John Wiley and Sons recently informed me of the excellent and exciting news that the 7th edition of Clinical Interviewing (CI7) has gone to press and will drop in the U.S. on or before September 30. Our wish for this edition is the same as previous editions: To provide research-based, theoretically supported, clinically insightful, and culturally informed education and training on how to conduct basic and advanced clinical interviews.
The Resource
Part of CI7 includes video updates. Most of the updates offer greater representation of culturally diverse counselors and psychotherapists. For example, the video link below features Dr. Devika “Dibya” Choudhuri describing a “grounding” technique that she uses when conducting tele-mental health (aka virtual) clinical interviews, the topic of Chapter 14.
Although you may have your own approaches to facilitating grounding during tele-mental health sessions, I believe Dr. Choudhuri’s idea is innovative and may be a resource that you can add to your toolkit.
Stay tuned, because over the next several weeks I’ll be posting additional fresh new text and video content from CI7.
The Request
Traditionally, publishers ask authors to gather promotional endorsements for new books. This time around, maybe because it’s the 7th edition, neither Wiley nor the absent-minded authors of CI7 thought about gathering endorsements. In the past, we’ve had Derald Wing Sue, John Norcross, Victor Yalom, Pamela Hays, Barbara Herlihy, Allen Ivey, David Jobes, and Marianne and Jerry Corey write short blurbs. Here’s what Derald Wing Sue said about the 6th edition:
The most recent edition of Clinical Interviewing is simply outstanding. It not only provides a complete skeletal outline of the interview process in sequential fashion, but fleshes out numerous suggestions, examples, and guidelines in conducting successful and therapeutic interviews. Well-grounded in the theory, research and practice of clinical relationships, John and Rita Sommers-Flanagan bring to life for readers the real clinical challenges confronting beginning mental health trainees and professionals. Not only do the authors provide a clear and conceptual description of the interview process from beginning to end, but they identify important areas of required mastery (suicide assessment, mental status exams, diagnosis and treatment electronic interviewing, and work with special populations). Especially impressive is the authors’ ability to integrate cultural competence and cultural humility in the interview process. Few texts on interview skills cover so thoroughly the need to attend to cultural dimensions of work with diverse clients. This is an awesome book written in an engaging and interesting manner. I plan to use this text in my own course on advanced professional issues. Kudos to the authors for producing such a valuable text.
―Derald Wing Sue, Ph.D., Professor of Psychology and Education, Teachers College, Columbia University
This time around, we’re less than two weeks from publishing and are without formal endorsements. As a consequence, I’m asking: “Is there ANYBODY out there who has read a portion of the CI7 manuscript or used a previous edition, who would like to share their thoughts about how the book influenced you or how the videos helped with your training?
[I know this last paragraph sounds pathetic. However, if you know me, you probably know my sense of humor, and the “Is there anybody out there?” call is BOTH a sincere request for your input AND me mocking myself for making this request.]
To be completely serious: If you want to share something positive about your experience—from any point in time—with the Clinical Interviewing text, I hope you’ll write a sentence or two or three (you don’t have to write half a page, like Derald Wing Sue) on the particular ways in which you found the book and/or videos meaningful to you.
To share your thoughts on any edition of the text, please post them here on this blog, or send them to me at john.sf@mso.umt.edu.
Thanks very much for considering this request. Please, please, I hope someone “out there” is listening!
I’m taking the opportunity this fine Sunday afternoon to post a blog piece that Rita wrote earlier this week. Oddly, or perhaps not that oddly for those who know her, Rita has an alter-identity that she refers to as “Dr. Bossypants.” In this alternate voice, Rita refers to herself in third person and lets herself be a bit more pedantic than she is in real life.
In this blog post, Dr. Bossypants jumps into the domain of forgiveness and offers up ideas that I found exquisitely interesting and very helpful.
Without further ado, I’d like you to meet, my friend, Dr. Bossypants.
Earlier this summer, as I sifted through page-proofs for the 7th edition of our Clinical Interviewing textbook, my wife and co-author thinned carrots in the garden. Later, while I responded to queries from a Wiley copyeditor in India, she worked on rock art near the river in the July sunshine.
