Most people intuitively know that emotions are a central, complex, and multidimensional part of human experience. Emotions are typically in response to perceptions, include sensations, and are at the root of much of our existential meaning-making. Emotions are at the heart (not literally, of course) of much of the motivation that underlies behavior.
What follows is another excerpt from Clinical Interviewing (7th edition). In this excerpt, we define and explore the use of an interpretive reflection of feeling as a tool to go deeper into emotion and meaning with clients. As with all things interpretive, I recommend proceeding with caution, respect, and humility. . . because sometimes clients aren’t interested in going deeper and will push back in one way or another.
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Interpretive Reflection of Feeling (aka Advanced Empathy)
Interpretive reflections of feeling are emotion-focused statements that go beyond obvious emotional expressions. Sometimes referred to as advanced empathy (Egan, 2014), interpretive reflection of feeling is based on Rogers’s (1961) idea that sometimes person-centered therapists work on emotions that are barely within or just outside the client’s awareness.
By design, interpretive reflections of feeling go deeper than surface feelings or emotions, uncovering underlying emotions and potentially producing insight (i.e., the client becomes aware of something that was previously unconscious or partially conscious). Nondirective reflections of feeling focus on obvious, clear, and surface emotions; in contrast, interpretive reflections target partially hidden, deeper emotions.
Consider again the 15-year-old boy who was so angry with his teacher.
Client: That teacher pissed me off big time when she accused me of stealing her phone. I wanted to punch her.
Counselor: You were pretty pissed off. (reflection of feeling)
Client: Damn right.
Counselor: I also sense that you have other feelings about what your teacher did. Maybe you were hurt because she didn’t trust you. (interpretive reflection of feeling)
The counselor’s second statement probes deeper feelings that the client didn’t directly articulate.
An interpretive reflection of feeling may activate client defensiveness. Interpretations require good timing (Fenichel, 1945; Freud, 1949). That’s why, in the preceding example, the counselor initially used a nondirective reflection of feeling and then, after that reflection was affirmed, used a more interpretive response. W. R. Miller and Rollnick (2002) made this point in Motivational Interviewing:
Skillful reflection moves past what the person has already said, though not jumping too far ahead. The skill is not unlike the timing of interpretations in psychodynamic psychotherapy. If the person balks, you know you’ve jumped too far, too fast. (p. 72)
Interpretive reflections of feeling assume clients will benefit from going “vertical” or deeper into understanding underlying emotions; they can have many effects, the most prominent include the following:
If offered prematurely or without a good rationale, they may feel foreign or uncomfortable; this discomfort can lead to client resistance, reluctance, denial, or a relationship rupture (Parrow, 2023).
When well stated and when a positive therapy relationship exists, interpretive reflections of feeling may feel supportive because therapists are “hearing” clients at deeper emotional levels; this can lead to enhanced therapist credibility, strengthening of the therapeutic relationship, and collaborative pursuit of insight.
Interpretive reflections of feeling are naturally invasive. That’s why timing and a good working alliance are essential. When using interpretive reflections of feeling, follow these principles.
Wait until:
You have good rapport or a positive working alliance.
Your clients have experienced you accurately hearing and reflecting their surface emotions.
You have evidence (e.g., nonverbal signals, previous client statements) that provide a reasonable foundation for your interpretation.
Phrase your interpretive statement:
Tentatively (e.g., “If I were to guess, I’d say…”)
Collaboratively (e.g., “Correct me if I’m wrong, but…”)
The need to phrase statements tentatively and collaboratively is equally true when using any form of feedback or interpretation. Many different phrasings can be used to make such statements more acceptable.
I think I’m hearing that you’d like to speak directly to your father about your sexuality, but you’re afraid of his response.
Correct me if I’m wrong, but it sounds like your anxiety in this relationship is based on a deeper belief that she’ll eventually discover you’re unlovable.
If I were to guess, I’d say you’re wishing you could find your way out of this relationship. Does that fit?
