Most people intuitively know that emotions are a central, complex, and multidimensional part of human experience. Emotions are typically in response to perceptions, include sensations, and are at the root of much of our existential meaning-making. Emotions are at the heart (not literally, of course) of much of the motivation that underlies behavior.
What follows is another excerpt from Clinical Interviewing (7th edition). In this excerpt, we define and explore the use of an interpretive reflection of feeling as a tool to go deeper into emotion and meaning with clients. As with all things interpretive, I recommend proceeding with caution, respect, and humility. . . because sometimes clients aren’t interested in going deeper and will push back in one way or another.
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Interpretive Reflection of Feeling (aka Advanced Empathy)
Interpretive reflections of feeling are emotion-focused statements that go beyond obvious emotional expressions. Sometimes referred to as advanced empathy (Egan, 2014), interpretive reflection of feeling is based on Rogers’s (1961) idea that sometimes person-centered therapists work on emotions that are barely within or just outside the client’s awareness.
By design, interpretive reflections of feeling go deeper than surface feelings or emotions, uncovering underlying emotions and potentially producing insight (i.e., the client becomes aware of something that was previously unconscious or partially conscious). Nondirective reflections of feeling focus on obvious, clear, and surface emotions; in contrast, interpretive reflections target partially hidden, deeper emotions.
Consider again the 15-year-old boy who was so angry with his teacher.
Client: That teacher pissed me off big time when she accused me of stealing her phone. I wanted to punch her.
Counselor: You were pretty pissed off. (reflection of feeling)
Client: Damn right.
Counselor: I also sense that you have other feelings about what your teacher did. Maybe you were hurt because she didn’t trust you. (interpretive reflection of feeling)
The counselor’s second statement probes deeper feelings that the client didn’t directly articulate.
An interpretive reflection of feeling may activate client defensiveness. Interpretations require good timing (Fenichel, 1945; Freud, 1949). That’s why, in the preceding example, the counselor initially used a nondirective reflection of feeling and then, after that reflection was affirmed, used a more interpretive response. W. R. Miller and Rollnick (2002) made this point in Motivational Interviewing:
Skillful reflection moves past what the person has already said, though not jumping too far ahead. The skill is not unlike the timing of interpretations in psychodynamic psychotherapy. If the person balks, you know you’ve jumped too far, too fast. (p. 72)
Interpretive reflections of feeling assume clients will benefit from going “vertical” or deeper into understanding underlying emotions; they can have many effects, the most prominent include the following:
If offered prematurely or without a good rationale, they may feel foreign or uncomfortable; this discomfort can lead to client resistance, reluctance, denial, or a relationship rupture (Parrow, 2023).
When well stated and when a positive therapy relationship exists, interpretive reflections of feeling may feel supportive because therapists are “hearing” clients at deeper emotional levels; this can lead to enhanced therapist credibility, strengthening of the therapeutic relationship, and collaborative pursuit of insight.
Interpretive reflections of feeling are naturally invasive. That’s why timing and a good working alliance are essential. When using interpretive reflections of feeling, follow these principles.
Wait until:
You have good rapport or a positive working alliance.
Your clients have experienced you accurately hearing and reflecting their surface emotions.
You have evidence (e.g., nonverbal signals, previous client statements) that provide a reasonable foundation for your interpretation.
Phrase your interpretive statement:
Tentatively (e.g., “If I were to guess, I’d say…”)
Collaboratively (e.g., “Correct me if I’m wrong, but…”)
The need to phrase statements tentatively and collaboratively is equally true when using any form of feedback or interpretation. Many different phrasings can be used to make such statements more acceptable.
I think I’m hearing that you’d like to speak directly to your father about your sexuality, but you’re afraid of his response.
Correct me if I’m wrong, but it sounds like your anxiety in this relationship is based on a deeper belief that she’ll eventually discover you’re unlovable.
If I were to guess, I’d say you’re wishing you could find your way out of this relationship. Does that fit?
This may not be accurate, but the way you’re sitting seems to communicate not only sadness but also some irritation.
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I hope this content has been of some interest or use to you in your work. If you want a bit more, a couple of emotion-related case examples are at the link below (and you can always buy the book:)).
In my last post, I reviewed the most basic of all therapeutic emotional responses, the reflection of feeling. As noted yesterday, reflections of feeling are, by definition, neutral . . . and providing a neutral reflection has benefits and liabilities.
