This post includes a link to the powerpoiint slides for our presentation at the Association for Counselor Education and Supervision in Denver, CO. For this we offer a BIG THANKS to Sidney Shaw, Ed.D. who presented on our behalf so we could be in Erie, PA for the birth of our new granddaughter, Nora Flanagan Bodnar. Thanks Sidney!!
Category Archives: Clinical Interviewing
Strategies for Working Effectively with Challenging Clients
Working with clients who are reluctant or resistant to counseling can be very challenging . . . unless you use skills to help minimize resistance and maximize cooperation. The following is adapted from Chapter 12: Challenging Clients and Demanding Situations of the forthcoming 5th edition of Clinical Interviewing. Remember, these skills have to come from a foundation of therapist genuineness.
Using Emotional Validation, Radical Acceptance, Reframing, and Genuine Feedback
Clients sometimes begin interviews with expressions of hostility, anger, or resentment. If this is handled well, these clients may eventually open up and cooperate. The key is to refrain from lecturing, scolding, or retaliating when clients express hostility. Speaking from the consultation-liaison psychiatry perspective, Knesper (2007) noted: “Chastising and blaming the difficult patient for misbehavior seems only to make matters worse” (p. 246).
Instead, empathy, emotional validation, and concession are more effective responses. We often coach graduate students on how to use concession when power struggles emerge, especially when they’re working with adolescent clients (J. Sommers-Flanagan & Sommers-Flanagan, 2007b). For example, if a young client opens a session with, “I’m not talking and you can’t make me,” we recommend responding with complete concession of power and control: “You’re absolutely right. I can’t make you talk, and I definitely can’t make you talk about anything you don’t want to talk about.” This statement validates the client’s need for power and control and concedes an initial victory in what the client might be viewing as a struggle for power.
Empathy and Emotional Validation
Empathic, emotionally validating statements are also important. If clients express anger at meeting with you, a reflection of feeling and/or feeling validation response can let them know you hear their emotional message loud and clear. In some cases, as in the following example, therapists might go beyond empathy and emotional validation and actually join clients with a parallel emotional response:
- “Of course you feel angry about being here.”
- “I don’t blame you for feeling pissed about having to see me.”
- “I hear you saying you don’t trust me, which is totally normal. After all, I’m a stranger, and you shouldn’t trust me until you get to know me.”
- “It pretty much sucks to have a judge require you to meet with me.”
- “I know we’re being forced to meet, but we’re not being forced to have a bad time together.”
Radical Acceptance
Radical acceptance is a dialectical behavior therapy principle and technique based on person-centered theory (Linehan, 1993). It involves consciously accepting and actively welcoming any and all client comments—even odd, disturbing, or blatantly provocative comments (J. Sommers-Flanagan & Sommers-Flanagan, 2007a). For example, we’ve had experiences where clients begin their sessions with angry statements about the evils of psychology or counseling:
Opening Client Volley: I don’t need no stupid-ass counseling. I’m only here because my wife is forcing me. This counseling shit is worthless. It’s for pansy-ass wimps like you who need to sit around and talk rather than doing any real work.
Radical Acceptance Return: Wow. Thanks for being so honest about what you’re thinking. Lots of people really hate psychologists but they just sit here and pretend to cooperate. So I really appreciate you telling me exactly what you’re thinking.
Radical acceptance can be combined with reframing to communicate a deeper understanding about why clients have come for therapy. Our favorite version of this is the “Love reframe” (J. Sommers-Flanagan & Barr, 2005).
Client: This is total bullshit. I don’t need counseling. The judge required this. Otherwise, I can’t see my daughter for unsupervised visitation. So let’s just get this over with.
Therapist: I hear you saying this is bullshit. You must really love your daughter . . . to come here even when you think it’s a worthless waste of your time.
Client: (Softening) Yeah. I do love my daughter.
The magic of the love reframe is that clients nearly always agree with the positive observation about loving someone, which turns the interview toward a more pleasant focus.
Genuine Feedback
Often, when working with angry or hostile clients, there’s no better approach than reflecting and validating feelings . . . pausing . . . and then following with honest feedback and a solution-focused question.
