Every chapter in Clinical Interviewing has several pop-out boxes titled, “Practice and Reflection.” In this–the latest–edition, we added many that include the practice and perspective of diverse counselors and psychotherapists. Here’s an example from Chapter One.
PRACTICE AND REFLECTION 1.3: AM I A GOOD FIT? NAVIGATING ETHNIC MATCHING IN PRIVATE PRACTICE
The effects of ethnic matching on counseling outcomes is mixed. In some cases and settings, and with some individuals, ethnic matching improves treatment frequency, duration, and outcomes; in other cases and settings, ethnic matching appears to have no effects in either direction (Olaniyan et al., 2022; Stice et al., 2021). Overall, counseling with someone who is an ethnic/cultural match is meaningful for some clients, while other clients obtain equal meaning and positive outcomes working with culturally different therapists.
For clients who want to work with therapists who have similar backgrounds and experiences, the availability of ethnically-diverse therapists is required. In the essay below, Galana Chookolingo, Ph.D., HSP-P, a licensed psychologist, writes of personal and professional experiences as a South Asian person in independent practice.
On a personal note, being from a South Asian background in private practice has placed me in a position to connect with other Asians/South Asians in need of culturally-competent counseling. In my two years in solo private practice, I have had many individuals reach out to me specifically because of my ethnicity and/or the fact that I am also an immigrant to the U.S. (which I openly share on my website). These individuals hold an assumption that I would be able to relate to a more collectivistic worldview. Because I offer free consultations prior to meeting with clients for an intake, I have had several clients ask directly about my ability to understand certain family dynamics inherent to Asian cultures. I have responded openly to these questions, sharing the similarities and differences I am aware of, as well as my limitations, since I moved to the U.S. before age 10. For the most part, I have been able to connect with many clients of Asian backgrounds; this tends to be the majority of my caseload at any given time.
As you enter into the multicultural domain of counseling and psychotherapy, reflect on your ethnic, cultural, gender, sexual, religious, and ability identities. As a client, would you prefer working with someone with a background or identity similar to yours? What might be the benefits? Alternatively, as a client, might there be situations when you would prefer working with someone who has a background/identity different than yours? If so, why and why not?
Reflecting on Dr. Chookolingo’s success in attracting and working with other Asian/South Asian people . . . what specific actions did she take to build her caseload? How did she achieve her success?
[End of Practice and Reflection 1.3]
For more info on ethnic matching, see these articles:
Olaniyan, F., & Hayes, G. (2022). Just ethnic matching? Racial and ethnic minority students and culturally appropriate mental health provision at British universities. International Journal of Qualitative Studies on Health and Well-being, 17(1), 16. doi:https://doi.org/10.1080/17482631.2022.2117444
Stice, E., Onipede, Z. A., Shaw, H., Rohde, P., & Gau, J. M. (2021). Effectiveness of the body project eating disorder prevention program for different racial and ethnic groups and an evaluation of the potential benefits of ethnic matching. Journal of Consulting and Clinical Psychology, 89(12), 1007-1019. doi:https://doi.org/10.1037/ccp0000697
The following excerpt is from our freshly published textbook, Clinical Interviewing (2024, 7th edition, Wiley).
What Is a Clinical Interview?
Clinical interviewing is a flexible procedure that mental health professionals use to initiate treatment. In 1920, Jean Piaget first used the words “clinical” and “interview” together in a way similar to contemporary practitioners. He believed existing psychiatric interviewing procedures were inadequate for studying cognitive development in children, so he invented a “semi-clinical interview.”
Piaget’s approach was novel. His semi-clinical interview combined tightly standardized interview questions with unstandardized or spontaneous questioning to explore the richness of children’s thinking processes (Elkind, 1964; J. Sommers-Flanagan et al., 2015). Interestingly, the tension between these two different interviewing approaches (i.e., standardized vs. spontaneous) continues today. Psychiatrists and research psychologists primarily use structured, or semi-structured clinical interviewing approaches. Structured clinical interviews involve asking the same questions in the same order with every client. Structured interviews are designed to gather reliable and valid assessment data. Virtually all researchers agree that a structured clinical interview is the best approach for collecting reliable and valid assessment data.
In contrast, clinical practitioners, especially those who embrace post-modern and social justice perspectives, generally use less structure. Unstructured clinical interviews involve a subjective and spontaneous relational experience. These less structured relational experiences are typically used to collaboratively initiate an assessment or counseling process. Murphy and Dillon (2015) articulated the latter (less structured) end of the interviewing spectrum:
We believe that clinical interviewing is—or should be—a conversation that occurs in a relationship 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. . . . we believe that clinicians need to work in collaboration with clients . . . (p. 4)
Research-oriented psychologists and psychiatrists who value structured clinical interviews for diagnostic purposes would likely view Murphy and Dillon’s description of this “conversation” as a bane to reliable assessment. In contrast, clinical practitioners often view highly structured diagnostic interviewing procedures as too sterile and impersonal. Perhaps what’s most interesting is that despite these substantial conceptual differences—differences that are sometimes punctuated with passion—structured and unstructured approaches represent legitimate methods for conducting clinical interviews. A clinical interview can be structured, unstructured, or a thoughtful combination of both. (See Chapter 11 for a discussion of clinical interviewing structure.)
