Category Archives: Clinical Interviewing

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice, Parenting

Doing an Internet Interview on IHeart Radio

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Today I did an internet interview with Dr. Carlos Vazquez on his “Circle of Insight” show on IHeart Radio. A few minutes after we finished, I got an email from Dr. Carlos indicating it was posted and ready to hear. Wow. Technology is amazing and it’s especially amazing when it works.

Here’s the link to the interview. Check it out if you like. Or ignore it if you prefer.

https://www.spreaker.com/episode/7224462

The show is titled: A discussion about Psychological Theories and how to talk to parents so they Listen with Dr. Sommers-Flanagan

This is what I look like when I do radio interviews.

OLYMPUS DIGITAL CAMERA

Clinical Interviewing, Cool Counseling, Counseling and Psychotherapy Theory and Practice, Multicultural, Therapy with Adolescents

Counseling Culturally Diverse Youth: Research-Based and Common Sense Tips

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This is a rough preview of a section from the 6th edition Clinical Interviewing. As always, your thoughts and feedback are welcome.

Counseling Culturally Diverse Youth: Research-Based and Common Sense Tips

Research on how to practice with culturally diverse youth is especially sparse. To make matters more complex, youth culture is already substantially different from adult culture. This means that if you’re different from young clients on traditional minority variables, you’ll be experiencing a double dose of the cultural divide. These complications led one writer to title an article “A knot in the gut” to describe the palpable transference and countertransference that can arise when working with race, ethnicity, and social class in adolescents (Levy-Warren, 2014).

To help reduce the size of the knot in your gut, we’ve developed a simple research- and common-sense list to guide your work with culturally diverse youth (Bhola & Kapur, 2013; Norton, 2011; Shirk, Karver, & Brown, 2011; Villalba, 2007):

1. Use the interpersonal skills (e.g., empathy, genuineness, respect) that are known to work well with adult minority group members. Keep in mind that interpersonal respect is an especially salient driver in smoothing out intercultural relationships.

2. Find ways to show genuine interest in your young clients, while also focusing on their assets or strengths.

3. Treat the meeting, greeting, and first session with freshness and eagerness. There’s evidence that young clients find less experienced therapists easier to form an alliance with.

4. Use a genuine and clear purpose statement. It should capture your “raison d’etre” (your reason for being in the room). We like a purpose statement that’s direct and has intrinsic limits built in. For example: “My goal is to help you achieve your goals . . . just as long as your goals are legal and healthy.” One nice thing about this purpose statement is that sometimes young clients think the “legal and healthy” limitations are funny.

5. Don’t use a standardized approach to always talking with youth about your cultural differences. Instead, wait for an opening that naturally springs up from your interactions. For example, when a teen says something like, “I don’t think you get what I’m saying” it’s a natural opening to talk about how you probably don’t get what the youth is saying. Then you can discuss some of your differences as well as you’re desire to understand as much as you can. For example: “You’re right. I probably don’t get you very well. It’s obvious that I’m way older than you and I’m not a Native American. But I’d like to understand you better and I hope you’ll be willing to help me understand you better. Then, in the end, you can tell me how much I get you and how much I don’t get you.”

6. Provide clear explanations of your procedure and rationale and then linger on those explanations as needed. If young clients don’t understand the point of what you’re doing, they’re less likely to engage.

7. Be patient with your clients; research with young clients and diverse clients indicate that alliance-building (and trust) takes extra time and won’t necessarily happen during an initial session

8. Be patient with yourself; it may take time for you to feel empathy for young clients who engage in behaviors outside your comfort zone (e.g., cutting)

I hope these ideas can help you make connections with youth from other cultures. The BIG summary is to BE GENUINE and BE RESPECTFUL. Nearly everything else flows from there.

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice, Ethics

A Summary of the American Psychological Association’s Record Keeping Guidelines

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The American Psychological Association (APA) has an online guide to record keeping for psychologists. Of the different mental health disciplines, the APA’s guidelines are the most extensive. For the full guide (and tons of fun), go to: http://www.apa.org/practice/guidelines/record-keeping.aspx. A brief summary of the guide follows.

As an introduction, the APA emphasizes that clinical records are beneficial for clients and practitioners. When done well, clinical records can:

1. Document that planning has occurred
2. Guide treatment services.
3. Allow providers to review and monitor their work.
4. Enhance continuity when there are treatment breaks or referrals to other providers.
5. Protect clients and providers during legal or ethical proceedings.
6. Fulfill insurance or third-party reimbursement requirements.

The APA’s document is a guide and not a mandate. It’s designed as aspirational. APA also notes that there’s no significant empirical research foundation upon which their guidelines are based. Instead, the guidelines are broadly based on APA policy, professional consensus, and other sources of ethics and legal information.

The following list paraphrases and summarizes APA’s 13 guidelines. There’s always the possibility that our list and descriptions include minor mistranslations. Consequently, please see the full document for comprehensive coverage of this important content.

1. Responsibility: Practitioners are responsible for the development and maintenance of their clinical records. This includes training staff in the appropriate confidential handling of client records.

