Clinical Interviewing - Practical Tips From Master Clinicians

Psychiatr Clin N Am 30 (2007) xvxvii
PSYCHIATRIC CLINICS
OF NORTH AMERICA
Preface
Shawn Christopher Shea, MD

Guest Editor
t has been my experience over the years that too often words such as
unique and outstanding find their ways into prefaces and introductions.
In this instance, it may be justifiable to use them; I hope you will agree as
you enjoy this issue of the Psychiatric Clinics of North America. Rather than give
a one- or two-sentence synopsis of the articles (each author has provided a concise synopsis in the Table of Contents), the editor of the Psychiatric Clinics, Sarah
Barth, suggested that in the Preface I say something about the unusual genesis
of this issue that reflects its unique qualities.
Let me begin by saying that it is an honor to be guest editor of this issue of
the Psychiatric Clinics of North America. I believe it is the first time in the history of
psychiatry that any journal has chosen to devote an entire issue to the practical
art of clinical interviewing, and it should be emphasized that this issue is about
clinical interviewing, not its close cousin psychotherapy. Having had the privilege of studying interviewing for nearly 30 years, I can say that such an issue
is, in my opinion, long overdue. At last, the complexities and nuances of the
interviewing skillsthat we all, as clinicians, know are the core of our healing
arthave been given the attention they warrant in a highly respected journal. In
this sense I think it may be safe to say that this issue is indeed unique.
I think this issue may be unique in yet another fashion. We wanted the articles to read with the informality of a valued clinician sharing his or her best
clinical pearls, as if we were standing at the bedside of a patient on rounds or in
a room with a trusted supervisor. Consequently, all the authors were asked to
write their articles in an informal style using first person, exactly as they teach.
Our collective goal as contributors was to create an easy-reading book, one
that we wish had been available to us during our residencies (and afterwards as
0193-953X/07/$ see front matter

doi:10.1016/j.psc.2007.03.004
2007 Elsevier Inc. All rights reserved.

psych.theclinics.com
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PREFACE
well), brimming with practical ideas and suggestions for overcoming everyday
challenges written in an enjoyable and no-nonsense fashion.
The conception of the issue was unusual in another regard, also, because it is
a spin-off from the Internet. Since 1999, I have had the opportunity of editing
an on-line feature at the Training Institute for Suicide Assessment and Clinical
Interviewing (www.suicideassessment.com) called the Interviewing Tip of the
Month. These interviewing tips are supplied, not by myself, but by visitors to
the Website and participants from my workshops on clinical interviewing. At
the time of this publication there are more than 85 such clinical gems archived
on this Website.
I learned so much from these tips that it struck me, What would happen if I
asked the greatest interviewers of our time to provide two or three of their best
tips each? I originally had thought of posting these tips on the Website itself
but subsequently was offered the rare opportunity to do so in the Psychiatric
Clinics of North America. Consequently, in Part II, Favorite Tips from Those
Who Wrote the Book, you will find the favorite tips of some of your favorite
authors covering an array of challenging interviewing tasks, from the assessment of violence and malingering to engaging difficult patients and uncovering
psychotic process.
Here is where I feel the word outstanding can be legitimately applied, because I believe it is the first time that such a collection of interviewing experts
most of whom have, as the section title suggests, written the gold-standard
books on clinical interviewinghas been assembled to provide their very best
tips in a single publication, whether book or journal.
To round out the clinical thrust of the journal, there were certain particularly
difficult aspects of clinical interviewing that I felt deserved a more detailed exploration. I collected these in Part I, Innovative Strategies for Navigating Difficult Clinical Interviewing Tasks. Some topics, such as enhancing the
therapeutic alliance, were chosen (despite having an extensive literature already
devoted to them) because of their key importance and because innovative developments, such as motivational interviewing, have opened new doorways
to the art of engagement.
In contrast, other topics were chosen because so little had been written about
them, despite their critical importance. Thus you will find splendid articles on
how to talk with patients about their spirituality and worldview and how to engage and help the family members of those suffering from severe mental illnesses such as schizophrenia, bipolar disorder, and obsessive-compulsive
disorder. These are the types of immediately practical articles that I think every
psychiatric resident and mental health professional, across all disciplines,
should read and savor for their wisdom. In addition I thought I would be remiss if I did not include an article on one of the difficult clinical tasks that we
all must navigate, passing the oral boards. I believe the resulting article will
prove to be a must-read for any newly minted clinician approaching this daunting rite-of-passage.
PREFACE
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One more aspect of this issue of the Psychiatric Clinics may warrant the distinction of the word unique. Although this is not a journal devoted to issues related to residency training and educational technology itself, the editors of the
Psychiatric Clinics have agreed to include an entire section on topics of immediate
importance to residency directors and supervisors. Part III, Training Psychiatric Residents in Clinical Interviewing: State-of-the-Art Strategies for Residency Directors and Interviewing Mentors, focuses on practical issues
related to the development of interviewing training courses and innovations
in supervision such as macrotraining and facilic supervision. For nearly 20
years my friends and colleagues at the Department of Psychiatry at the Dartmouth Medical School have been vigorously pushing the envelope on methods
of teaching clinical interviewing skills, and this set of four articles reflects their
efforts.
Adding to this unique stancecreating an issue devoted to both the description of clinical interviewing skills and to the methods for teaching those skills
this issue of the Psychiatric Clinics of North America, which began with the Internet,
ends with it as well. Three of the educational articles are to be found solely on
the Web in our Web archive. I would like to think that these lengthy articles are special, because, in essence, they are monographs regarding specific
supervision techniques (including a programmed text on facilic supervision that
can be downloaded and given by supervisors to their psychiatric residents). Because of their length, they never would have been amenable to publication in
a standard journal format, but Sarah Barth at the Psychiatric Clinics (to whom I
owe a debt of gratitude) had the creativity to suggest placing them on the Web,
where enough space could be devoted to the supervision techniques to make
them come to life for supervisors.
Finally, I would like to thank all the authors for their time and wisdom. As
with all issues of the Psychiatric Clinics, the authors are the cream of the crop. We
could not have hoped for a more impressive group of master clinicians. It has
been a privilege to work and to learn from all of them. In particular, I should
like to thank Dr. Leston Havens, whose writings inspired and guided me back
when I was a psychiatric resident in the early 1980s. I have always hoped to
have the honor of being involved in a project of which Dr. Havens was a part.
His wonderful article leads off our issue, and, as usual, he has produced an article at once both provocative and wonderfully practical. Enjoy!
Shawn Christopher Shea, MD
E-mail address: sheainte@worldpath.net
Psychiatr Clin N Am 30 (2007) 145156
PSYCHIATRIC CLINICS
OF NORTH AMERICA
Approaching the Mind in Clinical

Interviewing: The Techniques
of Soundings and Counterprojection
Leston Havens, MDa,b,*
a
Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA

Cambridge Health Alliance, 1493 Cambridge Street, Cambridge, MA 02139, USA
t is with great pleasure that I have the opportunity to write the lead article in
this unusual and highly practical issue of the Psychiatric Clinics of North America,
in which the focus is solely upon the art, craft, and science of clinical interviewing. It is a particular honor for I feel that, for the first time in the history of
psychiatry and psychology, many of the great innovators in clinical interviewing have been assembled into one volume, each providing their favorite interviewing tips and unique perspectives.
As the lead article I decided to emphasize a point, strongly shared by the editor of this issue, Dr. Shea [1], that all interviewing is enhanced by an understanding of the psychodynamics in which it invariably unfolds. I am hoping
that this article will set a perspective from which the wonderful articles that follow can be more powerfully understood and their techniques more effectively
employed.
In particular, I hope that my emphasis on the psychodynamic interplay of
the interviewer and the interviewee will accomplish two things: first, that it
will provide an integrating model with which to assimilate all of the wisdom
that follows in the subsequent articles; second, that it will show how an understanding of psychodynamics can move directly from theory to practice by
illustrating two specific interviewing techniquessoundings and counterprojectionthat derive directly from psychodynamic understanding.
THE INITIAL INTERVIEW: THE PLACE
IN WHICH TWO MINDS MEET
When an interviewer and a patient meet, it is the meeting place of two minds.
Both minds directly affect the other through conscious statements; both minds
*Cambridge Health Alliance, 1493 Cambridge Street, Cambridge, MA 02139. E-mail
address: sgallant@challiance.org
doi:10.1016/j.psc.2007.02.005

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indirectly affect the other through unconscious processes; both minds will forever be changed. There is no other way. At the end of the initial interview, two
slightly different people emerge from the office, whether they are aware of this
fact or not.
An initial interview is essentially a delightful stew in which the unconscious
minds of two people intertwine and stir about in the mysterious nuances of
each others shadows. To understand this process I believe it is best to begin
by better conceptualizing what is meant by the mind.
In psychiatry, from a historical perspective, the mind was often viewed,
rather awkwardly, as if it could be conceptualized like the brain, essentially
functioning as a container of thoughts as the brain was a container of neurons.
What if the mind is not simply a container to be reached into and sampled, as
we say, something self-contained? And what if this static neurologic metaphor
has become an outdated model of the brain itself? How are we then to describe
mind? In particular, how are the contemporary clinical interviewer and therapist to imagine it today?
These are not idle or merely academic questions, because the way we imagine mind affects how we approach it, and, subsequently, how we approach the
initial interview. If we see mind as a closed container to be reached into, we
risk doing solely just that, as witnessed by the questions and probings of descriptive psychiatry and of examining physicians in other branches of
medicine.
Psychiatrists, as trained physicians, long schooled in the ways of the physical
examination of the body, sometimes tend to approach the mind as if it were
merely a piece of the body. They want the mind to stand still, as the body
may stand still while it is investigated. They want the mind to cooperate,
answer, even testify against itself. Most important, the mind in this view can
be studied without essentially changing it. Reflexes can be tested, blood drawn
off, even parts of the body removed for study, without changing significantly
the state of body or, by implication, of the mind.
From an analytic perspective, which is more subtle, the clinician still may see
the mind as a container or as being divided into subcontainers. With different
degrees of accessibility, we may question one subcontainer, with another
be patient asking only for associations, and be even more patient with a
third subcontainer of the mind, waiting on those perhaps deeper revelations of
selftransferencesto crystallize before us.
Clearly, these views of the mind, which stem directly from a longstanding
comparison with the brain, have become outdated, because their model, the
brain itself, is far less static and stable as once thought. For most of the twentieth century, the brain seemed to be an early-maturing, fixed structure difficult to relate to the mind. The brain was a stable structure, constructing few
new cells and presenting itself as largely unchanged through much of life. No
wonder that a fluid mind envisioned as based on a static brain seemed to be
an uneasy metaphor, because, at a basic level, the two seemed to be worlds
apart.
TECHNIQUES OF SOUNDINGS AND COUNTERPROJECTION
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Today, the metaphor works better for we are aware that the brain, like the
mind, is shaped partly by experience. There are no containers and subcontainers in the brain. One cannot cleanly define where the sensory system
ends and the motor system begins, because they are entwined and interlocked.
Moreover, they are not static. They change. We now know that, even in
adults, synapses constantly are being built, torn down, and new ones rebuilt.
This newly understood neuroplasticity unites brain and mind in their shared
characteristic of ever-evolving flux. The Nobel prizes given for brain
research celebrated some of the ways the brain reflects its experience [23]. Perhaps as we come to understand the brain, it will seem more and more like
mind, subtle, responsive, and, most of all, difficult to locate.
Now that from the perspective of a more modern neurophysiology, we can
see that the mind and the brain may indeed have much in common, let us return to our pressing question: what exactly do we mean by mind? In particular,
what are the properties of the mind that an interviewer meets or may fail to
meet as the participants in an initial interview sit down together?
The interviewers account cannot be wholly introspective or dependent on
cognitive tests (eg, of the strength or brightness of mind) or on the mind as revealed by its products (eg, the judgments of art, literature, and science). The
interviewers goals are different from those of the art critic. Clinicians are
not there solely to observe and absorb: we are there to seek out what is
hidden and to heal what is difficult to find. The goal of the interviewer is transformation guided by compassion, not simply critique.
THE INVASIVE PROPERTY OF MIND
Very quickly in Freuds therapeutic work direct methods of approaching mind
gave way to indirect ones because he concluded that the most important parts
of mind were not the ones most accessible. Paradoxically, however, he also
noted that what seemed to him the most important property of mind therapeutically was difficult to access, because it was at once both active and potentially
invasive. The patients unconscious could reach out and touch the unconscious
of the interviewer, and often did so. The patient related personally to the clinician, and this relating connected the patient both to outwardly recognizable features of the therapist and to faint or even absent features of the therapist that
the patient nevertheless imagined were present (ie, transference). Therapists
themselves were changed by this relating/distorting property: they could
come to feel and think and act as if they were what the patient imagined, a truly
dynamic mixing of the unconscious! Let us look at an example:
A brilliant, attractive patient excited in her therapist the feeling he must
somehow possess or even enslave her. This was the way her mother had
acted and both her husbands. With the mother and the first husband the
patient experienced a growing wariness and eventually escaped. As the
therapist acknowledged his feelings toward the patient, the patient grew
bolder and was able to reduce the second husbands possessiveness and
create a livable relationship.
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In short, some of the most important parts of the mind are not only buried or
unconscious; in Freuds view; they also can emerge and attach themselves to
and affect the therapist. In doing so they are no longer unconscious, because
the patient sees them, often literally, in the person of the therapist. They do
remain unconscious in a different sense; the patient sees them but does not
know that he or she has created them. The patient is unconscious that they
are partly his or her own. The mind is capable of appearing and its ownership
going unrecognized, being present and absent at once. It is as if mind were the
product of a supremely absent-minded author, an author also capable of cribbing products from earlier needs and experiences and committing unconscious
plagiarism on an enormous scale. This plagiarism or transference cannot always be easily confronted or corrected.
The capacity to create and recreate worlds, whether authored by the patient,
the clinician or both parties, is imagination. It is through imagination that we
can flee. But it is also by imagination that we can go in search. It is both a wondrous and necessary tool of the interviewer.
CLINICAL IMAGINATION IN THE INITIAL INTERVIEW

By clinical imagination I mean the delicate uncovering, sometimes objective
and more often subjective, of the possible interweavings of patients biologic vicissitudes, their unconscious processes, and their life experiences, all of which
interviewers must discover to understand their patients. The information is
most detailed, precise, and objective about the body. Frequently, a considerable
number of unconscious possibilities also can be pinned down.
Curiously, the least systematic and detailed knowledge often concerns the
patients internal experience of the world as it is unfolding in real time: what
happens and how it feels as it happens. The interviewer must plumb not
only the unconscious phenomena possibly underlying changes in mood or
behavior, but also what exactly happened and then how the report of what
happened is told to the clinician, frequently distorted by the patients internal
experience of the world. What are the principal events that befall a 17-yearold going off to college or a woman with a wandering husband? What is the
real that the interviewer should imagine?
Truth be told, however much people are ruled by biologic and unconscious
processes, they live in their recalled experience of the actual and first must be
met there, no matter how much their actual experience is a distortion of the
real. Successful therapeutic meeting depends on the ability to make a projection
into the experience of the other, that is, in Bubers [4] phrase, to imagine the
real.
Our imaginative investigations can fail secondary to a broad range of clinical
gremlins. On the one hand, the patient may not internally exist; he or she
may not be anywhere; the mind or self or person may be psychologically
lost. Or the patient may barely exist, as when people live, as we say, from
mouth to mouth; they wait on the words of others, tending to agree with
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and imitate whomever they are with, a perpetual disappearance of the real self.
In such instances, because there is nothing inside the patient, the interviewer
may mistakenly find himself or herself in the patient; the empty patient functions as a mirror. Unhappily, these hollow men are common and can be easily overlooked or misunderstood. Even more problematic, a clinician plagued
by more than a fair share of narcissistic needs may be delighted to find himself
or herself in the mirror provided by the patient. Pathology begets more pathology, and no one is healed.
Such shallow existences, which can directly cause our imaginative explorations to be absolutely wrong if we are not aware of this potential hazard in
the initial interview, can come in many flavors. Children sometimes lose their
existence between warring parents and themselves are only this side and that
side of the quarrels. Actors, too, may exist in their parts and be empty or bewildered offstage. Others exist in a transcendental world of unlimited hopes
and fancies; none of the realities of life touch them. Still others you cannot
find at all: you may see a brilliant smile or the trace of an expression, but their
speech dissolves, and they seem affectless when you approach; it is like looking
into a hole. Existential psychiatry constructs its pathology out of the differing
types and amounts of this nonexistence.
There are also people who exist but are so deeply hidden that they defeat
every effort to locate them. They may, on the other hand, be so exquisitely
sensitive and uncertain that they transform as soon as they are seen. Like chameleons, they change and disappear into the background colors of their wildly rich
worlds. Sometimes, too, these hidden, changing, reflective existences function as
masks, tricking the initial interviewer into thinking he or she has seen the actor
when only the role was in the room. This is the nature of our psychologic
work as psychiatrists, psychologists, counselors, and therapists: we can seldom
be sure either that we have found the real person or if there is a person at all.
Thus far we have seen the roadblocks to the accurate projections of our
imaginations, which are caused directly by the patient. A failure in imaginative
inquiry also may arise from the therapist.
He or she may be unwilling or unable to imagine the actual internal world of
the other. Sometimes there are good clinical reasons not to do so. It can be
dangerous to get close to some people. Many paranoid patients, for example,
have been so victimized by their actual experiences of closeness that they
deal violently with too rapid an approach.
Our failures also can spring from a very well-intentioned effort to be well-informed. Many clinicians become like the White Knight in Alice in Wonderland.
Their clinical imaginations are so stocked that they can hardly move at all. Every time the White Knight took a step, something fell offa bucket, a sword, or
a saucer. The White Kinght knew he had a long way to go on his quest; he had
wanted to be ready; but he had no backpack to keep things compartmentalized
effectively. Many medical students, psychiatric residents, clinical psychology
interns, and counseling interns feel this way. In some respects, it is an expected
right of passage for all clinicians who appropriately push themselves toward
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excellence. In the early years of training, and sometimes much later as well, everything the patient says or does sets in motion so many trains of thought, so
many possibilities, that the clinician is afraid to hear any more lest he or she
forget something. At such moments there is no finding the patient, nor even
ourselves.
Clinical imagination must be carried lightly, and it must be brought lightly
to the patient, because, as we have just seen, there are many ways it can go
astray. Everyone recognizes those who come on too strong. Empathy may
be the imaginative projection of oneself into the mind of the other, but it
does not mean the substitution of oneself for the other; in fact, it means
the temporary setting aside of oneself for the other, perhaps the supreme
psychologic asceticism. Nevertheless, the most empathic therapist in the
world does not himself or herself go out of existence. If he or she succeeds
in being Carl Rogers [5] pane of glass through which the patient can be
seen, that pane of glass is cloudy. The question now becomes: are there
ways to make the glass more clear, to improve the accuracy of our imaginative explorations?
SOUNDINGS: MORE ACCURATELY GAUGING THE DEPTH
OF A PATIENTS FEELINGS AND INTENTIONS
This interviewing strategysoundingsdrew its name and its methodology
from a most unexpected clinician, Samuel Clemens, or Mark Twain as he
is more commonly known. He drew his pen name from the process that riverboat captains used to discover the depth of the treacherous Mississippi River.
In unknown waters, a leadsman would throw over a weighted rope until it
hit bottom and then call up the depth as indicated by the length of rope, yelling
out a phrase such as, By the mark four! or Mark three-and-one-half! If the
depth was found to be 2 fathoms, the boat was in danger of going aground, and
the leadsman would urgently call out, Mark twain! Such a process was called
soundings [6]. It was an accurate way of seeing what could not be seenthe
bottom of the river. Years ago, I became interested in the idea that a similar
interview strategy could be used to discern patients hidden thoughts and intentions more accurately, even at the first meeting.
With soundings, the interviewer tosses out specific statements and watches
how the patient responds to them. The responses often represent a fairly accurate record of how much the patient agrees or disagrees with the statement
proffered by the clinician. With each sounding, like our riverboat men, we
get a more accurate feeling for what is hidden.
I believe this strategy will be understood more easily by way of an example.
Let us take a look at a common clinical conundrumtrying to determine accurately a patients intention to do something, perhaps leave an abusive marriage.
Watch as the clinician, in this prototypic conversation helps both the patient
and herself ferret out the patients intention. The patient announces that she
intends to leave her husband soon. What does this statement really mean?
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How much intention is behind this statement? The interviewer tosses out a series of soundings to see where the depth of the intention actually lies:
Patient: I really feel that somehow I need to get out of this relationship. I know in
my heart, Jim is bad for me. Ill get out soon.
Clinician: You dream of this?
Patient: As a matter of fact, I think of it every day. I know that Jim is perhaps my
biggest problem.
Clinician: You might want to do this then, to leave?
Patient: Yea, I might need to do it.
Clinician: You feel you can do it?
Patient [sighs]: Well, I guess so . . . I think so.
Clinician: You feel you will do it within a month or two?
Patient: Well, I doubt that. . . . No I dont think that is in the cards in the near
future.
Watch the technique at use in another tricky clinical situation, determining