Formal definitions of the clinical interview emphasize its two primary functions or goals (J. Sommers-Flanagan, 2016; J. Sommers-Flanagan et al., 2020):
Assessment
Helping (including referrals)
To achieve these goals, all clinical interviews involve the development of a therapeutic relationship or working alliance. Optimally, the therapeutic relationship provides leverage for obtaining valid and reliable assessment data and/or providing effective interventions.
With all this background in mind, we define clinical interviewing as…
a complex, multidimensional, and culturally sensitive interpersonal process that occurs between a professional service provider and client. The primary goals are (a) assessment and (b) helping. To achieve these goals, clinicians may emphasize structured diagnostic questioning, spontaneous talking and listening, or both. Clinicians use information obtained in an initial clinical interview to develop a collaborative case formulation and treatment plan.
Given this definition, students often ask: “What’s the difference between a clinical interview and counseling or psychotherapy?” This is an excellent question that deserves a nuanced response. . . . [to be continued]
Yesterday I had a chance to do a 3-hour online workshop with a very cool group of about 22 smart, skilled, and dedicated professionals. They engaged with the content and consequently, we had some great discussions. One of the discussions has kept percolating for me today. The topic: How do we handle situations where clients are clearly suicidal, but are reluctant or unwilling to develop and agree to a collaborative safety plan.
We talked about how, often, the knee-jerk impulse is to pursue hospitalization. While that’s a viable and reasonable option, the problem is that hospitalization and discharge is a notable risk factor for death by suicide. The other problem is that it’s pretty much impossible for us to know if the client’s resistance to a safety plan indicates increased risk, or just resistance to what s/he/they view as a coercive mandate.
There’s no perfect clinician response to this dilemma. Hospitalization helps some clients, and causes demoralization and regression in others. Not hospitalizing can feel too risky for practitioners.
We talked about a few guidelines in dealing with this conundrum. They include: (a) consulting with colleagues, (b) reflecting on the client’s engagement in other aspects of treatment (increased engagement in treatment is a protective factor), (c) evaluating client intent and client impulsivity, and (d) documenting your decision-making process (including citations indicating that psychiatric hospitalization may not be the best alternative). But again, there’s no perfect guideline.
When discussing Kate’s situation and other scenarios that involve outpatient work with highly suicidal clients, the following question usually comes up, “What if your judgment is wrong and she either makes a suicide attempt, or she kills herself before your next session?” This is a great question and gets to the core of practitioner anxiety.
The answer is that, yes, she could kill herself, and if she does, I’ll feel terrible about my clinical judgment. Also, I might get sued. And, if I’m inclined toward suicidal thoughts myself, Kate killing herself might precipitate a suicidal crisis in me. Sometimes suicide tragedies happen, and sometimes we will feel like the tragedy was our fault and that we should have or could have prevented it. That said, most suicides are more or less unpredictable. Even if you think you’re correct in categorizing someone as high or low risk, chances are you’ll be wrong; many high-risk clients don’t die by suicide and some low-risk clients do (see Sommers-Flanagan, 2021, for a personal essay on coping with the death of a client to suicide; https://www.psychotherapynetworker.org/magazine/article/2565/the-myth-of-infallibility).
More depressing is the reality that hospitalization – the main therapeutic option we turn to when clients are highly suicidal – isn’t very effective at treating suicidality and preventing suicide (Large & Kapur, 2018). Hospitalization sometimes causes clients to regress and destabilize, and suicide risk is often higher after hospitalization (Kessler et al., 2020). Because hospitalization isn’t a good fit for many clients who are suicidal and because we can’t predict suicide very well anyway, some cutting edge suicide researchers recommend intensive safety planning as a viable (and often preferred) alternative to hospitalization. In the case of Kate, as long as she’s willing to collaborate, and I’m able to contact her husband, and we can construct a plan that provides safety, then I’m on solid professional ground (or at least as solid as professional ground gets when working with highly suicidal clients).
Kessler, R. C., Bossarte, R. M., Luedtke, A., Zaslavsky, A. M., & Zubizarreta, J. R. (2020). Suicide prediction models: A critical review of recent research with recommendations for the way forward. Molecular Psychiatry, 25(1), 168-179. doi:http://dx.doi.org/10.1038/s41380-019-0531-0
Large, M. M., & Kapur, N. (2018). Psychiatric hospitalisation and the risk of suicide. The British Journal of Psychiatry, 212(5), 269-273.
The idea that healthcare professionals must take an authoritarian role when evaluating and treating suicidal clients has proven problematic (Konrad & Jobes, 2011). Authoritarian clinicians can activate oppositional or resistant behaviors (Miller & Rollnick, 2013). If you try arguing clients out of suicidal thoughts and impulses, they may shut down and become less open.
For decades, no-suicide contracts were a standard practice for suicide prevention and intervention (Drye et al., 1973). These contracts consisted of signed statements such as: “I promise not to commit suicide between my medical appointments.” In a fascinating turn of events, during the 1990s, no-suicide contracts came under fire as (a) coercive and (b) as focusing more on practitioner liability than client well-being (Edwards & Sachmann, 2010; Rudd et al., 2006). Suicide experts no longer advocate using no-suicide contracts.