“I hear you saying you hate the idea of talking with me, and I don’t blame you for that. I’d hate to be forced to talk to a stranger about my personal life too. But can I be honest with you for a minute? [Client nods in assent]. You know, you’re in legal trouble. I’d like to try to be helpful—even just a little. We’re stuck meeting together. We can either sit and stare at each other and have a miserable hour or we can talk about how you might dig yourself out of this legal hole you’re in. I can go either way. What do you think . . . if we had a good meeting today, what would we accomplish?”
Think about how you can incorporate, empathy, emotional validation, concession, radical acceptance, and genuine feedback into your clinical practice. For more on this, check out the 5th edition of Clinical Interviewing.
A General Guide to Using Stages of Change Principles in Clinical Interviewing
This week I’ve been working on reading and editing the page proofs for the forthcoming 5th edition of Clinical Interviewing (John Wiley & Sons). The information below is from a “Putting It Into Practice” box from the 4th chapter. It focuses on a brief Q&A regarding the application of Prochaska and DiClemente’s “Stages of Change” concept in clinical interviewing and presupposes that you have basic knowledge of that particular piece of their Transtheoretical Model.
A General Guide to Using Stages of Change Principles in Clinical Interviewing
Below we pose and answer four basic questions about how to apply stages of change principles (Prochaska & DiClemente, 2005) to guide the techniques and responses you choose to use within a clinical interviewing context.
Q1: When should I use directive techniques like psychoeducation or advice?
A1: When clients are in the action or maintenance stages of change you’re free to be more directive (provided you have useful information to share that fits with what the client recognizes as his or her problem).
Q2: When should I use less directive listening responses like paraphrasing, reflection of feeling, and summarization?
A2: As a general rule, if your client is in the precontemplative or contemplative stages of change, you should primarily use nondirective listening skills to help the client look at his or her own motivations for change. This would include: (a) attending behaviors, (b) paraphrasing, (c) clarification, (d) reflection of feeling, and (e) summarizing. Many questions, especially open questions and solution-focused or therapeutic questions, may be appropriate for clients who are precontemplative or contemplative. When you’re with clients who present as precontemplative or contemplative, your best theoretical orientation choices will likely be person-centered, motivational interviewing, and/or solution-focused. Using more directive approaches can produce defensiveness or resistance with clients in precontemplative or contemplative stages.
Q3: How do I know what stage of change my client is in?
A3: We’re tempted to suggest you’ll know it when you see it . . . and there’s some truth to that. If you try directly recommending a strategy for change and the client responds defensively, you may be moving forward too fast and it’s advisable to retreat to using reflective listening skills. Conversely, if your client seems frustrated with your nondirective listening and expresses interest in changing now, then you’ve got the green light to be more directive. Also, we recommend using George Kelly’s (1955) credulous approach to assessment, meaning you can always just directly ask clients what they prefer. In our work with parents we do this explicitly by stating something like:
“I want to emphasize that this is your consultation. And so if I’m talking too much, just tell me to be quiet and listen and I will. Or, if you start feeling like you want more advice and suggestions, let me know that as well.” (J. Sommers-Flanagan & Sommers-Flanagan, 2011, p. 60)
There are also standardized methods for assessing clients’ readiness for change. Interestingly, most of these involve asking clients very direct questions about their motivation to change, how difficult they expect change to be, and how ready they are to change (all of which seem in the spirit of George Kelly’s credulous approach; for example, see (Chung et al., 2011) for a study on the predictive validity of four different measures assessing client readiness to stop smoking cigarettes).
Q4: Is the stages of change concept supported by empirical evidence?
A4: The data are mixed on whether and how much attending to and using interventions that fit your clients’ stages of change makes a difference. Of course, this is true for nearly every phenomenon in counseling and psychotherapy. Overall, some studies show strong support for gearing your interviewing techniques to your clients’ stage of change (Johnson et al., 2008). Other studies show that stages of change focused interventions do no better than interventions that don’t tune into clients’ particular motivational stage (Salmela, Poskiparta, Kasila, Vähäsarja, & Vanhala, 2009). We recognize this isn’t the clear and decisive research outcome you might hope for, but such is the nature of our profession.