As many of you know, Rita and I have been co-authors for decades. Our first co-written publication appeared as a commentary in the 1986 American Psychologist (volume 41), titled “Ethical considerations for the peace activist psychotherapist.” Cool stuff.
Over the past few years, Rita’s interest in academic writing has waned some, but she’s still helpful, so I don’t mind. I like fresh carrots. The problem is that she’s started a project with a new and far more demanding coauthor. Given the identity of her coauthor, it doesn’t work for me to be jealous. Eight years ago, she started publishing these co-authored works as blogs, posted every Sunday at 9am. When she’s in a good mood, she refers to them as prose poems, prayers, or parables. I won’t mention what she calls them when she’s in a bad mood.
When she and her other co-author are busily writing, I’ve learned it’s best to not interrupt. I’ve also learned—from reading these blogs and listening to her read them to me—about a big omnipresent challenging and empathic entity that changes identities from Black women to dust mites, clouds to cracks in the earth, and flocks of birds to herds of sheep in much less time than the colloquial blink-of-an-eye.
Many of her readers have noted that these meditative word-art pieces are best taken in small doses. David James Duncan, author of The Brother’s K, the River Why, the forthcoming Sun House, and other amazing novels, wrote a blurb about Rita’s work, featured on the back cover:
From paragraph to paragraph, or sometimes sentence to sentence, or even phrase to phrase, Rita Sommers-Flanagan’s visitations leap—with tireless wit and a welcome downpour of surprises—from trenchant, to despairing, to startlingly funny, to furious, to honest to God divine comforts that just carried me to page 90 when I needed to get to work! As you read, you’ll also ride two pendulums I love, from reverence to irreverence back to reverence, and from deep grief to genuine joy back to grief. Most of all I want to say this: No matter what guise Original Source uses for any particular visit, I believe in Rita’s God. I truly do.
As I mentioned on FB, Rita getting a blurb from DJD makes me flat-out jealous. I still remember reading The Brother’s K on an airplane, and having the flight attendant check on me because I was intermittently laughing and crying. . . which speaks to DJD’s immense writing talents. On the other hand, rather than a bitter jealousy, I can bask in Rita’s reflected glory, right? I mean, after all, I’m her other coauthor.
I hope you’ll check out Rita’s book. I AM one of her biggest fans and one of her biggest coauthors: I’m just not the only one.
Like many, I woke up this morning thinking about my father (Max Sommers).
When I saw a photo of him, it made me think about how long it has been since I’ve seen him standing up. For the last 3+ years of his life he was in bed, due to an un-repairable broken hip and severe neuropathy.
Despite being stuck in bed every day, Max stayed upbeat. Every visit—until he died—started with a cheerful greeting and ended with him saying, “I love you” and “big hugs.”
I could never maintain such a sunny disposition. Here’s what I wrote about him back in 2014:
This is the man I can never live up to. But that’s okay. That’s the way it SHOULD be. To have a role model who is really a role model because he is so good and kind and compassionate and smart. Just being around someone like him makes me want to be a better person.
Reflecting on my father’s metaphorical (not literal) big shoes, made me think of Adler’s concept of the inferiority complex. Adler says inferiority is all-natural, because all children experience many years of being inferior to their parents or older siblings. I also had the good luck of having two incredibly competent and capable older sisters. I experienced many years of natural inferiority. That’s probably why, in most situations and most of the time, my first reactions usually involve feeling inferior.
Nowadays, people seem to use the term imposter syndrome instead of inferiority. I like Adler’s terminology and explanations better.
Adler also said the cure to all mental health problems was a thing he called encouragement. Encouragement comes in many forms. When parents and others give their children encouragement, it translates into giving their children the “courage” to face and embrace the challenging tasks of life. Given that Max was and is impossible for me to live up to, I’m especially lucky that he gave me the gift of encouragement. His encouragement (along with my mom’s and sisters’) gave me the courage to face my feelings of inferiority.