Instead, collaborative approaches to working with suicidal clients are strongly recommended. One such approach is the collaborative assessment and management of suicide (CAMS; Jobes, 2016). CAMS emphasizes suicide assessment and intervention as a humane encounter honoring clients as experts regarding their suicidal thoughts, feelings, and situation. Jobes and colleagues (2007) wrote:
CAMS emphasizes an intentional move away from the directive “counselor as expert” approach that can lead to adversarial power struggles about hospitalization and the routine and unfortunate use of coercive “safety contracts.” (p. 285)
Yesterday I had the honor of presenting for the Mental Health Academy’s Mental Health Super Summit. My presentation, titled “Interviewing for Happiness: How to Weave Positive Psychology Magic into the Initial Clinical Interview” is still available, along with the other presentations, through this link: https://www.mentalhealthacademy.com.au/summit. There were 24 hours of possible continuing education for an incredibly low cost. Presenters included, Dr. Judith Beck and Dr. Cirecie West-Olatunji Professor, Xavier University of Louisiana, and me! You can access my powerpoints here:
Participating in this event was an honor also because the event is a fundraiser for “Act for Kids,” an Australian charity “that delivers evidence-led professional therapy and support services to children and families who have experienced or are at risk of harm.” Over $110K has already been raised. Here’s the Act for Kids link: https://www.actforkids.com.au/.
Back in the day, I was so into person-centered (aka nondirective) listening that I coauthored a 1989 article in the journal Teaching of Psychology titled, “Thou Shalt Not Ask Questions.” The point was that by temporarily eliminating questions from our therapeutic repertoire, we grow more aware of how to listen without using directive methods for facilitating client talk.
I’m still a fan of limiting therapist questions, if only to become more aware of their power. Even in the case of solution-focused or narrative therapies, when questions are the central therapeutic strategy, we should be as person-centered as possible when asking questions.
Below, I’ve included an excerpt of our coverage of listening from the forthcoming 7th edition of Clinical Interviewing. In the early 1990s, along with the first edition of Clinical Interviewing, we described a concept called the listening continuum. The excerpt starts there and then focuses in on what’s likely the most non-directive skill of all, therapeutic silence.
Here’s the excerpt. I hope you enjoy it and find it useful.
The Listening Continuum in Three Parts
Nondirective listening behaviors give clients responsibility for choosing what to talk about. Consistent with person-centered approaches, using nondirective behaviors is like handing your clients the reins to the horse and having them take the lead and choose where to take the session. In contrast, directive listening behaviors (Chapter 5) and directive action behaviors (Chapter 6) are progressively less person-centered. These three categories of listening behaviors (and the corresponding chapters) are globally referred to as the listening continuum. To get a visual sense of the listening continuum, see Table 4.1.
Nondirective Listening Behaviors on the LEFT Edge (Chapter 4)
Directive Listening Behaviors in the MIDDLE (Chapter 5)
Directive Action Behaviors on the RIGHT Edge (Chapter 6)
Attending behaviors or minimal encouragers
Feeling validation
Closed and therapeutic questions
Therapeutic silence
Interpretive reflection of feeling
Psychoeducation or explanation
Paraphrase
Interpretation (classic or reframing)
Suggestion
Clarification
Confrontation
Agreement/disagreement
Reflection of feeling
Immediacy
Giving advice
Summary
Open questions
Approval/disapproval
Urging
The ultimate goal is for you to use behavioral skills along the whole listening continuum. We want you to be able to apply these skills intentionally and with purpose. That way, when you review a video of your session with a supervisor, and your supervisor stops the recording and asks, “What exactly were you doing there?” you can respond with something like this:
I was doing an interpretive reflection of feeling. The reason I chose an interpretive reflection is that I thought the client was ready to explore what might be under their anger.
Trust us; this will be a happy moment for both you and your supervisor.
Hill (2020) organized the three listening continuum categories in terms of their primary purpose:
We hope you still (and will always) remember the Rogerian attitudes and have placed them firmly in the center of your developing therapeutic self. In addition, at this point we hope you understand the two-way nature of communication, the four different types of attending behaviors, and how your listening focus can shift based on a variety of factors, including culture and theoretical orientation.
Next, we begin coverage of technical skills needed to conduct a clinical interview. See Table 4.2 for a summary of nondirective listening behaviors and their usual effects. Having already reviewed attending behaviors, we now move to therapeutic silence.
Therapeutic Silence
Most people feel awkward about silence in social settings. Some researchers have described that therapists-in-training view silence as a “mean” response (Kivlighan & Tibbits, 2012). Despite the angst it can produce, silence can be therapeutic.
Therapeutic silence is defined as well-timed silence that facilitates client talk, respects the client’s emotional space, or provides clients with an opportunity to find their own voice regarding their insights, emotions, or direction. From a Japanese perspective,
Silence gives forgiveness and generosity to human dialogues in our everyday life. Without silence, our conversation tends to easily become too clever. Silence is the place where “shu”… (to sense the feeling of others, and forgive, show mercy, absolve, which represents an act of benevolence and altruism) arises, which Confucius said was the most important human attitude. (Shimoyama, 1989/2012, p. 6; translation by Nagaoka et al., 2013, p. 151)
Table 4.2 Summary of Nondirective Listening Behaviors and Their Usual Effects
Listening Response
Description
Primary Intent/Effect
Attending behaviors
Eye contact, leaning forward, head nods, facial expressions, etc.
