct mental status examinations. You can find my DVD with a clip of a mental status exam at: http://www.amazon.com/Clinical-Interviewing-Skills-John-Sommers-Flanagan/dp/1118390121

Paper Writing Tips for Grad Students in Counseling and Psychology

I recently had the honor and privilege of reading the first set of papers submitted to me by graduate students this semester. The papers were generally of good quality, but a few repeating patterns inspired me to provide the following list of basic tips for graduate students seeking to become mental health professionals.

  1. There’s nothing quite like a clear and concise topic sentence in academic writing. The topic (or focus sentence) introduces the content included in the paragraph. When used well, it’s a beautiful organizing force that brings joy and comprehension to the hearts and minds of many a reader (especially moi).
  2. Although I absolutely hate the saying “More is less” (because, in fact, “more” is always “more” even though “less” can better), it’s a good general rule to make your sentences shorter rather than longer because all too often I find students, like myself in this particular sentence, trying to fit too much information into one sentence when it would be clearer and better to break it up into two or three sentences. A corollary to this rule is that fewer quotation marks and exclamation marks are better than more of those particular “Marks!”
  3. A transition sentence or two that describes what you’ll be covering in your paper and placed at the end of your opening paragraph or in your second paragraph is very helpful to your reader.
  4. Unless you’re a Brit, you should put your commas, periods, and ellipsis inside the quotation marks, “Like this. . .” Think about it this way: commas and periods like to be on the inside; they don’t like to be floating outside the quotation marks because, unless they live on the British Isles, it increases their existential sense of isolation.
  5. You don’t need to use a comma when you have a short list of only two thoughts because all you need in that case is the word “and.” For example, notice the absence of a comma in the following sentence: Max was feeling quite spry and decided to post a smiley face to his Facebook status. In this case we do not need or want a comma after the word “spry.”
  6. Keep in mind that in most cases it best to maintain consistency between singular and plural within the same sentence and paragraph. For example, if you write: “The counselor should work to have empathy with their client” it will cause me to wonder why you didn’t go with: “Counselors should have empathy with their clients.” Note: There is also a good reason to use what is now commonly referred to as the singular “they.” Using they or their as singular (representing an individual) is perfectly acceptable–especially when referring to individuals who are averse to the gender binary. However, in most cases, it’s easier and IMHO maintains better grammar-flow to shift to plural-plural whenever reasonable.
  7. Remember that your professor really likes the appropriate use of the Harvard comma. What this means is that when providing a list of more than two items, you should place a comma after the first item, second item, and before the and. An example: John very much enjoys running, walking, and dancing. If you leave out that last comma, it seems like the final two items are somehow joined together. Remember also, that although journalists don’t use it, the Harvard comma is consistent with APA style.
  8. When you’re quoting someone you should use the past tense; this is because the person whom you’re quoting has already said it. For example, in his book Working with challenging youth, Richardson stated: “Yada, yada, and yada.” Although it’s tempting to write, “Richardson states” the past is the past even though Gestalt therapists might want us to bring everything into the here-and-now.
  9. Please include the page number or numbers when you’re quoting someone so your reader, if so inclined, can confirm the accuracy of your quotation. This is also APA style. Always avoid anything that might be viewed as plagiarizing.
  10. In contrast and opposite of how I’m writing in this list of writing tips, APA style doesn’t like contractions. Instead, just like Commander Data in the Star Trek series, you do not use contractions when writing in APA format and you will see a little red mark on your paper if you write with the casual contraction.
  11. You may recall that Michael Jackson sang: “A, B, C is easy as 1, 2, 3.” Well, APA actually thinks that (a), (b), (c). . . is better than 1, 2, 3. . . when it comes to in-paragraph list-making.
  12. If you use capital letters when you don’t need to, I will think you’ve freshly arrived from Germany. Words like counselor and psychologist should not be capitalized and even though specific mental disorders like major depressive disorder are often capitalized, we shouldn’t privilege particular words just because we feel like it or just because the American Psychiatric Association would like those words to take on greater significance.
  13. My old statistics professor always used to say that you write numbers just like you write words. What he meant by this is that justlikeyouwouldneverwritelikethis, when writing an equation you should always put a space between the operation and the integer. For example, it’s always n = 1 and never n=1.
  14. Although corporations are people (according to SCOTUS, not me), people are not corporations. This means you should use “who” when referring to actual people and “that” “them” or “it” when referring to non-people. When it comes to addressing corporations, make no reference at all, just bow your head in deference.
  15. Although it’s very cool and good form to cite your professor’s work in your paper, you should do your best to spell his name correctly.