Max has been gone for 13 ½ months now. I miss him terribly. I know I’m not the only one feeling sad and grateful on Father’s Day. If you’re feeling the pangs and pains of loss along with me, I wish you as much peace, purpose, and encouragement as you can find.
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.
I’m into narratives these days, having fallen into the abyss of believing in the social construction of reality. But before you dismiss me as a woo-woo post-modernist, let me say that when I refer to reality, I’m not talking about the molecular composition of the walls in my house. I’m not a magical social constructionist. My walls—and ceilings—are solid realities, regardless of what Richard Bach, my friends, and the media might tell me. When I refer to reality being socially constructed, I’m talking about social reality, mental health labels, the Tooth Fairy, neuro-chemical imbalances, political spin doctoring, and other things people believe in, in the absence of scientific evidence.
My narrative this morning included turning off NPR after less than 60 seconds. Turning off NPR came on the heels of my previous night’s lament of Al Jazeera’s unusually positive coverage of the latest legal indictment of a certain treasonous, lecherous, insurrectionist to whom I will refer to as the former guy (aka TFG), because I’m now refusing to make any further verbal donations to his narrative.
As I lumbered around the kitchen this morning, Rita sarcastically said something like, “You might as well turn on the news to see if NPR is saying anything nice about TFG.” Sadly, within seconds, that’s exactly what we heard. TFG’s voice told us things about, “the indictment” being “totally ridiculous,” and “They’re after you, not me. I’m just standing in the way.”
We never heard a peep about the details of the jeopardy to our national security that TFG has posed and is posing. Neither was there a jot nor a tittle about the nuclear secrets TFG scattered around his various bathrooms, closets, and dining rooms, allegedly making them available to onlookers. We didn’t hear a balanced or fair or representative articulation of the known facts. Nope, we were only provided with socially constructed and obvious lies that as anyone who studies history knows will grow less obvious and more favorable to TFG, the more the local, national, and international news repeat them. . . and repeat them they will.
Seriously, what’s wrong with the media? Why is the media quoting and privileging TFG’s narrative, when his penchant for lying about virtually everything is a known and witnessed fact that requires very little social construction?
Over the years, we’ve given many thousands of dollars to public radio. Today I regret every penny . . . again. The last time I regretted every penny and temporarily stopped giving was back in 2016, when NPR continually let TFG’s voice be front and center over and over on their news broadcasts. All too often I heard his voice on NPR twisting and fabricating reality by saying things like “Crooked Hillary” and “lock her up.” When NPR assigned a nasty conservative woman to cover Hillary’s presidential campaign, big surprise, day after day, she brought up Hillary’s emails, referred to them as a “scandal” and made Hillary sound terrible.
Who writes the news? Who makes decisions to polish up TFG on national news reports, simultaneously flushing the intellectual capacity of the American electorate down the toilet? Who makes the final determination that today and tomorrow and the next day we’ll keep hearing TFG’s voice proclaiming his innocence or using the words witch hunt or insulting his rivals?
We should be ready for a pattern of increasing denial, increasing blame of others, increasing lies, declarations of complete and total innocence, and repeated claims of mistreatment. He will protect and insulate himself from critique and responsibility through active counterattacks, along with alignment, even briefly, with whatever sources of power, control, and dominance he can find. This might mean further alignment with Vladimir Putin, more campaign rallies, and an additional need to gather others around him who will offer only adulation. He will gleefully throw anyone and everyone who betrays him under the bus. As he escalates, his insults toward others will become increasingly demeaning—virtually everyone questioning his superiority will be labeled a dog or disgrace or traitor.
That was from 2018. All this has been predictable, and continues to be predictable.
When I complain privately to NPR, they tell me they work hard to balance the news. Really? Are they balanced because they say so? They can’t be unaware of their misrepresentation of reality through consistent bashing of Biden and over-representation of the voice of TFG. NPR cannot be that obtuse. We need to push them and other news outlets to get it right this time.
We need to hear the news in context. We shouldn’t hear TFG’s voice without also hearing something about the history of his lies, his destruction, his assaulting of women, his defaming whomever he pleases to defame, and the rest of the whole package.