Facilitates or inhibits client talk.
Therapeutic silence
Absence of verbal activity
Allows clients to talk. Provides “cooling off ” or introspection time. Allows clinician time to consider next response.
Paraphrase
Reflecting or rephrasing the content of what the client said
Assures clients that you heard them accurately and allows them to hear what they said.
Clarification
Restating a client’s message, preceded or followed by a closed question (e.g., “Do I have that right?”)
Clarifies unclear client statements and verifies the accuracy of what the clinician heard.
Reflection of feeling
Restatement or rephrasing of clearly stated emotion
Enhances clients’ experience of empathy and encourages further emotional expression.
Summary
Brief review of several topics covered during a session
Enhances recall of session content and ties together or integrates themes covered in a session.
Silence also allows clients to reflect on what they just said. Silence after a strong emotional outpouring can be therapeutic and restful. In a practical sense, silence also allows therapists time to intentionally select a response rather than rush into one.
In psychoanalytic psychotherapy, silence facilitates free association. Psychoanalytically oriented therapists use role induction to explain to clients that psychoanalytic therapy involves free expression, followed by occasional therapist comments or interpretations. Explaining therapy or interviewing procedures to clients is always important, but especially so when therapists are using potentially anxiety-provoking techniques, such as silence (Meier & Davis, 2020).
CASE EXAMPLE 4.2: EXPLAIN YOUR SILENCE
While on a psychoanalytically oriented internship, I (John) noticed one supervisor had a disturbing way of using silence during therapy sessions (and in supervision). He would routinely begin sessions without speaking. He sat down, looked at his client (or supervisee), and leaned forward expectantly. His nonverbal behavior was unsettling. He wanted clients and supervisees to free associate and say whatever came to mind, but he didn’t explain, in advance, what he was doing. Consequently, he came across as intimidating and judgmental. The moral of the story: Use role induction—if you don’t explain the purpose of your silence, you risk scaring away clients.
[End of Case Example 4.2]
Examples of How to Talk About Silence
Part of the therapist’s role involves skilled explanations of process and technique. This includes talking about silence. Case Example 4.2 is a good illustration of how therapist and client would have been better served if the therapist had explained why he started his sessions with silence.
Here’s another example of how a clinician might use silence therapeutically:
Katherine (they/them) is conducting a standard clinical intake interview. About 15 minutes into the session the client begins sobbing about a recent romantic relationship break-up. Katherine provides a reflection of feeling and reassurance that it’s okay to cry, saying, “I can see you have sad feelings about the break-up. It’s perfectly okay to honor those feelings in here and take time to cry.” They follow this statement with about 30 seconds of silence.
There are several other ways Katherine could handle this situation. They might prompt the client,
Let’s take a moment to sit with this and notice what emotions you’re feeling and where you’re feeling them in your body.
Or they might explain their purpose more clearly.
Sometimes it’s helpful to sit quietly and just notice what you’re feeling. And sometimes you might have emotional sensations in a particular part of your body. Would you be okay if we take a few moments to be quiet together so you can tune in to your emotions and where you’re feeling them?
In each of these scenarios, Katherine explains, at least briefly, the use of silence. This is crucial because when clinicians are silent, pressure is placed on clients to speak. When silence continues, the pressure mounts, and client anxiety may increase. In the end, clients may view their experience with an excessively silent therapist as aversive, lowering the likelihood of rapport and a second meeting.
Guidelines for Using Silence Therapeutically
Using silence may initially feel uncomfortable. With practice, you’ll increase your comfort level. Consider the following suggestions:
When a client pauses after making a statement or after hearing your paraphrase, let a few seconds pass rather than jumping in verbally. Given an opportunity, clients can move naturally into important material without guidance or urging.
As you’re waiting for your client to resume speaking, tell yourself that this is the client’s time for self-expression, not your time to prove you can be useful.
Try not to get into a rut regarding silence. When silence occurs, sometimes wait for the client to speak next and other times break the silence yourself.
Be cautious with silence if you believe your client is confused, psychotic, or experiencing an acute emotional crisis. Excessive silence and the anxiety it provokes can exacerbate these conditions.
If you feel uncomfortable during silent periods, use attending skills and look expectantly toward clients. This helps them understand it’s their turn to talk.
If clients appear uncomfortable with silence, give them instructions to free associate (e.g., “Just say whatever comes to mind”). Or you can use an empathic reflection (e.g., “It’s hard to decide what to say next”).
Remember, sometimes silence is the most therapeutic response available.
Read the interview by Carl Rogers (Meador & Rogers, 1984). It includes examples of how Rogers handled silence from a person-centered perspective.
Remember to monitor your body and face while being silent. There’s a vast difference between a cold silence and an accepting, warm silence. Much of this difference results from body language and an attitude that welcomes silence.
Use your words to explain the purpose of your silence (e.g., “I’ve been talking quite a lot, so I’m just going to be quiet here for a few minutes so you can have a chance to say whatever you like”). Clients may be either happy or terrified at the chance to speak freely.