For clients who have a history of experiencing negative judgments and oppression, instead of remaining neutral, it may be necessary to be explicitly validating. In Chapter 5 of our Clinical Interviewing textbook, we begin by describing and providing examples of the technique called “Feeling Validation.”
If you’re tracking closely, you’ll recall that a reflection of feeling is on the left side of the “listening continuum” and feeling validation is in the center of the listening continuum. Below, you’ll find information on using feeling validation from the Clinical Interviewing text.
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Directive Listening Skills
Directive listening skills are advanced interviewing techniques that encourage clients to examine and possibly change their thoughts, emotions, and behaviors. Directive listening skills can be used for assessment, exploring client issues, and facilitating insight. They include:
Feeling validation
Interpretive reflection of feeling
Interpretation (psychoanalytic or reframing)
Confrontation
Immediacy
Questions
Directive listening skills place you in an expert role. The therapist’s behaviors in this chapter range from being mostly client centered to mostly therapist centered. Client-centered directives zero in on what the client is already talking about, but take clients deeper. Therapist-centered directives shift clients toward what they’re not yet talking about. Directive listening skills operate on the assumption that clients will benefit from guidance or direction.
Feeling Validation
Reflections of feeling (discussed in Chapter 4) are often confused with feeling validation. The difference is that reflections of feeling are more purely client centered, whereas feeling validation includes your opinion, approval, or validation of client emotions. A feeling validation is an emotion-focused technique that acknowledges and validates your client’s explicit feelings. It’s a message that communicates, “What you’re feeling is a natural or normal emotional response.” Feeling validation is an emotional affirmation.
The difference between reflecting feelings versus validating feelings may seem subtle, but it provides an excellent example of the complexities of skillful interviewing. Skilled interviewers use reflection of feeling as a method to prompt clients to evaluate their own emotions. In contrast, they use feeling validation as a method to support and reassure clients. Feeling validation includes a psychoeducational-authoritative-reassurance component. Novice interviewers may not be aware of the difference.
Psychoanalytic clinicians distinguish between supportive and expressive psychotherapy techniques. Based on this distinction, feeling validation is a supportive technique, and feeling reflection is an expressive technique. Clients usually feel supported and more normal when you validate their emotions. Clients may experience greater stress if you use reflections of feeling to have them examine and judge the validity of their own emotions.
Supportive techniques like feeling validation are outside-in self-esteem boosters. They’re based on the therapist (as an outside authority) saying something like “Your anger in response to being unfairly accused of stealing something seems natural.” One drawback of outside-in self-esteem boosters is that they don’t facilitate self-discovery. The boost that comes from external emotional validation may be temporary and not lead to lasting client change. If clients come to rely on validation of their feelings, they may continue to look outward for external validation.
All approaches to feeling validation give clients the message, “Your feelings are acceptable, and you have permission to feel them.” You might even use feeling validation to suggest to clients that they should be having particular feelings.
Client 1: I’ve been so sad since my mother died. I can’t seem to stop myself from crying. (Client begins sobbing.)
Therapist 1: It’s okay to feel sad about losing your mother. That’s perfectly normal. Crying in here as you talk about it is a natural response.
The preceding exchange involves validation. By openly stating that feeling sad and crying is normal, the therapist takes on an expert or educator role.
Another way to provide feeling validation is through self-disclosure:
Client 2: I get so anxious before taking tests, you wouldn’t believe it! All I can think about is how I’m going to freeze up and forget everything. Then, when I get to class and look at the test, my mind just goes blank.
Therapist 2: I remember feeling the same way about tests.
In this example, the therapist uses self-disclosure to validate the client’s anxiety. Although using self-disclosure to validate feelings can be reassuring, it’s not without risk. Clients may wonder if therapists can be helpful with anxiety symptoms if they have similar anxieties. Self-disclosure can also enhance therapist credibility, as a client may think, “Hmm. If my therapist went through test anxiety too, maybe he’ll understand and be able to help me.” Using self-disclosure to validate client emotions can diminish or enhance therapist credibility—depending on the client and the therapeutic relationship (see Case Example 5.1).
Therapists can also use universality to validate or reassure clients.
Client 3: I always compare myself to everyone else—and I usually come up short. I wonder if I’ll ever feel confident.
Therapist 3: You’re being hard on yourself. I don’t know anyone who feels a complete sense of confidence.