For more information on Clinical Interviewing, 5th edition, go to: http://www.wiley.com/WileyCDA/WileyTitle/productCd-1118270045.html
IS PATH WARM – An Acronym to Guide Suicide Risk Assessment
Suicide Risk Factors, Acronyms, and the Evidence Base
[This is adapted from our forthcoming 5th edition of Clinical Interviewing]
In 2003, the American Association of Suicidology brought together a group of suicidologists to examine existing research and develop an evidence-based set of near-term signs or signals of immediate suicide intent and risk. These suicidologists came up with an acronym to help professionals and the public better anticipate and address heightened suicide risk. The acronym is: IS PATH WARM and it’s outlined below:
I = Ideation
S = Substance Use
P = Purposelessness
A = Anxiety
T = Trapped
H = Hopelessness
W = Withdrawal
A = Anger
R = Recklessness
M = Mood Change
IS PATH WARM is typically referred to as evidence-based and, in fact, it was developed based on known risk factors and warning signs. Unfortunately, reminiscent of other acronyms used to help providers identify clients at high risk for suicide, in the only published study we could find that tested this acronym, IS PATH WARM failed to differentiate between genuine and simulated suicide notes (Lester, McSwain, & Gunn, 2011). Although this is hardly convincing evidence against the use of this acronym, it illustrates the inevitably humbling process of trying to predict or anticipate suicidal behavior. In conclusion, we encourage you to use the acronym in conjunction with the comprehensive and collaborative suicide assessment interviewing process described in our chapter in the Clinical Interviewing textbook. See: http://www.amazon.com/Clinical-Interviewing-2012-2013-John-Sommers-Flanagan/dp/1118390113/ref=sr_1_1?s=books&ie=UTF8&qid=1373655813&sr=1-1
After talking about IS PATH WARM in workshops over the past year or so, it seems important to emphasize that these “risk” factors are near-term risk factors. Other, very important longer-term risk factors, are not included. For example, previous attempts and clinical depression aren’t even on the list. And, although they include withdrawal, it seems that words like isolation or loneliness capture this dimension of risk at least as well.
The point of my criticism is to emphasize that even the best suicidologists on the planet struggle in their efforts to identify the most important immediate and longer-term suicide risk factors. This is primarily because suicide is nearly always unpredictable and one of the reasons that it’s unpredictable is because it occurs, on average in the U.S. in 13 people per 100,000. The other side of this dialectical coin is that, of course, we need to try to predict it and prevent it anyway.
You can check out more details about IS PATH WARM on many different internet sites, including a description of its origin provided by the American Association of Suicidology: http://www.suicidology.org/c/document_library/get_file?folderId=231&name=DLFE-598.pdf
A Summary Checklist of Strategies and Techniques for Managing Client Resistance
One friend of mine who is a therapist has a very deep voice. Years ago, we were both seeing lots of boys who were often angry. These boys were also, no big surprise, resisting the advice and direction of authority figures, like parents and teachers. Several times I got a chance to work with young male clients who had “blown out” of therapy with my friend.
They described him as frightening. They said he would joke about having a “rack” in the back room in his office building and threaten to take them there if they wouldn’t talk. For young clients who got his sense of humor and who could see past his deep voice, his style worked very well. But for other youth, a kinder and gentler approach with less room for misinterpretation was needed.
In the following excerpt from Clinical Interviewing (5th edition), Rita and I are just finishing our discussion of why clients lie and resist counseling. Most of our thinking in this are is based on a combination of motivational interviewing and our own counseling and psychotherapy experiences-like the one described above. Following the end of our brief comments about lying and resistance, we include a summary table listing strategies and techniques for dealing with resistant clients that might be helpful to you. If you want more information about this, feel free to email me at john.sf@mso.umt.edu and I can send you an article or a chapter on working with resistant youth. Here’s the excerpt:
. . . . There are many reasons why clients lie, most involving some form of self-protection or the belief that they profit from lying. As a general rule (with exceptions), people tend to lie more if they feel the need to lie and tend to lie less when they experience trust. As a consequence, your goal is to build an alliance that includes enough trust to facilitate honesty. Confrontation of obvious or subtle lying behavior may be less productive than waiting for rapport and trust to build and for honest disclosure to flow more naturally. This perspective or stance can be a relief; when in the role of therapist (and not judge) facts are usually less important than feelings. To summarize, resistance, or whatever we choose to call it, is a natural part of the change process. In fact, research suggests that client resistance is an opportunity for deeper work. When resistance is worked through, the likelihood for positive outcomes is increased (Mahalik, 2002).