This may not be accurate, but the way you’re sitting seems to communicate not only sadness but also some irritation.
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I hope this content has been of some interest or use to you in your work. If you want a bit more, a couple of emotion-related case examples are at the link below (and you can always buy the book:)).
In my last post, I reviewed the most basic of all therapeutic emotional responses, the reflection of feeling. As noted yesterday, reflections of feeling are, by definition, neutral . . . and providing a neutral reflection has benefits and liabilities.
For clients who have a history of experiencing negative judgments and oppression, instead of remaining neutral, it may be necessary to be explicitly validating. In Chapter 5 of our Clinical Interviewing textbook, we begin by describing and providing examples of the technique called “Feeling Validation.”
If you’re tracking closely, you’ll recall that a reflection of feeling is on the left side of the “listening continuum” and feeling validation is in the center of the listening continuum. Below, you’ll find information on using feeling validation from the Clinical Interviewing text.
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Directive Listening Skills
Directive listening skills are advanced interviewing techniques that encourage clients to examine and possibly change their thoughts, emotions, and behaviors. Directive listening skills can be used for assessment, exploring client issues, and facilitating insight. They include:
Feeling validation
Interpretive reflection of feeling
Interpretation (psychoanalytic or reframing)
Confrontation
Immediacy
Questions
Directive listening skills place you in an expert role. The therapist’s behaviors in this chapter range from being mostly client centered to mostly therapist centered. Client-centered directives zero in on what the client is already talking about, but take clients deeper. Therapist-centered directives shift clients toward what they’re not yet talking about. Directive listening skills operate on the assumption that clients will benefit from guidance or direction.
Feeling Validation
Reflections of feeling (discussed in Chapter 4) are often confused with feeling validation. The difference is that reflections of feeling are more purely client centered, whereas feeling validation includes your opinion, approval, or validation of client emotions. A feeling validation is an emotion-focused technique that acknowledges and validates your client’s explicit feelings. It’s a message that communicates, “What you’re feeling is a natural or normal emotional response.” Feeling validation is an emotional affirmation.
The difference between reflecting feelings versus validating feelings may seem subtle, but it provides an excellent example of the complexities of skillful interviewing. Skilled interviewers use reflection of feeling as a method to prompt clients to evaluate their own emotions. In contrast, they use feeling validation as a method to support and reassure clients. Feeling validation includes a psychoeducational-authoritative-reassurance component. Novice interviewers may not be aware of the difference.
Psychoanalytic clinicians distinguish between supportive and expressive psychotherapy techniques. Based on this distinction, feeling validation is a supportive technique, and feeling reflection is an expressive technique. Clients usually feel supported and more normal when you validate their emotions. Clients may experience greater stress if you use reflections of feeling to have them examine and judge the validity of their own emotions.
Supportive techniques like feeling validation are outside-in self-esteem boosters. They’re based on the therapist (as an outside authority) saying something like “Your anger in response to being unfairly accused of stealing something seems natural.” One drawback of outside-in self-esteem boosters is that they don’t facilitate self-discovery. The boost that comes from external emotional validation may be temporary and not lead to lasting client change. If clients come to rely on validation of their feelings, they may continue to look outward for external validation.
All approaches to feeling validation give clients the message, “Your feelings are acceptable, and you have permission to feel them.” You might even use feeling validation to suggest to clients that they should be having particular feelings.
Client 1: I’ve been so sad since my mother died. I can’t seem to stop myself from crying. (Client begins sobbing.)
Therapist 1: It’s okay to feel sad about losing your mother. That’s perfectly normal. Crying in here as you talk about it is a natural response.
The preceding exchange involves validation. By openly stating that feeling sad and crying is normal, the therapist takes on an expert or educator role.
Another way to provide feeling validation is through self-disclosure:
Client 2: I get so anxious before taking tests, you wouldn’t believe it! All I can think about is how I’m going to freeze up and forget everything. Then, when I get to class and look at the test, my mind just goes blank.
Therapist 2: I remember feeling the same way about tests.