2. Record Content: Records include information about the nature, delivery, treatment progress and outcomes, and fees. Information included is directly relevant to the clinical purpose of client contacts. Although detail is important, the following factors guide the level of details included in individual client case files:

a. Clients’ wishes
b. Disaster or emergency settings
c. Ethical or legal limitations (e.g., HIV testing results)
d. Contracts with third party payers
e. The APA guide includes extensive information regarding what content may or may not be appropriate.

3. Confidentiality: Maintenance of confidentiality is essential. In situations where who has access to records may be unclear (e.g., child custody conflicts), the provider seeks pertinent legal information to guide decision-making.

4. Informed Consent: Practitioners provide clients with information regarding their record keeping procedures, including limits to confidentiality.

5. Records Maintenance: Records are organized to comply with federal law (HIPAA) and accuracy is maintained.

6. Records Security: Records are kept safe from physical damage. Access to records is controlled via a variety of methods, including locked cabinets, locked storage rooms, passwords, data encryption, etc.).

7. Records Retention: Records are retained for a time period consistent with legal requirements. The general guide is seven years after service ended for adults and three years after a minor reaches age 18 (whichever is later).

8. Records Context: Because client symptoms or condition can vary with situational contexts, providers frame the content of client records within the appropriate historical context.

9. Electronic Records: Electronic records use and storage presents ongoing challenges. The best guidance is for practitioners to follow the HIPAA Security Rule, conduct a security analysis, and consistently upgrade policies and practices to keep up with changes in technology.

10. Records within Agencies: Practitioners must balance their professional ethical requirements and agency policy. The APA identifies three main areas: (a) conflicts between the agency and other requirements, (b) records ownership, and (c) records access.

11. Multiple Client Records: When providing couple, family, or group services, records management may become complex. You can consider either creating separate records for all clients or to identify a primary client and keep records for that person.

12. Financial Records: The nature of the fee agreement (including bartering agreements) as well as adjustments to account balances should be specified. Financial records include essential information such as procedure codes, treatment duration, fees paid, fee agreements, dates of service, etc.

13. Records Disposition: In the case of unexpected events, there may be a need for records transfer or disposal. This implies a need for a records transfer and disposal policy, including information on how current and former clients will be informed if the policy needs to be enacted.

The APA guide is a comprehensive document that can help all practicing clinicians maintain high ethical standards with respect to documentation.

Clinical Interviewing

Women’s Cleavage and the Man’s Package in Professional Counseling and Psychotherapy

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In 2013, for the first time in the history of counseling and psychotherapy textbook writing (at least our history), Rita and I included a section heading titled “Straight Talk about Cleavage” in the 5th edition of Clinical Interviewing. This section was inspired by comments posted on the Counselor Education and Supervision Listserv (aka CESNET). Now, we’re working on the revision for the 6th edition (affectionately referred to as CI6). For CI6 we solicited reactions from students, professional counselors, and professional psychologists. Not surprisingly, we received some fun, stimulating, and challenging responses.

For your reading pleasure, here’s the first draft of the revised section on cleavage. You’ll notice that it begins with a section on “Self-Presentation.” That’s because the cleavage and related content is a subsection of the self-presentation section.

This is a draft . . . and so please feel free to message me (or post) your comments and reactions. Thanks for reading.

Self-Presentation

You are your own primary instrument for a successful interview. Your appearance and the manner in which you present yourself to clients are important components of professional clinical interviewing.

Grooming and Attire
Choosing the right professional clothing can be difficult. Some students ignore the issue; others obsess about selecting just the right outfit. The question of how to dress may reflect a larger developmental issue: How seriously do you take yourself as a professional? Is it time to take off the ripped jeans, remove the nose ring, cover the tattoo, or lose the spike heels? Is it time to don the dreaded three-piece suit or carefully pressed skirt and come out to do battle with mature reality, as your parents may have suggested? Don’t worry. We recognize the preceding sentences are probably pushing your fashion-freedom buttons. We’re not really interested in telling you how you should dress or adorn your body. Our point is self-awareness. If you’re working in rural Texas your tattoo and nose ring will have a different effect than if you’re an intern in urban Chicago. Even if you ignore your physical self-presentation, your clients—and your supervisor—probably won’t.

We knew a student whose distinctive style included closely cropped, multicolored hair; large earrings; and an odd assortment of scarves, vests, sweaters, runner’s tights, and sandals. Imagine his effect on, say, a middle-aged dairy farmer referred to the clinic for depression, or a mother-son dyad having trouble with discipline, or the local mayor and his wife. No matter what effect you imagined, the point is that there’s likely to be an effect. Clothing, body art, and jewelry are not neutral; they’re intended to communicate, and they do (Human & Biesanz, 2012). An unusual fashion statement can be overcome, but it may use up time and energy better devoted to other issues (see Putting It in Practice 2.3). As a therapist your goals is to present yourself in a way that creates positive first impressions. This includes dress and grooming that foster rapport, trust, and credibility.

In one research study (albeit dated), Hubble and Gelso (1978) reported that clients experienced less anxiety and more positive feelings toward psychotherapists who were dressed in a manner that was slightly more formal than the client’s usual attire. The take home message from this research, along with common sense, is that it’s better to err slightly on the conservative side, at least until you’re certain that dressing more casually won’t have an adverse effect on your particular client population. As a professional colleague of ours tells her students, “A client should not walk away from your session thinking too much about what you wore” (S. Patrick, personal communication, June 27, 2015).

