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.
This morning I’m doing a one-hour webinar for Division 17 of the American Counseling Association. The focus is on how we can do suicide assessment, treatment, and prevention with people from historically and currently marginalized or oppressed communities. To deal with this immense issue, it would help if we had some superpowers.
We know, from decades of sociological and psychological research that many different factors contribute to global and regional changes in suicide rates. We also know that, in general, suicide is at least in part driven by individual experiences and perceptions of high personal distress (Shneidman’s “psychache”). Researchers have also identified how poverty, racism, and factors like neighborhood safety/climate can contribute to suicidality. In our suicide book, we call these factors–factors that are typically outside of the self, but that can be internalized–as “contextual.” What follows is an excerpt on contextual factors from Suicide Assessment and Treatment Planning: A Strengths-Based Approach.
Externalizing the External
At age 82, in an interview with the Los Angeles Times (Stein, 1986), B. F. Skinner said: “I have to tell people that they are not responsible for their behavior. They’re not creating it; they’re not initiating anything. It’s all found somewhere else.”
We find Skinner’s words reassuring. All humans are influenced—to some extent—by factors outside themselves. This is not to say people are helpless victims of their environments; there are methods for coping with external stressors. But the first step, even though the stressor is obviously external, is to re-externalize it, because all too often, it’s all too easy, to internalize the external.
Coping Strategies for Toxic or Malignant Stressors
When clients are exposed to larger sociological and uncontrollable stressors, they can experience frustration, helplessness, and hopelessness. As a counselor, mostly you’re unable to change the unchangeable for your clients. Within the counseling relationship, you can express both empathy for your client’s situation, and indignation that society can be so painful and difficult to change. Depending on the counseling goals, you can provide empathy, commiseration, assistance in discerning achievable goals, learning opportunities, and advocacy or support for activism.
Empathic Commiseration
News events pertaining to racism, climate change, global pandemics, and other topics activate and agitate some clients (and counselors). When this happens, empathic commiseration is a good first step. Empathy from you can universalize client emotional reactions and help clients feel more normal. Simple statements like, “I agree. It’s so hard to watch the news” can facilitate recognition that excessive media exposure heightens feelings of helplessness and depression.
Other scenarios where clients are exposed to environmental toxicity, but unable to extricate themselves from the situation, can be especially demoralizing. In such cases, brainstorming about how to mobilize community resources, how to gain access to safe spaces, and how to engage in self-advocacy can be important and empowering. As with goal-setting in other dimensions, helping clients evaluate their own behaviors and the factors over which they have control, may mitigate frustration. Having you to resonate with their frustration and show compassion is crucial.
Discernment and Goal-Setting
People associated with Alcoholics Anonymous are familiar with Richard Neibauer’s (1932) serenity prayer: God, grant me the serenity to accept the things I cannot change, courage to change the things I can, and wisdom to know the difference. Similar guidance comes from Shantideva, an 8th century Indian Buddhist Scholar, who put it this way: If there’s a remedy when trouble strikes, what reason is there for dejection? And if there is no help for it, what use is there in being glum? (Shantideva, The way of the Bodhisattva, p. 130). Clients who are religious or spiritually oriented may find particular comfort and insight in the words of Neibauer or Shantideva.
Yet another version of the Serenity Prayer comes from 20th century Philosopher W. W. Bartley. Bartley took a break from writing about philosophical rationalism, to put the message of the Serenity Prayer into a Mother Goose nursery rhyme format:
For every ailment under the sun
There is a remedy, or there is none;
If there be one, try to find it;
If there be none, never mind it.
When it comes to helping clients deal with complex contextual difficulties, these prayers or philosophies can be a good place to start, both for professionals, and for clients. Recognizing and accepting that some problems in life are unchangeable can bring solace. Trying to change that which is unchangeable generally fuels unhappiness.
The developers of mindfulness-based cognitive therapy (MBCT; Segal, Williams, & Teasdale, 2013) put their own brain-based 21st century spin on the Serenity Prayer. To summarize, they say the brain has two basic modes of functioning. The first mode is problem-solving. The brain is quite good at problem-solving. But some problems are unsolvable. When faced with insoluble problems, rather than letting go of the problem-solving process, the brain naturally persists, relentlessly continuing to problem-solve, ruminate, and chew on old ideas and failures. Anxiety and fear escalates. If the brain gets hooked on unsolvable problems, it can take clients down into bottomless rabbit-holes and exacerbate emotional discomfort.