In the end, it’s helpful to remember that resistance emanates from the very center of a person and is part of the force that gives people stability and predictability in their interactions with others. Resistance exists because change and pain are often frightening and more difficult to face than retaining the old ways of being, even when the old ways are maladaptive. Finally, with culturally or developmentally different clients, resistance may actually be caused when the therapist refuses or fails to make culturally or developmentally sensitive modifications in his or her approach (J. Sommers-Flanagan & Sommers-Flanagan, 2007b). Table 12.1 includes a summary of strategies and techniques for managing resistance.
| Table 12.1 Summary Checklist of Strategies and Techniques for Managing Resistance | |
| ____ | 1. Adopt an attitude of acceptance and understanding because developing a therapeutic alliance is almost always a higher priority than confrontation. |
| ____ | 2. Recognize that clients will feel some ambivalence about working toward and achieving positive change. |
| ____ | 3. Resist your impulses to teach, preach, and persuade clients to make “healthy” decisions. |
| ____ | 4. In the beginning and throughout the session, ask open-ended questions that are linked to potential positive goals. |
| ____ | 5. Look for positive goals that are underlying your clients emotional pain and discouragement—and then help your client be the one who articulates those goals. |
| ____ | 6. Use simple reflection to reduce clients’ needs to exhibit resistance. |
| ____ | 7. Use concession “You’re right. I can’t make you talk with me” to affirm to clients that they’re in control of what they say to you. |
| ____ | 8. Use amplified reflection to encourage clients to discuss the healthier side of their ambivalence. |
| ____ | 9. Use emotional validation when clients are angry or hostile. |
| ____ | 10. Use radical acceptance to compliment clients for their openness—even though the openness may be aggressive or disturbing. |
| ____ | 11. Reframe client hostility and negativity into more positive impulses whenever possible. |
| ____ | 12. Provide genuine feedback related to your concerns to your clients. |
| ____ | 13. Use paradox carefully to respectfully come up alongside clients’ resistance. |
| ____ | 14. If you’re concerned about truthfulness, get signed consent and then interview a significant other to help you get an accurate story. |
| ____ | 15. When clients ask “Do you believe me?” use a response that will encourage more disclosure, like, “I’m not here to judge the truth, but just to listen and try to be of help.” |
| ____ | 16. Remember (and be glad) that you’re a mental health professional and not a judge. |
From Clinical Interviewing (5th edition). See: http://www.wiley.com/WileyCDA/Section/id-302475.html?query=John+Sommers-Flanagan
DSM-5 and the Universal Diagnostic Exclusion Criteria
Sometimes, even when someone appears to meet all the diagnostic criteria for a mental disorder, assigning a psychiatric diagnosis is still not the right thing to do.
In the following excerpt from the forthcoming 5th edition of Clinical Interviewing, we offer an example of when and why psychiatric diagnosis is inappropriate (see: http://lp.wileypub.com/SommersFlanagan/). We refer to this as the “Three-Dimensional Universal Exclusion Criterion” which is our highly esoteric way of saying, “Whoa on psychiatric diagnosis until you’ve checked to see if there’s an alternative explanation for the observed behaviors!”
Multicultural Highlight 6.2
The Three-Dimensional Universal Exclusion Criterion: Is the Behavior Rationally or Culturally Justifiable or Caused by a Medical Condition?
Let’s say you meet with a client for an initial interview. During the interview the client describes an unusual belief (e.g., she believes she is possessed because someone has given her the “evil eye”). This belief is clearly dysfunctional or maladaptive because it has caused her to stop going out of her house due to fears that an evil spirit will overtake her and she will lose control in public. She also acknowledges substantial distress and her staying-at-home-and-being-anxious behavior is disturbing her family. In this case it appears you’ve got a solid diagnostic trifecta—her belief-behavior is (a) maladaptive, (b) distressing, and (c) disturbing to others. How could you conclude anything other than that she’s suffering from a psychiatric disorder?
This situation illustrates why diagnosis (see Chapter 10) is a fascinating part of mental health work. In fact, if the client has a rational justification for her belief-behavior . . . or if there’s a reasonable cultural explanation . . . or if the belief-behavior is caused by a medical condition—then it would be inappropriate to conclude that she has a mental disorder. One source of support for a universal exclusion criterion is the DSM-5. It includes the statement: “The level of severity and meaning of the distressing experiences should be assessed in relation to the norms of the individual’s cultural reference groups” (American Psychiatric Association, 2013, p. 750).
To explore our three-dimensional “universal” exclusion principle in greater depth, partner up with one or more classmates and discuss the following questions:
Can you think of any rational explanations for the client’s belief-behavior?