In this example, the therapist uses self-disclosure to validate the client’s anxiety. Although using self-disclosure to validate feelings can be reassuring, it’s not without risk. Clients may wonder if therapists can be helpful with anxiety symptoms if they have similar anxieties. Self-disclosure can also enhance therapist credibility, as a client may think, “Hmm. If my therapist went through test anxiety too, maybe he’ll understand and be able to help me.” Using self-disclosure to validate client emotions can diminish or enhance therapist credibility—depending on the client and the therapeutic relationship (see Case Example 5.1).
Therapists can also use universality to validate or reassure clients.
Client 3: I always compare myself to everyone else—and I usually come up short. I wonder if I’ll ever feel confident.
Therapist 3: You’re being hard on yourself. I don’t know anyone who feels a complete sense of confidence.
Clients may feel validated when they observe or are informed that nearly everyone else in the world (or universe) feels similar emotions. Yalom provided a personal example:
During my own 600-hour analysis I had a striking personal encounter with the therapeutic factor of universality… I was very much troubled by the fact that, despite my strong positive sentiments [towards my mother], I was beset with death wishes for her, as I stood to inherit part of her estate. My analyst responded simply, “That seems to be the way we’re built.” That artless statement not only offered considerable relief but enabled me to explore my ambivalence in great depth. (Yalom & Leszcz, 2020, p. 7)
Feeling validation is a common technique. People like to have their feelings validated; and, often, counselors like validating their clients’ feelings. However, open support, such as feeling validation, can reduce client exploration of important issues (i.e., clients assume they’re fine if their therapist says so).
Potential effects of feeling validation include:
Enhanced rapport
Increased or reduced client exploration of the problem or feeling (this could go either direction)
Reduction in client anxiety, at least temporarily
Enhanced client self-esteem or feelings of normality (perhaps only temporarily)
Possible increased client-therapist dependency
In many clinical scenarios, clinicians lead with less directive skills (i.e., Chapter 4) before using more directive skills (i.e., Chapter 5). However, there are some clinical situations where feeling validation or affirmation of clients take priority.
As you think about feeling validation, and all the complexities it can include, consider the following case example.
CASE EXAMPLE 5.1: Struggling to Manage the Impulse to Project My Disability Issues onto a Client
Eddy Fagundo, Ph.D., CRC, CVE, a Senior Manager of Education Content for the American Counseling Association wrote an essay on managing his impulse to project his own issues and lived experiences onto a client. Have you ever worked with someone who reminded you of yourself? Imagine yourself in Dr. Fagundo’s role. Would you be able to manage your impulses to be too comforting and too validating? Although this case is about countertransference, projection, and overidentification with the client, it’s also about appropriately validating self-disclosure and countertransference management.
“Mommy Rosemary, why does Eddy speak Russian?’” was an odd question that had become common for my friends (at age 5-years) to ask my mother . . . in Cuba. What my friends did not know was that I was not speaking Russian; I was speaking Spanish, or so I thought! Growing up, I had speech problems, but was determined to overcome them. I never missed any of my speech therapy appointments and was disciplined in practicing the difficult Spanish rolling Rs in front of the mirror before and after school. I did it! In third grade, I won the best reader in class award. Life was bright. Little did I know, that four years later, I would immigrate to the United States, and learn a new language. But I did this too!
These memories flashed before my eyes when counseling a young Cuban immigrant male with a speech impediment. The client felt defeated, isolated, and had low expectations of himself. I was conflicted; this young man was me as a child. If I could overcome my speech problems, I wanted to tell him: He could too! At the time, I was a new rehabilitation counselor. The situation made me keenly aware of potential projection issues. I knew I could not tell the client what to do. I knew I could not tell him he would be able to succeed, just as I did, because I was no more special than he was.