John Wiley and Sons recently informed me of the excellent and exciting news that the 7th edition of Clinical Interviewing (CI7) has gone to press and will drop in the U.S. on or before September 30. Our wish for this edition is the same as previous editions: To provide research-based, theoretically supported, clinically insightful, and culturally informed education and training on how to conduct basic and advanced clinical interviews.
The Resource
Part of CI7 includes video updates. Most of the updates offer greater representation of culturally diverse counselors and psychotherapists. For example, the video link below features Dr. Devika “Dibya” Choudhuri describing a “grounding” technique that she uses when conducting tele-mental health (aka virtual) clinical interviews, the topic of Chapter 14.
Although you may have your own approaches to facilitating grounding during tele-mental health sessions, I believe Dr. Choudhuri’s idea is innovative and may be a resource that you can add to your toolkit.
Stay tuned, because over the next several weeks I’ll be posting additional fresh new text and video content from CI7.
The Request
Traditionally, publishers ask authors to gather promotional endorsements for new books. This time around, maybe because it’s the 7th edition, neither Wiley nor the absent-minded authors of CI7 thought about gathering endorsements. In the past, we’ve had Derald Wing Sue, John Norcross, Victor Yalom, Pamela Hays, Barbara Herlihy, Allen Ivey, David Jobes, and Marianne and Jerry Corey write short blurbs. Here’s what Derald Wing Sue said about the 6th edition:
The most recent edition of Clinical Interviewing is simply outstanding. It not only provides a complete skeletal outline of the interview process in sequential fashion, but fleshes out numerous suggestions, examples, and guidelines in conducting successful and therapeutic interviews. Well-grounded in the theory, research and practice of clinical relationships, John and Rita Sommers-Flanagan bring to life for readers the real clinical challenges confronting beginning mental health trainees and professionals. Not only do the authors provide a clear and conceptual description of the interview process from beginning to end, but they identify important areas of required mastery (suicide assessment, mental status exams, diagnosis and treatment electronic interviewing, and work with special populations). Especially impressive is the authors’ ability to integrate cultural competence and cultural humility in the interview process. Few texts on interview skills cover so thoroughly the need to attend to cultural dimensions of work with diverse clients. This is an awesome book written in an engaging and interesting manner. I plan to use this text in my own course on advanced professional issues. Kudos to the authors for producing such a valuable text.
―Derald Wing Sue, Ph.D., Professor of Psychology and Education, Teachers College, Columbia University
This time around, we’re less than two weeks from publishing and are without formal endorsements. As a consequence, I’m asking: “Is there ANYBODY out there who has read a portion of the CI7 manuscript or used a previous edition, who would like to share their thoughts about how the book influenced you or how the videos helped with your training?
[I know this last paragraph sounds pathetic. However, if you know me, you probably know my sense of humor, and the “Is there anybody out there?” call is BOTH a sincere request for your input AND me mocking myself for making this request.]
To be completely serious: If you want to share something positive about your experience—from any point in time—with the Clinical Interviewing text, I hope you’ll write a sentence or two or three (you don’t have to write half a page, like Derald Wing Sue) on the particular ways in which you found the book and/or videos meaningful to you.
To share your thoughts on any edition of the text, please post them here on this blog, or send them to me at john.sf@mso.umt.edu.
Thanks very much for considering this request. Please, please, I hope someone “out there” is listening!
I just finished a nice session on the strengths-based approach to suicide with the NDCA. They asked for a little extra info/emphasis on working with men, because men are particularly vulnerable to suicide, and so I wove in some of the content from my ACA presentation with Matt Englar-Carlson and Dan Salois (thanks Matt and Dan!).
The ppt below is a big one because it includes an embedded video featuring a young man who articulates a number of potential suicide related drivers, including trauma (be forewarned: the content is intense and potentially triggering).
A big thanks to the NDCA organizers and to the attendees who were very impressive.
Hardly anyone with common sense or social skills ever argues about whether or not relationship factors are crucial to effective counseling and psychotherapy. Nevertheless, some scientists are reluctant to put relationship factors on par with counseling and psychotherapy techniques or procedures. IMHO, relationship factors are every bit as essential as so-called empirically-supported treatments.
This post is a pitch. Or it might be a pitch in a post. Either way, I am honored to share with you a hot-off-the-presses new book, titled Relationship Factors in Counseling, by Dr. Kimberly Parrow. Here’s the publisher’s link: https://titles.cognella.com/relationship-factors-in-counseling-9781793578754. The book is also available on Amazon and other booksellers.
Below, I’m pasting the Foreword to this book. Not only am I jazzed about the book, I’m also jazzed about the Foreword. You should read it. It’s really good. You’ll learn about Kimberly Parrow, as well as a bit of trivia about relationship factors that you should definitely know. I haven’t mentioned who wrote the Foreword, but I’m sure you’ll figure it out.
I first met Kimberly Parrow, before she was Dr. Kimberly Parrow, in a letter of recommendation from a psychology professor at the University of Montana. Having read well over 1,000 letters of recommendation over the years, this one imprinted in my brain. The professor wrote something like, “Kimberly Parrow is the real deal. You should admit her to master’s program in clinical mental health counseling. You will never regret it.”