Can you think of any reasonable cultural explanations for the client’s belief-behavior?
Can you think of any underlying medical conditions that might explain her belief-behavior?
After you’ve finished discussing the preceding questions, see how many new examples you can think of where a client presents with symptoms that are (a) dysfunctional/maladaptive, (b) distressing, and (c) disturbing to others. Then discuss potential rational explanations, cultural explanations, and medical conditions that could produce the symptoms (e.g., you could even use something as simple as major depressive symptoms and explore how rational, cultural, or medical explanations might account for the symptoms, thereby causing you to defer the diagnosis.
Recommendations for Developing and Using a Positive Working Alliance
Although Freud started the conversation, he might not recognize contemporary models of the working alliance. This is because Freud advocated analyst emotional distance and a detached psychoanalytic stance, whereas today’s working alliance involves therapists initiating a process of collaborative engagement with clients.
Therapists who want to develop a positive working alliance (and that should include all therapists) will integrate strategies for doing so during initial interviews and beyond. Based on Bordin’s (1979) model, alliance-building strategies would focus on (a) collaborative goal setting; (b) engaging clients on mutual therapy-related tasks; and (c) development of a positive emotional bond. Additionally, feedback monitoring within clinical interviews is recommended.
Initial interviews and early sessions appear especially important to developing a working alliance. Many clients who enter your office will be naïve about what will be happening in their work with you. This makes including role inductions or explanations of how you work with clients essential. Here’s an example from a cognitive-behavioral perspective:
For the rest of today’s session, we are going to be doing a structured clinical interview. This interview assesses a range of different psychological difficulties. It is a way to make sure that we “cover all of our bases.” We want to see if social anxiety is the best explanation for your problems and also whether you are having any other difficulties that we should be aware of. (Ledley, Marx, & Heimberg, 2010, p. 36)
Asking direct questions about what clients want from counseling and then listening to them and integrating that information into your treatment plan is also important: In cognitive therapy this is often referred to as making a problem list (J. Beck, 2011).
Therapist: What brings you to counseling and how can I be of help?
Client: I’ve just been super down lately. You know. Tough to get up in the morning and face the world. Just feeling pretty crappy.
Therapist: Then we definitely want to put that on our list of goals. Can I write that down? [Client nods assent] How about for now we write, “Find ways to help you start feeling more up?”
Client: Sounds good to me.
Engaging in a collaborative goal-setting process—and not proceeding with therapy tasks until it’s clear that mutual goals (even temporary mutual goals) have been established
Therapist: So far I’ve got three goals written down: (1) Find ways to help you start feeling more up, (2) Help you deal with the stress of having your sister living with you and your family, and (3) Improving your attitude about exercising. Does that sound about right?
Client: Absolutely yes. If we can climb those three mountains it will be great.
Soliciting feedback from clients during the initial session and ongoing in an effort to monitor the quality and direction of the working alliance. Although there are a number of instruments you can use for this, you can also just ask directly:
We’ve been talking for 20 minutes now and so I just want to check in with you on how you’re feeling about talking with my today. How are you doing with this process?
Making sure you’re able to respond to client anger or hostility without becoming defensive or launching a counterattack is essential to establishing and maintaining a positive working relationship. In our work with challenging young adults, we apply Linehan’s (1993) “radical acceptance” concept. For example, an initial session with an 18-year-old male started like this:
Therapist: I want to welcome you to therapy with me and I hope we can work together in ways you find helpful.
Client: You talk just like a shrink. I punched my last therapist in the nose (client glares at therapist and awaits a response) (J. Sommers-Flanagan & Bequette, 2013, p. 15).
Therapist: Thanks for telling me about that. I definitely want to avoid getting punched in the nose. And so if I accidentally say anything that offends you I hope you’ll tell me, and I’ll try my best to stop.
In this case the therapist accepted the client’s aggressive message and tried to transform it into a working concept in the session.
Having specific therapy tasks (no matter your theoretical orientation) that fit well with the mutually identified therapy goals. For example, if illuminating unconscious processes is a mutually identified goal, then using free association can be a task that makes sense to the client. On the other hand, if you’ve agreed to work toward greater self-acceptance and greater acceptance of frustrating people in the client’s life, then engaging in intermittent mindfulness tasks will feel like a reasonable approach.