And so, I consulted my colleagues and supervisor. I focused on being aware of and bracketing my feelings and reactions, and on building a therapeutic relationship. I accepted the client unconditionally and respected his right to be himself without having me project my lived experiences onto him. Instead, I used my lived experiences therapeutically by professionally and appropriately self-disclosing my past struggles with speech problems. Counselor self-disclosure, when done sparingly and effectively, builds trust, fosters empathy, and strengthens the counseling relationship.
Today, the client is fully fluent in what some would argue to be the true universal language: mathematics. He holds a doctorate in mathematics, the speech impediments are improved, and he lives a fulfilling life. Even today, I wonder how different the outcome would have been had I not had the self-awareness and professional support to counter my projection impulses.
We will encounter clients similar to us in ways that make us struggle to avoid projecting our own lived experiences onto them. We need to identify those clients, but to do so, we must first ask, “Who am I, and who is standing beside me to support me in this journey of self-discovery?”
[End of Case Example 5.1]
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Our Clinical Interviewing text also includes specific learning activities. If you want to check out a learning activity designed to add nuance to your feeling (emotional) vocabulary, check out this handout:
We’ve been talking about emotions in our Group Counseling course at the University of Montana. Even though focusing on emotions has grown immensely in popularity within contemporary counseling and psychotherapy, some students seem to be missing a few basics. Last week, when I took time to talk about the differences between (a) reflection of feeling, (b) interpretive reflection of feeling, and (c) feeling validation most of the students found the information useful. Consequently, I’m including here (and in a following blog post or two) excerpts from the latest edition of our Clinical Interviewing textbook. https://www.wiley.com/en-us/Clinical+Interviewing%2C+7th+Edition-p-9781119981985
The foundation that guides how clinicians respond to clients is described in our “Listening Continuum” (see below).
This excerpt is from the section in Chapter 4 on Reflection of Feeling.
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Reflection of Feeling (aka Empathy)
The primary purpose of a reflection of feeling is to let clients know, through an emotionally focused paraphrase, that you’re tuned in to their emotional state. Nondirective reflections of feeling encourage further emotional expression. Consider the following example of a 15-year-old male (he/him) talking about his teacher:
Client: That teacher pissed me off big time when she accused me of stealing her phone. I wanted to punch her.
Counselor: You were pretty pissed off.
Client: Damn right.
In this example, the feeling reflection focuses only on what the client clearly articulated. This is the rule for nondirective feeling reflections: Restate or reflect only the emotional content that you clearly heard the client say. No probing, interpreting, or speculation are included. Although we might guess at underlying dynamics contributing to this boy’s fury, a nondirective feeling reflection focuses on obvious emotions.
Emotions are personal. Every attempt to reflect feelings is a move toward closeness or intimacy. Some clients who don’t want relational connection with you may react negatively to reflections of feeling. You can minimize negative reactions to reflections of feeling by phrasing them tentatively, especially during an initial interview:
When using reflection to encourage continued personal exploration, which is the broad goal of reflective listening, it is often useful to understate slightly what the person has offered. This is particularly so when emotional content is involved. (W. R. Miller & Rollnick, 2013, p. 59)
Emotional accuracy is your ultimate goal. However, if you miss the emotional target, it’s better to miss with an understatement than an overstatement. If you overstate emotional intensity, clients will often backtrack or deny their feelings. As we’ll discuss in Chapter 12, there’s a proper time to intentionally overstate client emotions. Generally, however, you should aim for accuracy while proceeding tentatively and understating rather than overstating clients’ emotions. Rogers (1961) would sometimes use clarification with clients after giving a reflection of feeling (e.g., “I’m hearing sadness and pain in your voice… am I getting that right?”).
If you understate a reflection of feeling, your client may correct you.
Client: That teacher pissed me off big time when she accused me of stealing her watch. I wanted to punch her.
Counselor: Seems like you were a little irritated about that. Is that right?
Client: Irritated? Fuck no—I was pissed.
Counselor: You were way more than irritated. You were pissed.