We did (admit her into our master’s program . . . and our doctoral program). And we didn’t (ever regret it).
Kim Parrow was, is, and continues to be one of the most enthusiastic learners I’ve encountered. She walked onto our campus at 44-years-old, as a first-generation college student, having waited with bated breath for the money and opportunity to pursue her college degree. Nine years later she strolled off campus with her bachelor’s, master’s, and doctoral degrees. If we were Notre Dame, we’d call her a triple domer (n.b., that’s what you call people with three degrees from Notre Dame). At the University of Montana, we just call her amazing.
In one of her first doctoral classes, I introduced Kim to the concept of evidence-based relationship factors (EBRFs). She was hooked; hooked in the way that only graduate students get hooked. She was hooked by an idea. So hooked that she immediately wanted more; she wanted to write a journal article on EBRFs (so we did). She wanted to do her dissertation on EBRFs (so she did). She wanted to do extra additional trainings for practicum and internship students on EBRFs (and so she did). Kim’s attraction to EBRFs stemmed from her belief that relationships constitute the core of what’s therapeutic. As we explored EBRFs together, noting all the research supporting the idea that relationships drive counseling and psychotherapy, I came to see that Kim’s judgment was, and continues to be, practically perfect.
I’ve been reading dissertations for 30+ years. I’m embarrassed to say that I find reading most dissertations—even those written by students whom I love—drudgery. But Kim’s dissertation was electric. Page by page, she kept surprising me with new content and new learning; it was more than I expected. Kim had taken the basic knowledge and skills linked to EBRFs, contextualized them within the scientific literature, and then wrote about them in ways that inspired me to keep reading and keep learning. As she wrote more, her writing got better and better, and the content more illuminating.
About a month ago, I was unable to make it to my initial lecture for an advanced counseling theories course. I asked Kim to fill in. She quickly said yes. I offered to pay her. She quickly said no. To stick with the money theme, if I now had a dollar for every time one of my students has, since Kim’s lecture, mentioned Kim Parrow, eyes agog, and referenced the central role of relationship factors in counseling and psychotherapy, I would have many dollars. What I’m trying to say is that Kim is a natural and talented clinician-teacher. That’s a rare version of the real deal her former developmental psychology professor was trying to tell us about.
And now, a few words about this book. Kim has done what most scholars and professionals are unable to do. She has taken theoretical principles, empirical research findings, blended them with her common-sense-salt-of-the-earth style, and created a practical guide for helping counselors and psychotherapists be better. The book is aimed to slide into the educational development of practicum and/or internship students who have learned microskills and are facing their first clients. This particular point in student development is crucial; it’s a time when students sometimes lose their way as they try to make the improbable leap from microskills to counseling and psychotherapy techniques. In making that leap, they often fall prey to the urge to quickly “prove up” and “do something” with clients. In this process, they often abandon their microskills and forget about the therapeutic relationship. Kim’s overall point is this: Don’t forget about the therapeutic relationship because relationship factors are every bit as evidence-based as theory-based or research-based technical strategies. The renowned writer-researcher John C. Norcross put it this way:
Anyone who dispassionately looks at effect sizes can now say that the therapeutic relationship is as powerful, if not more powerful, than the particular treatment method a therapist is using.
The fact that therapeutic relationships are empirically supported makes Kim’s content relevant not only to students early in their clinical development, but also to all of us. Having taught this content with Kim, and to groups of professional counselors, psychologists, and social workers across the United States, I can say without hesitation that the content in this book can and will make all of us better therapists.
Kim covers 10 specific, evidence-based interactive relationship skills. What unique—and possibly the best thing about Kim’s coverage of relationship skills—is that she provides specific, actionable guidance for how to enact these 10 skills. As a preview, the 10 skills include:
Cultural humility
Congruence
Unconditional Positive Regard
Empathic Understanding
The Emotional Bond
Mutual Goal-Setting
Collaborative Therapeutic Tasks
Rupture and Repair
Countertransference Management
Progress Monitoring
In the pages that follow, you will get a taste of Kim Parrow’s relational orientation and a glimpse of the evidence supporting these 10 relationship factors as therapeutic forces that innervate counseling process. You will also experience the magic of a talented clinician-teacher. The magic—or, if you prefer, secret sauce—is Kim’s ability to make these distant intellectual relationship concepts real, practical, and actionable. To help make relationship concepts real, she has engaged several contributers (and herself) to write pedagogical break-out boxes titled, “Developing Your Skills.” Engaging with these skill development activities will, as the neuroscience fans like to say, “Change your brain” and help you develop neural pathways to enhance your relational connections.
As I write about skills and skill development, I’m aware that Carl (and Natalie) Rogers would view the reduction of his core conditions to “skills” as blasphemy. This awareness makes me want to emphasize that Kim “gets” Rogerian core conditions and does not reduce them into simple skills. Instead, she embraces the attitudinal and intentional dimensions of Rogerian core conditions, while simultaneously offering behaviors and words that counselors and psychotherapists can try on in hopes of expressing congruence, unconditional positive regard, and empathy.