Straight Talk about Cleavage
Although we don’t have solid scientific data upon which to base this statement, our best guess is that most people on the planet don’t engage in open conversations about cleavage. Our goal in this section is to break that norm and to encourage you to break it along with us. To start, we should confess that the whole idea of us bringing up this topic (in writing or in person) makes us feel terribly old. But we hope this choice might reflect the 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 might be viewed as provocative. This includes, but is not limited to, low necklines that show considerable cleavage. Among other issues, cleavage and clothing were discussed in a series of postings on the Counselor Education and Supervision (CES) listserv in 2012. The CES discussion inspired many of the following statements that follow. Please read these bulleted statements and consider discussing them as an educational activity.

• Female (and male) students have the right to express themselves via how they dress and should be able to dress any way they want.
• Commenting on how women dress and making specific recommendations may be viewed as sexist.
• Agencies and institutions have some rights to establish dress codes regarding 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 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,” a counseling or psychotherapy session is probably not the venue for initiating a discourse on social and feminist change.
• For better or worse, most 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 have a close up view of their therapist’s breasts.
• At the very least, we think excessive cleavage (please don’t ask us to define this) 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 any sex or gender) and then discuss how to manage sexual attraction that might occur during therapy.

We don’t have perfect answers to the question of cleavage during a clinical interview. Guidelines depend, in part, on interview setting and specific client populations. At the very least, we recommend you think about this dimension of professional attire and hope you’ll openly discuss cleavage and related issues with fellow students, colleagues, and supervisors.

Minding the Body for Males
It’s inappropriate to stop our discussion about sexuality and sexual perceptions without addressing the other end of the sexuality and gender continuum. To start, we should emphasize that, to a large extent, our cautions about cleavage aren’t really about breasts; instead, these are comments about cultural messages pertaining to sex and sexuality and how clients are likely to perceive and react to seeing too much of certain portions of their therapist’s skin. Back in Freud’s day and setting, viewing women’s ankles was reportedly rather titillating. This observation begs the question: “Is it possible for individuals who identify as being on the male end of the sexual identity continuum to dress in ways that might be described as titillating?” When we tried to experiment with this in a group counseling class, mostly the feedback was that the males were being “gross” and “disgusting.”

Despite the fact that our students reacted negatively to the idea of males exposing their skin, we should note that throughout the history of time, therapists who engaged in inappropriate, unethical, and illegal sexual behavior with clients have been disproportionately male. This leads us to conclude that our cautions about females showing cleavage is at the least ironic and at most sexist. Consistent with feminist theory, when men sexualize a woman’s body, it shouldn’t be viewed as the woman’s fault.

These issues are obviously laden with cultural stereotypes, norms, and expectations. In an effort to balance our coverage (no pun intended) of this topic, we went online and asked professionals and colleagues to give us feedback about the “Straight Talk about Cleavage” section. A summary of this feedback is included below.

Feedback on Cleavage
A warning to male therapists: Male therapists need to watch their own flirtatious behavior. They might consult with a female therapist friend to check out anything that might be questionable. I know, most males don’t have cleavage issues, but they sometimes do make provocative comments, such as, “You know, you should take that lovely sexuality of yours and use it to your advantage.” I’m not making this up. Also, they might want to rein in, “You are so pretty. I’ll bet this gets the guys going.” I’m not making this up either. (J. Hocker, personal communication, June 27, 2015).

Extending the conversation to male therapists: I do think part of the unfairness in professional attire for women vs. men is that men’s work wear is simply “easier.” But a woman doesn’t have to dress like a man in order to be taken seriously as a professional. Curiously, I do find that the conversation regarding appearance needs to take place with men; for example, male students who want to wear flip flops, large jewelry, or “muscle” shirts. We also talk about whether or not to wear things that reveal tattoos, hair styles, and so on – so I think men are now as much a part of the conversation as women (S. Patrick, personal communication, June 27, 2015)

A Message from a Licensed School Counselor: I know professionals in counseling and teaching who exhibit poor hygiene, dress, and might toss some cleavage out from time to time. Students do notice, and it’s not cool. In my profession I want students to see me as casual, clean, and someone they’re drawn to for a good ear and safe space. I don’t want them to see cleavage ever. It’s a distraction. Cleavage is sexy and draws attention no matter what. I’m not drawn to women sexually but I’m super distracted by cleav! I can’t imagine how a person attracted to females would react! I find that when I’m not at work there are dates and social functions available that allow me to find my sexy self, but that self doesn’t fit into the school counseling profession. Yes, women should be able to wear what they want, but the reality is if you sport cleav you’ll receive notice by everyone and there’s a time and place to celebrate our cleav; work may not be the place. (M. Robbins, personal communication, June 30, 2015)

The Man’s “Package”: I noticed there’s no mention of a man’s “package” or the open seating posture many men use that gives quite a clear view of any crotch bulging that may be had. I think this deserves to be discussed as well, and not just as an afterthought – it is at least as important as cleavage to the imagination and distraction.