the degree to which a patient believes in a delusion. Perhaps a patient presents
in an emergency room with a delusion that he is being constantly watched. The
following series of soundings can help the clinician decide the level of conviction the patient has regarding his delusion, a concept sometimes called the distance a patient has from a delusion: You may wonder can this be true?;
Theres too much evidence to doubt it?; There doesnt seem any doubt
at all? The clinician pauses after each of these soundings to see how the
patient responds.
In evaluating the level of the patients intention to act on the delusion, the
following soundings might be of use, once again with a pause after each one
to listen to the patients response: Youve thought of doing something about
it?; You want to do something about it?; and Youve planned to do something about it?
Perhaps one of the most powerful arenas for using soundings is in the
attempt to uncover accurately a patients intention of acting upon suicidal ideation. The gateway to this use of soundings is the sophisticated use of empathic
statements. Empathic statements, a basic clinical tool, are remarks intended to
imitate, acknowledge, share, or deepen a patients feeling state. These statements range from exclamations (How awful!; How frightening!) through
simple statements (You must be terrified) to more complex forms (No wonder you feel terrified!). Empathic statements place the observer close to and
able to share the patients feelings or memory states. They also, intrinsically,
are testing methods, that is, soundings. Because we can never do more than
approximate what another person is feeling or remembering, the nature of
the others response to our empathic statement provides data on how accurate
our approximation has been. It is here that empathic statements can play a powerful role in suicide assessment.
In evaluating suicidal intent, a succession of empathic remarks tests the level
of the suicidality the person has reached. You may feel awful or This may
be more than you can bear sounds a level of general distress. You may want
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to die, You do want to die, and You have planned out how to die plumb
increasingly dangerous levels of intent. I like to call this level of succession going below. The purpose is to establish how far down the patient follows. Often,
part way down, the patient corrects a statement and perhaps remembers some
happy event that has improved his or her mood. Other patients fall all the way
to the bottom, which puts the observer in touch with the extremity of their pain.
The strategy of soundings can be used in many difficult clinical situations. It
is a nice way of using intuition and imagination to gain a more accurate reading
of the patients internal experience. Interviewing technique, in this instance,
allows us to sharpen the image that our imaginations create in the clinical interview, decreasing the distortions that occur when two minds meet.
PSYCHOLOGIC SAFETY: THE IMPORTANCE OF FINDING
A WORKING DISTANCE
Besides the previously mentioned problems associated with the distortions at
work, as we try to use our imaginations effectively to understand the inner experiences of the patient, another critical clinical issue quickly emerges in an initial interview: safety. Does the patient feel psychologically safe in the room with
the interviewer, and does the interviewer feel safe with the patient? It is frightening to see a clinician for the first time, to open ones soul to a total stranger.
One patient put it brilliantly when she commented that there is always the possibility of a mind rape.
Keeping these concerns in mind, the initial interviewer walks a fine line attempting to be close enough to find the other but not so close as to smother the other so
that all therapeutic independence is lost or to frighten the other so that no second
session occurs. Many have remarked on what a curious and vexing combination
of closeness and distance both clinical interviewing and psychotherapy represent.
Winnicott [7] introduced the idea of being alone with another. He meant that it
is possible to sit near someone in an interview room, for example, and be or not be
alone. This is a pre-eminently psychological idea, because what close means here
is not bodily presence or absence but the subjective experience of feeling invaded,
needing to please, or in some other way being pulled out of shape by the presence
of another. Winnicott is indirectly addressing the issue of safety. Not being able
to be alone with someone is to lack self-possession in that persons presence.
Of course most of our boundaries, which provide a sense of psychological
safety, become tenuous in the presence of the very beautiful, the very rich, or
the very famous and when we are in love. In such circumstances, however
much we want to keep our head, it is all too human to sell out or find ourselves doing foolish things. Sometimes even defiance is a defensive response to
the presence of powerful or potentially alluring figures. But the response I want
to discuss, however, is almost the opposite of defiance: empathya sense of
merging with and losing ourselves in the other.
The therapist is to be present to listen empathically (and perhaps even gently
encourage the faint rumblings of the patients real selfas opposed to the social
selfas it begins warily to emerge in the interview) yet, simultaneously, and
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most importantly, not to invade. Hence Freud recommended an evenly-suspended attention. Note what this says about distance and closeness in the
interview. The therapist needs to be psychologically very close to catch the
faint signals from the wary patient and very distant so as not to distort
them: a curious and vexing combination indeed! An example from ongoing
therapy can highlight this paradoxical process:
A much-admired patient induced in his therapist a fear of displeasing the
patient by letting him down. It was important to tell the patient of both
the admiration and the fear. Doing so relieved the therapists self-consciousness and expressed to the shy patient the extent of the therapists admiration. Closeness and distance were then both present to the patient at the
same moment and in a way that remained memorable.
I believe it is the acknowledgment of this paradox that brings interpersonal

considerations strongly into focus in both the initial interview and in ongoing psychotherapy, as well as in therapeutic relationships that focus primarily on psychopharmacology. If we meet, we must sometimes collide. Unless we are unwilling
to deal with these collisions, we cannot be set too far apart from each other. What
we need to find is a principle that allows us to become close with our patients
while mediating the inevitable conflicts that such closeness begets. I call this
Brombergs common property principle: whatever occurs in the intersubjective space, which is the psychological meeting ground of the patient and the therapist, is the common property of both [8]. Both participants must feel safe within
this common psychological space for the interview to proceed smoothly.
To secure this safe space, there is one thing we must be willing to do, and as
clinicians we must become talented at doingnegotiate. Gifted interviewers are
gifted negotiators of psychological space, rules, and agreements. To negotiate
gracefully as clinicians, we must be willing to acknowledge both our invasiveness
and the possibility of our being wrong. When appropriate we also must be able to
apologize. The common property principle says that whatever occurs in the intersubjective space belongs to both of us. We cannot remove it as just ours
or disown it by blaming the other. We must live it and negotiate it together.
But how do we take these intriguing, albeit highly intellectual considerations,
and transform them into a useful interviewing technique that can help us help
our patients feel safe in the initial interview?
FROM THEORY TO PRACTICE: THE ART
OF COUNTERPROJECTION
For a moment, let us look at patients who are wary or perhaps even paranoid.
When first meeting us, such patients expect trouble. They do not feel safe.
They anticipate invasion of their psychological space by us, and they
commonly project out their own wariness and anger onto us, at which point
the interview relationship may already be lost.
From the perspective of Brombergs principle, there is no common space.
The patient has his or her own space and sees us as sitting in our own space,
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and fears that we intend to invade. There is no common ground. Such paranoid patients are traditionally some of the most difficult people to engage. Second appointments are rarities.
Harry Stack Sullivan, one of the most gifted interviewers of all time, had a variety of clever ways of creating shared space with such patients, a sense of being
with them as opposed to being against them. It is worthwhile to take a look at
his work for a moment, because it offers the beginnings of the counterprojective
technique that I have found so valuable over the years and that I hope will
prove to be of value to you.
Sullivans intuitive understanding of the approach to shy, suspicious, or angry people foreshadows couterprojection. He suggested sitting beside or at an
angle to the patient, to avoid staring at self-conscious people and also to direct
attention somewhere elseout there. This out there is a commonly shared
space that both the interviewer and the interviewee look at together. In essence,
the bad guys are out there somewhere, not in this room.
This out there or somewhere else is society itself, which in Sullivans
framework is where a lot of real psychopathology originated or is enabled.
For patients, it feels remarkably safer to experience the bad guy as out there,
not as the therapist sitting in the room with them. Redirecting clinical attention
away from the interviewing dyad nonverbally moves the projective screen
away from the therapist, where it can do damage. The question is, are there
verbal techniques that can even more effectively create Brombergs common
property?
When I first described counterprojection in an article many years ago, I
found the following everyday illustration of people responding to acute pain
to be useful in introducing the power of the technique [9]. For example, badly
stubbing ones toe on a loose brick typically results in anger toward the brick,
blaming of it, even the desire to kick the offending object again. A friend who
tries to add solace by comforting the fallen person (perhaps even touching the
injured friend) is sometimes shunned away because of overstimulation, almost
as if there is a transference of anger towards the friend meant to be directed at
the brick. Moreover, the hurt person may resent questioning, sometimes implying that the friend should already know what the matter is, suggesting a temporary loss of ego boundaries.
On the other hand there is one thing the friend can do that will not bother
the injured person at all: pick up the brick and throw it, yelling, That damn
brick! Just such an exclamation against a common enemy is a prototypic
form of counterprojective speech. Just as Sullivan nonverbally creates a common out there where the bad guys are by his seating arrangement, the
friend has, through the verbal phrase That damn brick! created an out
there by attacking the bad guy, which happens to be an inanimate brick
in this instance. It is very hard for someone to be mad at someone else who
is attacking a common enemy.
In counterprojection the interviewer counters (deflects) a patients projection
by pointing attention away from himself or herself and toward another object.
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A counterprojective statement has three components. First, it must point out

there, because in part projection follows attention. Second, it must speak specifically about the figures being projected; counterprojective statements place
the brick, boss, girlfriend, or parent on the projective screen before the therapist
and patient. Perhaps speak about is not right. No interpretation or explanation concerning these figures is offered; that would invite discussion centered
back again on therapist and patient; the figures are simply put out there.
Third, in order to move projections, some part of the patients negative feelings
about those figures must be jointly expressed by the therapist.
Counterprojection is a gentle technique. One must be careful not to attack
a specific person verbally in such a way that it inflames the patients anger toward
that person. Rather, the comments are made as temporary points of understanding of the patients viewpoint and generally are phrased in the third person, such
as, He always seems interested in himself, or They never seem to see your
side of things clearly. Sometimes society itself is the aim of counterprojection:
Its rough out there now; Times are so tough, a good man cant make a reasonable living out there; or Nobody seems to understand you.
In the following dialogue, a patient who is quite frustrated with his family, boss,
and friends begins to get angry at the clinician for not providing answers. Note
how the clinician deftly points away from himself (thus deflecting the patients
anger) using counterprojective statements that also convey a sense of empathy:
Patient: Why dont you clarify this? You know me very well, Im confused.
Clinician: I agree, it is confusing.
Patient: I cant do this alone, you know.
Clinician: Neither your boss nor your girlfriend has clarified things either.
Patient: They havent.
Clinician: Everywhere you look, no one helps [said empathically].
Patient: But you are supposed too.
Clinician: I suppose your parents were supposed to help, too.
Patient: They didnt [patient looks sad].
Clinician: No wonder you want someone out there to take their place. They left
such a hole!
The clinician has deflected the patients anger gracefully, provided a bit of
insight, and now has opened the door to continue a conversation about the parents, effectively keeping the anger off of himself.
SUMMARY
The main premise of this article is that minds are fluid: when an interviewer
and a patient meet, their minds meet and interact with each other. To be an
effective interviewer, it is critical to understand the clinical gremlins that arise
psychodynamically when these two minds interact. It is from an understanding
of these psychodynamics that sound interviewing techniques can be designed
to transform these gremlins.
I demonstrated that one of the main interactions of mind that occurs is the
clinicians attempt to use his or her mind to enter imaginatively the patients
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world of experience. Unfortunately this imaginative attempt to understand the

patients inner world of experience accurately can be thwarted by a variety of
distorting mechanisms including the inability to see the patients real self because of its defensive flight behind all sorts of unconscious and conscious
masks. We then saw how our psychodynamic understanding of this problem
led us to search for an interviewing techniquesoundingsthat can specifically
enhance the ability of our imaginative forays to come back with more valid
pictures of the real patient.
We also saw that a second major interaction between the minds of the interviewer and the patient is the joint process of finding interpersonal safety. From
a psychodynamic perspective, finding a common ground, or common property
as Bromberg puts it, can open the way to a psychologically safe environment.
We then looked at one of the most challenging arenas for establishing safety,
paranoia, and found a specific interviewing technique based upon our psychodynamic understanding of the problem, counterprojection, that can help transform this thorny problem. Once again our main point is highlighted; a sound
understanding of psychodynamics leads to the development of sound interviewing strategies and techniques.
In this article we have looked at just two complexities of the interviewing
process and two solutions. In the following articles you are in for a treat, for
some of the greatest interviewers in our field will explore numerous everyday
interviewing traps and problems, providing concrete and immensely practical
interviewing techniques for side-stepping those traps and solving those problems that are bound to occur when two minds meet.
References
[1] Shea SC. Psychiatric interviewing: the art of understanding. 2nd edition. Philadelphia: W.B.
Saunders Company; 1998.
[2] Hubel, Sperry, Weisel, 1981.
[3] Carlsson, Greengard, Kandel, 2002.
[4] Buber M. Guilt and guilt feelings. In: Friedman M, editor. The knowledge of man. New York:
Harper and Row; 1965.
[5] Rogers C. Client-centered therapy: its current practice, implications and theory. Boston:
Houghton Mifflin; 1951.
[6] Welland D. The life and times of Mark Twain. New York: Crescent Books; 1991.
[7] Winnicott DW. The maturational process and the facilitating environment. New York: International Universities Press; 1965.
[8] Bromberg P. Standing in the spaces. Hillsdale (NJ): The Analytic Press; 1998.
[9] Havens LL. Explorations in the uses of language in psychotherapy: counterprojections. Contemp Psychoanal 1980;16:5367.
PSYCHIATRIC CLINICS
OF NORTH AMERICA
New Approaches for Creating the

Therapeutic Alliance: Solution-Focused
Interviewing, Motivational
Interviewing, and the Medication
Interest Model
Michael K.S. Cheng, MD, FRCP(C)a,b,*
a
Mood and Anxiety Clinic, Childrens Hospital of Eastern Ontario (CHEO),

401 Smyth Road, Ottawa, Ontario, Canada K1H 8L1
b
University of Ottawa, Ottawa, Ontario, Canada
robably one of the most important skills learned as a medical student and
as a psychiatry resident is building the therapeutic alliance. Knowing how
to navigate the tricky complexities and subtle nuances of establishing
a therapeutic allianceespecially in the initial encounteris, arguably, the most
critical skill clinicians possess, whether seeing a patient for a single interview or
for long-term therapy.
As a trainee, I struggled however, because although there are literally thousands of research articles about the alliance and clinical interviewing, there are
many fewer that focus on how exactly to form the alliance. In this article we
will review the theory behind the therapeutic alliance and, more importantly,
explores three new approaches to establishing it effectively: (1) solution-focused
interviewing, (2) motivational interviewing, and (3) the medication interest
model.
DEFINING THE THERAPEUTIC ALLIANCE
Research studies and common sense indicate that a good therapeutic alliance is
essential for positive patient encounters and outcomes. Exactly what is this
therapeutic alliance? Decades ago, Bordin [1] presented his ground-breaking
transtheoretical conceptualization, in which he defined the alliance as having
three main components:

Agreement on goals, which are the desired outcomes of the therapeutic process
Agreement on tasks, which are the steps that will be undertaken to achieve the
goals
*Childrens Hospital of Eastern Ontario (CHEO), 401 Smyth Road, Ottawa, Ontario, Canada
K1H 8L1. E-mail address: www.drcheng.ca
doi:10.1016/j.psc.2007.01.003

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Bond between client and therapist, which encompasses Rogerian aspects such
as trust, respect, genuineness, unconditional positive regard, and empathy.
WHAT IS THE MOST IMPORTANT FACTOR IN ESTABLISHING

THE THERAPEUTIC ALLIANCE?
Most individuals would state that the most important factors for achieving
a sound therapeutic alliance are listening to patients sensitively, being empathetic, and building trust and respect. Are these traditional factors really the
most important?
Consider a very significant alliancethe alliance between the Allies during
the Second World War. During that time, members of the alliance included
the United States, Britain, Canada, and Russia. Was the alliance between Russia and the United States based on trust, respect, and empathy for one another?
Probably not! The alliance was based more on mutual goalsthe destruction of
a common enemy.
Indeed, there is nothing wrong with having a relationship founded on mutual trust and empathy, but unfortunately in many situations the psychiatrist
and the client will not yet have developed that sense of trust and empathy.
For example, the psychiatrist might have just met the patient, or the patient
might place a higher value on his or her autonomy than on bonding with
the psychiatrist (like most teenaged patients!).
Fortunately, in addition to the traditional ways of securing the alliance
through empathy, some exciting new strategies are available. These strategies
focus on the power inherent in joining with the patient in a collaborative effort
to define the goals and tasks defined by Bordin [1].
GOALS
What exactly are the goals Bordin [1] mentions in his first step in establishing
an alliance? Goals are the intended outcome from the clientclinician interaction. Universal, normal goals for most people include

Biologic needs such as food, shelter, safety, and physical health

Various psychosocial needs such as being emotionally and psychologically
well. These include needs for agency and autonomy (the desire to have a sense
of competency or control in ones life) and affiliation (the need to have some
sense of attention, connection, and relationship with other people).
Spiritual needs, such as the quest for a sense of hope or meaning in ones life
Goals may vary with the individuals interpersonal style. For example, some
individuals place a higher value on autonomy and agency, whereas others may
place more value on affiliation and connection.
Goals also may vary across the life span. For example, adolescents typically
have a higher need for autonomy and independence from adults, combined
with an increased need to affiliate and connect with their peers.
Having identified the goals, the psychiatrist needs to understand how to
achieve themthe second step in Bordins [1] conceptualization.
NEW APPROACHES FOR CREATING THE THERAPEUTIC ALLIANCE
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TASKS
Tasks are what the patient (or therapist) does that moves the client toward
healthy, therapeutic goals. Examples of physical tasks include ensuring good
sleep, nutrition, exercise, and appropriate use of medications. Examples of psychotherapeutic tasks include identifying automatic thoughts and cognitive distortions (as in cognitive-behavior therapy), linking mood to interpersonal
events (as in interpersonal psychotherapy), using solution-directed rather
than problem-talk (as in solution-focused therapy), and instillation of hope
(as in a common-factors approach). Examples of spiritual tasks include prayer
or participating in a religious community.
Several points worth keeping in mind when setting goals and tasks. One
should remember the crucial role of obtaining genuine, nonpressured agreement from the client on specific goals and the tasks chosen to achieve them.
The clinician also should keep in mind how the strategic use of different tasks
may help the patient achieve a single goal (eg, a relaxed state of mind may be
achieved by using a variety of tasks: listening to gentle music, relaxation therapy, and the use of antianxiety agents). Although discussions tend to make
a theoretical distinction between goals and tasks, such distinctions often blur
together in clinical practice.
THE PRIMARY IMPORTANCE OF UNCOVERING
THE PATIENTS GOALS
Finding agreement on goals starts with finding out what the patients goals actually are as opposed to what the clinician may think they should be. Although
there are two main ways to interview clients (problem-based interviewing versus goal-based interviewing), only goal-based interviewing really asks about
goals directly from the clients viewpoint.
Medical students typically are taught to start patient encounters by asking
the classic, problem-based question: What [problem] brings you in today?
and Whats been bothering you? These questions usually lead the patient
to answer in a narrative that moves from the past to the present.
For example, the patient may state, I hurt my foot yesterday and today I
cant walk on it anymore. After eliciting the problem, the clinician diagnoses
the problem and determines the appropriate treatment to reach that goal. In
most cases, the patient agrees. For example, the clinician may state, Youve
broken your toe. Youll need to use crutches for the next several weeks, but
the good news is that it will heal without your requiring a cast.
With straightforward medical conditions, goals are deduced easily, rendering it unnecessary actually to ask about goals. In fact, using goal-focused questions in such situations could sound quite silly, leading a patient to doubt the
clinicians competence. For example:
Patient: I hurt my foot yesterday and today I cant walk on it anymore.
Clinician: So what would you like to get from coming here today?
Patient: Isnt that obvious? Just fix my foot!
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When the situations or goals are not so obvious, however, problems can
arise from relying solely on problem-based questioning. The following example
shows the inherent traps with traditional problem-based interviewing when
used with a reluctant teenager brought in by his parents:
Clinician: What seems to be the problem?
Teenager: I dont have a problem. I dont need to be here. My parents need
help, not me.
Clinician: Your parents told me that your mood is irritable, youve lost interest
in things, and you have trouble with your sleep, appetite, and concentration.
Sounds to me like you might have a depression and need treatment for it.
Teenager: I knew this was gonna be a waste of my time. Im getting out of
here!
In this example, the alliance got off to a poor start, because the clinician and
patient did not agree on goals; in addition, the clinician prematurely recommended treatment (ie, a task) before achieving a buy-in from the teenager on
what the goals should be in the first place.
It also is interesting to note the meta-assumption posed by the question,
What problem brings you here? The message to the patient seems to be,
You have a problem. Interestingly, Whats your problem? (said in a sarcastic tone) is a common insult among teenagers. It is ironic how a simple problem-based question can end up being interpreted as an insult!
SOLUTION-FOCUSED INTERVIEWING: THE NEW WAVE

IN ENGAGEMENT
In the 1990s a particularly innovative style of psychotherapy evolved that had
many ramifications for establishing the therapeutic alliance more effectively in
psychotherapy in general and in the initial interview as well. Solution-focused
interviewing is a form of goal-directed interviewing. When the patients goals
cannot be assumed readily, I think that you will find that solution-focused interviewing can be exquisitely effective. Typical situations include chronic medical conditions and emotional, behavioral, or psychiatric problems. Solutionfocused questions, with their ability to create hope and promote client
strengths, figure prominently in ongoing solution-focused therapy [25]. Examples of solution-focused questions include

What would make this a helpful visit?