Clients may feel validated when they observe or are informed that nearly everyone else in the world (or universe) feels similar emotions. Yalom provided a personal example:
During my own 600-hour analysis I had a striking personal encounter with the therapeutic factor of universality… I was very much troubled by the fact that, despite my strong positive sentiments [towards my mother], I was beset with death wishes for her, as I stood to inherit part of her estate. My analyst responded simply, “That seems to be the way we’re built.” That artless statement not only offered considerable relief but enabled me to explore my ambivalence in great depth. (Yalom & Leszcz, 2020, p. 7)
Feeling validation is a common technique. People like to have their feelings validated; and, often, counselors like validating their clients’ feelings. However, open support, such as feeling validation, can reduce client exploration of important issues (i.e., clients assume they’re fine if their therapist says so).
Potential effects of feeling validation include:
Enhanced rapport
Increased or reduced client exploration of the problem or feeling (this could go either direction)
Reduction in client anxiety, at least temporarily
Enhanced client self-esteem or feelings of normality (perhaps only temporarily)
Possible increased client-therapist dependency
In many clinical scenarios, clinicians lead with less directive skills (i.e., Chapter 4) before using more directive skills (i.e., Chapter 5). However, there are some clinical situations where feeling validation or affirmation of clients take priority.
As you think about feeling validation, and all the complexities it can include, consider the following case example.
CASE EXAMPLE 5.1: Struggling to Manage the Impulse to Project My Disability Issues onto a Client
Eddy Fagundo, Ph.D., CRC, CVE, a Senior Manager of Education Content for the American Counseling Association wrote an essay on managing his impulse to project his own issues and lived experiences onto a client. Have you ever worked with someone who reminded you of yourself? Imagine yourself in Dr. Fagundo’s role. Would you be able to manage your impulses to be too comforting and too validating? Although this case is about countertransference, projection, and overidentification with the client, it’s also about appropriately validating self-disclosure and countertransference management.
“Mommy Rosemary, why does Eddy speak Russian?’” was an odd question that had become common for my friends (at age 5-years) to ask my mother . . . in Cuba. What my friends did not know was that I was not speaking Russian; I was speaking Spanish, or so I thought! Growing up, I had speech problems, but was determined to overcome them. I never missed any of my speech therapy appointments and was disciplined in practicing the difficult Spanish rolling Rs in front of the mirror before and after school. I did it! In third grade, I won the best reader in class award. Life was bright. Little did I know, that four years later, I would immigrate to the United States, and learn a new language. But I did this too!
These memories flashed before my eyes when counseling a young Cuban immigrant male with a speech impediment. The client felt defeated, isolated, and had low expectations of himself. I was conflicted; this young man was me as a child. If I could overcome my speech problems, I wanted to tell him: He could too! At the time, I was a new rehabilitation counselor. The situation made me keenly aware of potential projection issues. I knew I could not tell the client what to do. I knew I could not tell him he would be able to succeed, just as I did, because I was no more special than he was.
And so, I consulted my colleagues and supervisor. I focused on being aware of and bracketing my feelings and reactions, and on building a therapeutic relationship. I accepted the client unconditionally and respected his right to be himself without having me project my lived experiences onto him. Instead, I used my lived experiences therapeutically by professionally and appropriately self-disclosing my past struggles with speech problems. Counselor self-disclosure, when done sparingly and effectively, builds trust, fosters empathy, and strengthens the counseling relationship.
Today, the client is fully fluent in what some would argue to be the true universal language: mathematics. He holds a doctorate in mathematics, the speech impediments are improved, and he lives a fulfilling life. Even today, I wonder how different the outcome would have been had I not had the self-awareness and professional support to counter my projection impulses.
We will encounter clients similar to us in ways that make us struggle to avoid projecting our own lived experiences onto them. We need to identify those clients, but to do so, we must first ask, “Who am I, and who is standing beside me to support me in this journey of self-discovery?”
[End of Case Example 5.1]
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Our Clinical Interviewing text also includes specific learning activities. If you want to check out a learning activity designed to add nuance to your feeling (emotional) vocabulary, check out this handout:
The following excerpt is from our freshly published textbook, Clinical Interviewing (2024, 7th edition, Wiley).
What Is a Clinical Interview?
Clinical interviewing is a flexible procedure that mental health professionals use to initiate treatment. In 1920, Jean Piaget first used the words “clinical” and “interview” together in a way similar to contemporary practitioners. He believed existing psychiatric interviewing procedures were inadequate for studying cognitive development in children, so he invented a “semi-clinical interview.”
