Clinical interview and Counseling final

A Supportive Presence

 Clinical Repose
 Warmth and Caring
 Acceptance
 Genuineness
 Availability
 Validation of the
Client’s Story
 Identifying and
Affirming Strengths
 Provision of
Concrete Supports
 Advocacy

Clinical Repose

 Relaxed, attentive, reassuring steadiness of
the clinician
 Therapy session as “holding environment”
 Anchored, client-centered and caring presence
 Allows the client to stay self- and problem-focused
without distraction or fear of judgment or
abandonment
 Deliberate yet warm
 Calm and confident manner

Warmth and Caring

 Care about clients and their well-being
 Part of relational process
 Conveying warmth appropriately

Acceptance

 Unconditional positive regard
 Appreciation and affirmation of client
 Clinician communicates nonjudgmental
acceptance
 Genuine care for the client

Acceptance is affected by

 Societal Norms
 Personal Values
 Stylistic Differences

Societal Norms

 Standards and expectations of conduct
 Often codified into law
 Change over time
 Different cultures, different norms
 Culture-bound syndromes

Culture-bound syndromes

A set of behaviors, often a combination of psychological and somatic symptoms, that are only found in specific localities, societies, or groups. It is assumed that these behaviors are influenced by local cultural factors. The current DSM refers to these as cultural concepts of distress.

Personal Values

 Developed in context of family and
sociocultural influences
 Nonjudgmental- unconditionally accepting
people but not all behaviors
 Must be prepared to have personal values
challenged by client’s values or behaviors

Stylistic Differences

 Everyone has a personal style—clients and
clinicians
 Personal style- habits and preferences
 May feel more comfortable with some styles
than others
 Clinician’s responsibility to make ambiance
harmonious

Genuineness

 Congruence
 Honesty
 Free from pretense, hypocrisy
 Meaning what we say, but not saying
everything we think

Congruence

When clinicians are genuine and authentic with clients, free of pretense and hypocrisy, and do not hide behind a mask of professionalism.

Availability

 Easy accessibility and flexibility
 Physically and psychologically available
 Using technology to increase availability
 Additional contact in crisis
 Accompanying client under duress
 Establishing a safety net

Validation of the Client’s Story

 The clinician’s endorsement and appreciation
of the realities of the client’s story
 Universalizing
 Clinician verbally situates the client in a
community of people sharing similar feelings,
experiences, or opinions.
 Used to undercut client’s sense of isolation or
differentness
 Not always useful

Strengths perspective

A view of human development and functioning that highly values client assets and potentials. Clinicians identify and underscore the often undervalued or unnoticed strengths that clients have used successfully to resolve problems, as well as highlighting and utilizing new strengths and supports.

Transferability of skills

The clinical concept asserts that one’s strengths, talents, or methods of coping in one situation might work well in others.

Provision of Concrete Supports

 Help client access needed services
 Maslow’s hierarchy of needs
 Concrete needs are foundation
 Builds trust and working alliance
 Avoid rescue fantasies and excessive “doing
for”

Advocacy

 Work with social service agencies, other
institutions, and social action groups to
increase benefits, access, opportunities,
justice, and rights for clients and all people
 Help clients get proper amount and kinds of
services
 Energizes the clinical work

Empathy

Experiencing the world from another ’s subjective perspective while maintaining one’s own perspective as an outside observer

Basic empathy

 What is on the surface
 What client knows and has communicated

Advanced empathy

 What client has not yet verbalized
 What client may not yet be aware of
 Reflecting what lies beneath the surface to help
the client gain new perspective

Empathy: A Balancing Act

Separate but involved in experience: observing the client, feeling, and thinking about the client’s experience

No separation: feeling and thinking as if one were the client

Three Facets of Empathy

 Cognitive empathy
 Emotional empathy
 Emotional regulation

Cognitive empathy

The ability to take the perspective of another, to understand the intentions, desires, and beliefs of another person by thinking about the other person’s situation.