What would you like to see different from coming here?
The following example illustrates some of the advantages of solution-focused

questions, revisiting the disgruntled teenager met earlier:
Clinician: Whats the problem that brings you here today?
Teenager: I dont have a problem. I dont need to be here. My parents need
help, not me.
Clinician: Okayso what would make this a helpful visit?
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Teenager: Tell my parents that I dont need to be here; theyre the ones who
have the problem.
Clinician: Things sound stressful with your parents. What do you wish could be
different with your parents?
Teenager: For one, tell them to stop nagging me all the time, they just dont
understand how hard it is for me these days.
Clinician: So if we could get things better between you and your parents,
would that be helpful? (Clinician seeks out healthy goal of improving the
relationship between the teenager and parents.)
Teenager: Sure, that would make things better.
Clinician: Any other things you wish could be different? (Clinician continues
to ask about more goals . . ..)
MIRACLE OF MIRACLES
One of the most popular solution-focused strategies for uncovering the clients
goals is called the miracle question as described by de Shazer [2]. Although
the exact wording will differ depending on the interviewer, the question works
by shifting the patients focus to the future and by tapping into the power of the
patients imagination to envision life without the problems that brought the
patient to seek help.
Clinician: Imagine that tonight you go to bed, like you normally do. Then,
imagine that while youre asleep. . .. [pause)] . . .a miracle happens. Imagine
that because of this miracle, your depression [or whatever the patients problem is] goes away. What will your day be like tomorrow?
Patient: Well, I guess I would wake up, and rather than sleep in, Id wake up
on time and get ready instead of procrastinating. Then Id eat breakfast
rather than skipping it, and at breakfast, wed all get along better without
fighting. Then Id go to work, and Id have more confidence, so I would
say no to people if they ask me to do too much. . .
From this brief exchange alone, the clinician would have learned that some
possible goals could include (1) helping the patient wake up on time (which
may thus involve helping the patient have better sleep hygiene and go to
bed on time); (2) eating breakfast; (3) improving relationships at home; and
(4) being more assertive at work. These are goals that the patient wants. These
are the goals that the patient might readily agree to set.
Thus, if in the initial interview the interviewer and patient jointly agree to
work on these goals, the patient will be much more inclined to a positive
view of the interviewer. The alliance is off and running. One must never forget that the main goal of the first interview is to make sure that there is a second one. Once the alliance is better established, the clinician may be much
more effective subsequently in helping the client address some new goals
that may be more important and that perhaps may require more motivation
to address, such as character flaws, substance abuse problems, or anger control issues.
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MOTIVATIONAL INTERVIEWING: THE ART OF

TRANSFORMING UNHEALTHY GOALS AND TASKS
Patients may report unhealthy goals or tasks. Examples include not taking
appropriately prescribed medications or harmful behaviors such as substance
abuse, self-injury, or suicide.
With topics such as suicide, one of the first obstacles an interviewer must
tackle when uncovering the clients goals is a paradoxical one. Interviewers
may find that, consciously or unconsciously, they do not want to hear the patients goals because of the potential ramifications (eg, need for involuntary
commitment, need for a prolonged assessment, need for collaborative calls
or consultations, or the clinicians own biases about suicide).
To address this obstacle, an innovative and flexible interview strategy has
been developed. This strategythe Chronological Assessment of Suicide Events
(the CASE Approach)was designed to help clinicians uncover suicidal goals
and intent effectively and reliably, despite their own hesitancies about asking
or the clients hesitancies about sharing [6].
Once problematic client goals have been uncovered successfully, various
strategies have been discussed to transform unhealthy, maladaptive, and regressive goals into healthy, progressive, and adaptive ones, such as exploring
for the healthy goals that usually lie beneath unhealthy goals and tasks [7].
Getting teenagers to share their unhealthy goals often is quite a challenge because, more often than not, teenagers do not willingly choose to see psychiatrists. They are more like reluctant visitors or even more like the mandated
patient. Therefore one cannot necessarily use the strategies that would work
with more willing participants.
With such teenagers, and with some adults as well, narrative techniques
offer a possible solution. The narrative techniques, described by White and
Epston [8], offer a way by which a problem (eg, an unhealthy goal or task)
can be externalized outside the person, so that the clinician and client can
ally together against the problem. Examples include such questions as If it
were possible, would you like to limit the way that alcohol pushes you around?
. . . How has alcohol been tricking you into withdrawing and avoiding people?
. . . What would life be like if alcohol werent around anymore?
Of all the approaches to transforming a clients reluctance to change, by far
the most influential has been the concept of motivational interviewing first
delineated in 1991 by Miller and Rollnick [9] in their classic book, Motivational
Interviewing: Preparing People to Change Addictive Behavior.
Motivational interviewing was designed originally for substance abuse treatment, which is a classic example of a situation in which forming a therapeutic
alliance is challenging because clients prefer their unhealthy goal or task (eg,
abusing alcohol or drugs). Motivational enhancement techniques can be helpful when the clinician wants to promote a healthy or positive behavior (eg, seeing a counselor, taking appropriately prescribed medications, smoking or
drinking cessation, or adopting healthier lifestyle habits such as eating more
healthily).
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The following example demonstrates some of the motivational interviewing

techniques that can be used to form an alliance when faced with a patient who initially maintains an unhealthy goal. The reluctant client has been brought to the
emergency room for suicidal ideation and is being seen by the clinician, who
has done some initial history and is now trying to establish a better alliance:
Clinician: What would make todays (emergency room) visit helpful? (Clinician asks for goals.)
Patient: I want to kill myself, just let me die. . . (Patient states unhealthy goal/
task.)
Clinician: Im sure you must have your reasons for feeling that way. . . What
makes you want to hurt yourself? (Clinician searches for underlying healthy
goal.)
Patient: I just cant stand the depression anymore; and all the fighting at home.
I just cant take it. (The underlying healthy goal/task may be trying to cope
with depression and fighting.)
Clinician:I think I understandso we need to find a way to help you cope with
the depression and the fighting. You told me yourself that there used to be
less fighting at home. What would it be like if we found a way to reduce
the fighting, have people getting along more?
Patient: A lot better, I guess. But its probably not going to happen.
Clinician: Okay, I can see why youre frustrated, and I do understand that
probably the depression makes it hard to see hope. But I believe that there
is a part of you that is stronger and more hopeful, because otherwise you
wouldnt be here talking with me. (Clinician externalizes unhealthy
thoughts or behaviors as being part of the depression and tries to help the
patient ally against the depression.) That hopeful part of you said that
your mood used to be happy. What would it be like if we could get your
mood happy again?
Patient: A lot better, I guess. . .
Clinician:Just to help me make sure Im getting this right then, what would you
like to see different with your mood? (The clinician reinforces the clients
goals by having the client articulate them.)
Patient: I want to be happy again.
Clinician: And at home, what would you like to see with how people get
along?
Patient: I want us to get along better.
Clinician: Lets agree then, that we will work together on finding a way to help
people get along, as well as help your mood get better. How does that
sound? (Clinician paraphrases patients healthy goals.)
Patients: Sounds good. . . (Patient agrees with goals.)
Even after agreement on goals, clients may have unhealthy tasks. For example, the clinician and client may agree on reducing the depression, but the client
may believe that an unhealthy task, such as using marijuana, is the best strategy. One possible avenue in such situations might be to agree to give the client
a chance to try his or her strategy but to also agree that, if the strategy does not
work, something different needs to be tried.
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Additional questions can be used to help the client to

See alternative tasks (eg, Are there any other ways to help you cope with
stress?)
See that the task is unhealthy. This process might start by asking about positives of the behavior, to help the client feel validated, followed by asking
about negatives of the behavior (eg, What are the positives about using
marijuana?; What are the negatives about using marijuana?; How
does the self-cutting work for you?; How does the self-cutting work against
you?)
Motivational interviewing, as well as Bordins [1] transtheoretical stages in

forming the therapeutic alliance, bears striking similarities to Prochaska and
colleagues [10] transtheoretical stages of change model, another model that is
well worth exploring and which is quite popular among clinicians in both substance abuse programs and community mental health work. According to Prochaska and colleagues [10], the main stages of change are
1. Precontemplation: The client has no intention to change and is unaware of
a problem. In other words, there is no agreement on goals.
2. Contemplation: The client is aware of a problem and would like to change it
but has not yet made a commitment to take action. In other words, there is
agreement on goals but not yet agreement on tasks.
3. Preparation: The client intends to take action in the near future. In other words,
there is agreement on goals, but agreement on tasks is just beginning.
4. Action: The client is taking action to overcome problems. In other words, there
is agreement on goals and task.
THE MEDICATION INTEREST MODEL: THE FINE ART

OF COLLABORATIVE INTERVIEWING
Shea [11], in his book Improving Medication Adherence: How to Talk with Patients
About Their Medications, has delineated a model that integrates the principles discussed in this article into a flexible approach for motivating patients to improve
their medication adherence, as well as increasing their initial interest in trying
a medication. Shea suggests that much of the alliance that forms between patients and any clinician prescribing medications or involved with medication
management (eg, psychiatrists, nurses, and psychiatric case managers) evolves
from the dialogue unfolding over the use of the medications.
In essence, the medication interest model suggests that the macrocosm called
the patient/physician alliance often is a reflection of the microcosm called
prescribing and discussing medications. To a large extent, a patient determines how trustworthy and caring a clinician is, as well as how good a listener
he or she is, by how the clinician introduces the idea of medications, listens to
the patients concerns about side effects, and is willing to change medication
recommendations flexibly based upon the patients input. According to the
model, even the language used to describe this process should be changed
165
from oppositional terms such as medication compliance and medication adherence to the much more collaborative term medication interest.
It is useful to see the medication interest model at work in actual clinical practice. About 40 different interviewing techniques for increasing medication interest have been developed. One is called the inquiry into lost dreams. This
technique was first described by a pediatrician in one of Sheas workshops,
who was talking about the difficulties of getting a reluctant teenager to take
medications for his asthma, but it is just as useful in motivating patients who
have mental illnesses, such as depression, obsessive-compulsive disorder, or bipolar disorder.
This particular interviewing strategy is a nice way to wrap up this article, because it integrates and illustrates many of the points discussed here. By using
this strategy the clinician helps the client bring forth his or her own personal goals.
At the same time the clinician and the client collaboratively choose a task for
achieiving those goals (no easy feat when the client is a leery asthmatic teenager
in the room with an adult clinician suggesting side-effect-laden medications).
For many of these adolescents, the key to improving their medication interest lies not so much in their desire for relief from something that the asthma has
given them (acute breathing problems) as their desire to regain something that
the asthma has taken from them (lost dreams). There is no better way to describe this technique than listening to the pediatricians own words as recorded
in Sheas [11] book:
I find it useful with my kids with asthma to ask them this question or a variation of it, Is there anything that your asthma is keeping you from doing
that you really wish you could do again? What I find with this age group
is that there is often a quick answer to this question, and the answer is often
related to a sport, say, football or soccer.
What I find to be so useful about this question is that it opens the door for
adolescents, who by definition are prone to form oppositional relationships
with adults, to tell me what they want me to do for them. They are calling
the shots, not me. The oppositional field seems to dissolve away. Meanwhile, I gain a deeper insight into their motivation for seeking help from
their asthma that goes beyond their desire for symptom relief. I might never
have known this powerful motivator had I not asked. I can use this knowledge to enhance the adolescent patients desire to start a medication
and to stay on it.
First, although I never provide false hope, if I feel it is within reason, I can
use this newly uncovered information immediately to help shape a shared
agenda with a comment like, Now I cant promise this, but I have had
some very good luck with helping other students, with asthma like yours,
to get back into sports. We have some great meds that can help with
that goal. Once again, no promises, but I would like to work with you to
see if we might be able to get you back out on that soccer field. How
does that sound to you?
Second, in the future, if there are tough side effects or if the stigma concerns so often seen with kids having to take meds at school become
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problematic, I can say something like, I know you are getting some tough
side effects - and they are tough - but, fortunately, I have some ideas on how
we might be able to make them much better, and I dont think we have yet
seen the full power of these meds to help you feel better. We are still trying
to get you back on that soccer field that we talked about in our first meeting.
If you can give me another two weeks to see if I can lower the side effects
and get you some better relief from these attacks, I think I might be able to
do that. Is it a deal?
The pediatrician has elegantly accomplished exactly what Bordin [1], the solution-focused therapists, and the motivational interviewers have advised: seek
out the goals of the client and get clients input on what tasks the client wants to
use to achieve these goals. Even the pediatricians very last phrase, Is it
a deal?, turns control over the decision to use a new task (making a medication
change) over to the teenager. Translated into psychiatric practice, the inquiry
into lost dreams question simply becomes, Is there anything that your
OCD [or whatever other psychiatric disorder is the focus of treatment] is keeping you from doing that you really wish you could do again?
SUMMARY
I hope that you will find this introduction to solution-focused interviewing, motivational interviewing, and the medication interest model to be of immediate
value in your clinical practice. I have found that these approaches provide
a fresh perspective on the engagement process, a phenomenon that will always
provide moments of fascination and, if handled well, will provide patients with
moments of healing.
References
[1] Bordin E. The generalizability of the psychoanalytic concept of the working alliance.
Psychotherapy: Theory, Research and Practice 1979;16:25260.
[2] de Shazer S. Clues: investigating solutions in brief therapy. New York: W.W. Norton &
Company; 1988.
[3] Budman S, Hoyt M, Friedman S. The first session in brief therapy. New York: The Guilford
Press; 1992.
[4] Miller S, Hubble M, Duncan B. Handbook of solution-focused brief therapy. San Francisco
(CA): Jossey-Bass; 1996.
[5] de Jong P, Berg I. Interviewing for solutions. New York: Brooke and Cole Publishers; 1998.
[6] Shea SC. The delicate art of eliciting suicidal ideation. Psychiatr Ann 2004;34:385400.
[7] Book H. How to practice brief psychodynamic psychotherapy. Washington, DC: American
Psychological Association Press; 1998.
[8] White M, Epston D. Narrative means to therapeutic ends. New York: Norton; 1990.
[9] Miller W, Rollnick S. Motivational interviewing: preparing people to change addictive
behavior. New York: Guilford Press; 1991.
[10] Prochaska J, Norcross J, DiClemente C. Changing for good. New York: William Morrow
and Co; 1992.
[11] Shea SC. Improving medication adherence: how to talk with patients about their medications. Philadelphia: Lippincott Williams & Wilkins; 2006.
PSYCHIATRIC CLINICS
OF NORTH AMERICA
Practical Interview Strategies

for Building an Alliance with the
Families of Patients who have
Severe Mental Illness
Aaron Murray-Swank, PhDa,b,*, Lisa B. Dixon, MD, MPHa,b,
Bette Stewart, MSb
a
VA Capitol Network (VISN 5) Mental Illness Research, Education, and Clinical Center
(MIRECC), VA Maryland Healthcare System, 6A-157, 10 North Greene Street,
Baltimore, MD 21201, USA
b
Department of Psychiatry, Division of Services Research, University of Maryland School
of Medicine, 737 West Lombard Street, 5th Floor, Baltimore, MD 21201, USA
amily members play an integral role in the lives of most persons who have
serious mental illness, and the importance of family involvement in the
treatment of persons who have serious mental illness is widely recognized.
The recent report of the Presidents New Freedom Commission calls for a care
system that is consumer and family centered [1]. Moreover, in a large body
of randomized trials, family psychoeducation programs have demonstrated robust effects in reducing patients rates of relapse [2]. Best-practice treatment
guidelines of the American Psychiatric Association [3] and other professional
organizations strongly recommend family involvement in treatment as a critical
element of quality care for persons who have serious mental illness.
This article provides a practical interviewing guide for mental health professionals who work with patients who have serious mental illness and their families. At the outset, we want to emphasize that we write this article as family
members of people living with mental illness, in addition to our professional
roles as mental health clinicians and researchers who focus on the delivery
of services for patients who have a serious mental illnesses (such as schizophrenia, schizoaffective disorder, and bipolar disorder) and their families. This article offers our perspectives grounded in our experience as spouses, siblings,
parents, and children of people who have mental illness. By considering this
topic from the dual vantage points of both family members and professionals,
*Corresponding author. VA Maryland Healthcare System, MIRECC, 6A-157, 10 North

Greene Street, Baltimore, MD 21201. E-mail address: aaron.murray-swank@va.gov
(A. Murray-Swank).
doi:10.1016/j.psc.2007.01.004