In this example, a stronger emotional descriptor is better because the client expressed more than irritation. However, any adverse effect of “missing” the emotion is minimized because the counselor phrased the reflection tentatively with “Seems like…” and then added a clarifying question at the end. Then, perhaps most important, when the client corrected the counselor, the counselor repaired the reflection to fit with the client’s emotional experience. From a psychoanalytic perspective, the repairing of emotional mirroring or empathy might be the most therapeutic part of listening (Kohut, 1984; see Practice and Reflection 4.3 to practice emotional responses to clients).
Reflections of feeling are often labeled as empathy. If only empathy were so simple. As Clark noted, “Rogers . . . was appalled by this . . . as the rich and nuanced process of empathy was reduced to trivial and repetitive expressions of a therapist identifying a client’s feelings” (p. 23). As we move forward through this chapter and other content on more directive interviewer responses, remember that empathy should be woven into nearly every therapist utterance, including confrontation, advice, and behavioral homework (Clark, 2023).
With clients, mental health professionals engage in emotional clarification, exploration, validation, and education. Your role varies depending on your clients’ needs and situation. As a technique, reflection of feeling aids clients in clarifying and exploring their emotions. For this chapter and reflection of feeling, the best path is a tentative one, wherein you function as a mirror to help clients experience and articulate their emotions with greater clarity. Doing so can serve to help clients explore and gain greater understanding of their emotional worlds. To accomplish your interviewing goals, you don’t need to know everything about the academic and popular debates over emotions; instead, you partner with clients to deepen your mutual understanding of the emotional experiences.
[Several pages of the text are skipped here]
Gender, Culture, and Emotion
Imagine you’re in an initial clinical interview with a Latino (he/him) cisgender male husband and father. He looks unhappy and your impression is that he’s angry about his wife’s employment outside the home. You’re aware that some Latine/x people have traditional ideas about male and female family roles. This knowledge provides you with a foundation for using a reflection of feeling to focus on his anger:
I’m getting the sense that you’re a little angry about your wife deciding to go back to work.
He responds,
Nah. She can do whatever she wants.
You hear his words. He seems to be empowering his wife to do as she pleases. But his voice is laden with annoyance. This leads you to try again to connect with him on a deeper level. You say,
Right. But I hear a little annoyance in your voice.
This reflection of feeling prompts an emotional response, but not the one you hoped for.
Sure. You’re right. I am annoyed. I’m fucking annoyed with you and the fact that you’re not listening to me and keep focusing on all this feelings shit.
This is a dreaded scenario for many clinicians. You take a risk to reflect what seems like an obvious emotion, and you get hostility in return. Your emotional sensitivity and effort at empathy backfires. The client moves to a defensive and aggressive place, and a relationship rupture occurs (see Chapter 7 for more on dealing with relationship ruptures).
It’s tempting to use culture and gender to explain this client’s negative reaction to your reflection of feeling. But it’s not that simple.
Although culture, gender, race, and other broad classification-based variables can sometimes predict whether specific clients will be comfortable with emotional expression, individual client differences are probably more substantial determinants. Comfort in expressing emotion is often a function of whether the client comes from a family-neighborhood-cultural context where emotional disclosure was a norm. For example, Knight (2014) reported that Black and Latino males who were unlikely to disclose to their peers attributed this tendency to their experiences living in violent communities. These young men learned that emotional expression and trusting others were bad ideas in their neighborhoods. Conversely, emotional disclosure is more likely in the comfort range of Black and Latine/x males raised in safer communities. This makes good common sense: Whether clients perceive you as safe to talk with about emotional concerns probably has more to do with their backgrounds and past experiences than you.
Overall, it’s likely that clients’ willingness to tolerate feeling reflections is based on a mix of their cultural, gender, and individual experiences. Although biogenetics may be involved too, how people handle emotions is largely socialized (McDermott et al., 2019). If you have reason to suspect that your client is socialized to be uncomfortable with emotions, you should avoid emotionally specific words. Examples of emotionally specific words include angry, sad, scared, and guilty.