One thing that seems to go on in common discourse is an acceptance of the idea that men are more sexually focused than women. This is problematic on a couple fronts, I think. Although research shows some increased arousal for men from visual stimuli compared to visual stimuli for women BOTH men and women have been shown to be aroused by visual stimuli. BOTH women and men want sex for physical pleasure, not just as a relational tool. The difference is in degree to which these things are acknowledged by each sex, perhaps, but I haven’t seen compelling evidence that there’s actually a difference in the degree to which men and women can be sexually distracted by physical bodies. It’s neither then men’s nor women’s job, then, to “protect” clients from that distraction more than another (C. Yoshimura, personal communication).

Monitoring Flirtatious Behavior
Behavior standards for mental health professionals are high. This is partly true for being a professional of any type. However, mental health professional standards for dress and flirtation are higher than most other professions. If you think about the setting and process, the high standards make sense. Personal disclosures and conversations that happen during clinical interviews and other mental health-related encounters naturally involve non-sexual intimacy. It follows that deep emotional disclosures and exchanges between client and therapist might arouse feelings related to sexual intimacy in clients and/or therapists. It’s perfectly natural for non-sexual intimacy to sometimes trigger feelings of sexual intimacy . . . and so maintaining professional boundaries in this area is essential. All ethical codes that pertain to professional counselors, psychologists, and social workers prohibit sexual contact between therapist and client. The bottom line is that it’s your responsibility, as a mental health professional or student therapist, to closely monitor your attire and behavior to make certain you’re not directly or indirectly communicating flirtatiously with your clients.

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice, Personal Reflections

What’s the Difference between the Clinical Interview and Full-On Counseling or Psychotherapy?

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I know my obsession with all things clinical interviewing is abnormal. This means I already know that most humans on the planet will have no interest in my hashing out the details and differences between clinical interviewing and psychotherapy. So, why then do I persist on blogging about such things? Well, the answer is simple: Obsessions are thoughts and compulsions are behaviors. Therefore, obsessions and compulsions go together like beans and rice. And so, as George Bush senior might have said, “It wouldn’t be prudent to not follow my clinical interviewing obsessions with a clinical interviewing behavior or two.” Now that I think of it, I’m certain that’s exactly what GWB I would have said, had he been asked about this very important situation.

There is, of course, the other reason. I’m revising (along with Rita) our Clinical Interviewing text to put it into the 6th edition. While doing so I have intermittent inspirations to post some of the new material we’re adding here and there. I think to myself . . . “this is the 6th edition of one of the most profound and exciting textbooks of all time and so I’m sure there might be 6 people out there who are interested in reading about what we’re writing.” Then again, as most of us know from either psychological research or common sense, it’s super-easy for me to fool myself into thinking other people are interested in whatever I’m interested in.

Now, having sufficiently fooled or rationalized or intellectualized or inspired myself . . . I present you with our latest thinking on clinical interviewing vs. counseling and psychotherapy.

Clinical interviewing vs. Counseling and Psychotherapy

Students often ask: “What’s the difference between a clinical interview and counseling or psychotherapy?” This is an excellent question and although it’s tempting to answer flatly, “There’s no difference whatsoever” the question deserves a more nuanced response.

The clinical interview is a remarkably flexible and ubiquitous interpersonal process. It’s designed to simultaneously initiate a therapeutic relationship, gather assessment information, and begin therapy. As such, it’s the entry point for clients (or patients) seeking mental health treatment, case management, or any form of counseling. Depending on setting, clinician discipline, theoretical orientation, and other factors, the clinical interview is also commonly known as the intake interview, the initial interview, the psychiatric interview, the diagnostic interview, the first contact or meeting, or any one of a number of other idiosyncratic and theoretically-driven names (Sommers-Flanagan, 2016, in press).

Although it includes therapeutic dimensions, the clinical interview is viewed primarily as an assessment procedure. This is one reason why clinical interviewing is typically included within the assessment portion of course curricula in counseling, psychology, psychiatry, psychiatric nursing, and social work. However, beginning with Constance Fischer’s work on Individualized Psychological Assessment and continuing with Stephen Finn’s articulation and development of therapeutic assessment, it’s also clear that, when done well, clinical assessment is or can be simultaneously therapeutic.

To make matters more complex, every attitude, technique, and strategy described in this text are also the attitudes, techniques, and strategies used in counseling and psychotherapy. Examples (along with their theoretical orientations) range from projective questions (psychoanalytic), therapeutic questions (solution-focused therapy), unconditional positive regard (person-centered), to psychoeducation (cognitive behavior therapy). Even further, some theoretical orientations ignore or de-emphasize assessment to such an extent that the traditional initial clinical assessment interview is transformed completely into an intervention (think solution-focused or narrative). In other cases, the clinical setting or client problem require that single therapy sessions involve an entire course of counseling or psychotherapy. For example,

“. . . in a crisis situation, a mental health professional might conduct a clinical interview designed to quickly establish . . . an alliance, gather assessment data, formulate and discuss an initial treatment plan, and implement an intervention or make a referral.” (Sommers-Flanagan et al., 2015, p. 2)

From this perspective, not only is the clinical interview always the starting point for counseling, psychotherapy, and case management, it also may be the end-point. This is partly because many clients stop treatment after only one therapy session.