Emotional empathy

The ability to feel as another person feels, to experience the emotional state of another.

Emotional regulation

The ability to self-soothe or calm oneself. Emotional regulation is essential for clinicians so that they can act in helpful ways instead of being overwhelmed by their empathy for a client.

Clinical Empathy

 Developing empathy
 Learn how to understand the perspective and feelings of the client
 Communicating empathy
 Effectively communicating understanding to client
 Checking with client about its accuracy
 Using empathy
 Acting on that understanding in a helpful way in the clinical relationship

Developing Empathy

 Mutual empathy
 Relational awareness
 Mindfulness and meditation
 Learning to read facial expressions
 Role playing
 Gathering information
 Experience with “others”
 Practice and supervision

Mutual empathy

The relational process of reciprocal caring and attending that leaves the participants in the relationship feeling seen, understood, and moved by the other.

Communicating Empathy

 Supportive sounds
 Mirroring
 Behavioral synchrony
 Facial mimicry
 Physical form of reflection
 Empathic echo
 Empathic reflection of content
 Empathic reflection of affect

Mirroring

A skill in which the clinician subtly matches the client’s posture, facial expression, and gestures, while being careful not to mimic or parrot them, in order to increase rapport and empathy. Can be used as a physical form of reflection.

Behavioral synchrony

The participants in a conversation often change their postures, gestures, and mannerisms to match each other. Behavioral synchrony helps us perceive and recognize the emotional experience of another, builds rapport, and increases empathy.

Facial mimicry

An observer matches his or her facial musculature to the facial gestures in another person’s facial expression. Facial mimicry helps us perceive and recognize the emotional experience of another, build rapport, and increase empathy.

Empathic echo

A verbal reflection of both the content and the affect within a client’s story, to signal that the clinician is attending closely to what the client says and does in the moment.

Empathic Reflection of Content

 Verbal reflection of client’s story
 Clinician shares client’s perspective
 Challenge to reflect verbally what client has
said
 May reflect parts of what client has said and
save other content for later

Empathic Reflection of Affect

 Reflect feelings expressed by the client
 May reflect feelings not explicitly expressed but which may underlie the client’s story

Using Empathy

 Demonstrates support and caring
 Encourages client self-disclosure
 Builds the working alliance
 Serves as the basis for clinical hunches

Empathic Failures

 Reflects the wrong content, feeling, or
meaning
 Misses important themes
 Piles on too much sympathy
 Confuses one client’s story with another
 Clinician seems disingenuous

Boilerplate empathy

“I feel your pain”

Piling it on

That is the saddest story that I have ever
heard”

Getting the facts wrong

• Clinician: “Sounds like your dad was not listening to you.”
• Patient: “It was my uncle who was not listening

Trivializing/Universalizing

• “lot of people get sad”
  • “What do you think it is about your break-ups that makes them so much more painful than the norm?

Mistaking similarity for empathy

• “I had a lot of trouble adjusting to college too”
  • “I was nervous about dating when I started but it got better for me and I am sure it will for you too.”

Common Reasons for Empathic Failures

 Countertransference
 Projection
 Overidentification
 Antipathy

Countertransference

A term from psychodynamic theory to describe an unconscious process in which the clinician views the client as representative of an important figure from the clinician’s past, and then behaves toward the client as though he or she were that person.

Projection

A psychodynamic term to describe the clinical process in which clinicians disavow and repress their own unpleasant or taboo feelings, then attribute these feelings to clients or others (“I’m not angry, she is!”).

Overidentification

A psychological process in which clinicians emphasize the similarities between themselves and their clients, while minimizing or denying things that would reveal differences between them.