What about that second basic brain modality? Mindfulness practitioners say that engaging the second mode can unhitch our brains from the out-of-control problem-solving train. The second brain modality operates on a less natural principle: The principle of acceptance. MBCT practitioners emphasize shifting into noticing, or nonjudgmental acceptance. Although the brain is capable of intermittent nonjudgmental acceptance, shifting into that modality is tough. Most clients can’t make that switch in the moment. That’s okay. Accepting failure to switch into nonjudgmental mindfulness is part of mindful acceptance. Coaching clients to make efforts at mindfulness and then to accept their failings and inadequacies might facilitate client self-acceptance and grow mindful parts of the brain, like the insula (Haase et al., 2016). Nonjudgmental acceptance requires regular practice. No one ever gets it right all the time.
Opportunity Ameliorates
James Garbarino (2001) wrote: “Stress accumulates; opportunity ameliorates” (p. 361). Within the trauma literature, it’s clear that toxic stress increases illness (Shern et al., 2016); it’s also clear that providing traumatized youth and adults with physical, social, and academic opportunities mitigates trauma and increases health. In part, your role with clients who have experienced trauma and who are chronically reactivated by socio-political events, is to assist them in finding and participating in local resources and opportunities.
Clients who are suicidal and in the midst of toxic and uncontrollable contextual factors, may feel they don’t have the time or energy for new opportunities. Like Katie from chapter 5, they may need support, assistance, and resources to step outside of their survival mode. Practical problems like childcare, transportation, and inaccessible community organizations can loom large. In such situations, you may need to engage in advocacy or activism to help your clients get connected to the resources and opportunities they need.
Today I’ll be online providing a 2-hour workshop titled “Evidence-Based Relationship Factors in Supervision and Practice” on behalf of the Cognitive Behavioral Institute and Geneva College. This workshop content is related to the excellent work of John Norcross, Michael Lambert, and other prominent professionals who have advocated (and researched!) the scientific truth that RELATIONSHIPS are powerful influencers of positive treatment outcomes in counseling and psychotherapy. This topic is also the focus of a forthcoming book authored by a former doc student of mine, Kimberly Parrow (more on her excellent work in a future blog).
For now, I’m posting the ppts for today’s online workshop here:
And here’s the workshop description: Counselors and psychotherapists have a long and storied history of arguing with one another over what makes therapy effective. Some say: We should teach and supervise our students to use empirically-supported treatments (i.e., procedures, as in medicine). Others say: We should teach and supervise our students to establish therapeutic relationships. Although it’s clear that specific treatments and therapeutic relationships both contribute to outcomes, when supervisors and practitioners think of empirically-supported approaches, they tend to think of manualized treatments or procedures. However, in recent years, specific relationship factors have been identified and linked to positive counseling and psychotherapy outcomes (Norcross & Lambert, 2018). These factors include: cultural humility, congruence, unconditional positive regard, empathic understanding, emotional bonds, mutual goal-setting, and more. In this workshop, participants will learn to identify, describe, and apply evidence-based relationship factors in supervision and practice. Video-clips, live demonstrations, and reflective opportunities will be used to facilitate learning.
I hope you have an excellent day and weekend wherein you are enacting as many evidence-based relationship factors as you can fit into your life!
In 90-minutes, Rylee and I fly out of Seattle to Istanbul. Upon our arrival, the amazing Dr. Umit Arslan will pick us up from the airport, and then we’ll have three days of Umit, Turkish coffee, Turkish breakfasts, and tours of Istanbul with him (thank you, Umit!). As part of the trip, I’ll be offering a talk (translated live and in-person by Umit) at Yildiz Technical University (motto: “The ever-shining star”) in Istanbul. For those of you interested in such things, here are the ppts for the presentation, titled, Skills and Strategies for Conducting Excellent Clinical Interviews:
To start, I should say that I generally dislike pop-psych articles and promotional efforts that include cute sayings like, you can “Train (or re-wire) your Brain.” Most of you know this about me, partly because I like to make pithy comments about how, in fact, our brains actually don’t have any wires.