If you want representational, contextual, and historically-informed political news, you should subscribe the Heather Cox Richardson (https://heathercoxrichardson.substack.com/). Or you should check out the fantastic writings of Timothy Snyder, Levin Professor of History at Yale and author of “On Tyranny” (https://timothysnyder.org/). Recently, Snyder wrote:
The job of the executive is to enforce the law. Putting the executive above the law makes nonsense of the Constitution. Does trying a former president make us a banana republic? No, not doing so makes us a banana republic, or really something worse. The moment we say that one person is above the law, we no longer have the rule of law. The moment we no longer have the rule of law, we cease to exist as any kind of republic. . . . In our country, citizens play interesting roles in the judicial branch. For example, they serve on grand juries, such as the one that issued the indictment of Trump on espionage and other charges. This is a process, one to be respected, especially by elected representatives. None of this is political advice. These are just the words of a citizen who cares about the country. The political advice, however, would be this: if you commit yourself now to an anti-constitutional position, you will have a hard time extracting yourself later.
Snyder’s words made me think of the news outlets as TFG’s minions. A minion is a follower or underling of a powerful person, especially an unimportant or servile one. Thinking about minions led me to reconstruct Snyder’s words as a message for TFG’s media minions:
If you commit yourself now to an anti-constitutional narrative from TFG, you will have a hard time extracting yourself later.
Write to your news media. Tell them you want representative, contextual, and factual news. Tell them you don’t want to hear TFG’s voice without also hearing the context and history of his dangerous, self-serving, and anti-patriotic lies. This time around, we don’t want an election narrative controlled by TFG and his minions. . . principally because, we do not want to grow up to be minions, which is precisely the future our news media is marching us toward.
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.
As many of you know, over the past year or so I’ve been frustrated in my efforts to publish a couple of journal articles. I know I’m not the only one who has experienced this, but this morning we got another rejection (the third for this manuscript) that triggered me in a way that, as the feminists might say, raised my consciousness.
Three colleagues and I are trying to publish the outcomes from a short online “happiness workshop” I did a couple years ago for counseling students. Mostly the results were nonsignificant, except for the depression scale we used, which showed our workshop participants were less depressed than a non-random control group. Also, based on open-ended responses, participants seemed to find the workshop experience helpful and relevant to them in their lives.
Problems with the methodology in this study are obvious. In this most recent rejection, one reviewer noted the lack of “generalizability” of our data. I totally agree. The study has a relatively small n, nonrandom group assignment, yada, yada, yada. We acknowledge all this in the manuscript. Having a reviewer point out to us what we have readily acknowledged is annoying, but accurate. In fact, this rejection was accompanied by the most informed and reasonable reviews we’ve gotten yet.
Nevertheless, I immediately sent out a response email to the editor . . . which, because I’m partially all about entertainment, I’m sharing below. As you’ll see, for this rejection, my concerns are less with the reviews, and more about WHAT IS BEING PUBLISHED IN SO-CALLED SCIENTIFIC JOURNALS. Although I don’t think it’s necessary, I’ve anonymized my email so as to not incriminate anyone.
Dear Editor,
Thanks for your timely processing of our manuscript.
Overall, I believe your reviewers did a nice job of reading the manuscript, noting problems, and providing feedback. Being very familiar with the journal submission and feedback process, I want to compliment you and your reviewers on your evaluation of our manuscript. Compared to the quality of feedback I’ve obtained from other journals, you and your team did well.
Now I’d like to apologize in advance for the rest of this email because it’s a critique not only of your journal, but of counseling research more generally.
Despite your professional review, I have concerns about the decision, and rather than sit on them, I’m going to share them.
Although the reviews were accurate, and, as Reviewer 1 noted, there are generalizability concerns (but aren’t there always), I looked at the most recent online articles published in [your journal], to get a feel for the journal’s standards for generalizability, among other issues. What I found was disturbing.