Antipathy

hatred of man(kind)

Ways to Avoid Empathic Failures

 Detailed process recordings
 Video and audio recordings
 Individual and group supervision
 Role-plays
 Personal therapy

Learning from Empathic Failures

 Models for clients that mistakes can occur without destroying a relationship
 Two-way feedback heightens mutuality
 Sorting things out together helps the clinical alliance

Exploration

 Clinician gathers initial information
 Using questions, prompts, or probes

Elaboration

Encourages clients to expand on, deepen, or enrich the details of their stories

Levels of Exploration & Elaboration

 Moving between circles of conversation
 Outer circle
 Middle circle
 Inner circle
 Guided by awareness of cultural norms, customs, and taboos
 Use intervals of respite to cushion process
 Don’t go too deep too fast

Outer Layer

Opening surface exploration that occurs early in the interview when the client is assessing for trustworthiness

Middle Layer

More revealing exploration of deeper level content, conflicts, and feeling as the therapeutic relationship develops

Inner Layer

Feelings and content about frightening, taboo, or shame-bound areas.

Questions and Questioning

 Reliable and effective for gathering information, deepening discussion, or broadening focus
 Help to build relationship
 Serve as intervention
 Most often used:
 Early in work
 For assessment
 During crisis

Topics of Questions

Client’s thoughts, feelings, behaviors, and relationships
Strengths and resources
Cultural identities, beliefs about help seeking, what causes problems and how might be resolved
Other people in the client’s life
Larger social contexts- effects of discrimination, bias, or other oppression
Client’s reactions to the clinician

General Principles Regarding the Use of Questioning 1

 Questions should be intentional
 Clients should know why questions are being asked and how the information will be used
 Clinicians need to be sensitive to cultural attitudes toward questioning
 Questions should be well timed
 Too much questioning makes the clinician the director

General Principles Regarding the Use of Questioning 2

 Questions can interrupt concentration
 Flexibility in data gathering is essential
 Good questions can be supportive and therapeutic, as well as data-gathering
 Difficult questions should be introduced carefully

General Principles Regarding the Use of Questioning 3

 Too little questioning can make for drift or leave the client at a loss for direction
 Follow-up questions are often necessary
 Clinician questions can be both verbal and nonverbal
 Answers to questions can be both verbal and nonverbal

General Principles Regarding the Use of Questioning 4

 Attend to apparent patterns and themes emerging in client answers to questions
 Clinicians need to be aware of what they are not asking
 Both clinicians and clients can use questions as defenses or weapons
 Wording of questions can affect answers

Closed-ended questions

 More focal of the two types
 Can usually be answered with a word or two
 Often begin with “do you” or “are you”

Open-ended questions

 Give the client more opportunity or flexibility in responding and elaborating
 Often begin with “what” or “how”

Problems with Closed-Ended Questions

 Give the client little opportunity or encouragement to expand
 Clinician keeps the initiative, disempowering the client
 Often leading questions
 Suggest the answer the interviewer expects or prefers

Benefits of Closed-Ended Questions

 Help get lots of information in very short time
 Can be imperative in establishing clear assessment or understanding
 Often provide needed structure and calming

Tried-and-True Questions

 Easily and directly get at the things we need to know to assess, plan, and act wisely
 Examples:
 Where would you like to begin?
 Can you tell me more about your situation?
 Who is available to support you in this?
 Are there things you haven’t mentioned yet that would be important for me to know?
 Can you say more about that?

Problematic Types of Questions

 “Why” questions
 Pseudoquestions
 Double questions
 Tangential questions
 Rat-a-tat questioning

Why” questions

Often sound and are judgmental and rarely work.

Pseudoquestions

Clinician directives or commands disguised as questions.

Double questions

Confuse clients by asking them to reply to a stream of two or more questions at once.

Tangential questions

Veer from the main topic of the interview, taking side roads without good reason and creating an aura of poorly focused conversation.

Rat-a-tat questioning

Barrage the client with one rapid-fire question after another. No topic is pursued long enough to develop any real depth or meaning.