I’ve had a few conversations with Derald Wing Sue over the years and he has always emphasized that culture in counseling and psychotherapy shouldn’t be relegated to a separate chapter at the end of the book—as if culture is ever a separate or standalone issue. Reading how Kim handles culture reminded me of Derald Wing Sue’s message. Instead of relegating it to the end, Kim begins with the relationship factor of cultural humility. That makes for a beautiful start. Cultural humility involves, above all else, the adoption of a non-superiority interpersonal stance. . . which is a simple and excellent anti-racist message. But Kim doesn’t stop talking about culture after Chapter 1. She does what Derald Wing Sue recommends: She integrates cultural awareness, knowledge, and skill development into the whole book. This stance—non-superiority and anti-racist—is consistent with Kim’s interpersonal style and is also the right place to start as counselors set about the journey to collaborate and co-create positive outcomes.
One of Kim’s writing goals is to offer ideas and activities that are likely to increase counselor cognitive complexity. You can see that in the two preceding paragraphs. Instead of reducing Rogerian core conditions into skills, she honors how they can become both attitudes and skills. And instead of putting culture into a silo, she spreads seeds of culture through all her chapters.
This book is a remarkable accomplishment. The language, the examples, the science, the skill development activities, and the tone, welcome readers to engage with this book, and bring the material to life. I believe if you read this book and engage in the activities, your counselor self-efficacy will grow.
For anyone who has gotten this far in reading this foreword, I have some reading tips to share. First, read this book with your heart wide open. I say this because this book is about the heart of the counselor or psychotherapist. Second, as you read, keep yourself in relationship with Kim. The book is about relational factors and the details Kim shares will not only help you in your relationships with clients, but, as she often reminded me and other people whom she cornered so she could talk to us about relational factors, these relationship factors are relevant and applicable to all relationships.
Obviously, I respect Dr. Kimberly Parrow and believe she has produced an excellent book. Obviously, I think you should read this book and do as so many of us have already done, learn about evidence-based relationship factors from someone who is a remarkably talented clinician-teacher. To paraphrase what that developmental psychology professor wrote about Kim many years ago, you should accept Kim Parrow into your personal program of learning immediately, and begin learning from her as soon as you can. You will not regret it.
All my best to you in your counseling and psychotherapy work.
Now that we’ve sent the 7th edition of our Clinical Interviewing textbook to the publisher, I’ve got more time on my hands. So, along with springtime mowing, gardening, weed-eating, NYT games, and hanging upside down in our basement, I did the natural thing that people do when they’ve got extra time: I Googled “What is Clinical Interviewing?”
Along with a few links to our books and videos, I also find lots of new (to me) and interesting information and resources. Cool.
Then I realized I should probably create a blogpost titled, “What is Clinical Interviewing?” because I’m pretty sure I’m not the only one who wants to know the answer to that scintillating question.
Because we’ve already written a ton on this topic, rather than re-invent the wheel, below, I’ve excerpted a couple pages from Chapter 1, where we discuss and define the clinical interview. Here we go . . .
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Chapter Orientation
Clinical interview is a common phrase used to identify an initial and sometimes ongoing contact between a mental health professional and client. Depending on many factors, this contact includes varying proportions of psychological assessment and biopsychosocial intervention. For many different mental health disciplines, clinical interviewing begins the treatment process. In this chapter we focus on the definition of clinical interviewing, foundational multicultural competencies, and a model for learning how to conduct clinical interviews.
Welcome to the Journey
When we blend our unique talent with service to others, we experience the ecstasy and exultation of our own spirit, which is the ultimate goal of all goals. — Deepak Chopra, The Seven Spiritual Laws for Parents, 1997, p. 23
Imagine you’re face-to-face with your first client. You’ve carefully chosen your clothing. You intentionally arranged the seating, set up the camera, and completed introductory paperwork. In the opening moments of your session, you’re communicating warmth, acceptance, and compassion through your body posture and facial expressions. Now, imagine your client
Immediately offends you with language, gestures, or hateful beliefs
Refuses to talk
Talks so much you can’t get a word in
Asks to leave early
Starts crying
Says you can never understand or be helpful because of ethnic, religious, or sexual differences
Suddenly gets angry (or scared) and storms out
These are all possible client behaviors in a first interview. If one of these scenarios occurs, how will you respond? What will you say? What will you do? Will you be able to have kindness, honesty, and compassion guide your response?
Every client presents unique challenges. Your goals are to establish rapport, build a working alliance, gather information, instill hope, maintain a helpful yet nonjudgmental attitude, identify treatment goals, develop a case formulation, and, if appropriate, provide therapy interventions. You also want to gracefully end the interview on time. And sometimes, you’ll need to do all this with clients who don’t trust you or who don’t want to work with you.
These are no small tasks—which is why it’s important to be patient with yourself. Becoming a competent mental health professional takes time and practice. Being imperfect is natural. You’ll need persistence, an interest in developing your intellect, interpersonal skills, emotional awareness, therapeutic skills, compassion, authenticity, and courage. Due to the ever-evolving nature of this business, you’ll need to be a lifelong learner to stay current and skilled. Despite all these demands, most mental health professionals who practice self-care and stress management are satisfied with their career choice (Bellamy et al., 2019).