168
MURRAY-SWANK, DIXON, & STEWART
we hope to provide a useful roadmap clinicians can use to navigate their work
with families.
The article begins by considering the role of the family in the inpatient phase
of treatment and then moves to a discussion of working with families while the
patient is in outpatient care.
PART I: BUILDING AN ALLIANCE WITH FAMILIES IN INPATIENT
SETTINGS
The family experience of mental illness varies substantially, depending on the
family members relationship to the patient (eg, parent, spouse, sibling) and on
the patients diagnosis and phase of illness. There are, however, several typical
themes and issues among families who experience the psychiatric decompensation and hospitalization of a loved one.
Common Fears, Anxieties, and Concerns of Family Members
This section addresses three common themes: (1) emotional responses of the
family to illness and hospitalization, (2) family expectations of inpatient treatment, and (3) family roles and determining spokespersons.
Emotional responses of the family to illness and hospitalization
As family members, we have experienced the roller coaster of emotional responses that accompany this phase of illness and treatment. Family members
often experience profound fear, shock, and trauma related to their relatives illness and its impact on family life. Their loved ones illness and need for hospitalization is likely to be a time of instability and chaos in the life of the
family. Coupled with this tremendous stress, family members may feel a sense
of relief when their loved one has landed somewhere with their admission to
the hospital.
When interviewing family members, clinicians should be attuned to their emotional state and make active efforts to acknowledge and normalize what they
might be feeling. Techniques such as reflection (eg, sounds like you are feeling
frustrated) and summarizing statements can help family members feel heard and
understood. Another way for a clinician to communicate this message could be
I realize that you have really been through a lot during this timeyou may
be feeling anxious, worried, overwhelmed, angry, or maybe a combination
of many different feelingsthis is certainly understandable, normal, and to
be expected as you are dealing with everything going on with [patients
name].
It also is important to realize the impact that family members often feel when
visiting their loved one on an inpatient psychiatric unit. One of us can remember the experience of first seeing our loved one hospitalized: I burst into tears
. . . it was worse than I could imagine it was.
This initial impact can be particularly jarring to family members who have
been involved in an involuntary commitment of their loved one. Confronted
INTERVIEWING FAMILIES OF MENTALLY ILL PATIENTS
169
with the realities of a locked inpatient unit, the family member can be filled with
guilt and second thoughts about having done the right thing. A reassuring comment at the right moment can be greatly comforting:
Naturally it can be disturbing to see [name] in the hospital. I just want to
emphasize that you really did the right thing bringing [name] into the hospital, even though he didnt want to come in. I think you might have saved
his life. It took real courage and love to do what you did. And we are going
to do everything we can to help him get better. He is very lucky he has you,
and that you were there to do what needed to be done to help him.
We have found that it also is useful to be aware of the settings unique impact on each family member as the family becomes familiar with the unit. For
instance, it can be helpful to inquire about family members experience when
first meeting them in the inpatient context. A clinician might say
Thanks so much for making the time to come in today to meet with me. We
believe that your participation in the treatment process is really important.
Im wondering if you have had the opportunity to meet with inpatient staff
when [name] has been hospitalized in the past?
It can be helpful to learn what the familys experience has been like in the
past to understand how they may be experiencing the current inpatient setting:
Im also wondering if you have had any particularly good or particularly bad
experiences with inpatient staff before?
This also can be a point at which the clinician can orient the family to the
unit and the hospital. Such an orientation and introduction can put family
members at ease and also can help the clinician understand where the family
is at as they are entering the often unfamiliar (and, at times, chaotic and frightening) world of inpatient psychiatric treatment.
Family expectations of inpatient treatment
Families may have a wide variety of expectations of hospitalization and treatment. Particularly in the initial years of illness, family members may have unrealistic expectations that hospitalization will cure the problem and return
their loved one back to normal upon discharge. It often is frustrating for clinicians to encounter such beliefs, and we certainly have felt these frustrations
when working with families in their professional roles. At the same time, it is
critical to realize that families unrealistic expectations typically are not rooted
in a willful denial of their loved ones illness. Instead, families beliefs often reflect a lack of information coupled with an emotional coping process of trying
to come to terms with the painful reality of their relatives illness.
In addressing families expectations, it can be helpful to provide an orientation to the current context of inpatient care at some point during the family interview. For example, a clinician may explain:
It is important for you to know what we do here on the inpatient unit and the
role that we play in [names] treatment. Typically, the purpose of
170
hospitalization is to help get people through a crisis when their symptoms

get worse, to provide an environment to ensure their safety, and to make
sure they are linked up with outpatient care as they are discharged.
Nowadays, extended periods of hospitalization are pretty unusual for
people who have mental illness. Instead, the emphasis is more focused
on helping people get back to the community when they are safe and
able to return to their living environment. I know this can be difficult for family members, who sometimes experience a sense of relief when their loved
ones are hospitalized. It can be frustrating for all of us to deal with the limits
of what we can accomplish while [name] is in treatment here.
However, we do hope that we can work with you too, as we help [name]
get her illness more under control. We also hope to address your needs for
information about [names] illness and treatment and her plan for care
while she is hospitalized here.
This explanation also may serve as a point of entry to discuss sources of support for family members, including professional family services and other education programs and avenues of support for family members. For example,
some inpatient units have educational family programs that provide a forum
for family members to learn about their loved ones illness. Community resources, such as family education programs offered by the National Alliance
for the Mentally Ill, can offer another place to refer families for education
and support. As a practical matter, we have found it helpful for staff who interview families to have a current, well-organized repository of information about
mental illness and such resources, so information can be provided to families
rapidly and smoothly.
Family roles and determining spokespersons
It is important for clinicians who interview families to recognize the ways in
which families are organized and the roles that different family members of
the patient may play. It is common for one family member to act as the designated spokesperson for the family when the patient is hospitalized. It is critical
to take the time to establish a positive bond with this spokesperson, because his
or her translations of what the clinician says may be the only information from
which the family makes its impression of the care. Also, it is important to realize that the patients illness often prompts a reshuffling of family roles.
Moreover, as time passes, there may be generational transitions, so that siblings assume a more active role as the patients parents age. The key point for
interviewers is to assess and be sensitive to who in the family are the central
figures in the life of the patient. For example, interviewers may ask, Who is
usually involved in helping [name] when he has difficulties?
Potentially Disruptive Issues for Clinicians in the Inpatient Setting
Contact between clinicians and families may occur in a variety of ways in the
inpatient context. Family meetings may be planned during the course of hospitalization. More often, we have found that contact with families happens
through a variety of more informal avenues: during family visits to the patient,
171
family telephone calls to the unit, or telephone calls from the treatment team to
the family. This section examines two issues in communication that sometimes
can create stress between staff and family: (1) time and (2) confidentiality.
Time limitations
For clinicians, the first difficulty is lack of time. In a common scenario, family
members visit and request an unplanned meeting with their loved ones physician or other staff on the unit. Frequently, it is not possible for staff to set aside
other duties and make time for such a meeting. In building an alliance with
families, however, we believe that it is critical to communicate the message
that the clinical team values family input and involvement in treatment. As
family members, we have found it frustrating to be brushed off by clinical
staff completing paperwork or attending to other duties on the unit. Thus,
we believe that it is important for staff to be attentive to families, within the context of their limited time and other demands. For example, a busy psychiatrist
with only 10 minutes to meet with a visiting family could explain:
Your input is really valuable, and talking with you is very important to me. I
wish I had several hours to review all that we need to talk about. I only have
10 minutes right now, however, so lets set priorities in how we might use
our time. Perhaps you could tell me about your main questions and concerns, and we can come up with a plan to make sure you are included
in the treatment process while [name] is being treated here.
Confidentiality concerns
Issues of confidentiality can pose particular challenges to clinicians in working
with families in the inpatient setting. Professional ethics and organizational policies appropriately require clinicians to obtain the consent of patients before releasing specific information about their treatment to family members (although there
can be specific exceptions when safety issues, such as suicide and homicide, are
active). This consent typically is documented in a written release-of-information
form. Marsh [4] has provided useful guidelines for organizational policy and clinical practice concerning issues of confidentiality, designing appropriate forms,
and working with families of patients who have serious mental illness.
Perhaps one of the most difficult and common scenarios is when a family
member asks clinicians for information about the patients treatment, and the
patient has not provided permission to release information to family. In such
situations, we believe it is important for clinicians first to reinforce the family
members interest in the patients treatment and in their effort to make contact
with the staff. For example: I am so glad that you called [came in], and that
you are interested in learning more about [names] treatment here.
Next, the clinician should provide a straightforward explanation to the family member regarding the relevant confidentiality issues:
As you probably know, medical information is private and protected.
Therefore, I cant share any specific information about [names] treatment
at this time without her permission. I know its hard for family members in
172
these situations; it is difficult for us, too, because we really value the opportunity to include patients families as part of the treatment whenever we
can. What I can do is talk with [name] the next chance that I get to try
to get her permission to talk with you more about her treatment.
It then can be helpful to ask the family members about their needs and offer
information that can be shared, such as answering general questions about psychiatric illness, treatment programs, and resources for family members. For
example:
I cant share specific information about [names] treatment, but I would be
happy to answer more general questions you might have at this time. Do
you have any general questions about our unit, or about mental illness,
that I might be able to help with?
Information that can be helpful for families includes a description of the inpatient unit, other treatment resources in the community, programs to support
family members of people who have mental illness, and general information
about psychiatric illness and treatment. Materials also can be sent to family
members to provide this information (eg, brochures or booklets about mental
illness, Internet-based information, flyers about specific programs).
PART II: BUILDING AN ALLIANCE WITH FAMILIES
IN OUTPATIENT SETTINGS
Common Fears, Anxieties, and Concerns of Family Members
This section addresses three important themes: (1) unmet needs for information/support, (2) differences in opinion on how to help the patient, and (3)
problems in establishing a sound rapport and reliable contact with the treatment team.
Unmet needs for information
Research consistently has documented that family members of people who
have serious mental illness report strong, and often unmet, needs for information and support related to their loved ones psychiatric disorder [5]. In our experience as family members, we have felt the desperation of not knowing where
to find help in coping with the mental illness of a loved one. A lack of knowledge, combined with societal stigma regarding psychiatric disorders, often
leaves family members feeling profoundly isolated in dealing with the many
challenges they face related to their loved ones disorders.
It is important for clinicians to keep in mind that family members may have
varying levels of knowledge about mental illness. Some families may have
a great deal of information about psychiatric disorders, whereas others may
have little knowledge. It is important, therefore, to avoid making assumptions
about family knowledge (or to assume a lack of knowledge). At this point, in
building an alliance with families, we have found it helpful to meet the family
where they are at by first supporting the familys desire to be involved and
173
then asking some introductory questions to assess family members understanding of their relatives problems. For example:
Thanks for taking the time to meet with me today about [names] treatment. To
begin, it would be helpful to get your thoughts about the problems that [name]
is seeking treatment for. If it is okay with you, I would like to ask you a couple
questions to get your input and learn about your understanding of things. Can
you tell me a little bit about what you think about [names] problems?
Follow-up inquiries can include more focused questions such as:

1. What do you think has caused [name] to have these problems?
2. Has anybody ever given you a diagnosis for his/her problems? (If they
have been told of a diagnosis, it is useful to follow up with a question such
as, What is your understanding of what that diagnosis means?)
3. Are there things that make things better for [name]?
4. Are there things that make things worse?
Questions such as these can help the interviewer learn about family members views about their relatives psychiatric problems. In addition, such questions can provide useful information to enhance the patients treatment. For
example, family members often have valuable observations about prodromal
symptoms that signal a risk for relapse in the patient. Note that these inquiries
avoid using the term illness, disorder, or other psychiatric terminology. It
is best to avoid using this language and hold off on offering educational information until the interviewer has a good understanding of the family members
view of the patients problems.
Differences in opinion on how to help the patient
Perhaps one of the most challenging scenarios for the interviewer is when the
family has views that are in direct contrast to the current biopsychosocial understanding of psychiatric disorders. For example, family members may believe
that the patient just needs to pull him or herself up by the bootstraps in dealing with their problems, believing that psychiatric medications are not needed.
In such situations it is helpful to listen attentively and understand the family
members perspectives. To the extent that it is appropriate, it is useful first to
validate the family members concerns or points of view. But the clinician
should follow with respectful and culturally appropriate educational information. As in the example given, if a family member opposes medication and
believes that the patient just needs to try harder, the clinician can acknowledge
this perspective:
I agree that its almost always true that people do better if they try harder
and if they believe they can be successful. So, it would be really great if
Johnny could try harder at cleaning up around the house. But one of the
things we are learning about the illness of schizophrenia is that chemical
changes in the brain change a persons ability to plan and be organized.
It can also reduce a persons ability to feel satisfied and proud of
174
completing a task. All of these problems limit someones ability to pull themselves up by the bootstraps.
With regard to medication, an example dialogue may be as follows:

Clinician: I completely understand your hesitation about medication. Can you
help me understand what your concerns are about Johnny taking the
medicine?
Family member: Well, every time he comes in, it seems like they add more
medicines for him to take! And the more medicines you take, the more problems that you getand I dont see any of them helping.
Clinician: Im glad you raise these questions about the medicines he is on, and
how they might be affecting him. Let me also say that I know its frustrating to
see such limited progressI wish we had more effective ways to help people
get better quicker. Lets talk more about the role that medications might play
in helping Johnny at this time. The overall goal of the medications is to help
reduce the symptoms that are part of schizophreniathings like developing
unusual beliefs, not making sense, hearing voices. When Johnny gets sick,
these are the kind of symptoms that get worse for him.
Family member: Yea, he acts pretty crazy sometimes.
Clinician: For most people, the medicines can help control these kinds of symptoms. They wont make everything better, but controlling these kinds of symptoms is an important first step. You also raised a concern about the number of
medicines he is on and the possible side effects of they might have. Let me tell
you a little bit about each of his medications, and the possible side effects to
watch out for [provides appropriate info on specific medications]. Im so
glad that you raised these questionsthings usually work best when we
can all work togetherJohnny, you, and Ito find the medicines that
work best for him and have the fewest negative side effects.
Problems with establishing a sound rapport and reliable contact

with the treatment team
To family members, the array of clinicians who provide mental health services
to their loved onepsychiatrists, social workers, nurses, psychologists, vocational counselors, residential staff, case managersoften represent a confusing
maze to navigate. In our experience, we have found that it is hard for families
to learn the system so as to identify the appropriate contact person for a particular concern. Thus, it can be helpful for interviewers to orient family members
to the landscape of services that their loved one is receiving, with a brief explanation of the role that each team member plays and the types of concerns they
may be able to address. This type of information helps build an alliance with
the family by empowering them to become more knowledgeable allies in the
care of their loved one. Family members often benefit from having a point
person among the array of professionals providing services to their loved one.
A related challenge for families is how to establish contact with different
members of the treatment team in the outpatient setting. In building a working
alliance with family members in the outpatient setting, it is helpful for interviewers to provide advice about how family members might become involved
175
in care and how they can contact team members. Such advice may vary according to the situation (eg, the patients willingness to have family involved) and
treatment setting. As one example, consider the following example from an interview between a social worker (SW) and the mother (Mrs. Jones) of a patient
(Susan). The conversation is focused on how the mother can address her concerns about medications to the patients psychiatrist:
Mother: My main concern is the medicines. You know, Susan seems tired all of
the time, like she is totally out of it.
SW: Sounds like your main concern is about the medications, and I think you
have identified an important issue. I would like to work with you to figure out
how to best address these concerns. It seems to me that a good first step
might be to talk with Susans psychiatrist about the medications she is taking.
Have you had the opportunity to talk with her doctor who prescribes her psychiatric medicines?
Mother: Well, sometimes I drive her to the doctors appointment at the clinic,
but Ive never gone in with her to talk to the doctor.
SW: Lets talk about how you might be able to speak with her doctor. Let me
throw out a couple ideas for your to considerfirst, you could ask Susan
if you could come to one of her appointments and raise your questions about
the medicines; another way to approach it might be over the phone.
Mother: I think it might be easier in personI would rather sit down and talk
with the doctor.
SW: So, you think coming to one of her appointments might be a good ideamaybe we can go through the steps you can take to get to come to one of her
appointments. Have you ever talked with Susan about coming in to meet with
her doctor?
Mother: No, Ive never brought it up. Im not sure what she would say.
SW: A good first step might be to talk with Susan about this. I know that she
gave me permission to speak with you today, so I think that she will be
open to having you meet with the doctor. When you talk with her, it might
be good to let her know why you want to come to the appointmentto learn
more about her treatment and how to best help her.
Mother: OK, I can ask her if I can come to the next appointment with her.
SW: I think that is a great plan. There is one other issue for you to be aware
of. As you know, medical information is confidential and protected, and
this can be an issue when family members want to talk with professionals.
So, if you come into meet with the psychiatrist, Susan would need to give
her permission to allow the doctor to speak to you; usually, this involves
a written form that Susan would sign. Here is an example of the kind of
form that is usually used to do this [shows copy of release-of-information
form] . . .
In this example, the social worker is actively coaching Mrs. Jones as to

how she can get her concerns about the medications addressed with the appropriate member of the treatment team and providing information about potential barriers to family participation (eg, patients permission, confidentiality
issues).
176
Potential Obstacles for Clinicians in the Outpatient Setting

This section discusses two particularly important problems encountered in the
outpatient setting: (1) procuring permission from patients to talk with family
members in an ongoing basis, and (2) transforming difficulties encountered
while trying to engage family members in ambulatory settings.
Talking with patients about involving family in care
To initiate contact with families, it is necessary to ask the patient to identify members of his or her family and to obtain the patients permission to speak with them.
Although the primary focus of this article is on interviewing family members,
these interviews will be brief or nonexistent unless the clinician has done
a good job of interesting the patient in involving family members. Consequently,
we would like to devote attention to some techniques we have found useful.
Patients have a wide range of family experiences and preferences with regard
to family involvement in their mental health care. As an initial starting point, it
is important to assess who the patient considers to be their family support system and what role, if any, these individuals may play in helping the patient
manage his or her psychiatric disorder. For example one could say, I would
like to ask you some questions to understand your family relationships and
support system better. Do you have people you would consider to be your
family or are like family to you? Who would those people be for you?
For many patients, significant family and potential allies in treatment may
include members of the support network who are not relatives (eg, a friend,
pastor, Alcoholics Anonymous or Narcotics Anonymous sponsor). After identifying the key members of the support network, it is helpful to learn about
patients level of contact with these individuals: for example,
1. Does the patient live with a family member?
2. If not, how close do family members live?
3. How often does the patient talk, e-mail, or get together with family members?
Next, it is important to understand the role that these individuals play in supporting the patient, including any involvement in their mental health treatment.
For example, one could say, So, you have said that you are closest to your
two brothers, and you get together with them every couple of weeks. Im wondering if your brothers have been supportive as you have been dealing with
your mental illness?
Patients may have a variety of experiences with family in relation to their
illness. Interviewers should use techniques such as summaries and reflections
to gain an understanding of the patients experience and help him or her feel
supported. Finally, if it not yet known, the interviewer can assess the degree
to which family has been involved in the patients mental health treatment in
the past and the patients preferences with regard to involving family at this
time. For example, one could ask:
1. Have your brothers been involved in your mental health treatment by coming
in to meet with your doctor?
177
2. Have they ever attended any kind of educational programs or groups?

3. Would you like to have your brothers involved in your mental health
treatment?
4. What might be the possible benefits?
5. What, if any, are your concerns about having them involved?
Overall, the goals of this discussion are to help the patient (1) identify family
members who could be allies in their treatment; (2) consider the potential advantages of family involvement in treatment; and (3) identify concerns they
might have about family participation.
In some instances, the patient may be ambivalent about involving the family.
This feeling is understandable, given the complexity of family relationships and
the possibility of the presence of abusive family members, as well as the personal nature of mental health treatment. When the patient experiences mixed
feelings about involving the family in mental health care, the primary task of
the interviewer is to help the patient make informed choices, considering the
potential advantages and disadvantages of family involvement in care.
It is particularly important to try to enhance communication with carefully
selected family members regarding safety issues such as suicide and violence.
Every effort should be made to get permission from the patient to talk openly
with key family members (such as a family member or parents with whom a patient is currently living) about these critical issues, for two reasons. First, family
members may, in the process of ongoing care, provide life-saving information
regarding the patients risk for suicide and also may be effective partners with
the patient and treatment team in suicide prevention plans. Second, it is hard
to put into words the stress, fear, and anxiety that family members experience
when they are worried that a loved one may attempt suicide. One can imagine
the extreme anxiety that a family member can face in making even a simple everyday decisionsuch as whether to go to workif there are concerns that leaving the patient alone could result in death by suicide. Family members need
guidance from clinicians to navigate these difficult waters effectively. They
also can receive great reliefso that they do not fret undulyfrom reassurance,
when it is appropriate, that safety concerns are not an issue at this moment.
Good communication, guidance on setting limits, and education on how to
react appropriately are also critical for anyone living with a patient who is finding relief through the use of nonlethal self-damaging actions such as self-cutting.
By helping family members understand the dynamics of these behaviors and
how to respond appropriately without enabling secondary gain, clinicians
can provide tremendous relief to the family members and help break the maladaptive cycle of self-cutting itself.
On a final note, never forget that, if suicide is a definite risk, the need to procure the information necessary to perform a sound suicide assessment takes
precedence over confidentiality. Information from family members may be
life saving in this regard, and at times confidentiality must be broken. If at
all possible, in such situations, consult with a supervisor or colleague to decide
whether the crisis requires overriding of confidentiality.
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Difficulties with engaging family members