There may be other situations where an ordinary therapy session (if there is such a thing) can suddenly transform into a clinical assessment interview. The most common example of this involves suicide assessment interviewing (see Chapter 10). If and when clients begin talking about suicide ideation or exhibiting other suicide risk factors, the usual and customary standard of practice for all mental health and healthcare professionals is to smoothly shift the clinical focus from whatever was happening to a state-of-the-art suicide assessment.

All this leads us to the stunning conclusion: Everything that happens in a full course of counseling or psychotherapy may also occur within the context of a single clinical interview—and vice versa. Although it’s usually the starting point of counseling and psychotherapy, parts of a traditional clinical interview also occur during counseling and psychotherapy, regardless of theoretical orientation. The entire range of attitudes, techniques, and strategies you learn from this text constitute the foundation of skills you’ll need for conducting more advanced and theoretically specific counseling or psychotherapy.

R and J in Field

Boys and Men, Clinical Interviewing, Counseling and Psychotherapy Theory and Practice, Personal Reflections

Cleavage, Revisited

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It’s revision time for the Clinical Interviewing textbook (the 6th edition is coming). Revision time also means revisiting time. About three years ago I posted a new proposed section for the 5th edition cleverly titled, “Straight Talk about Cleavage.”

This time around I’m posting our slightly revised version of that section. What’s new is that I’m explicitly asking and hoping for your comments and feedback. Please note that this makes me nervous, but we (Rita and I) hope your comments and feedback will help us provide more perspective and depth to our discussion. We don’t want to come across as old fogeys or rabid feminists. Instead, we want to be reasonable, thoughtful, and balanced . . . and so we’re turning to YOU.

The section is below. You can post comments directly here at Word Press for all to see or email me privately at john.sf@mso.umt.edu.

Straight Talk about Cleavage

Although we don’t have any solid scientific data upon which to base this statement, our best guess is that most of the time most people on the planet don’t engage in open conversations about cleavage. Our goal in this section is to break that norm and to encourage you to break it along with us. To start, we should confess that the whole idea of us bringing up this topic (in writing or in person) and saying something like, “Okay, we need to have a serious talk about cleavage” makes us feel terribly old. But we also hope this choice might reflect the 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 might be viewed as somewhat provocative. This includes, but is not limited to, low necklines that show considerable cleavage. Among other issues, cleavage and clothing were discussed in a series of postings on the Counselor Education and Supervision (CES) listserv back in 2012. The CES discussion inspired many of the following statements that follow. Please read these bulleted statements and consider discussing them as an educational activity.

  • 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’s true that women should be able to dress any way they want.
  • It’s also true that agencies and institutions have some rights to establish dress codes regarding 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,” a counseling or psychotherapy session 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 have a close up view of their therapist’s breasts.
  • At the very least, we think 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 (and men) 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.

Obviously, we don’t have perfect or absolute answers to the question of cleavage during a clinical interview. Guidelines depend, in part, on interview setting and specific client populations. At the very least, we recommend you take time to think about this dimension of professional attire and hope you’ll openly discuss cleavage and related issues with fellow students, colleagues, and supervisors.

Clinical Interviewing

Opportunities for Graduate Students and Professors as We Revise Our Clinical Interviewing Textbook

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Revising textbooks is a joy and a burden. When I’m first forced to face the revision process, I feel unfairly burdened. I think things like, “I thought we wrote a perfect book that would last forever. How could anyone think it needs revision?” To say that I lack the necessary enthusiasm is an understatement. I lack any enthusiasm.

However, once I dive back into the text, it’s like visiting an old friend. And in this case, the good news is that it’s like visiting an old friend whom I like very much.

Rita and I started working on the first edition of Clinical Interviewing way back in 1990. Yep. It’s a very old friend.

During the next 6-8 months, we’ll be working on the 6th edition revision. If you’re a graduate student or faculty in Counselor Education, Psychology, or Social Work, we’re looking for your help. But, as before, we really only want your help if it will be meaningful to you. If you think that might be the case, read on:

You’re invited to help in one of four ways:

1. You can choose one or more of the chapters from the fifth edition, read it (them), and offer feedback and advice on changes you think would improve the text. We can take up to three reviewers for each chapter, but more than that will overwhelm us.

2. You can provide us with feedback and recommendations for DVD content that will help in the teaching and learning of basic and advanced counseling and interviewing assessment skills. This is very important because having excellent video content facilitates learning and is one of our big goals.

3. You can provide expert analysis of specific literature related to basic counseling skills and/or advanced interviewing assessment strategies. For example, if you’re on the cutting edge of administering mental status exams (or want to be), we can work together to read and select new literature that will help us update that chapter.

4. You can develop and write up specific classroom activities that help students learn basic and more advanced interviewing skills. If your contribution in this area is original, we’ll work with you to organize your learning activity so that it can be included as a short publication in our electronic instructor’s manual.

5. If you’re an expert in a particular area and want to send us citations of your published work, we’ll review your work and consider including those citations in the 6th edition, as appropriate.

If any of these opportunities sound good to you, or, if you have other ideas, questions, or comments about our revision process, please email me directly at: john.sf@mso.umt.edu.

Thanks for considering these opportunities to contribute to the Clinical Interviewing 6th edition!