Piaget’s approach was novel. His semi-clinical interview combined tightly standardized interview questions with unstandardized or spontaneous questioning to explore the richness of children’s thinking processes (Elkind, 1964; J. Sommers-Flanagan et al., 2015). Interestingly, the tension between these two different interviewing approaches (i.e., standardized vs. spontaneous) continues today. Psychiatrists and research psychologists primarily use structured, or semi-structured clinical interviewing approaches. Structured clinical interviews involve asking the same questions in the same order with every client. Structured interviews are designed to gather reliable and valid assessment data. Virtually all researchers agree that a structured clinical interview is the best approach for collecting reliable and valid assessment data.
In contrast, clinical practitioners, especially those who embrace post-modern and social justice perspectives, generally use less structure. Unstructured clinical interviews involve a subjective and spontaneous relational experience. These less structured relational experiences are typically used to collaboratively initiate an assessment or counseling process. Murphy and Dillon (2015) articulated the latter (less structured) end of the interviewing spectrum:
We believe that clinical interviewing is—or should be—a conversation that occurs in a relationship characterized by respect and mutuality, by immediacy and warm presence, and by emphasis on strengths and potential. Because clinical interviewing is essentially relational, it requires ongoing attention to how things are said and done, as well as to what is said and done. . . . we believe that clinicians need to work in collaboration with clients . . . (p. 4)
Research-oriented psychologists and psychiatrists who value structured clinical interviews for diagnostic purposes would likely view Murphy and Dillon’s description of this “conversation” as a bane to reliable assessment. In contrast, clinical practitioners often view highly structured diagnostic interviewing procedures as too sterile and impersonal. Perhaps what’s most interesting is that despite these substantial conceptual differences—differences that are sometimes punctuated with passion—structured and unstructured approaches represent legitimate methods for conducting clinical interviews. A clinical interview can be structured, unstructured, or a thoughtful combination of both. (See Chapter 11 for a discussion of clinical interviewing structure.)
Formal definitions of the clinical interview emphasize its two primary functions or goals (J. Sommers-Flanagan, 2016; J. Sommers-Flanagan et al., 2020):
Assessment
Helping (including referrals)
To achieve these goals, all clinical interviews involve the development of a therapeutic relationship or working alliance. Optimally, the therapeutic relationship provides leverage for obtaining valid and reliable assessment data and/or providing effective interventions.
With all this background in mind, we define clinical interviewing as…
a complex, multidimensional, and culturally sensitive interpersonal process that occurs between a professional service provider and client. The primary goals are (a) assessment and (b) helping. To achieve these goals, clinicians may emphasize structured diagnostic questioning, spontaneous talking and listening, or both. Clinicians use information obtained in an initial clinical interview to develop a collaborative case formulation and treatment plan.
Given this definition, students often ask: “What’s the difference between a clinical interview and counseling or psychotherapy?” This is an excellent question that deserves a nuanced response. . . . [to be continued]
Yesterday I had the honor of presenting for the Mental Health Academy’s Mental Health Super Summit. My presentation, titled “Interviewing for Happiness: How to Weave Positive Psychology Magic into the Initial Clinical Interview” is still available, along with the other presentations, through this link: https://www.mentalhealthacademy.com.au/summit. There were 24 hours of possible continuing education for an incredibly low cost. Presenters included, Dr. Judith Beck and Dr. Cirecie West-Olatunji Professor, Xavier University of Louisiana, and me! You can access my powerpoints here:
Participating in this event was an honor also because the event is a fundraiser for “Act for Kids,” an Australian charity “that delivers evidence-led professional therapy and support services to children and families who have experienced or are at risk of harm.” Over $110K has already been raised. Here’s the Act for Kids link: https://www.actforkids.com.au/.
Back in the day, I was so into person-centered (aka nondirective) listening that I coauthored a 1989 article in the journal Teaching of Psychology titled, “Thou Shalt Not Ask Questions.” The point was that by temporarily eliminating questions from our therapeutic repertoire, we grow more aware of how to listen without using directive methods for facilitating client talk.
I’m still a fan of limiting therapist questions, if only to become more aware of their power. Even in the case of solution-focused or narrative therapies, when questions are the central therapeutic strategy, we should be as person-centered as possible when asking questions.
Below, I’ve included an excerpt of our coverage of listening from the forthcoming 7th edition of Clinical Interviewing. In the early 1990s, along with the first edition of Clinical Interviewing, we described a concept called the listening continuum. The excerpt starts there and then focuses in on what’s likely the most non-directive skill of all, therapeutic silence.
Here’s the excerpt. I hope you enjoy it and find it useful.