Engaging families as allies in the treatment process can be a challenge, particularly in the outpatient setting, in which access to the family can be more limited. It is important to recognize that family members may have reservations
about meeting with their loved ones mental health clinicians or participating
in family services. For example, family members may be concerned about intruding on their relatives privacy or may be worried that such participation
will add additional care-giving demands. Practical barriers, such as limited
time, child-care needs, and lack of transportation also may prevent family
members from participating in services. Unfortunately, some family members
may have past negative experiences with the mental health system or family
therapy, given prior outdated theories that emphasized the family environment
as a causative influence on mental disorders (eg, the schizophrenogenic
mother).
Clinicians should communicate appropriately the message that the illness is
not the familys fault and should provide educational information about what is
known about the etiology of psychiatric disorders. For example, when given
the opportunity, a clinician can explain:
Relatives often have questions about why their loved one developed schizophrenia. Although the causes are not completely understood, we know that
genetics play a big part in determining who is most likely to develop schizophrenia. Also, we know that stressful life events play a role in triggering episodes of the illness. Research has shown that schizophrenia is an illness of
the brain. In other words, the symptoms of the illness are caused when certain areas of the brain are not functioning properly, and the chemicals that
the brain uses to communicate are out of balance. I want to emphasize that
schizophrenia is not caused by parenting or family behaviors. In fact, some
of the most loving parents I have ever met have had children who go on to
develop schizophrenia. On the other hand, we do know that families can
play an important role in helping their loved ones manage and cope with
this difficult illness.
To engage families, clinicians must communicate the value of family involvement to both patients and their relatives. Shea [6] describes a variety of interviewing techniques that can help address the underlying fears that family
members may bring to the initial meeting. Two of these techniques are particularly germane to this discussion. In the first the clinician openly acknowledges
the immense value of the family members first-hand longitudinal knowledge of
both the patient and their care to date:
One of the things I want to emphasize early on is how important your input
and background information are in our helping John. There is no one in the
world who knows him better than you. We are dependent on your input. I
also really want to know what you think has worked and what you think
hasnt.
Shea [6] goes on to describe a common fear of parents that the new psychiatrist is going to screw around with the meds. Many times the patient has
179
been tried on numerous ineffective cocktails of medications, whose painful

results have affected both the patient and family members.
Although the urgency of the presenting symptoms may necessitate immediate major medication changes, this situationin an outpatient settingis not typical at the time of many first meetings with a family member. With this
interviewing technique, the clinician emphasizes that although new medication
ideas may be triedand prove to be quite helpfulnothing is going to be done
hastily. Moreover the clinician emphasizes that the ongoing input of the family
(if allowed by the patient) will be sought first:
One of the most foolish things a physician can do is to change the medications before talking with parents and the patient about what is working.
Your input is vital. Who knows? We may find some really useful new medications to try, or we may find that his current meds are the best. No matter
what, I have no intention of changing anything until I learn more from you
on what has and has not worked. By the way, if your son agrees, in the future I would like to talk with you and get your thoughts about any potential
major medication changes. At this point in time, what is your opinion about
the medications that [patients name] is taking?
In their discussion of how to best engage families, Mueser and Glynn [7]
offer three useful strategies that interviewers can use to enhance engagement:
(1) letting the family know they are not alone; (2) providing support and allowing relatives to vent; and (3) instilling hope for change. In addition to these
strategies for interacting with family members, persistence and flexibility are
important ingredients in the effort to engage family members as allies in
treatment.
For example, clinicians can offer the chance for family members to be involved at multiple points in the treatment process, recognizing the changing
needs of the patient and family members. Using individually tailored approaches to invite family members to participate in care (eg, by e-mail, telephone, exchanging written updates) can go a long way toward engaging
families successfully.
In summary, in both inpatient and outpatient settings, interviewing families
requires a combination of the clinical skills required for working with patients
and the communication skills necessary for interacting effectively with colleagues. In many ways, the interviewer is best viewed as a consultant to family
members, who often are faced with multiple stresses and challenges and can
benefit tremendously from practical information, guidance, and support. By
establishing an effective working alliance with patients families, clinicians enhance the quality of care provided and provide greater opportunities for recovery in their work with persons with serious mental illness.
References
[1] Presidents New Freedom Commission on Mental Health. Achieving the promise: transforming mental health care in America. SDHHS Publication No. SMA-03-3832, Rockville (MD);
2003.
180
[2] Murray-Swank AB, Dixon LB. Family psychoeducation as an evidence-based practice. CNS
Spectr 2004;9(12):90512.
[3] American Psychiatric Association practice guidelines for the treatment of schizophrenia.
Washington, DC: American Psychiatric Association; 1997.
[4] Marsh D. Serious mental illness and the family: the practitioners guide. New York: Wiley;
1998.
[5] Tessler R, Gamache G. Family experiences with mental illness. Westport (CT): Auburn House;
2000.
[7] Mueser KT, Glynn SM. Behavioral family therapy for psychiatric disorders. 2nd edition. Oakland: New Harbinger Publications; 1999.
PSYCHIATRIC CLINICS
OF NORTH AMERICA
Talking with Patients About

Spirituality and Worldview:
Practical Interviewing Techniques
and Strategies
Allan M. Josephson, MDa,*, John R. Peteet, MDb
a
Division of Child and Adolescent Psychiatry, Department of Psychiatry

and Behavioral Sciences, University of Louisville, 200 East Chestnut Street,
Louisville, KY 40292, USA
b
Department of Psychiatry, Harvard Medical School, 75 Francis Street,
Boston, MA 02115, USA
ome things are difficult to talk about with strangers. Religion and spirituality are in that category. The aphorism dont discuss religion or politics, intended to promote harmonious relations with others, often
seems to guide psychiatric interviewing. Until recently, psychiatrists rarely
taught trainees to inquire about religion and spirituality, and when they did
it was often to investigate its pathologic aspects. Psychiatrists now recognize
that these matters are important to much of the populace and that attending
to them probably will improve clinical psychiatric practice.
Research increasingly demonstrates that religion and spirituality affect health
[1] and mental health in particular [2]. Recognizing the importance of religion
and spirituality as a resource, The Accreditation Council on Graduate Medical
Education and the guidelines of the Residency Review Committee for Psychiatry now require programs to instruct residents about the religious and spiritual
aspects of patients lives [3]. There is a growing clinical literature on ways in
which clinical practice can include consideration of patients spirituality and
worldview [4,5].
Consequently, we felt it was an opportune time to create an article that presents a down-to-earth, practical guide for addressing some of the key interviewing skills needed to explore a patients framework for meaningthe patients
religion, spirituality, and worldview. The article offers guidelines on the process of the interview, including ways to initiate conversation in this area,
with suggestions and specific questions useful for a more thorough exploration
of the patients religious and spiritual life. We have found all these techniques
to be useful in our daily practices.
*Corresponding author. E-mail address: allan.josephson@louisville.edu (A.M. Josephson).

doi:10.1016/j.psc.2007.01.005

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JOSEPHSON & PETEET
Agreement on how best to define religion and spirituality remains elusive,

but the authors offer these operational definitions. Spirituality is concerned
with the transcendent and the individuals connection to a larger reality or context of meaning. Religion is the form that spirituality takes within given traditions, with basic tenets or beliefs often set within a historical context. The
increasingly common term worldview is even broader in scope: it refers to
a persons philosophy of life [6]. Certainly religious individuals have a worldview, but the use of the term worldview allows the inclusion of those who
have a set of precepts by which they live and organize their lives even if
they do not ascribe to a formal creed or religion.
Clinicians should keep in mind that sometimes a patients worldviewwhat
makes him or her tickis rooted firmly not in a spiritual tradition or religious
belief but in secular frameworks for meaning such as patriotism, family loyalties, community service, recovery groups (such as Alcoholics Anonymous or
Narcotics Anonymous), or the values of a street gang. These frameworks for
meaning, which often have a profound impact on daily behavior, are equally
important to explore when eliciting a patient worldview.
GENERAL INTERVIEWING CONSIDERATIONS
The Importance of Spiritual Inquiry
Why is it important to inquire about the spiritual aspect of patients lives? The
rationale for acquiring this information has been elaborated fully elsewhere
[7,8]. Simply put, inquiry in this area has the potential to enhance how much
we can help people and improve our treatment planning. The term biopsychosociospiritual reflects the fact that spirituality may, along with biologic, psychologic, and social factors, impact a variety of issues related to clinical care including
contributing to the risk of developing clinical disorders and serving as a protective
factor [9]. It also should be noted that religious and spiritual factors may exacerbate or ameliorate a condition that arises from independent sources.
The other benefits of uncovering a patients worldview include:
1. Religious and spiritual questioning during an interview can improve a treatment alliance, because patients feel that important aspects of their existence
are understood.
2. At times patients present religious reasons for resisting treatment recommendations, whether they be pharmacotherapy, psychotherapy, or a specific
medical therapy.
3. An understanding of the patients worldview may be a critical component in
a suicide assessment, because a strong belief in a hereafter, in which one
can reunite with loved ones, may provide a powerful pull toward suicide if
the patient believes that his or her god would forgive the act.
4. An understanding of the moral codes and values by which children are
raisedor the effects of the absence of such codesmay have a major impact
on the choice of treatment interventions and the clients interest in pursuing them.
A more thorough understanding of the patients spirituality and spiritual

practices can enhance treatment planning significantly. In this regard, Shea
SPIRITUALITY AND WORLDVIEW
183
[10] has shown, in a book written to be read by patients, how the interaction of
the wings of the biopsychosociospiritual model, an interaction he calls the human matrix, can be useful in developing a common language for collaborative
treatment planning. In matrix treatment planning, the patients worldview is
seen as interacting with intrapersonal factors, biologic and psychologic factors,
and the patients social context. For example, could an intervention consistent
with the patients spirituality (eg, meditation or listening to Gregorian chant)
have a positive impact on the patients biology, perhaps accentuating or replacing the use of an antianxiety agent? Worldview, as an integral aspect of such
matrix treatment planning, can help the client and the clinician jointly brainstorm untapped, and often overlooked, avenues for intervention.
The Potential Impact of the Interviewers Own Beliefs on the Inquiry
The goal of this article is to help contemporary clinicians demystify exploration
of the religious and spiritual aspects of their patients lives, just as a previous
generation of clinicians learned to demystify in-depth exploration of a patients
sexual functioning.
Why is this exploration difficult? Griffith and Griffith [11], when exploring
this topic in their remarkably thorough and practical book, Engaging the Sacred
in Psychotherapy: How to Talk with People About Their Spiritual Lives, noted that
many therapists reported struggling with how to bring up spirituality. Clinicians often ask: Why doesnt this topic come up more in my therapies?
and What are the questions I need to ask?
In the initial diagnostic interview, subtle references by patients to matters of
faith or worldview may not be noticed by some clinicians, may seem an irritating detour to others, and may present inviting opportunities to still others. We
view these discrepancies as being powerfully influenced by the clinicians own
spiritual beliefs and possible countertransference issues. In addition to clinicians potential lack of training in exploring spiritual issues, it is likely that their
worldview or spiritual position influences what material is followed up and
how it is explored. Asking questions about spirituality and worldview implicitly
forces the clinician to examine his or her own spiritual life.
Some therapists who have not resolved these questions for themselves may
find it disconcerting to ask questions such as Do you believe in God?, What
are you living for?, or Do you believe you have a connection beyond the
material world? In part, the therapists ambivalence may explain why this
area might be so difficult to pursue.
Moreover, an interviewer may be hesitant to inquire about a patients belief
in God, because the interviewer fears the possibility of the patients responding,
How about you, do you believe in God? Once interviewers have thought
through a range of reasonable responses to such a question, they may feel significantly more comfortable inquiring about spirituality during initial assessments and in subsequent therapy.
In the process of interviewing regarding spirituality, a clinician also may need
to consider Why am I having such a strong reaction to this patient?; Is my
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JOSEPHSON & PETEET
own skepticism about some of these matters an impediment to the therapeutic

process?; Is my personal interest in this area leading me to focus too much
on it? A careful examination of ones own worldview therefore is essential
preparatory work to conducting interviewing that is as unbiased as possible.
Our experience, both personally and with our supervisees, is that although
even seasoned clinicians practice as if their worldview does not influence
the clinical encounter, it undeniably does.
In clinical practice, the clinician either holds the same worldview as the patient or does not. Discrepancies in worldview between the interviewer and the
patient can lead to misunderstanding and prejudice in the same way that ethnic
and cultural differences can. In such circumstances, it is essential to explore the
patients worldview with an open attitude and unconditional positive regard,
always being attuned to indications that the patient rejects the interviewers
worldview perspective.
Sometimes a patient becomes aware that the clinician holds the same worldview as the patient. This knowledge may facilitate the patients comfort in communicating personal religious beliefs, because the patient realizes that these
beliefs will be received without distortion or misunderstanding. At the same
time, a similarity in religious background or beliefs can be a liability in the therapeutic relationship and the clinical interview. It may lead to the avoidance of
troubling questions that threaten tenets of the faith shared by the client and clinician. A shared similarity in background also may interfere with the clinicians
empathy for the patient and preclude an accurate interpretation of the patients
conflicts if the clinicians own faith experience is conflicted [12].
The Risks and Benefits of Self-Disclosure
In most instances there is no need to communicate our worldview to the patient. In some instances, it is clearly inappropriate to do so (eg, when a patient
is psychotic or manic). Increasingly, however, therapists are examining
whether self-disclosure could occur in some situations. This question is receiving careful attention from the psychotherapeutic community, and the reader is
referred elsewhere for a more extensive discussion [13].
Given the potential for inappropriate influence on a patient, the clinician
should have a specific clinical reason for volunteering his or her spiritual beliefs, such as when doing so is thought to be necessary to engage the client.
Such sharing must be solely for the clinical benefit of the client and never
for the personal agenda of the clinician [14]. If such communication takes place,
it does so with a clearer rationale when it follows a patients inquiry rather than
being part of a therapist-initiated disclosure.
The following vignette illustrates some of the problems that can arise if
a clinician inappropriately communicates his or her worldview and uses that
communication to influence the patient:
A 26-year-old Asian American social worker presented after a hospitalization for a suicide attempt. The psychiatric consultant elicited a history that
work stressors following graduation from high school had compounded
185
lifelong feelings of inferiority. Shortly before becoming suicidal he began

seeing an Asian American therapist who, like himself, attended church regularly. The patient reported that the therapy had not been going well because the therapist talked with him about her own religious experiences
and her belief that if he committed suicide he would go to hell.
There are, however, situations in which some disclosure serves as a catalyst

for therapeutic change and enhances the treatment alliance:
A 19-year-old college student was referred for psychotherapy after a medical
evaluation for headaches and abdominal pain revealed no known physical
cause. Therapy addressed increasing her self-efficacy and expression of negative affect. She had been subservient to others her entire life, which angered
her. In particular, she raged about an authoritarian priest who had insisted
that all anger was sinful and not of God. When the therapist commented,
As I understand the Bible, there were some angry people in there who were
quite righteous and good, the young woman visibly relaxed. She responded, You seem to know my world, to which the therapist continued,
I am not Catholic but I understand something of the life of faith.
Deciding to share ones worldview for clinical reasons, such as engagement

of the patient, requires careful attention to boundary issues and presents ethical
challenges for the clinician [15]. The clinician always should keep in mind that
it is unethical for the clinician to proselytize or to influence a patients worldview unduly [16]. Effective interviewing gathers the facts necessary to develop
a picture of the whole person. Concerns about boundary issues, however well
founded, should not prevent exploration of the patients spirituality. Indeed, we
believe that ignoring the worldview of the clienta significant component in the
assessment of the whole patientwould raise additional ethical issues [17]. The
questions, What makes this person tick? and What are the most important
things in her life? are spiritual questions. Patients often are motivated to discuss what is meaningful to them if asked in sensitive ways.
For many years, it was common for the religiously devout to feel that this
area of life would be viewed skeptically by a psychiatrist. For practical reasons
alone, clinicians need to take care to be open about spirituality and to suspend
judgment and cynicism regarding any faith or spiritual position. When the patients integrity and personhood are accepted, she probably will feel comfortable in telling her story.
RAISING THE TOPICS OF GOD, RELIGION,
AND SPIRITUAL BELIEF
Indirect Methods for Raising Spirituality
Griffith and Griffith [11] offer three practical tips for raising the topic of spirituality in an indirect fashion. First, follow up the patients own use of religious
or spiritually laden language. For instance if the patient uses a phrase such as
By the grace of God I passed the final examination, you might ask something
like, It sounds like God plays a role in your life, is that true? Second, pursue
shifts in emotions that occur related to spiritual themes. Third, facilitate the
JOSEPHSON & PETEET
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interview by appealing to stories of a tradition that a clinician and patient may

share.
Griffith and Griffith [11] also have found that indirect questions, such as the
following, often lead to fascinating and important self-revelations from clients
about their worldviews:
1.
2.
3.
4.
5.
For what are you deeply grateful?

From where do you draw your strength?
Where do you find peace?
Who truly understands your situation?
When you are afraid or in pain, how do you find comfort?
Such questions may unlock information about important people who may
provide rich resources for support. They also make it easy for the client spontaneously to describe spiritual supports such as a personal god or goddess and/
or religious beliefs. It is quite informative to see which path the patient chooses.
Additional indirect opportunities to explore worldview occur when patients
spontaneously offer that they regularly attend religious services or comment on
their life goals. Clothes and jewelry that patients wear (eg, a cross pendant) and
objects they bring into the consulting room (eg, books) often are clues to a religious and or spiritual position. Simply pursuing a statement emblazoned on
a tee shirt can be productive:
A 13-year-old boy presented for evaluation of depressive symptoms. He
had few vegetative signs of depression, but the interviewer noted a sense
of hopelessness and cynicism. The interview was progressing poorly until
the clinician noted the boys tee shirt declaring, Never underestimate
the power of stupid people in large groups. Exploring existential themes
of unfairness in life and peer rejection was productive.
There are times when the clinician should note but not pursue religious or
spiritual material (eg, when there is strong patient resistance to doing so, or
when it has little apparent relevance to the clinical problem). Of course, evidence of conflict in this area may be a reason to explore it further, at least
briefly.
A 45-year-old divorced writer with recently diagnosed colon cancer presented with anxiety about her illness and anger about working with her oncologist, whom she perceived as controlling. When asked in the initial
interview if she had been a spiritual or religious person, she emphatically
answered no. Asked to explain, she said she had grown up in a religious cult led by her parents, who practically disowned her when
she left. Her distrust of authority figures based on this early religious experience had stimulated considerable anxiety about depending on a physician with an authoritarian style. In this case, it was fruitful for the
clinician to probe gently an apparent end to a line of questioning. On
the other hand, although her traumatic religious background helped
explain her current symptoms, more detailed questioning may have
seemed intrusive.
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Direct Methods for Raising the Topic of Spirituality

Most psychiatric interviews are performed with individuals who are obviously
symptomatic, reporting and requesting help with problematic thoughts, behaviors, and/or feelings. Although some of these patients also may present with
spiritual crises, the majority do not, so the question arises: are there direct
methods of raising the topic of spirituality with these individuals who are
not coming in spiritual crisis and for whom any talk of spirituality must occur
naturally in the context of the disorder being evaluated? Koenig and Pritchett
[18] have described a routine screening interview tool (similar to those used to
assess vegetative symptoms of depression or a brief marital history) that has
become known by the acronym FICA:
1.
2.
3.
4.
(F) Is religious faith an important, daily part of your life?

(I) How has this faith influenced your life?
(C) Are you currently part of a religious community?
(A) Are there spiritual aspects that you would like to address in the development of a treatment plan?
Although these screening questions may elicit responses of limited interest,

they often point to areas worth deeper inquiry.
Jennifer was a 17-year-old high school senior referred for treatment of depression
and anxiety, after a negative, extensive workup of physical symptomatology.
For the 6 months before referral she had been home schooled, the result of the
negative school experience in which she felt ostracized by her peers.
Clinician: How long have you been home schooled?
Jennifer: Just this year.
Clinician: How was this decision made?
Jennifer: I have always attended parochial schools and it has usually worked
out. This time, in high school, the group is becoming a clique. My parents
said I should stop going there.
Clinician: Parochial school? Is your family a family of faith?
Jennifer: Faith! Faith! Thats my whole problem.
Clinician: You really have strong feelings associated with your faith. Tell me
about your experience.
In this instance, a simple, even self-evident request to elaborate on her educational experience led to an angry, emotional response. In asking about the
word parochial, the clinician opened up a discussion of significant religious
conflicts. Further interviews demonstrated that these conflicts were related directly to her symptoms.
Here are three other direct questions that can provide graceful methods for
raising the topic of worldview. The first one, in particular, makes sure that the
patient has a chance to describe any of the nonreligious worldviews mentioned
earlier in the introduction to this article:
1. People vary in what makes them tick. For some it is religion, for others
it is their family, for others it is their community, and, of course, it could
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JOSEPHSON & PETEET
be a combination of things. What would you say makes you

tick?
2. People vary in their spiritual beliefs from believing in a god to being agnostic
to being an atheist. How would you describe your own beliefs?
3. When you were a child did your parents raise you with a specific religious
belief?
GOING DEEPER
A number of situations, not all as dramatic as the one seen with Jennifer, call
for a more in-depth exploration. We will consider two areas in particular.
Moral Concerns
Most humans are defensive about moral failings, and there may be no area
more difficult to explore. Moral choices and failures, however, can be related
to dysphoric states, if not disorders. Sheehan and Kroll [19], in a survey of psychiatric inpatients, found that a substantial minority of patients believed moral
transgressions played some role in the development of their illnesses. The majority was not psychotic. Sheehan and Kroll wrote, Most physicians provide
their patients with a biological reductionistic explanation as to the etiological
mechanisms of disease and assuredly gloss over the moral or transcendental
import of the disease to the ill person.
Clinicians may be able to explore moral concerns more deeply at clinically
appropriate points, by asking, for example: Do you feel your problems developed as the result of making a morally wrong decision? or Are you having
trouble deciding what is the right thing to do? or Are you having trouble forgiving yourself (or someone else)? Affirmative answers to these questions lead
directly to spiritual questions about the process of forgiveness [20].
At times, the intersection of morality and clinical issues can be dramatic:
A 52-year-old woman finally was apprehended for her role as an accomplice in a murder many years earlier. She described relief at shedding
her assumed identity, and she related that guilt, anxiety, and depression
had plagued her for years as she harbored the knowledge of her wrongdoing. She described several trials of antidepressant therapy as well as
psychotherapy that had been unsuccessful. Her arrest and legal accountability resulted in the relief of her symptoms [9].
Existential Issues
Existential crises associated with feelings of meaninglessness, despair, and helplessness, occasioned by medical illnesses or serious disruptions in interpersonal
relationships or religious beliefs (eg, feeling abandoned by God), can mimic depression and even lead to suicide. Such crises require interviewing with an existential focus. Questions designed to identify existential themes as well as
spiritual resources include: Where do you find the strength to cope?;
What means most to you at this point in your life?; What are you are living
for?; Where do you find love and peace?; and, with terminally ill patients,
How do you feel about the approach of death?
189
A 64-year-old lawyer described his lack of energy and general hopelessness by commenting, I am not very optimistic about people. After this
clue, not specifically religious or spiritual but suggesting existential
angst, the therapist merely asked, Could you tell me more? At this question, the patient launched into a long description of his view that people,
given the opportunity, will always choose evil over good, that moral codes barely keep people under control, and that at the end of the day, evil
and darkness will surface in most people. Finally he stated, The world
will do you in if you are not careful. Here a simple, encouraging question
revealed hopelessness and a despairing worldview.
Raising children presents existential challenges, leading to moral conflict

over spiritually based values if parents goals for their children differ.
A successful businessman was contemplating a significant job offer, just as
his 16-year-old daughter was recovering from anorexia nervosa. When
challenged by a clinician about the advisability of moving when his daughter remained vulnerable to relapse, he stated, Sometimes you need to
climb the mountain. A bitter argument with his wife ensued, ending
with her rhetorical question, Whats important in life, anyway? [9].
RISK AND PROTECTIVE FACTORS