Instead of emotionally specific words, you can substitute words that are emotionally vague (and less intense). Later, as trust develops, you might be able to use specific emotional words. Consider the following phrases:
You found that frustrating.
It seems like that bothered you a bit.
It’s a little upsetting to think about that.
Practice and Reflection 4.4 lists examples of emotionally vague words you might use instead of emotionally specific words.
PRACTICE AND REFLECTION 4.4: USING VAGUE AND EMOTIONALLY SAFE WORDS
Emotionally Specific Words
Substitute (Safer) Words
Angry
Frustrated, upset, bothered, annoyed
Sad
Down, bad, unlucky, “that sucked”
Scared
Bothered, “didn’t need that,” “felt like leaving”
Guilty
Bad, sorry, unfortunate, “bad shit”
Note: These words may work as substitutes for more emotionally specific words, but they also may not. It will be more effective for you to work with your classmates or in your work setting to generate less emotionally threatening words and phrases that are culturally and locally specific.
[End of Practice and Reflection 4.4]
Gender diverse clients may be emotionally sensitive in ways different than clients on the gender binary. Due to their neutrality, reflections of feeling—even when accurate—can be activating if clients are sensing you’re coming from a place of judgment. Consider the following:
Counselor: You said your family is rejecting your sexual identity, and you’re feeling terribly sad about that.
Client: Wouldn’t you?
When clients have a substantial history of interpersonal rejection, emotional invalidation, and/or oppression, neutral comments from clinicians can be perceived as judgmental. In this exchange, the counselor uses an accurate simple paraphrase along, with an emotional reflection, but the client feels judged and responds defensively. Given the client’s history, feeling judged in response to neutral reflections is natural. What the client needs (to feel connected and supported) is a response that’s explicitly affirming or validating (Alessi et al., 2019). In this case, at least until rapport is established, rather than a feeling reflection, the client would likely react better to a feeling validation (“Your sadness in response to your family’s rejection of your sexual identity seems totally normal”; see Chapter 5 for information on feeling validations).
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Thanks for reading. In the coming week, there will be additional posts on the basics and nuances of working with emotions in counseling and psychotherapy.
Imagine the possibility of a scalable single-session intervention that has been shown to be effective with a wide range of mental health issues. In these days of widespread mental health crisis and overwhelmed healthcare and mental health providers, you might think that effective single-session interventions are a fantasy. But maybe not.
This morning, my older daughter emailed me a link to two videos from the lab of Dr. Jessica Schleider of Northwestern University. Dr. Schleider’s focus is on single-session therapeutic interventions. Although I hadn’t seen the website and videos, I was familiar with Dr. Schleider’s work and am already a big fan. Just to give you a feel for the range and potential of single-session interventions, below I’m sharing a bulleted list of titles and dates of a few of Dr. Schleider’s recent publications:
Realizing the untapped promise of single‐session interventions for eating disorders – 2023
In-person 1-day cognitive behavioral therapy-based workshops for postpartum depression: A randomized controlled trial – 2023
A randomized trial of online single-session interventions for adolescent depression during COVID-19 – 2022
An online, single-session intervention for adolescent self-injurious thoughts and behaviors: Results from a randomized trial – 2021
A single‐session growth mindset intervention for adolescent anxiety and depression: 9‐month outcomes of a randomized trial – 2018
Reducing risk for anxiety and depression in adolescents: Effects of a single-session intervention teaching that personality can change – 2016
Single-session therapy or interventions aren’t for everyone. Many people need more. However, given the current mental health crisis and shortage of available counselors and psychotherapists, having a single-session option is a great thing. As you can see from the preceding list, single-session interventions have excellent potential for effectively treating a wide range of mental health issues. Given this good news about single-session interventions, I’m now sharing with you that link my daughter shared with me: https://www.schleiderlab.org/labdirector.html
I’ve been interested in single-session interventions for many years. Just in case you’re interested, here’s a copy of my first venture into single-session research (it’s an empirical evaluation of a single-session parenting consultation intervention, published in 2007).
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!
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John Sommers-Flanagan 