Despite overuse of the “wiring” analogy, I’m all-in on the principle that our behavior influences our brain structure, function, including a vast array of neurochemicals, hormones, and yada, yada, yada. In the following excerpt from our forthcoming Clinical Interviewing text, we provide a brief scientific commentary and recommendations for what we might oversimplify as “empathy training.”
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Neurogenesis refers to the birth of neurons and is one of the biggest revelations in brain research. Although neurogenesis primarily occurs during prenatal brain development, humans and other mammals generate new neurons (brain cells) throughout the life span (Jenkins et al., 1990). When adult neurogenesis occurs, new neurons are integrated into existing neurocircuitry.
Over 30 years ago, researchers demonstrated that repeated tactile experiences produced functional reorganization in the primary somatosensory cortex of adult owl monkeys (Jenkins et al., 1990). This finding and subsequent research supporting neurogenesis underscore a commonsense principle: Whatever behavior you practice or repeat is likely to stimulate neural growth and strengthen skills in that area. This is our explanation and prescription for how you can become more like Carl Rogers.
Multiple brain regions are activated during an empathic experience. Kim and colleagues (2020) summarized the complexity of what’s happening in the brain during empathic or compassionate responding, “Our analysis of sixteen fMRI studies revealed activation across seven broad regions, with the largest peaks localized to the Periaqueductal Grey, Anterior Insula, Anterior Cingulate, and Inferior Frontal Gyrus” (p. 112). In a similar review, Sezer and colleagues (2022) wrote:
If we focus in (somewhat inappropriately) on a particular brain structure, the anterior insula or insular cortex, a small structure residing deep within the fissure that separates the temporal lobe from the frontal and parietal lobes, seems particularly linked to empathy experiences, self-regulation, and other compassionate counseling-type responses (Chen et al., 2022).
Compassion meditation (aka lovingkindness meditation) is also associated with neural activity and structural development (or thickening) of the insula. Individuals who engage in regular compassion meditation have thicker insula, and when they view or hear someone in distress, they show more insula-related neural activity than individuals without compassion meditation experience (Hölzel et al., 2011). Other researchers have conducted meta-analyses and written reviews indicating that several brain structures are activated during cognitive-emotional perception, regulation, and response, and the relationships among them are highly complex (Kim et al., 2020; Pernet et al., 2021).
To oversimplify a complex neurological process, it appears generally safe to conclude that compassion meditation and other human activities related to empathy may contribute in some way to the thickening of the insula and development of other brain processes that enhance empathic responsiveness.
Although our knowledge about what’s actually happening in the brain is limited, these findings imply that you should engage in rigorous training to strengthen and grow your insula—as well as some of its empathic and self-regulating buddies like the posterior cingulate cortex, dorsolateral prefrontal cortex, rostral anterior cingulate cortex region, and dorsomedial prefrontal cortex (Sezer et al., 2022). This “training regimen” might contribute to you becoming more empathic and therefore, more therapeutic. In addition to practicing mindfulness or lovingkindness meditation, such a regimen could include:
Committing to the intention of becoming a person who listens to others in ways that are accepting, empathic, and respectful.
Developing an empathic listening practice. This would involve regular interpersonal experiences where you devote time to using active listening skills described in this chapter. As you practice, it’s important to have listening with compassion as your primary goal.
Engaging in the active listening, multicultural, and empathy development activities sprinkled throughout this text, offered in your classes, and obtained from additional outside readings.
When watching videos/television/movies, reading literature, and obtaining information via technology, lingering on and experiencing emotions that these normal daily activities trigger.
Reflecting on these experiences and then… repeating… repeating… and repeating them over time and across situations
Rogers wrote in personal ways about his core conditions for counseling and psychotherapy. Contemplating his perspective is part of our prescription for developing an empathic orientation toward the variety of individuals with whom you will work.