Sincerely yours,

John SF

P.S.: In case you don’t know much about this text and the accompanying DVD, here’s what a couple reviewers said:

“A superb synthesis and presentation of the key concepts any beginning student absolutely needs to know about clinical interviewing. John and Rita Sommers-Flanagan make an eloquent case that connecting with the client on a human level is the superordinate task, without which little else of value can be achieved. Replete with relevant clinical examples, helpful how-to hints, as well as pearls of clinical wisdom, this comprehensive yet accessible text is highly recommended.”—Victor Yalom, Ph.D., Founder and CEO, Psychotherapy.net

About the DVD:
“Indispensable interviewing skills imparted by two master teachers in an engaging, multimedia presentation. Following the maxim of ‘show and tell,’ the Sommers-Flanagans provide evidence-based, culture-sensitive relational skills tailored to individual clients. An instructional gem!”
— John C. Norcross, PhD, ABPP, Distinguished Professor of Psychology, University of Scranton; Editor, Psychotherapy Relationships That Work

Clinical Interviewing, Personal Reflections

The Art and Science of Clinical Interviewing (in Chicago)

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In about 10 days I’ll be on my way to Chicago to video-record five short lectures on Clinical Interviewing. Alexander Street Press is producing this video project and Dr. Sharon Dermer of Governor’s State University is hosting. The project is titled “Great Teachers, Great Courses.” [This is pretty cool and my thanks to JC for getting me included.]

I’ll be recording the morning of Tuesday, May 19, which happens to be just before Debbie Joffe Ellis, who just happens to be the wife of the late Albert Ellis. She asked to switch times with me and so I obliged, noting in an email to Dr. Dermer:

Sure. I can do morning. Besides, if I said no I would end up with the Ghost of Albert Ellis’s scratchy voice in the back of my head saying things like, “What the Holy Hell is wrong with you?”

I’d just as soon avoid that.

All this is my slightly braggy way of explaining why I’ll be writing about five upcoming blogs on Clinical Interviewing. Here we go.

What is a Clinical Interview?

Definitions can be slippery. This is especially true when our intention is to define something related to human interaction.

One of my favorite descriptions of clinical interviewing is scheduled for inclusion in the forthcoming “Handbook of Clinical Psychology.” Mostly I suppose I like this description because I wrote it (smiley face). Here it is:

In one form or another, the clinical interview is unarguably the headwaters from which all mental health interventions flow. This remarkable statement has two primary implications. First, although clinical psychologists often disagree about many important matters, the status of clinical interviewing as a fundamental procedure is more or less universal. Second, as a universal procedure, the clinical interview is naturally flexible. This is essential because otherwise achieving agreement regarding its significance amongst any group of psychologists would not be possible. (page numbers tbd)

When it comes to formal definitions, it’s clear that clinical interviewing has been defined in many ways by many authors. Some authors appear to prefer a narrow definition:

An interview is a controlled situation in which one person, the interviewer, asks a series of questions of another person, the respondent. (Keats, 2000, p. 1)

Others are more ambiguous:

An interview is an interaction between at least two persons. Each participant contributes to the process, and each influences the responses of the other. However, this characterization falls short of defining the process. Ordinary conversation is interactional, but surely interviewing goes beyond that. (Trull & Prinstein, 2013, p. 165)

Others emphasize the development of a positive and respectful relationship:

. . . we mean a conversation characterized by respect and mutuality, by immediacy and warm presence, and by emphasis on strengths and potential. Because clinical interviewing is essentially relational, it requires ongoing attention to how things are said and done, as well as to what is said and done. The emphasis on the relationship is at the heart of the “different kind of talking” that is the clinical interview. (Murphy & Dillon, 2011, p. 3)

From my perspective, the BIG goals of this “different kind of talking” can be broken into two main parts: (1) ASSESSMENT and (2) HELPING That said, I’m likely to further break these two main parts into four interrelated and overlapping parts that may or may not be formally including in a single clinical interview:

1. Establishing a therapeutic relationship
2. Collecting assessment information
3. Developing a case formulation or treatment plan
4. Providing a specific educational or psychotherapeutic intervention

What are the Goals of a Clinical Interview?

[In the following two paragraphs I’m including a more wordy and erudite way of saying the preceding . . . which is one of the things that we academics are wont to do. I should note these paragraphs are excerpted from my entry in the Encyclopedia of Clinical Psychology (2015). This piece, very recently published, is cleverly titled, “The Clinical Interview” and coauthored with Drs. Waganesh Abeje Zeleke, and Meredith H. E. Hood.]

Perhaps the clearest way to define a clinical interview is to describe its purpose or goals. Generally, there are four possible goals of a clinical interview. These include: (a) the goal of establishing (and maintaining) a working relationship or therapeutic alliance between clinical interviewer and patient; research has suggested the relationship between interviewer and patient is multidimensional, including agreement on mutual goals, engagement in mutual tasks, and development of a relational bond (Bordin, 1979; Norcross & Lambert, 2011); (b) the goal of obtaining assessment information or data about patients; in situations where the goal of the clinical interview is to formulate a psychiatric diagnosis, the process is typically referred to as a diagnostic interview; (c) the goal of developing a case formulation and treatment plan (although this goal includes gathering assessment information, it also moves beyond problem definition or diagnosis and involves the introduction of a treatment plan to a patient); (d) the goal of providing, as appropriate and as needed, a specific educational or therapeutic intervention, or referral for a specific intervention; this intervention is tailored to the patient’s particular problem or problem situation (as defined in items b and c).