Why Therapists Should Never Say, “I know how you feel”
The following excerpt is adapted from the fifth edition of the text, Clinical Interviewing (John Wiley & Sons, 6th edition forthcoming in October).
**********************************************************************
Many writers have tried operationalizing Carl Rogers’s core conditions. However, efforts to transform person-centered therapy core conditions into specific behavioral skills always seem to fall short. As Natalie Rogers (J. Sommers-Flanagan, 2007) emphasized, trying to translate the core conditions into concrete behaviors is usually a sign that the writer or therapist simply doesn’t understand person-centered principles.
This lack of understanding occurs principally because core Rogerian attitudes are attitudes, not behaviors. This is a basic conceptual principle that has proven difficult to understand—perhaps especially for behaviorists. The point Rogers was making then (in the 1950s), and that still holds today, is that therapists should enter the consulting room with (a) deep belief in the potential of the client; (b) sincere desire to be open, honest, and authentic; (c) palpable respect for the individual self of the client; and (d) a gentle focus on the client’s inner thoughts, feelings, and perceptions. Further complicating this process is the fact that the therapist must rely primarily on indirectly communicating these attitudes because efforts to directly communicate trust, congruence, unconditional positive regard, and empathic understanding is nearly always contradictory to each of the attitudes.
A counselor educator friend of ours, Kurt Kraus, articulated why trying to directly communicate understanding is problematic. He wrote:
When a supervisee errantly says, “I know how you feel” in response to a client’s disclosure, I twitch and contort. I believe that one of the great gifts of multicultural awareness is for me accepting the limitations to the felt-experience of empathy. I can only imagine how another feels, and sometimes the reach of my experience is so short as to only approximate what another feels. This is a good thing to learn. I’ll upright myself in my chair and say, “I used to think that I knew how others felt too. May I teach you a lesson that has served me well?” (J. Sommers-Flanagan & Sommers-Flanagan, 2012) (p. 146)
Kraus’s lesson is an excellent one for all of us. The phrases, “I know how you feel” and “I understand” should be stricken from the vocabulary of counselors and psychotherapists.
The DSM-5 as Poetry
This morning I was trying to make fun of the DSM-5. My strategy was to read passages from the DSM-5 Introduction to Rita after breakfast. Somehow, I must have read them slowly and poetically because Rita really liked the passages . . . which I didn’t expect.
Rita’s response inspired me to place the DSM passages into an appropriate poetry format. And so although I’ve taken the liberty to title and format the words based on my own judgments, the words themselves are taken directly from the DSM-5 (with page numbers cited, so you can find them yourselves).
Diagnosing Peter Piper
The symptoms in our diagnostic criteria
are part
of
the relatively limited repertoire
of
human emotional responses to
internal
and
external stresses
that are generally maintained in a
homeostatic balance
without a disruption in normal functioning.
It requires clinical training to recognize
when the combination
of
predisposing,
precipitating,
perpetuating,
and
protective
factors
has resulted in a
psychopathological
condition in which
physical signs and symptoms exceed
normal
ranges. [From the DSM-5, p. 19]
Shifting Boundaries and Thresholds
The boundaries between normality and pathology
vary
across cultures
for specific types
of behaviors.
Thresholds of tolerance
for specific symptoms
or behaviors
differ
across cultures,
social settings,
and families.
Hence,
the level at which an experience becomes problematic
or pathological
will differ. (DSM-5, p. 14)
The Exciting New Preface from Clinical Interviewing (5th edition)
It’s hard to adequately express the excitement surrounding the upcoming publication of the DSM-5. Oops. I meant to write: “the 5th edition of Clinical Interviewing.” I knew there was a 5 in there somewhere.
To help the many world citizens eagerly anticipating this 5th edition, I’m including, hot off of my computer, the first part of the preface. I know . . . it really couldn’t get much more exciting than this.
Who knows, soon I might even be releasing the second part of the preface to this long-awaited masterpiece. [I hope you all can recognize the sarcasm I’m directing toward myself when you read this. It’s just that I’m working on the preface right now and I felt the need to post something on my blog . . . and these two things suddenly merged in space and time.]
Here it is.
Preface
Clinical interviewing is the cornerstone for virtually all mental health work. It involves integrating varying degrees of psychological or psychiatric assessment and treatment. The origins of clinical interviewing long precede the first edition of this text (published in 1993).