The Listening Continuum in Three Parts
Nondirective listening behaviors give clients responsibility for choosing what to talk about. Consistent with person-centered approaches, using nondirective behaviors is like handing your clients the reins to the horse and having them take the lead and choose where to take the session. In contrast, directive listening behaviors (Chapter 5) and directive action behaviors (Chapter 6) are progressively less person-centered. These three categories of listening behaviors (and the corresponding chapters) are globally referred to as the listening continuum. To get a visual sense of the listening continuum, see Table 4.1.
Nondirective Listening Behaviors on the LEFT Edge (Chapter 4)
Directive Listening Behaviors in the MIDDLE (Chapter 5)
Directive Action Behaviors on the RIGHT Edge (Chapter 6)
Attending behaviors or minimal encouragers
Feeling validation
Closed and therapeutic questions
Therapeutic silence
Interpretive reflection of feeling
Psychoeducation or explanation
Paraphrase
Interpretation (classic or reframing)
Suggestion
Clarification
Confrontation
Agreement/disagreement
Reflection of feeling
Immediacy
Giving advice
Summary
Open questions
Approval/disapproval
Urging
The ultimate goal is for you to use behavioral skills along the whole listening continuum. We want you to be able to apply these skills intentionally and with purpose. That way, when you review a video of your session with a supervisor, and your supervisor stops the recording and asks, “What exactly were you doing there?” you can respond with something like this:
I was doing an interpretive reflection of feeling. The reason I chose an interpretive reflection is that I thought the client was ready to explore what might be under their anger.
Trust us; this will be a happy moment for both you and your supervisor.
Hill (2020) organized the three listening continuum categories in terms of their primary purpose:
We hope you still (and will always) remember the Rogerian attitudes and have placed them firmly in the center of your developing therapeutic self. In addition, at this point we hope you understand the two-way nature of communication, the four different types of attending behaviors, and how your listening focus can shift based on a variety of factors, including culture and theoretical orientation.
Next, we begin coverage of technical skills needed to conduct a clinical interview. See Table 4.2 for a summary of nondirective listening behaviors and their usual effects. Having already reviewed attending behaviors, we now move to therapeutic silence.
Therapeutic Silence
Most people feel awkward about silence in social settings. Some researchers have described that therapists-in-training view silence as a “mean” response (Kivlighan & Tibbits, 2012). Despite the angst it can produce, silence can be therapeutic.
Therapeutic silence is defined as well-timed silence that facilitates client talk, respects the client’s emotional space, or provides clients with an opportunity to find their own voice regarding their insights, emotions, or direction. From a Japanese perspective,
Silence gives forgiveness and generosity to human dialogues in our everyday life. Without silence, our conversation tends to easily become too clever. Silence is the place where “shu”… (to sense the feeling of others, and forgive, show mercy, absolve, which represents an act of benevolence and altruism) arises, which Confucius said was the most important human attitude. (Shimoyama, 1989/2012, p. 6; translation by Nagaoka et al., 2013, p. 151)
Table 4.2 Summary of Nondirective Listening Behaviors and Their Usual Effects
Listening Response
Description
Primary Intent/Effect
Attending behaviors
Eye contact, leaning forward, head nods, facial expressions, etc.
Facilitates or inhibits client talk.
Therapeutic silence
Absence of verbal activity
Allows clients to talk. Provides “cooling off ” or introspection time. Allows clinician time to consider next response.
Paraphrase
Reflecting or rephrasing the content of what the client said
Assures clients that you heard them accurately and allows them to hear what they said.
Clarification
Restating a client’s message, preceded or followed by a closed question (e.g., “Do I have that right?”)
Clarifies unclear client statements and verifies the accuracy of what the clinician heard.
Reflection of feeling
Restatement or rephrasing of clearly stated emotion
Enhances clients’ experience of empathy and encourages further emotional expression.
Summary
Brief review of several topics covered during a session
Enhances recall of session content and ties together or integrates themes covered in a session.
Silence also allows clients to reflect on what they just said. Silence after a strong emotional outpouring can be therapeutic and restful. In a practical sense, silence also allows therapists time to intentionally select a response rather than rush into one.
In psychoanalytic psychotherapy, silence facilitates free association. Psychoanalytically oriented therapists use role induction to explain to clients that psychoanalytic therapy involves free expression, followed by occasional therapist comments or interpretations. Explaining therapy or interviewing procedures to clients is always important, but especially so when therapists are using potentially anxiety-provoking techniques, such as silence (Meier & Davis, 2020).