Prompts

 Brief responses that encourage the client to continue with the story or to add to what has been said
 Meant to be minimal
 Signal close attending

Silence

 A form of communication, not just a blank space between communications
 May serve as a natural breather between topics or as a period of thoughtful reflection
 Can indicate comfort, discomfort, anger, calm, or many other things
 Culture influences use of and response to silences

Dot-dot-dot reflection

An interview response in which the clinician repeats back the last thing said and leaves it hanging, unfinished, in midair for the client to complete.

Underlining

An interview response in which the clinician underscores important content or experience by the strategic use of verbal or nonverbal emphasis, often rendered through tone, facial expressions, or emphatic gestures.

Summarizing

An interview technique in which the clinician pulls together in condensed form
the major ideas, themes, or patterns that have just been discussed, and then reflects them back to the client.

Refocusing

 Returning the client to a desired topic by gently inserting it into the conversation again
 Keeps conversation focused on stated objectives
 Prevents rambling

Initiating New Topics

 Fruitful areas for exploration
 Areas not yet introduced by client
 Know when to follow the client’s lead and when to address new topic

Sensitive Timing

 What and how much to ask, when to ask it, and whom to ask
 Aware of in each interview and across sequence of all interviews
 Watch what evolves once exploration begins
 Note reactions to exploration
 Remember no one is “ON” all the time in clinical work – clinician nor client

The State of the Clinical Relationship

 Level of trust and comfort
 Will have ups and downs
 Sort through stumbling points
 Check-in with client throughout work together about how relationship is going

The Client’s Readiness to Explore Charged Areas

 Intent is to do nothing to harm or needlessly intrude on the client
 Weigh new learning against emotional price
 Gradually introduce deeper-level exploration
 Check in with clients about their reactions
 Coping levels and resources (or lack of them) important clues to client readiness and capacity

The Client’s Cognitive Capacity and Expressive Style

 Try to “be where the client is”
 Keep language simple, encouraging, and respectful of each client’s style
 Use client’s metaphor
 Creates sense of close following
 Respect for way client frames world
 Be aware of cultural meanings

Use client’s metaphor

A word or phrase that stands for another similar concept

Informed and Respectful Process

 Avoid jargon, pomp, and talking down to people
 Educational and class differences can negatively affect the language clinicians use with and about clients
 Clinicians may make mistaken assumptions about groups of people that undermine appropriate inquiry

Maintaining the Not-Knowing Position

 Not-knowing perspective
 It is okay not to know
 Clients often know more than we do about the realities of their experience and of everyday life
 Introspection- look inside for our own bias
 Extrospection- observe our outward behavior and adjust as needed so that power stays with the client

Introspection

look inside for our own bias

Extrospection

observe our outward behavior and adjust as needed so that power stays with the client

Sustaining techniques

attend to timing and usage of inquiry
 Checking-in
 Crediting client strengths
 Slowdowns
 Validation of difficulty of disclosure

Checking-in

Asks client how things feel after a period of exploration.

Crediting client strengths

Appreciate client's courage, determination, and accomplishments during hard work.

Slowdowns

Taps the brakes, modeling patience and carefulness. There is no need to rush the unfolding story or feelings.

Validation of difficulty of disclosure

Recognizing and appreciating reluctance to share private matters with an outsider.

Appreciating and Using Resistance

 Resistance - the client’s reluctance or refusal to follow the clinician’s leads or suggestions
 Should not be seen as negative trait of client
 Clients signaling a need for caution/protection
 Responding to resistance
 Reflect the resistance
 Explore why client does not want to continue on topic
 Honor and reframe resistance as sensible

Resistance

the client’s reluctance or refusal to follow the clinician’s leads or suggestions

Enough is Enough

 Go down a different path or explore with different words on another day
 Interns and new employees are especially vulnerable to pressure from supervisors and consultants to go after information
 Recognize when to let go and move on- unless imminent risk of harm to client or others