In the seven published 2023 articles from your most recent issue, none have data that are even close to generalizable, and yet all of the articles offer recommendations, as if there were generalizable data. In the [first] article there’s an n of 8; [the second article] has an n of 6 and use a made-up questionnaire. I know these are qualitative studies, but, oh my, they don’t shy away from widely offering recommendations (is that not generalizing?), based on minimal data. Four of the articles in the most recent issue have no data; that’s okay, they’re interesting and may be useful. The only “empirical” study is a survey with n = 165, using a correlational analysis. But no information is provided on the % response to the survey, and so any justification for generalization is absent. Overall, some of these articles are interesting, and written by people I know and like. But none of them have anything close to what might be considered “generalizability.”
What’s most concerning to me is that none of the published articles employ an experimental design. My impression is that “Counselor Education and Preparation” (not just the journal, but the whole profession) mostly avoids experimental or quasi-experimental designs, and privileges qualitative research, or correlational designs that, of course, are really just open inquiries about the relationships among 2 or more variables.
This is the third rejection of this manuscript from counseling journals that, to be frank, essentially have no scientific impact factor. Maybe the manuscript is unpublishable. I would be open to that possibility if I didn’t read any of the published articles from [your journal and other journals]. My best guess (hypothesis) is that counseling journals have double standards; they allow generalizing statements from qualitative studies, but they hold experimental designs to inappropriately high standards. I say inappropriate here because all experimental designs are flawed in one way or another, and finding those flaws is easier than understanding them.
I know I’m biased, but my last problem with the rejection of this manuscript has to do with relevance. We tried to offer counseling students a short workshop intervention to help them cope with their COVID-related distress and distress in general–something that I think more counseling programs should do, and something that I think is innately relevant and potentially very meaningful to counseling students and practitioners.
Sorry again, for this email and it’s length, but I hope some of what I’ve shared is food for thought for you in your role as journal editor.
Thanks again for the timely review and feedback. I do appreciate the professionalism.
Sincerely,
John SF
If you’re still reading and following my incessant complaining, for your continued pleasure, now I’m pasting my email response to my coauthors, one of whom wrote us all this morning beginning with the word “Bummer.”
Hi There,
Yes! Another bummer.
For entertainment purposes, I kept you all on my email to the editor.
Although I’m clearly triggered, because I just read some articles in the [Journal], I now know, more about self-care, because in their [most recent lead published article], the authors wrote:
“Most participants also offered some recommendations for self-care practices to process crisis counseling. One participant (R2) indicated, “I keep a journal with prayers, thoughts and feelings, complaints and poetry.”
Now that I’ve done my complaining, I need to take time off to pray and write a poem or two, but then, yes . . . I will continue to send this out into the world in hopes of eventual validation.
Happy Friday to you all,
John
I hope you all caught my clever utilization of recommendations from the offending journal to cope with this latest rejection. The good news is, like most rejections, this one was clarifying and inspired me with even more snark energy than I usually have.
What’s new about anger? Everything and nothing. You will feel angry over and over in your life. Each time it will be your familiar anger, which may come to feel old, tired, and boring. But each time it also will be new and compelling—as if you’ve been charged with energy to change the world.
Here’s one big truth about anger; it will come around again.
Here’s another: when doing anger management, it’s helpful to develop awareness of your usual triggers because if you see it coming, you may have a better chance to handle your anger in ways that are less embarrassing or destructive.
Here’s a third. This one I like to tell my clients and students: One good thing about having anger problems is that—and you can count on this—you will get many opportunities to work on your anger in the future, because it won’t be long until your anger visits you again (and again).
To summarize: Anger is repetitive; it’s good to develop self-awareness of your personal triggers; you will be presented with many opportunities to deal with your anger differently.
What follows is a slight revision of a post from seven years ago.
The speedometer reads 82 miles per hour. The numbers 8 and 2, represent to me, a reasonable speed on I-90 in the middle of Montana. Our speed limit signs read eight-zero. So technically, I’m breaking the law by two miles per hour. But the nearest car is a quarter mile away. The road is straight. Having ingested an optimal dose of caffeine, my attention is focused. All is well.
In my rear-view mirror, I notice a car slowly creeping up on me from behind. He gets a little to close to my rear bumper, and then slowly drifts into the left lane past me, lingering beside me and edging ahead. Then, with only three car lengths between us, he puts on his blinker and drifts in front of me. Now, with no other cars in sight, there’s just me and Mr. 83 mph on I-90, three car lengths apart.