In formulating a case, the mental health clinician will want to consider whether
the patients religion and spirituality is constructive (an integrating resource),
destructive (contributing to psychopathology), or both:
1. Religion and spirituality can provide a flexible structure that encourages selfcontrol and a discipline that respects the rights of others. This benefit is particularly true in the areas of aggression and sexuality, where moral codes
protect human relationships from being exploitative. Religion and spirituality
can be pathogenic when the rules they reinforce become rigid, unyielding,
and regarded as ends in themselves.
2. Religion and spirituality can affirm relationships. The sacred religious writings and the modeling of religious leaders typically affirm the rights of others
and the inestimable value of persons. Betrayal by religious or spiritual
leaders can be traumatic and destructive of a patients ability to trust.
3. A spiritual worldview may affirm relationships and strengthen basic trust in
other individuals and humanity at large, facilitating supportive relationships
within families. On the other hand, religious parents can be destructive if, in
trying to protect their children from an evil world, they stunt the development
of healthy adaptive capacities.
4. Religion and spirituality often provide an intellectual framework by which to
manage existential anxiety and doubt. The concept that life has meaning
and purpose seems to buffer many stressful situations. Distorted religious beliefs, however, can be damaging to mental health when they preclude the
use of medication or assert that the devout do not get depressed.
5. Spiritual and religious communities often provide individuals with support,
social relationships, and personal identity which can buffer life stresses,
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decreasing the risk of psychiatric disorders. Conversely, the expectations of

a religious community can be burdensome to an individual who desires to
live outside the communitys norms.
Keeping these general risk and protective factors in mind will assist the interviewer in gathering more detailed information about whether the patients spirituality is a resource or a detriment. This information is supplemented further
by the clinicians specific line of inquiry informed by developments in psychiatric epidemiology. For example, most clinicians inquire about a history of
abuse in patients who have borderline personality disorder because this association has emerged from the literature. The psychiatric literature is developing
quickly in the area of the epidemiology of spirituality and religion, suggesting
specific questions regarding spirituality that could be asked when assessing disorders such as depression, substance abuse, and anxiety disorders.
Kendler and colleagues [21] noted in a large twin study that religious devotion buffered the effects of stress in depression-prone individuals. Koenig and
colleagues [1] have noted that studies of adolescents and young adults consistently demonstrate an inverse relationship between substance abuse and religious involvement. Sexual problems also require questioning regarding
spirituality and worldview. Weaver and colleagues [22] noted that religious involvement of the family and a teenagers religious commitments play an important role in delaying the onset of sexual intercourse. This finding has increasing
clinical relevance because recent data suggest an increased incidence of depression with premature sexual activity in young girls [23].
On the other hand, some negative associations are emerging also. One study
noted that when church-going youth were sexually active, they were less likely
to use contraceptives than nonchurch attendees [24]. This article cannot review fully the associations between disorders and the risk and protective factors
offered by religion and spirituality. It is important, however, for any clinician to
be aware of this developing science and its database, which can help inform any
rational interview process.
Systematic interviewing in the following areas can complete a spiritual and
religious inventory and, in combination with previous explorations, provide
a more in-depth understanding of the patients spiritual problems and resources. Although touched upon in the initial interview, in-depth explorations,
such as the following, usually are done during ongoing therapy.
SIX AREAS FOR IN-DEPTH EXPLORATION
Development: What Were You Taught?
Families are the first place an individual receives spiritual instruction (or lack
thereof), and interviewing about spiritual development fits naturally into a general
review of the patients experience in her family of origin. Many individuals remain within their familys tradition; others rebel or change spiritual perspective,
some through a conversion experience. These transitions often occur at times
of stress and can have profound effects on future development. Such a conversion
191
should be explored fully, reviewing antecedents, accompanying events, and subsequent behavioral integration of the change in spiritual perspective.
Developmental experience often is conveyed by metaphor as a way of conceiving one thing in terms of another. The patient may describe the constancy
of faith positively (My faith was an island in a sea of trouble) or painfully
relate an upbringing that was a living hell. Such comparisons are a potentially
rich area for clinical exploration. When a patient says, Im a recovering Catholic, comparing her faith to illness or addiction, a clinician could respond simply by asking, What are you recovering from? The interviewer also could
stay with the metaphor by asking, Did certain treatments help you recover
from this condition? Or the interviewer could offer his or her own metaphor,
such as, As I hear you describe your spiritual background, it seems it was
a ball and chain, holding you back.
Specific questions with which to explore development might include:

Did you attend religious services or receive spiritual instruction growing up?
Was there a spiritual emphasis in your family?
What was your familys religious tradition? And how did they practice that
tradition?
Was religion a source of conflict between your parents?
What experiences helped shape your beliefs?
Did your parents behave in a manner consistent with their beliefs?
Are your beliefs similar to, or different from, those of your parents?
Growing up, were other people important to you in your spiritual
development?
Community: Where Do You Belong?

Belonging to a spiritual or religious community can be a source of support for
those suffering from psychiatric problems, but conflicts within the community
or the expectations of the community also can be a source of stress [25]. Community is about belonging, a value of enduring importance and one that may
be harder to find in contemporary society. A religious community typically is
more organized, often requiring formal membership, whereas a spiritual community is a broader, more loosely knit network. Consider the meaning of community for Ms. AB, recently bereaved of her grandmother:
Dr. X: It sounds like your grandmas funeral was meaningful.
Ms. AB: I got to share memories of grandma with all the other people there who
loved her, and I got to be with her one last time in a place that she loved and
where we had spent so much time together.
Dr. X: The church?
Ms. AB: Thats right.
Dr. X: What did it mean to you that her funeral was in the church?
Ms. AB: I hadnt thought about it, really, because I think all funerals ought to be
in a church. But I guess it is the fact that the church represents God, and its
God who creates us and is there at our very beginning and the end, no matter what happens in between. And its where all the people who have known
you the best and longest are.
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Ms. AB shows what Allport and Ross [26] would have described as intrinsic
religiosity. Her participation in a religious community reflected her deeply internalized beliefs and values. By contrast, individuals with extrinsic faith are
those who take part in community purely for social reasons. Specific questions
about a patients religious or spiritual community could include:

What is your community? To whom do you belong?

What does your community expect of you?
What does it do for you?
Do the leaders of the community communicate with clinicians? How? [11]
Beliefs: What Is Your World View?

Because, as cognitive therapists point out, the thought is the mother to the
deed, an examination of the patients beliefs elucidates not only how individuals make sense of the world but how they are inclined to act. For example, the
common if implicit religious belief that an aspect of the person (a soul) lasts
forever contrasts with the atheists belief that humans are passing products of
time and chance.
Interviewing should assess the clinical impact of a deeply held belief and not
merely its presence. For example, the conservative Christian belief that the
world is a sinful, fallen place is clinically relevant if it causes parents to prevent their children from engaging in developmentally appropriate experiences.
Statements of belief in propositional truth and theological dictates that may
be more rigidly required for one to be considered a genuine member of a specific religion can engender conflict. Spirituality itself rarely takes the form of
propositional statements and can seem safer to discuss than religion. More rigid
religious beliefs often deserve inquiry, however; defensiveness about them can
indicate their importance and justify sensitive, respectful exploration. In addition, the personal interpretation that a patient gives to religious stories can
provide important clues to the patients psychologic functioning [9,11].
It is important to ask about both broader theological beliefs and the implications of those beliefs for daily living and personal conduct. Clinicians now have
a number of resources available for educating themselves about positions on
life taken by the major traditions [4,27]. Are the patients beliefs convictions
or assumptions? Are they conservative or liberal?
Interviewing about core beliefs also should include attention to timing. In
most cases, in-depth interviewing in this area should occur only after a therapeutic relationship has been established. Discussion about beliefs can turn
quickly into a negative experience for patients, particularly in interviews conducted by inexperienced clinicians who may miss subtle cues about what material to pursue and what to leave unexplored. Some questions about beliefs
could include:

What would you describe as your single most important belief?

How do you determine what is right and wrong?
How do you believe most other people determine what is right and wrong?

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Do you have religious and spiritual beliefs that cause you conflict? Do you believe in an after life?
How do you believe marriage and child rearing should be structured?
What is success?
What is the good life?
What is happiness?
Do you believe in absolute values?
God: Is There an Ultimate Source of Life?

One foundational question about belief deserves special attention: Do you believe in the existence of God? The answer to this question divides individuals
into those who believe there is ultimate purpose in life and those who believe
that life is the product of time and chance. Interviewing about religion and spirituality flows from this basic categorization.
Asking about a persons perception of what God is like also is informative
because ones mental representation of God is intimately connected to ones
perceptions of parents or other important authority figures in life [28]. Asking
a patient to elaborate on his or her image of God helps the clinician understand
the patients internalized object relations.
Further, a clinician will want to know what role belief in God plays in the patients life. Freud [29] hypothesized that belief in God was a way of dealing with
feelings of helplessness and wishes for parental protection. Although this global
statement has been largely discredited, it is not totally without merit. The clinician
must consider both hypotheses. Does the patients belief in God serve an integrating, maturing function by helping the patient function independently and
responsibly? Or, in recognizing that he or she is not self-made and owes his or
her existence and allegiance to a higher authority, does it seem to justify dependence and avoidance of responsibility (eg, God must have wanted me to do
that.)?
Questions to ask after Do you believe in God? include:

What led you to this belief?

If you do not believe in God, what led you to this unbelief?
What are Gods most meaningful characteristics?
How does God affect your personal experience?
Does your belief in God support coping with problems?
Rituals and Spiritual Practices: How Do You Conduct Your Life?

Rituals as symbolic behavioral expressions of belief allow social participation in
celebrations of historical events important to a particular faith tradition. As in
the case of the funeral for Ms. ABs grandmother, experiences of awe and wonder are more powerful when shared with others of like belief.
Although the terms ritual and ceremony often are used synonymously,
some distinguish ceremony as a prescribed social behavior, choreographed to proclaim order in the face of lifes uncertainties (eg, a graduation ceremony), from ritual as an encounter with the numinous world [11]. For example, rituals such as
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prayer, meditation, and religious songs stir emotions of wonder and reverence,
whereas ceremonies such as inaugurations tend to reinforce certainty and conviction. In reality, ritual and ceremony often merge. For example, religious rituals that
evoke awe and wonder, such as Sabbath in the Jewish week and Ramadan in the
Muslim calendar, may be repeated to become regular ceremonies.
What function does a given ritual serve in the patients life? Is it a maladaptive, obsessional means of binding anxiety and fear or an occasion for joy,
whether religious (eg, Easter) or developmental (eg, birthdays; anniversaries)
that functions to foster peace and the integration of ones relationships with
others? Rituals driven by psychopathology are associated with urgency or compulsion rather than with choice, ease, and anticipation. Adaptive rituals are associated with values and beliefs that have significant meaning for the individual
in contrast to irrationally held beliefs that cause distress.
Dr. X: And what gave you peace after your grandmother died?
Ms. AB: Just knowing that grandma had all her friends around her and she was
at peace with God. Ill never forget her funeral. She had all her favorite
hymns and Bible passages picked out, and she planned her funeral to be
what she called a Good-bye World, Hello Heaven Party. For a funeral,
it really was a great daythe only thing missing was grandma! And the
words of the service itself were so comforting, like my grandma herself
was there hearing the same words that she heard at funerals when she
was a child, and the same words and songs that will be at my funeral and
millions of other peoples funerals. The same words, and songs, and rituals
that connect the dead with the living with those already in heaven, no matter
who they were on earth. That made me feel like I was going to be OK without
her here in person, because lots of what she loved is staying with me.
Rituals often mitigate the social differences of wealth, social status, race, culture, and power. C.S. Lewis, the brilliant scholar and lay theologian, was asked
why he attended church when he was unlikely to learn anything new there. He
replied that singing hymns and offering prayers beside uneducated laymen was
a powerful ritual for him, reinforcing that all humankind is the same before
God.
Questions that can help the clinician distinguish between healthy rituals and
those of psychopathological origin include:

What does prayer mean to you? How and how often do you pray?
Do you pray alone or with others?
How often do you engage in meditation or private religious practices that
include the study of scriptures?
How often do you attend spiritual or religious services?
Spiritual Experiences: Do You Have Experiences Beyond Words?

Spiritual experiences transcend the patients material, day-to-day life. They are
linked closely with ritual and ceremony and are components of these events but
tend to be individual and not necessarily shared with others. They may be
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linked to beliefs but can occur apart from explanatory constructs, later taking
on meaning within the patients narrative (eg, as life-changing out-of- body or
conversion experiences).
Patients typically find it difficult to put these experiences into words because
they defy explanation. A specific type of spiritual experiencethe mystical experienceis, by its very definition, beyond words and has been reported across
essentially all religions. It typically is marked by intense feelings of a oneness
with the godhead, in which a sense of personal self dissolves, time seems to disappear, and one feels an indescribable certainty of the importance of the eternal
Now, as well as an almost overpowering sense of compassion. Spiritual experiences, such as those seen in mystical revelations, often involve an intense
awareness of physiologic states (as seen in meditative practices); behaviors
such as fasting can heighten this awareness further.
Just as psychiatry has been reluctant to incorporate an awareness of the patients worldview and belief system, it similarly has paid relatively little attention to understanding spiritual experience. Consider the following questions
as a guide to interviewing in this area:

Have you had experiences that you or others would describe as spiritual?
Have you told others about your experiences?
How important is spiritual experience in your life?
Have spiritual experiences led to behavioral changes in your life?
Does your sense of the presence of a higher power change how you
approach personal decisions?
Do you think you have ever had a mystical experience?
SUMMARY
Asking about a patients worldview and spiritual concerns in the initial diagnostic interview is a daunting task but is worth the effort. Getting to the heart of
the patients concerns improves patient care and deepens the clinicians understanding of the patient. At the very least, asking the larger questions of life
lessens the chance that the patients experience of the interview will mirror
that of a despondent physician who had just been interviewed by a psychiatrist
[30]:
I dont think he heard me . . . Depression may be the disease, but it is not the
problem. The problem is my life. . . .. Its falling apart. My marriage. My
relationship with my kids. My confidence in my research. My sense of
purpose. My dreams. Is this depression? . . . I want this depression treated,
all right. There is something more I want, however. I want to tell this story,
my story. I want someone trained to hear me. I thought that was what
psychiatrists did.
References
[1] Koenig HG, McCullough ME, Larson DB. Handbook of religion and health. New York:
Oxford University Press; 2001.
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[2] Koenig HG, editor. Handbook of religion and mental health. San Diego (CA): Academic
Press; 1988.
[3] American Medical Association. Program requirements for residency education in psychiatry. In: Graduate Medical Education Directory, 20022003. Chicago: American Medical
Association; 2002. p. 30917.
[4] Josephson A, Peteet J, editors. Handbook of spirituality and worldview in clinical practice.
Washington, DC: American Psychiatric Publishing, Inc; 2004.
[5] Josephson A, Dell ML. Religion and spirituality. Child Adolesc Psychiatr Clin N Am
2004;13(1):xvxvii and 1230.
[6] Nicholi AM. Definition and significance of a worldview. In: Josephson AM, Peteet JR, Josephson A, et al, editors. Handbook of spirituality and worldview in clinical practice. Washington, DC: American Psychiatric Publishing, Inc; 2004. p. 312.
[7] Josephson A, Wiesner I. Worldview in psychiatric assessment. In: Josephson A, Peteet J,
editors. Handbook of spirituality and worldview in clinical practice. Washington, DC:
American Psychiatric Publishing, Inc; 2004. p. 1530.
[8] Richards PS, Bergin AE. A spiritual strategy for counseling and psychotherapy. Washington,
DC: American Psychological Association; 1997. p. 17199.
[9] Josephson A, Peteet J. Worldview in diagnosis and case formulation. In: Josephson A,
Peteet J, editors. Handbook of spirituality and worldview in clinical practice. Washington,
DC: American Psychiatric Publishing, Inc; 2004. p. 3146.
[10] Shea SC. Happiness is: unexpected answers to practical questions in curious times. Deerfield Beach (FL): Health Communications, Inc; 2004.
[11] Griffith JL, Griffith ME. Encountering the sacred in psychotherapy: how to talk with people
about their spiritual lives. New York: Guilford; 2002.
[12] Abernethy AD, Lancia JJ. Religion and the psychotherapeutic relationship: transference and
counter transferential dimensions. J Psychother Pract Res 1998;7:2819.
[13] Psychopathology Committee of the Group for the Advancement of Psychiatry. Reexamination of therapist self-disclosure. Psychiatr Serv 2001;52(11):148993.
[14] Peteet J. Therapeutic implications of worldview. In: Josephson A, Peteet J, editors. Handbook
of spirituality and worldview in clinical practice. Washington, DC: American Psychiatric
Publishing, Inc; 2004. p. 4759.
[15] Post SP, Puchalski CM, Larson DB. Physicians and patient spirituality: professional boundaries, competency, and ethics. Ann Intern Med 2000;132(7):57883.
[16] American Psychiatric Association, Committee on Religion and Psychiatry. Guidelines
regarding possible conflict between psychiatrists religious commitments and psychiatric
practice. Am J Psychiatry 1990;147(4):542.
[17] Sexson S. Religious and spiritual assessment of the child and adolescent. Child Adolesc Psychiatr Clin N Am 2004;13:3547.
[18] Koenig HG, Pritchett J. Religion and psychotherapy. In: Koenig HG, editor. Handbook of
religion and mental health. San Diego (CA): Academic Press; 1988. p. 32336.
[19] Sheehan W, Kroll J. Psychiatric patients belief in general health factors and sin as causes of
illness. Am J Psychiatry 1990;147:1123.
[20] Peteet J. Doing the right thing: an approach to moral issues in mental health treatment.
Washington, DC: American Psychiatric Publishing, Inc; 2004.
[21] Kendler KS, Gardner CO, Prescott CA. Religion, psychopathology, and substance abuse:
a multimeasure, genetic-epidemiologic study. Am J Psychiatry 1997;154:3229.
[22] Weaver AJ, Samford JA, Morgan V, et al. Research on religious variables in five major
adolescent research journals: 1992 to 1996. J Nerv Ment Dis 2000;188:3644.
[23] Hallfors D, Waller M, Bauer D, et al. Which comes first in adolescencesex and drugs or
depression? Am J Prev Med 2005;29:16370.
[24] Studer M, Thornton A. Adolescent religiosity and contraceptive usage. J Marriage Fam
1987;49:11728.
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[25] Dell ML. Religious professionals and institutions: untapped resources for clinical care. Child
Adolesc Psychiatr Clin N Am 2004;13:85110.
[26] Allport GW, Ross JM. Personal religious orientation and prejudice. J Pers Soc Psychol
1967;5:43243.
[27] Richards PS, Bergin AE. Handbook of psychotherapy and religious diversity. Washington,
DC: American Psychological Association; 2000.
[28] Rizzuto AM. The birth of the living god. A psychoanalytic inquiry. Chicago: University of
Chicago Press; 1979.
[29] Freud S. Future of an illusion (1927). In: Strachey J, editor, The standard edition of the complete psychological works of Sigmund Freud, Vol. 20. London: Hogarth Press; 1962.
p. 556.
[30] Kleinman A. Rethinking psychiatry: from cultural category to personal experience. New
York: Free Press; 1988. p. 867.
PSYCHIATRIC CLINICS
OF NORTH AMERICA
How to Pass the Psychiatry Oral