The clinical interview is the most fundamental component of mental health training in professional counseling, psychiatry, psychology, and social work (Allen & Becker, 2019; Sommers-Flanagan et al., 2020). The clinical interview is the basic unit of connection between the helper and the person seeking help; it is the beginning of a therapeutic relationship and the cornerstone of psychological assessment; it is also the focus of this book.
This text will help you acquire fundamental and advanced clinical interviewing skills. The chapters guide you through elementary listening skills onward to more advanced, complex professional activities, such as mental status examinations, suicide assessment, and diagnostic interviewing. We enthusiastically welcome you as new colleagues and fellow learners.
For many of you, this text accompanies your first taste of practical, hands-on mental health training experience. For those of you who already possess substantial clinical experience, this book may place your previous experiences in a new or different learning context. Whichever the case, we hope this text challenges you and helps you develop excellent skills for conducting professional clinical interviews.
What Is a Clinical Interview?
VIDEO 1.2**
Clinical interviewing is a flexible procedure that mental health professionals use to initiate treatment. In 1920, Jean Piaget first used the words “clinical” and “interview” together in a way similar to contemporary practitioners. He believed existing psychiatric interviewing procedures were inadequate for studying cognitive development in children, so he invented a “semi-clinical interview.”
Piaget’s approach was novel. His semi-clinical interview combined tightly standardized interview questions with unstandardized or spontaneous questioning to explore the richness of children’s thinking processes (Elkind, 1964; J. Sommers-Flanagan et al., 2015). Interestingly, the tension between these two different interviewing approaches (i.e., standardized vs. spontaneous) continues today. Psychiatrists and research psychologists primarily use structured, or semi-structured clinical interviewing approaches. Structured clinical interviews involve asking the same questions in the same order with every client. Structured interviews are designed to gather reliable and valid assessment data. Virtually all researchers agree that a structured clinical interview is the best approach for collecting reliable and valid assessment data.
In contrast, clinical practitioners, especially those who embrace post-modern and social justice perspectives, generally use less structure. Unstructured clinical interviews involve a subjective and spontaneous relational experience. These less structured relational experiences are typically used to collaboratively initiate an assessment or counseling process. Murphy and Dillon (2015) articulated the latter (less structured) end of the interviewing spectrum:
We believe that clinical interviewing is—or should be—a conversation that occurs in a relationship 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. . . . we believe that clinicians need to work in collaboration with clients . . . (p. 4)
Research-oriented psychologists and psychiatrists who value structured clinical interviews for diagnostic purposes would likely view Murphy and Dillon’s description of this “conversation” as a bane to reliable assessment. In contrast, clinical practitioners often view highly structured diagnostic interviewing procedures as too sterile and impersonal. Perhaps what’s most interesting is that despite these substantial conceptual differences—differences that are sometimes punctuated with passion—structured and unstructured approaches represent legitimate methods for conducting clinical interviews. A clinical interview can be structured, unstructured, or a thoughtful combination of both. (See Chapter 11 for a discussion of clinical interviewing structure.)
Formal definitions of the clinical interview emphasize its two primary functions or goals (J. Sommers-Flanagan, 2016; J. Sommers-Flanagan et al., 2020):
Assessment
Helping (including referrals)
To achieve these goals, all clinical interviews involve the development of a therapeutic relationship or working alliance. Optimally, the therapeutic relationship provides leverage for obtaining valid and reliable assessment data and/or providing effective interventions.
With all this background in mind, we define clinical interviewing as…
a complex, multidimensional, and culturally sensitive interpersonal process that occurs between a professional service provider and client. The primary goals are (a) assessment and (b) helping. To achieve these goals, clinicians may emphasize structured diagnostic questioning, spontaneous talking and listening, or both. Clinicians use information obtained in an initial clinical interview to develop a collaborative case formulation and treatment plan.
Given this definition, students often ask: “What’s the difference between a clinical interview and counseling or psychotherapy?” This is an excellent question that deserves a nuanced response.
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Sorry to leave you hanging with such an exciting question.
In our Clinical Interviewing text, we open each chapter with a quotation. One of my favorite of all time is from Ursula K. LeGuin (the Left Hand of Darkness). She wrote: “
It is good to have an end to journey towards; but it is the journey that matters, in the end.” (p. 109)
Last week, we finished our year-long journey of revising Clinical Interviewing into the 7th edition. The last publication date was 2017, so this is, IMHO, a significant and important revision. With the help of the Amazing Dylan Wright, we recently uploaded the supplementary videos (there are over 100 clips that align with all of the textbook learning objectives). In the video recording process, we had much help, partly because this edition weaves in greater representation from professionals with diverse identities. Over the next several months, I will be posting additional sneak-peeks, including identity-diverse case examples and video clips. Stay tuned.
For today, I’m posting a rough copy of the final (of the 100+) Clinical Interviewing videos. In this one, I’m lamenting—while Rita consoles me—that our imperfect video recording project is ending. This video was recorded and produced by the multi-talented and aforementioned Dylan Wright, who took the liberty (as he often does in one way or another) of inserting laugh-tracks to help viewers “get” our silly efforts to be funny.
You may wonder why Rita and I are on our cell phones during this clip. It’s because the last chapter is about clinical interviewing and technology. That’s just one example of how hilarious we are.
John Sommers-Flanagan 