CASE EXAMPLE 4.2: EXPLAIN YOUR SILENCE
While on a psychoanalytically oriented internship, I (John) noticed one supervisor had a disturbing way of using silence during therapy sessions (and in supervision). He would routinely begin sessions without speaking. He sat down, looked at his client (or supervisee), and leaned forward expectantly. His nonverbal behavior was unsettling. He wanted clients and supervisees to free associate and say whatever came to mind, but he didn’t explain, in advance, what he was doing. Consequently, he came across as intimidating and judgmental. The moral of the story: Use role induction—if you don’t explain the purpose of your silence, you risk scaring away clients.
[End of Case Example 4.2]
Examples of How to Talk About Silence
Part of the therapist’s role involves skilled explanations of process and technique. This includes talking about silence. Case Example 4.2 is a good illustration of how therapist and client would have been better served if the therapist had explained why he started his sessions with silence.
Here’s another example of how a clinician might use silence therapeutically:
Katherine (they/them) is conducting a standard clinical intake interview. About 15 minutes into the session the client begins sobbing about a recent romantic relationship break-up. Katherine provides a reflection of feeling and reassurance that it’s okay to cry, saying, “I can see you have sad feelings about the break-up. It’s perfectly okay to honor those feelings in here and take time to cry.” They follow this statement with about 30 seconds of silence.
There are several other ways Katherine could handle this situation. They might prompt the client,
Let’s take a moment to sit with this and notice what emotions you’re feeling and where you’re feeling them in your body.
Or they might explain their purpose more clearly.
Sometimes it’s helpful to sit quietly and just notice what you’re feeling. And sometimes you might have emotional sensations in a particular part of your body. Would you be okay if we take a few moments to be quiet together so you can tune in to your emotions and where you’re feeling them?
In each of these scenarios, Katherine explains, at least briefly, the use of silence. This is crucial because when clinicians are silent, pressure is placed on clients to speak. When silence continues, the pressure mounts, and client anxiety may increase. In the end, clients may view their experience with an excessively silent therapist as aversive, lowering the likelihood of rapport and a second meeting.
Guidelines for Using Silence Therapeutically
Using silence may initially feel uncomfortable. With practice, you’ll increase your comfort level. Consider the following suggestions:
When a client pauses after making a statement or after hearing your paraphrase, let a few seconds pass rather than jumping in verbally. Given an opportunity, clients can move naturally into important material without guidance or urging.
As you’re waiting for your client to resume speaking, tell yourself that this is the client’s time for self-expression, not your time to prove you can be useful.
Try not to get into a rut regarding silence. When silence occurs, sometimes wait for the client to speak next and other times break the silence yourself.
Be cautious with silence if you believe your client is confused, psychotic, or experiencing an acute emotional crisis. Excessive silence and the anxiety it provokes can exacerbate these conditions.
If you feel uncomfortable during silent periods, use attending skills and look expectantly toward clients. This helps them understand it’s their turn to talk.
If clients appear uncomfortable with silence, give them instructions to free associate (e.g., “Just say whatever comes to mind”). Or you can use an empathic reflection (e.g., “It’s hard to decide what to say next”).
Remember, sometimes silence is the most therapeutic response available.
Read the interview by Carl Rogers (Meador & Rogers, 1984). It includes examples of how Rogers handled silence from a person-centered perspective.
Remember to monitor your body and face while being silent. There’s a vast difference between a cold silence and an accepting, warm silence. Much of this difference results from body language and an attitude that welcomes silence.
Use your words to explain the purpose of your silence (e.g., “I’ve been talking quite a lot, so I’m just going to be quiet here for a few minutes so you can have a chance to say whatever you like”). Clients may be either happy or terrified at the chance to speak freely.
John Wiley and Sons recently informed me of the excellent and exciting news that the 7th edition of Clinical Interviewing (CI7) has gone to press and will drop in the U.S. on or before September 30. Our wish for this edition is the same as previous editions: To provide research-based, theoretically supported, clinically insightful, and culturally informed education and training on how to conduct basic and advanced clinical interviews.
The Resource
Part of CI7 includes video updates. Most of the updates offer greater representation of culturally diverse counselors and psychotherapists. For example, the video link below features Dr. Devika “Dibya” Choudhuri describing a “grounding” technique that she uses when conducting tele-mental health (aka virtual) clinical interviews, the topic of Chapter 14.
Although you may have your own approaches to facilitating grounding during tele-mental health sessions, I believe Dr. Choudhuri’s idea is innovative and may be a resource that you can add to your toolkit.