All clinical interviews implicitly address the first two primary goals (i.e., relationship development and assessment or evaluation). Some clinical interviews also include, to some extent, case formulation or psychological intervention. A single clinical interview can simultaneously address all of the aforementioned goals. For example, in a crisis situation, a mental health professional might conduct a clinical interview designed to quickly establish rapport or an alliance, gather assessment data, formulate and discuss an initial treatment plan, and implement an intervention or make a referral.

What Happens During a Clinical Interview?

The range of interactions that can happen during a clinical interview is staggering. This could partly explain why we (foolishly) wrote a textbook on this topic that’s 598 pages long and includes an instructional DVD.

My son-in-law says one good way to get a flavor for any book is to put together the first and last words. In this case, our Clinical Interviewing text reads (not including the front or back matter), “This . . . culture.” To give you a further taste of “This . . . Clinical Interviewing . . . culture,” here’s a modified excerpt from the text:

Imagine sitting face-to-face with your first client. You carefully chose your clothing. You intentionally arranged the seating, set up the video camera, and completed the introductory paperwork. You’re doing your best to communicate warmth and helpfulness through your body posture and facial expressions. Now, imagine that your client:

  • Refuses to talk.
  • Talks so much you can’t get a word in.
  • Asks to leave early.
  • Starts crying.
  • Tells you that you’ll never understand because of your racial or ethnic differences.
  • Suddenly gets angry (or scared) and storms out.

Any and all of these responses are possible in an initial clinical interview. If one of these scenarios plays out, how will you respond? What will you say? What will you do?

From the first client forward, every client you meet will be different. Your challenge or mission (if you choose to accept it) is to make human contact with each client, to establish rapport, to build a working alliance, to gather information, to instill hope, and, if appropriate, to provide clear and helpful professional interventions. To top it off, you must gracefully end the interview on time and sometimes you’ll need to do all this with clients who don’t trust you or don’t want to work with you. (pp. 3-4)

In my opening Great Teachers, Great Courses lecture I’ll be focusing on the definition of the clinical interview and then limit myself to describing and demonstrating about 18 different interviewing “behaviors” or responses that clinicians who conduct clinical interviewing have at their disposal. These behaviors are named and organized into three categories. And so to help myself stop writing this blog and get back to work, I’ll wait and write about them later.

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Clinical Interviewing

Nice Review

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Victor Yalom of Psychotherapy.net recently emailed us a copy of a review of our Clinical Interviewing DVD. This is a wonderful review from someone we’ve never met . . . but we think we’d like him. He’s a professor at Western Illinois University.
Here’s an abstract of the review.
Interviewing with humanity intact.
By Knight, Tracy A.
PsycCRITIQUES, Vol 60(9), 2015, No Pagination Specified.
Abstract
Reviews the video, Clinical Interviewing: Intake, Assessment & Therapeutic Alliance by John Sommers-Flanagan and Rita Sommers-Flanagan (2014). This video blends the procedural with the human in a way that will enhance and deepen the training of mental health professionals. Beyond describing the most valuable guidelines of clinical interviewing, John and Rita Sommers-Flanagan provide multiple illustrative interviews with clearly nonscripted participants. Most importantly, the Sommers-Flanagans discuss both the information as well as the interviews, displaying both their depth of knowledge and perhaps the most important attributes of gifted clinicians: humility and curiosity. They not only provide a map, therefore, but also fully display and describe the landscape that interviewers and their clients traverse. The DVD includes seven distinct areas of focus, each one building on the previous. Initially, the authors succinctly describe basic listening skills, including both nondirective and directive approaches. Their definitions are clear and evocative, and during the sample interviews, the distinct attributes of the therapist’s actions are listed for viewers. This sets the stage for the authors’ subsequent discussion, during which they explore the dynamics of the sample interview and lucidly discuss important human factors. The reviewer concludes this video offers both knowledge and wisdom, providing students and trainees with an approach to clinical interviewing that makes the process more efficient, while always respecting the beating heart of humanity that rests within it. (PsycINFO Database Record (c) 2015 APA, all rights reserved)
Clinical Interviewing, Suicide Assessment and Intervention

Suicide Risk Factors, Part III

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It’s been awhile since I started my holiday and post-holiday look at suicide risk factors. In previous posts I focused on Demographic and Ethnic Factors related to death by suicide and then on the broad category of Mental Disorders and Psychiatric Treatment. This post focuses on Personal and Social Factors that are linked to suicide.

Not to worry, soon I’ll be moving beyond this tragic but important topic.

The following is mostly an excerpt from our Clinical Interviewing text.

Social and Personal Factors

There are a number of social and personal factors linked to increased suicide risk. Many of these factors have been reviewed and integrated into Thomas Joiner’s interpersonal theory of suicide (Joiner & Silva, 2012; Van Orden et al., 2010).