An emotion rises into awareness. It’s anger, from a distance. I see it coming slowly, as if it’s in the rear-view mirror of my brain. At this distance, it’s only annoyance. I feel it and see it coming and immediately know it can go in one of three directions: My annoyance could sit there and remain unpleasant, until I tire of it. If I provide it with oxygen, could rise up and blossom into full-blown anger. Or, I can send it away, leaving room for other—more pleasant—thoughts and actions.
That’s not to say annoyance and anger is wholly unpleasant. Part of me likes it; part of me feels so damn aggrieved and indignant and justified.
All this self-awareness is fabulous. This is the Sweet Spot of Self-Control.
Without moving or speaking, “Hello anger,” I say, to myself, in my brain.
In this sweet spot, I experience expanding awareness, a pinch of energy, along with unfolding possibilities. I love this place. I love the strength and power. I also recognize anger’s best buddy, the behavioral impulse. This particular impulse (they vary of course), is itching for me to reset my cruise control to 84 mph. It’s coming to me in the shape of a desire—a desire to send the driver in front of me a clear message. Isn’t that what anger, in its behavioral manifestation, aggression, is all about—sending a message?
“You should cut him off,” the impulse says, “and let him know he should give you some space.”
The sweet spot is sweet because it includes the empowered choice to say “No thanks” to the impulse and “See you later” to anger.
Now I’m listening to a different voice in my head. It’s smaller, softer, steadier. “It doesn’t matter” the voice whispers. “Let him move on ahead. Revenge is only briefly sweet. Those who seek revenge should dig two graves.”
I smile remembering an anger management workshop. With confidence, I had said to the young men in attendance, “No other emotion shifts as quickly as anger. You can go from feeling completely justified and vindicated, but as soon as you act, you can feel overwhelmed with shame, regret, or embarrassment.”
One participant said, “Lust. Lust is like anger. One second you want something more than anything, but the next second you might wish you hadn’t.”
“Maybe so,” I said.
There are many rational reasons why acting on aggressive behavioral impulses is ill-advised. Maybe the biggest is that the man in the car wouldn’t understand my effort to communicate with him. This gap of understanding is common across many efforts to communicate. But it’s especially linked to retaliatory impulses. When angry, I can’t provide nuance in my communication; I can’t make it constructive.
The quiet voice in my brain murmurs: “You’re no victim to your impulses. You drive the car; the car doesn’t drive you.” That doesn’t make much sense. Sometimes the voice in my head speaks in analogy and metaphor. It’s a common problem. I want straight talk, but instead I get some silly metaphor from my elitist and intellectual conscience.
But here’s what I get. I get that my conscience is telling me that this sweet spot is sweet because I get to see and feel my self-control. Not only do I see my behavioral options, I get to see into the future and evaluate their likely outcomes. I get to reject poor choices and avoid negative outcomes. I’m not a victim of annoyance, anger, or aggressive impulses. I make the plan. I drive the car.
The other driver is now far ahead. I recognize that I could resurrect my anger. I choose to let it go instead.
I haven’t always let go of my anger. In my teen years I developed a temper. I had many sport-related fits of embarrassing anger. I went to psychotherapy. My therapist listened, and helped me grow my better judgment. He said, “I don’t believe in the bowel movement theory of anger control.” That was a little indirect, and interesting. We don’t have to expel it. We can sit with it. We can reflect on it. We can watch it go away. We can put it in the rear-view mirror, or let it pass us by. Using our functional frontal lobes, we can experience the joy of the Sweet Spot of Self-Control.
My anger is like an old, greedy, needy, and fickle friend. It has an all-or-nothing mentality. My anger wants attention and power, because it values power over long-term happiness.
Anger is also a source of energy; it can fuel us to be assertive, to fight injustice, to be clear on our values. Anger has its place, and is sometimes a useful partner: a partner whom we should keep in the passenger seat, never letting it get behind the wheel and drive—even on a wide-open Montana highway.
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.
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John Sommers-Flanagan 