Stay tuned, because over the next several weeks I’ll be posting additional fresh new text and video content from CI7.
The Request
Traditionally, publishers ask authors to gather promotional endorsements for new books. This time around, maybe because it’s the 7th edition, neither Wiley nor the absent-minded authors of CI7 thought about gathering endorsements. In the past, we’ve had Derald Wing Sue, John Norcross, Victor Yalom, Pamela Hays, Barbara Herlihy, Allen Ivey, David Jobes, and Marianne and Jerry Corey write short blurbs. Here’s what Derald Wing Sue said about the 6th edition:
The most recent edition of Clinical Interviewing is simply outstanding. It not only provides a complete skeletal outline of the interview process in sequential fashion, but fleshes out numerous suggestions, examples, and guidelines in conducting successful and therapeutic interviews. Well-grounded in the theory, research and practice of clinical relationships, John and Rita Sommers-Flanagan bring to life for readers the real clinical challenges confronting beginning mental health trainees and professionals. Not only do the authors provide a clear and conceptual description of the interview process from beginning to end, but they identify important areas of required mastery (suicide assessment, mental status exams, diagnosis and treatment electronic interviewing, and work with special populations). Especially impressive is the authors’ ability to integrate cultural competence and cultural humility in the interview process. Few texts on interview skills cover so thoroughly the need to attend to cultural dimensions of work with diverse clients. This is an awesome book written in an engaging and interesting manner. I plan to use this text in my own course on advanced professional issues. Kudos to the authors for producing such a valuable text.
―Derald Wing Sue, Ph.D., Professor of Psychology and Education, Teachers College, Columbia University
This time around, we’re less than two weeks from publishing and are without formal endorsements. As a consequence, I’m asking: “Is there ANYBODY out there who has read a portion of the CI7 manuscript or used a previous edition, who would like to share their thoughts about how the book influenced you or how the videos helped with your training?
[I know this last paragraph sounds pathetic. However, if you know me, you probably know my sense of humor, and the “Is there anybody out there?” call is BOTH a sincere request for your input AND me mocking myself for making this request.]
To be completely serious: If you want to share something positive about your experience—from any point in time—with the Clinical Interviewing text, I hope you’ll write a sentence or two or three (you don’t have to write half a page, like Derald Wing Sue) on the particular ways in which you found the book and/or videos meaningful to you.
To share your thoughts on any edition of the text, please post them here on this blog, or send them to me at john.sf@mso.umt.edu.
Thanks very much for considering this request. Please, please, I hope someone “out there” is listening!
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.
Textbook writing is a particular kind of writing that requires a variety of ways to present relatively boring material to students and aspiring professionals. Although we pride ourselves on writing the most entertaining textbooks in the business, our efforts to entertain are all part of a reader-friendly delivery system.
Another (less humorous) reader-friendly delivery strategy is the checklist. We intermittently use checklists to summarize essential information in our Clinical Interviewing text. Below, I’m including links to three checklists. Please note, these checklists are in process, and so if you see any typos or missing information or have some excellent feedback to share with me . . . post your feedback here on this blog or email me: john.sf@mso.umt.edu. I will greatly appreciate your feedback!
From Chapter 10: A Checklist on Suicide Assessment Documentation:
For those of you who are still reading (and I hope that’s everyone), I’m still looking for someone who can write me a short (400 word) case or two on working with LGBTQ+ youth. A transgender case would be especially nice. If you’re interested, send me an email: john.sf@mso.umt.edu
As we begin the revision process for Clinical Interviewing, I’m discovering content here and there that I want to share. Below is a short excerpt from the Intake Interviewing chapter where we’re discussing the process of evaluating clients’ interpersonal behavior patterns. Please email me your reactions and recommendations if you have some.
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Evaluating Interpersonal Behavior
Interpersonal behavior is central in the development and maintenance of client problems. Some theorists claim that all client problems have their roots in relationship problems (Glasser, 1998). Evaluating client interpersonal behavior is an essential part of an intake interview.
Intake interviewers have five potential data sources pertaining to client interpersonal behavior.
Client self-report. This includes self-report of (a) past relationship interactions (e.g., childhood) and (b) contemporary relationship interactions.
Clinician observations of client interpersonal behavior during the interview.
Formal psychological assessment data.
Information from past psychological records/reports.
Information from collateral informants.
Although some behaviorists and in-home family therapists also observe clients outside the office (e.g., in school, home, and work environments), it’s unusual to have those data available prior to an intake.