Social Isolation/Loneliness
In a review of the literature, 34 research studies were identified that include support for social isolation as a suicide risk factor (Van Orden et al., 2010). These findings provide support for Joiner’s (Joiner & Silva, 2012) attachment-informed interpersonal theory of suicide. Van Orden et al (2008) described the two primary dimensions of Joiner’s interpersonal theory:

The theory proposes that the needs to belong and to contribute to the welfare of close others are so fundamental that the thwarting of these needs (i.e., thwarted belongingness and perceived burdensomeness) is a proximal cause of suicidal desire. (Van Orden et al., 2008, p. 72)

Interpersonal theory explains why a number of social factors, such as unemployment, social isolation, reduced productivity, and physical incapacitation are associated with increased suicide risk. Specifically, research indicates that divorced, widowed, and separated people are in a higher suicide-risk category and that single, never-married individuals have a suicide rate nearly double the rate of married individuals (Van Orden et al., 2010). Based on interpersonal theory, an underlying reason that these factors are linked to suicidality is because they involve thwarted belongingness and a self-perception of being a burden to family and friends, rather than contributing in a positive way to the lives of others.

In a fairly recent study, the suicide notes of 98 active duty U.S. Air Force (USAF) members were analyzed. Using Joiner’s interpersonal theory, results indicated strong themes of hopelessness, perceived burdensomeness, and thwarted belongingness. Overall, interpersonal risk factors were communicated more often than intrapsychic risk factors. (Cox et al., 2011).

Physical Illness

Many decades of research have established the link between physical illness and suicide. Specific illnesses that confer suicide risk include brain cancer, chronic pain, stroke, rheumatoid arthritis, hemodialysis, and HIV-AIDS (e.g., (Lin, Wu, & Lee, 2009; Martiny, de Oliveira e Silva, Neto, & Nardi, 2011). Overall, although physical illness is a major predictor, several social factors appear to mediate the relationship between illness and death by suicide. In particular, Joiner’s concept of becoming a social burden seems a likely contributor to suicidal behavior, regardless of specific diagnosis (Van Orden et al., 2010). Similar to previously hospitalized psychiatric patients, medical patients also exhibit higher suicidal behavior shortly after hospital discharge (McKenzie & Wurr, 2001).

Previous Attempts

Over 27 separate studies have indicated that suicide risk is higher for people who have previously attempted (Beghi & Rosenbaum, 2010). Van Orden et al. (2010) refer to previous attempts as “. . . one of the most reliable and potent predictors of future suicidal ideation, attempts, and death by suicide across the lifespan” (p. 577).

As one example, in a 15-year prospective British study of deliberate self-harm, repeated self-harm was a strong predictor of eventual suicide, especially in young women (Zahl & Hawton, 2004). By the study’s end, 4.7% of women who had repeatedly engaged in deliberate self-harm committed suicide as compared to 1.9% in the single episode group. In this study, deliberate self-harm was defined as intentionally poisoning or self-injuring that resulted in a hospital visit. The study concluded that repeated deliberate self-harm increases suicide risk in males and females, but is a particularly salient predictor in young females. This is the case despite the fact that some clients use cutting, burning, or other forms of self-harm to aid in emotional regulation. Overall the research suggests that self-harm that rises to the level of hospitalization is likely beyond that which enhances self-regulation and instead constitutes practicing or successive approximation toward suicide.

Unemployment

Individuals who have suffered any form of recent, significant personal loss should be considered higher suicide risk (Hall, Platt, & Hall, 1999). However, in particular, unemployment is a life situation that repeatedly has been linked to suicide attempts and death by suicide. Joiner’s (2005) interpersonal theory of suicide posits that unemployment confers suicide risk at least partly because of individuals experiencing an increased sense of themselves as a burden on others. Other losses that can increase risk include (a) status loss, (b) loss of a loved one, (c) loss of physical health or mobility, (d) loss of a pet loss, and (e) loss of face through recent shameful events (Beghi & Rosenbaum, 2010; Packman, Marlitt, Bongar, & Pennuto, 2004).

Sexual Orientation

Over the years the data have been mixed regarding whether gay, lesbian, bisexual, or transgender individuals constitute a high suicide risk group. More recently, a 2011 publication in the Journal of Homosexuality reported there is no clear and convincing evidence that GLBT individuals die by suicide at a rate greater than the general population (Haas et al., 2011).
Although this is good news, the data also show that GLB populations have significantly higher suicide attempt rates. Haas et al (2011) wrote:

Since the early 1990s, population-based surveys of U.S. adolescents that have included questions about sexual orientation have consistently found rates of reported suicide attempts to be two to seven times higher in high school students who identify as LGB, compared to those who describe themselves as heterosexual. (p. 17)

Overall, it’s likely that transgender people and youth questioning their sexuality may be at increased risk for suicide attempts or death by suicide. Additionally, GLBT youth who have experienced homosexual-related verbal abuse and parental rejection for their behaviors related to gender and sexuality are more likely to engage in suicidal behaviors (D’augelli et al., 2005).

In conclusion, as you can probably see from this and the two previous posts, there are many complex and potentially interacting factors associated with increased suicide risk, but no great predictors. This is unfortunate for those of us who would like to use prediction methods to prevent and reduce suicide rates. But, at the same time, the fact that many people who experience great suffering in their lives still choose life, is a testament to human strength and resiliency.

And, speaking of resiliency, maybe I’ll be focusing on an exciting and upbeat topic like that next time. Until then, I wish you all the best in your efforts to help your clients through difficult times in their lives. Your work may be more important than you think.