The term interview dates back to the 1500s, originally referring to a face-to-face meeting or formal conference. The term clinical originated around 1780; it was used to describe a dispassionate, supposedly objective bedside manner in the treatment of hospital patients. Although difficult to determine precisely when clinical and interview were joined in modern use, it appears that Jean Piaget used a variant of the term clinical interview in 1920 to describe his approach to exploring the nature and richness of children’s thinking. Piaget referred to his procedure as a semi-clinical interview (see Sommers-Flanagan, Zeleke, & Hood, in press).
Our initial exposure to clinical interviewing was in the early 1980s in a graduate course at the University of Montana. Our professor was highly observant and intuitive. We would huddle together around an old cassette player and listen to fresh new recordings of graduate students interviewing perfect strangers. Typically, after listening to about two sentences our professor would hit the pause button and prompt us: “Tell me about this person.”
We didn’t know anything, but would offer limited descriptions like “She sounds perky” or “He says he’s from West Virginia.” He would then regale us with predictions. “Listen to her voice,” he would say, “she’s had rough times.” “She’s depressed, she’s been traumatized, and she’s come to Montana to escape.”
The eerie thing about this process was that our professor was often correct in what seemed like wild predictions. These sessions taught us to respect the role of astute observations, experience, and intuition in clinical interviewing.
Good intuition is grounded on theoretical and practical knowledge, close observation, clinical experience, and scientific mindedness. Bad intuition involves personalized conclusions that typically end up being a disservice to clients. Upon reflection, perhaps one reason we ended up writing and revising this book is to provide a foundation for intuition. In fact, it’s interesting that we rarely mention intuition in this text. Although one of us likes to make wild predictions of the future (including predictions of the weather on a particular day in Missoula, Montana, about three months in advance), we still recognize our limitations and encourage you to learn the science of clinical interviewing before you start practicing the art.
Language Choices
We live in a postmodern world in which language is frequently used to construct and frame arguments. The words we choose to express ourselves cannot help but influence the message. Because language can be used to manipulate (as in advertising and politics), we want to take this opportunity to explain a few of our language choices so you can have insight into our biases and perspectives.
Patients or Clients or Visitor
Clinical interviewing is a cross-disciplinary phenomenon. While revising this text we sought feedback from physicians, psychologists, social workers, and professional counselors. Not surprisingly, physicians and psychologists suggested we stick with the term patient, whereas social workers and counselors expressed strong preferences for client. As a third option, in the Mandarin Chinese translation of the second edition of this text, the term used was visitor.
After briefly grappling with this dilemma, we decided to primarily use the word client in this text, except for cases in which patient is used in previously quoted material. Just as Carl Rogers drifted in his terminology from patient to client to person, we find ourselves moving away from some parts and pieces of the medical model. This doesn’t mean we don’t respect the medical model, but that we’re intentionally choosing to use more inclusive language that emphasizes wellness. We unanimously voted against using visitor—although thinking about the challenges of translating this text to Mandarin made us smile.
Sex and Gender
Consistent with Alfred Adler, Betty Freidan, contemporary feminist theorists, and American Psychological Association (APA) style, we like to think of ourselves as promoting an egalitarian world. As a consequence, we’ve dealt with gender in one of two ways: (1) when appropriate, we use the plural clients and their when referring to case examples; and (2) when necessary, we alternate our use between she and he.
Interviewer, Psychotherapist, Counselor or Therapist
While working at a psychiatric hospital in 1980, John once noticed that if you break down the word therapist it could be transformed into the-rapist. Shocked by his linguistic discovery, he pointed it out to the hospital social worker, who quipped back, “That’s why I always call myself a counselor!”
This is a confusing issue and difficult choice. For the preceding four editions of this text we used the word interviewer because it fit so perfectly with the text’s title, Clinical Interviewing. However, we’ve started getting negative feedback about the term. One reviewer noted that he “hated it.” Others complained “It’s too formal” and “It’s just a weird term to use in a text that’s really about counseling and psychotherapy.”
Given the preceding story, you might think that we’d choose the term counselor, but instead we’ve decided that exclusively choosing counselor or psychotherapist might inadvertently align us with one professional discipline over another. The conclusion: Mostly we use therapist and occasionally we leave in the term interviewer and also allow ourselves the freedom to occasionally use counselor, psychotherapist, and clinician.
John Sommers-Flanagan 