Evaluating interpersonal behavior is difficult. Each of the preceding data sources can be suspect. For example, client self-report may be distorted or biased; often clients cast their interpersonal behaviors in a favorable light, or they may excessively blame themselves for negative interpersonal experiences. Clinician observations are also subjective. When you’re evaluating client interpersonal behavior, it’s wise to use several basic assessment principles to temper your conclusions:
Single observations are often unreliable. This is partly because interpersonal behavior can shift dramatically from situation to situation. Multiple observations of behavior patterns (e.g., interpersonal aggression or interpersonal isolation) are more reliable.
Just as construct validity is established through multimethod, multitrait assessments (Campbell & Fiske, 1959), interpersonal assessments are more valid when you have converging data from more than one source (e.g., self-report plus clinician observation).
The literature is replete with theory-based models for interpersonal assessment. When clinicians hold strong theoretical beliefs, confirmation bias is more likely (in other words, you will make observations that confirm your theoretical stance or hypothesis). Therefore, you should regularly question conclusions about client interpersonal behavior based on your preexisting ideas.
One of the most popular models for conceptualizing interpersonal behavior is attachment theory. Adherents to this perspective believe that early caregiver-child relationship interactions create internal working models about how relationships work. Essentially, this leaves clients with consistent (and sometimes rigid) interpersonal expectations and reactions. For example, clients with insecure attachment styles may expect or anticipate rejection or abandonment, while clients with ambivalent attachment styles alternate between pushing others away and clinging to them. Typically, maladaptive components of client internal working models are activated during the early stages of new relationships or during times of significant stress, when support and reassurance are needed (O’Shea, Spence, & Donovan, 2014).
Interpersonal assessment based on attachment theory is a psychodynamic approach and involves a depth-oriented assessment process. However, the idea that individuals have internal working models that guide their interpersonal behaviors is consistent across many different theoretical perspectives. Specifically,
Cognitive therapists emphasize client schema or schemata that shape what clients expect in interpersonal relationships (Young, Klosko, & Weishaar, 2003).
Adlerian therapists use the term lifestyle assessment to refer to the evaluation of client expectations about the self, the world, and others (Carlson, Watts, & Maniacci, 2006).
Psychoanalytic therapists refer to the client’s core conflictual relational theme (CCRT) as a target for treatment (Luborsky, 1984).
The whole emphasis of the empirically supported interpersonal psychotherapy for depression is based on addressing problematic interpersonal relationship dynamics (Markowitz & Weissman, 2012).
It’s always advisable to attend to feelings and reactions that clients elicit in you (Teyber & McClure, 2011). For example, some clients may trigger boredom, arousal, sadness, or annoyance. These personal and emotional reactions can be viewed as countertransference (Luborsky & Barrett, 2006). However, if there’s convergent evidence that reactions the client is evoking in you are also evoked in others, it’s likely that the client’s interpersonal behavior is the culprit. If your reactions are unique, then your countertransference reaction may be more about you and less about the client.
Evaluating a client’s personal history and interpersonal behaviors is a formidable task that could easily take several sessions. Expecting that you should have a precise sense of your client’s interpersonal style after a single interview is unrealistic. A better goal is to have a few working hypotheses about your client’s interpersonal behavior patterns (see Case Example 8.2).
CASE EXAMPLE 8.2: DESCRIBING INTERPERSONAL OBSERVATIONS
The following intake note focuses on interpersonal observations and, consistent with a collaborative/therapeutic assessment model, uses a descriptive rather than a labeling approach.
Miriam, a 36-year-old White, married female, described herself as suffering from tension and stress in her marital relationship. She reported, “My husband always calls me controlling, and I hate that, but sometimes he’s right.” During our session, Miriam repeatedly (about five times) asked for more information, complaining that she “really needed” to understand exactly what counseling was about before she could be sure she wanted to proceed. As we discussed her husband’s comments in greater detail, Miriam noted that she believed her “need for control” was related to anxiety. Together we identified several triggers that elicit anxiety and are then followed by self-identified controlling behaviors. These comprised (a) new situations (like counseling), (b) her husband leaving the house without telling her his plans, and (c) when she feels neglected by her husband. Overall, these triggers may be related to an internal working model where Miriam’s sense of relational security is threatened. Consequently, one of our first therapy tasks is for Miriam to engage in a self-monitoring homework assignment to help further refine our understanding of the interpersonal triggers that activate her “controlling” behaviors.
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