Board Examination
Jack Krasuski, MD
he American Board of Psychiatry and Neurology (ABPN) Psychiatry Part

II Examination (the oral boards) is among the most challenging exams
in all of medicine. The pass rate for the oral boards has hovered around
55% to 60% for years and remains lower than in other medical specialties [1,2].
Indeed, the oral boards have become an all-too-painful rite of passage for
young psychiatrists.
Residency programs have designed innovative mock examinations to help
candidates feel more comfortable and to be better prepared. If you have an interest in designing such a program, details are available [3]. The recent change
in exam format, which Ill be discussing in this article, may raise the pass rate.
Nevertheless, make no mistake, this exam remains difficult and requires extensive preparation to pass.
I was asked to write this article by the editor of this issue of the Psychiatric
Clinics of North America because I have spent much of my professional career trying to help psychiatrists pass these boards, and to do so with the least pain and
most enjoyment possiblefor the learning that can occur in the preparation process can be both valuable and enjoyable if the candidate has the appropriate
attitude.
Let me elaborate on my last comment, that some may find puzzling. For most
people the boards occur at a crucial and exciting time in their careersthe early
postgraduate yearswhen we are establishing our practices, forging our identities, and working with substantially less supervision. It is a wonderful time to consolidate what we have learned during our residencies and to push ourselves to
further improve our clinical skills so as to optimize our ability to help others.
Moreover, the move out of the nest can be a bit harrowing, and with a sound,
concerted effort at intensively securing our clinical acumen, we can emerge with
a good deal more confidence, which helps usnot only to provide better carebut
to make our jobs a good deal more fun. Confidence in our skills is an immense gift.
Consequently, I urge you to view your preparation for the boards, to be not
only an important task for passing them, but as a uniquely rich chance to
E-mail address: jk@blueti.com

doi:10.1016/j.psc.2007.02.006

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become a more skilled and mature clinician. It really is a great opportunity for
advancement of clinical skill.
The source of the insights that follow is based on my experience of personally training over 400 psychiatry oral board candidates each year. Keep in
mind, that all of the following suggestions are merely my own opinions and
are not coming from the ABPN. In the interests of full disclosure, and to
give some sense of my credibility to write an article that can help you to
pass the boards, here are a few facts about my qualifications:
I derive income from preparing psychiatrists for the oral boards and other board
exams. The large numbers of psychiatrists I train gives me a down-in-thetrenches understanding of the errors that candidates make and how to
most quickly prepare for the boards [4].
I failed my oral boards twice before finally (hallelujah!) passing on my third attempt. I believe I richly deserved to fail my first two exams and concur with
my examiners decisions.
I have never worked for nor am I associated with the ABPN. I hope the reader
will find my independent point of view refreshing.
My goal in this article is to write a no-nonsense, nitty gritty, primer on how

to pass the oral boards. To do so, we will cover the following areas:
1. Description of the oral board format
2. Information on what knowledge-base areas are covered and how best to
prepare yourself to have the knowledge base you will need
3. Tips for passing the 30-minute interview format
4. Tips for passing the 60-minute vignette format
In each of the sections I will also suggest books that may be of particular
value (and explain why). I know you have little time to read, and Id like to
give you a heads-up on where that time may be best spent.
PART I. THE FORMAT OF THE ORAL BOARDS
The oral board exam consists of two examination sections: the patient interview examination and the vignette examination.
The patient interview lasts approximately 30 minutes and is immediately followed by a 30-minute session with examiners during which the candidate presents the entire case and responds to examiner questions.
The vignette exam, instituted in May 2006, lasts approximately 60 minutes
and consists of four vignettes, three written and one video, each presented at
a separate station. The candidate has each vignette read to him and observes
the video and, in each case, responds to a series of questions based on the
data presented in the written or video vignette.
An excellent book (which I feel certain is being updated to the new board
format) in which you can gain a more realistic understanding and feeling for
what the board experience is really like, was written by Morrison and Munoz
[1] and carries the title, Boarding Time: The Psychiatry Candidates New Guide to the
HOW TO PASS THE PSYCHIATRY ORAL BOARD EXAMINATION
201
Part II of the ABPN Examination. The title almost makes it sound like fun, doesnt
it? Concise and well-written, it is well worth your money and time. Pay particular attention to their descriptions of how to prepare for the experience both
mentally and through practice.
PART II. THE NEEDED KNOWLEDGE BASE AND HOW TO GET IT

Put succinctly, deficits in the knowledge base include deficits both in the
Diagnostic and Statistical Manual, fourth edition TR (DSM-IV-TR) diagnostic
criteria and in the treatment and management of patients. In this section
we will look at tips in the following three areas: (1) DSM-IV-TR diagnostic
criteria, (2) psychotherapeutic knowledge, and (3) core treatment planning
knowledge.
How to Master the DSM-IV-TR Diagnostic Criteria
With the new vignette format, candidates are exposed to four vignette cases,
thus increasing the breadth of diagnostic knowledge that can be assessed. To
be blunt, candidates need to review diagnostic criteria more thoroughly.
Since attempting to read through and memorize the DSM-IV-TR can be boring, and thus difficult to attend to, I provide this recommendation: when studying the DSM-IV-TR, the candidate should translate each criterion into question
form, as if querying a patient for the presence of that symptom. This increases
the degree of mental processing required during the study period and thus increases attentiveness to the task. The candidate also gains practice in generating
queries from diagnostic criteria.
With Which Psychotherapies Should Candidates Be Familiar?
Candidates, at a minimum, should be able to articulate the basics of the following forms of psychotherapies:
Psychodynamic therapy
Cognitive behavioral therapy (CBT) including techniques such as cognitive restructuring and exposure-response prevention
Dialectical behavioral therapy (DBT)
Supportive therapy
Psychosocial rehabilitation programs
Chemical dependence rehabilitation (eg, motivation enhancement therapy,
relapse prevention therapy)
In the above list, I wish to highlight chemical dependence rehabilitation

(addiction treatment) because that is the area of greatest weakness for the
largest number of candidates. In particular, candidates should know that
12-Step Programs are adequate interventions only for some patients but
not for most and are NOT the same treatment intervention as a rehabilitation
program, which incorporates a case manager and cognitive behaviorally
based interventions.
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With regard to preparatory reading, you might enjoy a quick perusal of my

monograph, Lightning Review of the Psychotherapies [5].
Knowledge About Treatment Interventions: What to Know and What
Not to Know
It goes without saying that you must be well-grounded in key biologic therapiesespecially psychopharmacologyas well as core psychosocial interventions. The logical question arises, How much do I need to know?
Once again, I recommend viewing your educational review for the boards as
an opportunity for optimizing your clinical knowledge so that you can provide
even better care for your patients in the years to come. Accomplish this task
and you will have prepared well for the boards. From an operational level
one can view the task as follows: the psychiatrist must be able to convey sufficient information to the patient about each and every intervention prescribed
by the psyhiatrist so that the patient is in a position to give valid informed
consent.
The psychiatrist must know the indications and benefits of the intervention,
the potential adverse effects of the intervention, the alternate treatments available, and the risks and benefits of the alternative interventions. In addition,
a competent psychiatrist should know enough about the practicalities and underlying concepts of the treatment to be able to sensitively explain the treatment to the patient and the patients family. The psychiatrist also should
know enough to respond to the common questions that patients and families
may have about that form of treatment.
I will use electroconvulsive therapy (ECT) as an example, since most psychiatrists do not administer this form of treatment, yet must competently include it
in their armamentarium. So, how much does a psychiatrist need to know to
prescribe ECT and to obtain informed consent from a patient? This is my
view:
The psychiatrist need NOT know the dose of methylhexitol or whichever other
induction agent is given the patient,or perhaps even that methylhexitol is
an induction agent.
The psychiatrist need NOT know the exact voltage/current settings of the ECT
machine.
The psychiatrist need NOT be competent in personally administering ECT.
The psychiatrist does need to know this:

The indications for ECT, including, for instance, that it may be particularly apt as
a treatment for pregnant women with severe mania.
The adverse effects of ECT, including that there is 1 in 10,000 to 1 in 50,000
risk of death with each treatment.
The conceptual basis of ECTs efficacy (eg, being able to explain to the patient
that the electrical current induces a short seizure in the brain lasting less than
a minute, and that it is the seizure that, for unclear reasons, has mood-stabilizing effects).
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The outline of the procedure (eg, that patients are asleep under general anesthesia and that they receive a muscle relaxant so that they do not sustain
injury during the seizure; that they must take nothing by mouth from midnight
and must have someone drive them home following the procedure, if it is
done as an outpatient procedure).
With regard to knowledge-based preparation, if you want to read just one

book, I really like Nathan Strahls Clinical Study Guide for the Oral Boards in Psychiatry,
second edition [6]. It is concise and well written, and it represents a great onestop-shop for getting the core knowledge base you need to pass the boards.
Another nice book, if you want just a little more beef is Tasmans Pocket Companion
to Accompany Psychiatry [7]. It is an easy-to-read, condensed version of his major textbook on psychiatry, and it almost as if it were written to prepare one for the
boards, with concise sections on DSM-IV diagnostic criteria, descriptive psychopathology, psychotherapies, psychopharmacology, and other treatments.
PART III. TIPS ON PASSING THE PATIENT INTERVIEW
EXAMINATION
In many respects the patient interview is the most daunting and intimidating
part of the examination for examinees. It does not necessarily have to be so,
although dont get me wrong, it is filled with pressures (I failed twice, so I
know of what I speak). With time, and in helping so many people to pass
the boards, I have come to realize how much successful completion depends
on attitude. In this regard, fear is clearly not the desired attitude. Choking is
not limited to sporting events.
In the second edition of his book, Psychiatric Interviewing, the Art of Understanding, Shea [8] provides a useful appendix dedicated to tips on passing the oral
boards. His sage advice can help the examinee avoid unnecessary anxiety:
One of the biggest hurdles I find, with clinicians having problems with the
Boards, arises from an unnecessarily intense fear of the Boards themselves,
often generated by a false belief. This anxiety-provoking belief sounds one
way or another something like the following statement, The Boards are extremely difficult and artificial. They dont look like any type of clinical interview that I do.
Dont say this to yourself, because it is very anxiety producing and suggests that the examinee is being tested on a technique that is unfamiliar.
This concept is indeed a frightening thought. Avoid itit is very
counterproductive.
But there is a more important reason to avoid this belief, other than that
it is counterproductive. It is patently false. You have successfully performed
a similar 30-minute interview many times in your training, under extremely
difficult circumstances, and you have done it well. You have performed this
type of interview when you have been beat tired, harried, and under incredible time pressures. You have done this style of interview successfully
many times, when an error does not result in someone failing a test but
can result in someone losing his or her life. You have successfully and
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gracefully done this interview many times, because you have done a very
similar interview every single time that you have been on call. You see,
in many respects the Board Interview is an emergency room interview
with a few extras.
When you enter the interview room, dont focus on passing a test. Focus on doing a good clinical interview, much like you have done scores of
times in the emergency room. Tell yourself, Ive done this before and I
know how to do it. Do a good clinical interview, and you will have
done a good Board Interview.
The APBN is trying to ensure that practicing psychiatrists are safe and
can soundly perform key clinical skills such as interviewing, case formulation, and treatment planning. They are not trying to see if you can do a comprehensive 60-minute intake in 30 minutes. The Board is attempting to
determine whether the interviewer can gather a reasonable database
in a 30-minute time period that results in a sound formulation and disposition. They do not expect you to do the impossible, but they do expect you to
appropriately structure the patient toward giving pertinent information. In
a nutshell they want to see if examinees are facile at engagement, practical
in choosing areas to explore, and safe in judgement. These skills are exactly the ones that you have used numerous times in the emergency room.
Savor these words by Shea. Read these paragraphs over and over, until the
wisdom sinks into your bones. It really is true that, except for a few small modifications, you already have done this type of interview and done it well. Relax.
Moreover, I think I have a variety of tips and strategies that can help you
navigate this interview segment of the oral boards successfully. The tips can
be arranged in the following categories, each of which we will take a look at:
Types of patient you are likely to encounter
Logistics of the format
Importance of exam prep
How to practice the interview
How to practice presenting the history and treatment formulation
The style of the interview as in the good enough interview
How to avoid big mistake #1the sketchy interview
How to avoid big mistake #2ignoring psychologic factors and the psychodynamics of the interview itself
What Types of Patients Can You Expect to Interview?

The sites at which the actual exams occur invariably include a university hospital and clinic and a Veterans Administration medical center. The sites also
frequently include a state psychiatric hospital and at least one community hospital and clinic. The interviewee-patient may be receiving treatment in either an
inpatient or outpatient setting.
Often patients from specialty clinics are recruited as interviewees. Therefore
it is possible that a candidate will interview a patient from, for instance, an eating disorders clinic, a womens clinic, or a dialectical behavioral therapy
program.
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Patients may be high-functioning individuals, such as attorneys, college professors, and mental health workers, or conversely, lower-functioning individuals with severe major mental illness as well as homeless individuals residing
in area shelters. Hospital units from which patients are drawn include forensic
units and other long-term units in which patients remain hospitalized for years
or even decades.
The Logistics of the Live Patient Interview Examination
On arriving at the examination site, the candidate is ushered to a waiting room
where he or she waits with the other candidates. At the appointed time the candidates names are called sequentially. The called candidate steps out of the
waiting room and meets his two examiners. The examiners then walk with
the candidate to the assigned room where the patient is waiting.
Once in the room, the candidates goal is to seat himself or herself across
from the patient and wait as the examiners seat themselves. If the chair is
not positioned conveniently, the candidate can reposition it. It is unnecessary,
however, to start rearranging the furniture for the sake of taking control or for
the sake of having something to do. The candidates behavior should be that of
a clinical psychiatrist conducting a diagnostic interview with a new patient.
The Importance of Adequate Examination Preparation
Failing performances on the oral boards may be related either to deficits in the
candidates knowledge base or to deficits in observable skills such as interviewing, presenting, and thinking on ones feet. Of the two deficits, I believe that
candidates fail more frequently because of deficits in observable skills as opposed to a lack of knowledge.
You must be absolutely clear that the oral board exam is a performance. As
performers, candidates are in the same category as dancers, musicians, athletes,
and soldiers. Given this fact, it is critical that candidates should prepare for the
oral boards not only by brushing up on the clinically relevant knowledge base,
but also by practicing board-style interviews, case presentations, and questionand-answer sessions. There are three keys to passing the interview section of
the boards: (1) Practice, (2) Practice, and (3) Practice. Moreover, the more realistic the practice sessions are, the more learning and desensitization are
achieved [3,9].
How to Practice the Interview
To do well, candidates are advised to practice board-style interviews and case
presentations. Many candidates consistently undermine the power of their
practice interviews by taking effectiveness-sapping shortcuts. Here are tips on
doing it right [10].
1. Practice 30-minute diagnostic interviews and do not take a moment longer.
Ive done hundreds of practice board-style interviews over the years to keep
my skills sharp. This is what Ive learneddoing an interview that is 32 or 33
minutes long is very different from doing one that is the required 30 minutes.
(In the examination, however, the 30-minute time is approximate. Oral
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2.
3.
4.
5.
6.
board examiners may end the interview slightly earlier or, rarely, permit the
candidate to continue for somewhat longer. These small deviations from the
norm should not be taken as a reason not to prepare for the normal allotted
time.) By doing the interview right, the candidate develops procedural or
body memory for doing it just that way. On a personal note, for me, the
challenge in conducting competent board-style interviews is fitting all the interview regions into the allotted time. I chronically run overtime and I need
to practice repeatedly in order to adjust my pace to the 30-minute interview.
Do NOT use your own patients in practice interviews. The dynamic between
a physician and patient in the process of establishing an ongoing therapeutic relationship differs from the dynamic between a physician whose interaction with the patient is limited to a single diagnostic interview and differs
even more when the single interview, as on the board exam does not involve
a formal clinical provider-patient relationship.
Call a colleague to get permission to interview his or her patients with whom
you do not have a physician-patient relationship. Explain the purpose of the
interview to the prospective interviewees and obtain their oral agreement.
(Some clinics have policies that obligate you to obtain written consent
when interviewing patients from their clinics for training purposes.) Depending on the policies and/or expectations, offer to pay the interviewee $10 to
$20 for each interview. Since youre there at the clinic, conduct two or three
successive interviews to speed the establishment of your body memory for
conducting board-style interviews.
It is preferable to have a colleague mock examine you. If you can not get this
in place, do NOT let it stop you from doing the practice board-style interviews. I cannot stress enough how important practice interviews are, even
without an observer/examiner.
If you DO have a colleague who will mock exam you, you will benefit because it adds another layer of realism to your practice session. Even if
your colleague has not taken the oral boards or has taken them but is not
a good assessor of your performance, just having someone observing
your performance is effective in helping you desensitize to being observed
and judged. (By the way, most colleagues will tell you that you did fine.
Do not necessarily take their word on it. Most people do not know what
to look for. Nevertheless, the benefit lies in helping you desensitize to being
observed and judged.)
Do NOT be shy asking for help. If colleagues are not readily available in
your home town, strongly consider contacting your former residency director. Most residency directors are willing and even eager to help recent graduates. Your success reflects on them and their program. Again, there is no
shame in asking for help. You are not an expert in the oral boards and
your ignorance of the process or of the expectations for your performance
does not reflect negatively on you.
How to Practice Presenting the History, Case Formulation, and Treatment