“I come now to a central learning which has had a great deal of significance for me. I can state this learning as follows: I have found it of enormous value when I can permit myself to understand another person. The way in which I have worded this statement may seem strange to you. Is it necessary to permit oneself to understand another? I think that it is. Our first reaction to most of the statements which we hear from other people is an immediate evaluation or judgment, rather than an understanding of it. When someone expresses some feeling or attitude or belief, our tendency is, almost immediately, to feel “That’s right”; or “That’s stupid”; “That’s abnormal”; “That’s unreasonable”; “That’s incorrect”; “That’s not nice.” Very rarely do we permit ourselves to understand precisely what the meaning of [the] statement is to him [or her or them]. I believe this is because understanding is risky. If I let myself really understand another person, I might be changed by that understanding.” (Rogers, 1961, p. 18; italics in original)
As always, send me your thoughts on this content, as well as any ideas for improvement. Thanks and happy Friday!
Art historians point to images like John Henry Fuseli’s 1754 painting “The Nightmare” as early depictions of sleep paralysis.
Consensus among my family and friends is that I’m weird. I’m good with that. Being weird may explain why, on the Saturday morning of Thanksgiving weekend, I was delighted to be searching PsycINFO for citations to fit into the revised Mental Status Examination chapter of our Clinical Interviewing textbook.
One thing: I found a fantastic article on Foreign Accent Syndrome (FAS). If you’ve never heard of FAS, you’re certainly not alone. Here’s the excerpt from our chapter:
Many other distinctive deviations from normal speech are possible, including a rare condition referred to as “foreign accent syndrome.” Individuals with this syndrome speak with a nonnative accent. Both neurological and psychogenic factors have been implicated in the development of foreign accent syndrome (Romö et al., 2021).
Romö’s article, cited above, described research indicating that some forms of FAS have clear neurological or brain-based etiologies, while others appear psychological in origin. Turns out they may be able to discriminate between the two based on “Schwa insertion and /r/ production.” How cool is that? To answer my own question: Very cool!.
Not to be outdone, a research team from Oxford (Isham et al., 2021) reported on qualitative interviews with 15 patients who had grandiose delusions. They wrote: “All patients described the grandiose belief as highly meaningful: it provided a sense of purpose, belonging, or self-identity, or it made sense of unusual or difficult events.” Ever since I worked about 1.5 years in a psychiatric hospital back in 1980-81, I’ve had affection for people with psychotic disorders, and felt their grandiose delusions held meaning. Wow.
One last delight, and then I’ll get back to my obsessive PsycINFO search-aholism.
Having experienced sleep paralysis when I was a frosh/soph attending Mount Hood Community College in 1975-1976, I’ve always been super-delighted to discover old and new information about multi-sensory (and bizarre) experiences linked to sleep paralysis episodes. Today I found two articles stunningly relevant to my 1970s SP experiences. One looked at over 300 people and their sleep paralysis/out-of-body experiences. They found that having out-of-body experiences during sleep paralysis reduced the usual distress linked to sleep paralysis. The other study surveyed 185 people with sleep paralysis and found that most of them, as I did in the 1970s, experienced hallucinations of people in the room and many believed the “others” in the room to be supernatural. I find these results oddly confirming of my long-passed sleep insomnia experiences.
All this delight at scientific discovery leads me to conclude that (a) knowledge exists, (b) we should seek out that knowledge, and (c) gaining knowledge can help us better understand our own experiences, as well as the experiences of others.
And another conclusion: We should all offer a BIG THANKS to all the scientists out there grinding out research and contributing to society . . . one study at a time.
Isham, L., Griffith, L., Boylan, A., Hicks, A., Wilson, N., Byrne, R., . . . Freeman, D. (2021). Understanding, treating, and renaming grandiose delusions: A qualitative study. Psychology and Psychotherapy: Theory, Research and Practice, 94(1), 119-140. doi:https://doi.org/10.1111/papt.12260
Herrero, N. L., Gallo, F. T., Gasca‐Rolín, M., Gleiser, P. M., & Forcato, C. (2022). Spontaneous and induced out‐of‐body experiences during sleep paralysis: Emotions, “aura” recognition, and clinical implications. Journal of Sleep Research, 9. doi:https://doi.org/10.1111/jsr.13703
John Sommers-Flanagan 