Plan
Shea [8] makes the pithy point that, unlike the 30-minute board-style interview,
which is similar to the 30-minute interview that you have done many times
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before in an emergency room, case presentation may very well be something

that you have seldom done. Equally importantly, you may have received previous little training in how to do it well. In short, this is one part of the oral
exam that most of us do not do routinely in our daily practices. Consequently,
it is imperative that you practice presenting. There is a definite art to doing it
effectively. It really is a performance skill. Rightly or wrongly, examiners may
make a quick decision on your skill level based on how fluid and organized
your presentation is. As in social situations, first impressions count.
My advice is simple: practice doing your interview and then immediately allow yourself only a minute to prepare your presentation and proceed to provide a succinct presentation to a colleague, or, if no one is available, in front
of a mirror. If you make a mistake, do NOT stop. Practice covering your mistake gracefully, exactly as you would in the examination room. Also be aware
that during your presentation, some examiners may stop you to ask a question.
Never look flustered or irritated at the interruption. Simply field the question
gracefully and then proceed with your presentation. Shea [8] describes a number of other tips for quickly organizing the presentation and for giving it fluidly.
Space limitations prevent a discussion of those tips here, but I urge you to take
a look at them.
The Good Enough Interview
What type of interview should I do? The answer is a good enough interview
that would allow you to make a safe disposition and treatment plan if you only
had 30 minutes with a patient, much as you would do in an emergency room.
If you do so, then you will have done a good enough interview to pass the
boards as well. Candidates get into trouble when they try to do a perfect 60-minute interview in 30 minutes. It cant be done.
The interview is only 30 minutes long. To be blunt, something has to give.
In 30 minutes even an excellent interviewer cannot obtain full detail in every
area of psychopathology. A 30-minute initial psychiatric diagnostic interview
allows only 15 to 17 minutes for straight diagnostic interviewing. The rest of
the time should be devoted to obtaining other pertinent psychiatric information
such as social history, family history, lethality assessment, conducting a screening cognitive assessment, and responding to the patients questions or concerns
as they arise. In a good board-style interview, you will even, at times, take
a minute or two to pursue a more psychodynamically-informed line of questioning as deemed relevant.
From watching literally hundreds of interviews, I have found that a common
error candidates make is to devote too MUCH time to one particular area of
psychopathology or diagnosis. A common candidate profile is the diagnostic
perfectionist. This type of candidate asks every last symptom criterion on every single syndrome that is present (or could be present) and follows this by
evaluating the temporal relationships among all the symptoms. Such a perfectionisticdare I say obsessive-compulsivecandidate usually is usually positively
stunned when time is up, only then realizing that he or she has obtained little
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or no medical, social, and family history nor have they conducted even a cursory screening cognitive exam.
The difficulty some perfectionistic candidates encounter is that it is emotionally difficult to let go and move on before a complete diagnostic picture is
established. Even though perfectionistic candidates may have an intellectual understanding of the need to pace themselves and even have a watch on the clipboard to guide their use of time, they are unable emotionally to tolerate the sense
of a lack of completion. That lack of completion, however, is the feeling perfectionistic candidates must learn to tolerate to give themselves adequate time to
pursue other areas of crucial interest. Note that it is also the skill that a talented
emergency room psychiatrist must have in order to function effectively in a hectic emergency department. I have described other problematic styles of interviewing, akin to the diagnostic perfectionist in my free e-book, 12 Mistakes
That Will Sink Your Oral Boards and How to Avoid Them [11].
A note of warning to candidates who believe that the social history is optional and of second-level interest. I emphatically say, Not true! Exactly as
in the real world of a clinic or emergency room, if an examinee only understands a patients psychopathology, without understanding the patients station
in life, stresses, and underlying concerns, then the interviewer understands little
about the most important thingthe person beneath the diagnostic label. Consequently, the interviewer will not be in a position to present an individualized
and nuanced treatment plan relevant to the unique human being whom he or
she just interviewed. Trust me on this one, examiners do not like this trait in
a candidatebig time.
So what approach should a candidate take to avoid the curse of
perfectionism?
Three levels of detail
Because the oral board interview is brief, not all areas of psychopathology can
be assessed thoroughly. The candidate, however, is expected to delve deeply
enough into the patients psychopathology to establish a working diagnosis.
One approach to resolving this dilemma is to assess different areas of psychopathology to various degrees of precision.
Highest level of detail
Assess the chief complaint/working diagnosis with the highest level of detail.
For instance, if the patient gives as a chief complaint, Im in treatment for
schizophrenia, the candidate should plan on conducting a highly detailed assessment of psychotic symptoms. This means querying Schneidarian first-rank
types of delusions and hallucinations. If the patient does not endorse hearing
voices when no one is around, the candidate should notice the discrepancy
between the patients self-reported diagnosis and the denial of auditory
hallucinations.
This discrepancy may mean that the patient truly never experienced auditory
hallucinations, that the patient is lying (perhaps in response to command hallucinations telling the patient to deny the presence of voices), or that the
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patient has a different understanding of the hallucinatory experience than the

question suggests (there is a miscommunication between interviewer and
patient).
For instance, the patient may believe he or she hears voices only when people ARE around. The voices may be experienced as coming from the air ducts
connecting the apartment next door or from neighbors whispering about the
patient from their gangways as the patient walks down the street to return
home. In both cases the patient may truthfully deny hearing voices when
no one is around, because the phrasing of the question did not reflect accurately his or her experience of the phenomenon.
In such a case, I recommend following up with questions such as, Do you
ever find that people are whispering about you? and, Do you ever receive
telepathic messages or intercept radio waves? and, Do spirits or other beings
ever speak to you? Only after such a more detailed query can a candidate validly report to the examiners that the patient denied presence of auditory
hallucinations.
Always keep in mind that a personality disorder, such as borderline personality, may be the major problem and focus of care, in which case a thorough
exploration is required.
Moderate level of detail
Assess the syndromes highly comorbid with the chief complaint/working diagnosis with a moderate level of detail. Continuing the above example, if
a candidate believes that the patients working diagnosis will turn out to
be a form of schizophrenia, he or she should assess other possible disorders
in the differential diagnosis that also could cause psychotic symptoms with
some care, such as mood disorders, substance abuse disorders, delusional
disorders, and organic causes of psychosis.
Lowest level of detail
You should plan on conducting a review of psychiatric symptoms that briefly
covers the areas of psychopathology that either have not been raised spontaneously by the patient nor yet assessed by the candidate because they did not appear to be related to the chief complaint or to be highly comorbid with it. Dont
forget that Axis II process may need to be tapped lightly.
With regard to strategically fitting in all the other pertinent topics for
a board exam interviewa very brief cognitive examination, social history,
family history, past psychiatric history, medical history, and suicide assessmentthere are different strategies you can take, and I suggest you familiarize yourself with them so that you can flexibly adapt as the interview
proceeds [1,8].
Avoiding Big Mistake #1the Sketchy Interview
Earlier we reviewed the perfectionistic interviewer and I suggested how to
avoid that problem. In addition, the opposite approach also may be lethal,
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that is, an interview that is far too incomplete in diagnostic information. These
are some of the ways the sketch-artist approach can occur:
The candidate who has a mistaken notion of the level of detail the examiners
expect: The majority of examiners expect that the most likely diagnoses,
and especially the working diagnosis, will be supported by an assessment
of specific diagnostic criteria. Our three levels of detail from above apply.
For instance, when a patient reports, Ive been depressed for 3 months. My
mood is low, and I havent been able to work, the candidate should follow
up with, What other symptoms of depression did you notice? and then, if
a major depressive episode has not yet been established, to follow that with
assessment of other symptom criteria.
The candidate who is lulled into complacency by a talkative, easygoing patient:
Some patients are overinclusive on details that do not advance the clinicians
diagnostic understanding. Some candidates accept the patients chattiness and only during the case presentation realize their dearth of specific
diagnostic detail.
The candidate who finds it difficult to interrupt and redirect the patient when
needed: Other candidates, especially those who were raised in more traditional cultures than the prevailing, more casual one in the United States, often find it difficult to interrupt patients because interruptions are considered
rude and offensive. Although all candidates should minimize interrupting
patients and avoid speaking over patients, some interruptions are necessary. The perspective to take is that the candidate is a professional who
needs to obtain enough information to form a sensible professional
judgment.
The candidate who stops the interview early with the mistaken notion that he or
she has obtained all the information needed. For any candidate who, during
the board exam is tempted to stop the interview before being told to do so by
the examiners, I have one comment, Plan on coming back. You WILL fail!
During our board review courses, never once have I witnessed a passing interview conducted by a participant who ended early. There simply are too
many facts that can and should be obtained from even the most seemingly
straightforward case to permit completion of a diagnostic interview in less
than 30 minutes.
Avoiding Big Mistake #2Ignoring Psychological Factors and the

Psychodynamics of the Interview Itself
My Beat The Boards! Course participants often convey a sense of frustration at my strong focus on psychological issues, particularly what the significance is of specific patient behaviors or statements made to the interviewer
during the interview itself. Such interpersonal dynamics are great grist for
the mill to board examiners. They love to ask about such stuff. Let me share
an example:
Dr. Bhatti (not his real name) interviews Ms. Begamy (not her real name).
Dr. Bhatti is a rather heavy-set man who is quite anxious and is sweating
profusely as he enters the examination room on a warm September day
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in Indianapolis. During the introduction phase, Ms. Begamy hands Dr.

Bhatti a tissue to wipe his brow. He thanks her and continues orienting
her to the interview process.
Ms. Begamy interrupts him in midsentence and asks if he is board certified. He says no and continues his incessant stream of questions. She interrupts again and, pointing in the direction of the two seated examiners, asks
Dr. Bhatti if they are board certified. Flustered, Dr. Bhatti says he thinks so
and then corrects himself, saying that of course they must be because they
are examiners. That is the end of this exchange, and Dr. Bhatti conducts the
rest of his interview without further occurrence.
When Dr. Bhatti begins to present the case, he reported to me that one of
his examiners interrupted him almost immediately and asked what Dr. Bhatti made of the fact that Ms. Begamy handed him a tissue to wipe his brow.
Dr. Bhatti became flustered and was unprepared to respond to such a question. He told me that he thought, Can you just leave me alone and let me
present the case!
The answer is, No. The examiners, wisely and expectedly, were
highly interested in this exchange, wondering what the possible meanings
and implications of the here and now interaction between the physician
and the patient could mean. Indeed, in actual clinical practice, such an
awareness and the subsequent corrective attention to the patients concerns
and anxieties might be critical for fostering a more effective engagement,
gathering a more valid database, enhancing the patients buy-in to medication recommendations, and even securing that a second appointment
occurs.
The problems that candidates encounter when faced with psychologically

meaningful patient behaviors during the interview (and with psychologically
focused examiner questions after the interview) are several. First, many candidates do not understand their importance and thus do not attend to them. Second, even when candidates realize the need to attend to such communications,
their performance anxiety interferes with their ability to maintain a broad
awareness of these communications as they occur in real time during the interview. Third, even if candidates realize the need to attend to such psychologically meaningful behaviors and do so, they do not have the ability to
articulate their observations and thus, often keep silent from fear of saying
something that will get me into trouble. Fourth, and this is for many psychiatrists, the foundational problem, is that so MANY psychiatrists have little to
no training in developing a psychodynamic or, more broadly, a psychological
understanding of their patients and the need for flexible approaches to their
care dependent on their psychological quirks and proclivities.
Fortunately, several books can really help you to tackle these problems and
prepare effectively for the interview section of the boards. Right off the bat, if
you only have time to read one book on interviewing, I would begin with
Shawn Sheas Psychiatric Interviewing: the Art of Understanding, second edition
[8]. It covers all the bases mentioned previously, from DSM-IV-TR diagnosis
to effective structuring and time-management, and is fun to read.
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In addition, as I had stated earlier, preparing for the boards is a good way to
prepare oneself to be a better clinician in ensuing years. Sheas book is a perfect
example of this principle, for it is not just an interviewing primer, it is also a sophisticated exploration of advanced interviewing tips illustrated with vivid depictions of patients from actual clinical practice. With regard to avoiding Big
Mistake #2, Shea provides a wealth of information concerning the psychological and psychodynamic aspects of the interview, including methods for opening-up reticent patients, roping-in wandering patients, handling awkward
patient questions such as Dr. Bhatti encountered, and understanding and using
nonverbal communication.
Another gem of a book, useful both for board preparation and growth as
a clinician, is Carlats The Psychiatric Interview: a Practical Guide, second edition
[12]. Carlat, a noted expert on psychopharmacology, is also a gifted interviewer
and writer. His book is filled with an array of great interviewing questions for
uncovering DSM-IV-TR diagnoses and is written with a real sense of practicality. Finally, if you want a particularly sophisticated exploration of the psychodynamic aspects of the interview (yet another great bridge into advanced
practice), you cant go wrong with the second edition of MacKinnon and colleagues [13] classic text, The Psychiatric Interview in Clinical Practice.
PART IV: TIPS ON PASSING THE 60-MINUTE VIGNETTE
EXAMINATION
In this section, we will cover the following key areas:
The logistics of the vignette examination
A comparison of the new vignette format with the old format
What type of questions that might be asked
Some special areas of knowledge base often focused upon in the vignette section (including consult-liaison issues, forensic concerns, information gleaned
from the mental status, and interpersonal dynamics between the patient and
the observed interviewer such as transference/countertransference issues)
The Logistics of the Vignette Exam

The new vignette examination replaced the 30-minute videotaped interview
exam section beginning in May of 2006. The new vignette examination consists
of four vignettes presented in a period of 60 minutes. Each vignette is presented
by one examiner at a separate station. The candidate is given approximately 3
minutes to transfer between stations, which are located in separate rooms. That
leaves the candidate approximately 12 minutes to review the vignette and respond to the examiners queries.
Three vignettes are written and one is a video clip. The written vignettes are
between 300 and 500 words in length and take about 3 minutes to read. The
video clip is approximately 4 to 5 minutes in length.
Each written vignette has a primary area of focus, either diagnostic or treatment related. The video vignette presents a patient with either predominantly
Axis I or Axis II psychopathology.
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The New Vignette Format Compared with the 30-Minute Videotaped

Format
The consensus among psychiatrists that I have spoken with, who have been
examined using both the old-style 30-minute videotaped interview format
and the new vignette format, seems to be a preference for the new format.
The two most common positive comments I hear are (1) the new exam
format no longer requires the candidate to generate an entire case presentation based on an interview the candidate did not conduct. Rather, the candidate now simply responds to one question at a time. (2) The exam is
more guided and thus decreases uncertainty and anxiety among most
candidates. Also, the new format places a greater emphasis on ones knowledge base as compared to ones ability to perform. This may particularly
benefit international medical graduates, who often have a strong knowledge
base.
On the negative side, some candidates report that the new format felt fastpaced and mentally draining. Also, with four separate cases replacing a single
long case, the ability of the ABPN to test multiple areas of knowledge is
greatly increased. Candidates feel like there is no place to hide. By the
way, this probably means it is a more valid test of clinical skills. Now more
than ever, a candidate must be prepared in every aspect of psychiatric diagnosis and care.
Questions You Might Encounter in the Vignette and Video-clip Exam
To provide you with a sampling of the type of questions you might encounter in this segment of the boards, let me take a typical 300- to 500-word
vignette and radically shorten it to three sentences, just to give us a basis
for seeing where the questions might come from. Imagine the following synopsis is about 400 words longer and that you have just had it read to you:
A 50-year-old woman, bedridden, living with her daughter, believes her
food and tapwater are being poisoned. She is distrustful of men. She has
a history of multiple neuroleptic use for short periods of time and is now
referred to you by her internist.
Here are questions that examiners might come up with from such a case
history:
1. Doctor, how would you address the patients noncompliance?
2. What is your medical treatment plan? What meds will you start her
on?
3. What psychotherapy would you recommend for her?
4. If the patient were diagnosed with breast cancer, what would you recommend to the surgeons?
5. What type of social treatment will you consider?
6. If the patients daughter moved to another state, how would you alter your
treatment plan for the patient?
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Knowledge Base Areas That May Be of Particular Focus in the Vignette

Exam
The new exam format permits a broad assessment of psychiatrists competencies. Below are the areas that are currently receiving much greater emphasis. I
describe each and give recommendations. By the way, these areas can also can
come up in the questioning following your 30-minute patient interview, indeed,
mental status questions almost always do. The areas of increased emphasis are:
Consult-liaison issues
Forensic issues
Mental status exam items
Interpersonal functioning, including transference-countertransference issues
Consult-liaison issues
As exemplified by our vignette synopsis from above, vignettes of patients with
medical comorbidities such as cancer, renal failure, and hepatic insufficiency
are common. This focus requires that candidates become more familiar with
the effects of medical illnesses and medical treatments, including medications,
on psychiatric conditions.
For instance, the vignette example is of a patient who has a psychotic disorder and who, the candidate is later told, has been diagnosed with breast cancer
and is now awaiting surgery. The question, What would you tell the surgeons? is phrased broadly, purposely not suggesting a particular focus or
boundaries of the response. In this case, the response would likely include
a consideration of:
Whether the patients antipsychotic medication(s) should be discontinued during the time of surgery
What alternative or additional medications or treatments should be considered
What behavioral problems can be anticipated, given the patients psychiatric
diagnosis
What specific issues the surgeons should be educated about
Forensic issues
Another area of increased focus is on forensic issues. All of the following can be
considered fair game for examiner questions:
Treatment contracts
Informed consent and its exceptions
Confidentiality and its limits
Mandated reporting of child abuse and elder neglect
HIV disclosure guidelines
Duty to warn and duty to protect
Patient termination and patient abandonment
For instance, a vignette may present a young mother with acute decompensation who is the primary provider for her infant daughter. One of the concerns the candidate needs to recognize, and for which interventions must be
215
recommended, regards the risk at which the infant is placed due to her
mothers decompensation.
The candidate should recognize that he or she is a mandated reporter and
would need to notify child protective services. Further, the candidate should
recognize that removing the child from the mothers care, even temporarily,
can be traumatic for the mother and that education and support may be indicated. The patients rapport with and trust of the clinician also may be placed in
jeopardy. Recognition of this may lead the candidate to address this issue directly with the patient whom he is about to report.
Mental status exam
There are only two forms of data that a candidate can obtain from the
video clip and that is what he or she heard and observed. From my experience training candidates in responding to the video format, the candidates
observations are often inadequate. In fact, the shortcomings in the visual observation of videotaped patients are so frequent and so severe that I regard
them as an example of an inherent limitation in our brains ability to simultaneously process auditory and visual information that is accentuated under
conditions of stress. Bottom line, you need to practice watching short videotaped interview segments and also practice how to describe the patients
mental status as seen on the video excerpt.
My recommendation is that on the video clip, candidates write as few notes
as possible while, with conscious intent, keep scanning every aspect of the patient as seen on the screen. In addition, when preparing for the exam, candidates should carefully review the key concepts behind the mental status and
the correct clinical descriptors that should be used in writing or describing
a mental status. Also review what types of physical and psychiatric pathology
might be suggested by specific mental status abnormalities.
As one common example of inadequate preparation on the mental status exam
whenever a patient displays abnormalities in thought processes, the only descriptors I invariably hear from candidates are that the patient is circumstantial or
tangential, even when the patient is nothing of the sort, but, in fact is overinclusive or perseverative or shows signs of poverty of thought content.
The way I characterize this problem is, You dont see what you dont
know by which I convey that a phenomenon for which one does not have
a specific term in mind is either not perceived, misperceived, or mischaracterized. My simple advice is that every oral board candidate carefully review the
items and terms used when conducting a mental status exam. The chapter in
Sheas book [8] on the mental statusits terms and implicationsis excellent
and all the review you will need.
Here are just a few more of the common items frequently missed that candidates should be closely looking for:
Scanning the face for dysmorphisms and other anatomic or neurological abnormalities: if for example, the patient had the stigmata of fetal alcohol syndrome, would the candidate be able to detect it?
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Observing the face, trunk, and limbs for disturbances in movement: Is range of
motion full and movement fluid, or are there signs of rigidity? Are there any
dyskinesias, and if so, what kind? Are there any tics, stereotypies, or mannerisms? (Of course, the candidate should at this point have reviewed, understood, and recognized the phenomena of tics, stereotypies, and mannerisms.)
Observing the patients appearance: What is the body habitus? Is the patient
obese or cachectic? Is grooming adequate, or is the patient disheveled or
wearing odd clothes or makeup?
Listening to the patients voice: Is the voice husky or raspy, or is a cough present?
These are signs frequently present in smokers and could indicate various
medical ailments.
Interpersonal dynamics occurring between the interviewer and the patient on the video
excerpt
The video clips have as their focus either Axis I or Axis II psychopathology.
Especially on the Axis II focused video clips, evidence of interpersonal functioning is stressed, including the transference and countertransference reactions
between physician and patient.
Transference refers to the patients emotional and behavioral reactions toward the interviewer. Countertransference refers to the clinicians emotional
and behavioral reactions to the patient.
Here is what the ABPN tells us to attend to:
Describe the patients interaction with the interviewer and/or the pattern
of relationships described in the video clip. Identify pertinent nonverbal
communication and behavior demonstrated by the patient and the interviewer. (ABPN.com)
How do you approach transference and countertransference even if you

dont feel comfortable in this area? Here is a simplified three-step approach
to get you started:
Step 1: Describe the behavior: Focus on the patients behaviors toward the
interviewer, without attempting to infer their meaning.
Step 2: The transference step: Discuss how the patients observed interpersonal behaviors are (1) likely to generalize to the patients interactions
with his or her entire treatment team and to important others in the patients
life and (2) what the implications this could have for the patients treatment.
Step 3: The countertransference step: Describe your reactions to the patient and how these reactions could affect your approach to the patient
if you were the treating clinician. Remember that your reactions are likely
to be the type of reactions that many other clinicians also would have.
You are the stand-in for every other psychiatrist, mental health clinician,
and even adult authority figure. Focus especially on how your possible
emotional and behavioral reactions could derail or undermine the
patients treatment and how you would prevent this problem from
happening.
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How to Master Treatment Presentations and the Fielding of Questions

Regarding Treatment
Serious knowledge deficits are often present in the area of treatment and management. Candidates should familiarize themselves with two categories of
knowledge when it comes to treatment and management:
1. Information about each treatment intervention, whether the intervention is
a medication (or other somatic treatment) or a form of psychotherapy (or
other psychosocial intervention)
2. Treatment algorithms
The books I mentioned earlier on knowledge base should be adequate for

your preparation here.
In the area of treatment, a common line of questioning by examiners might
proceed as follows: You will be asked to present a biopsychosocial treatment
plan. Whichever intervention you present first, you may be requested to describe it in a fair degree of detail. For instance, if the intervention is a medication
such as divalproex sodium, you might be asked to discuss any work-up required prior to starting the medication, the starting dose, the target dose, potential adverse effects, possible drug-drug interactions, dose adjustments due to
hepatic or renal insufficiency, and any follow-up assessments needed based
on the patients continued use of the medication.
A candidate who, for example, recommends prescribing divalproex sodium
to a female patient of childbearing age who does not discuss the need for a pregnancy test and use of adequate birth control will probably be prompted to do
so by the examiner (ie, given a chance to recognize the deficit in the recommended work-up). If the candidate does not pick up on this clue, that candidate
may be failed for recommending a treatment without adequately assessing
and protecting the patient.
After responding to the examiners satisfaction regarding the initial treatment
intervention, the next examiner statement is likely to be something like, What
if that medication, at that dose, didnt work. What would you do next? The
examiner is requesting that you proceed down a treatment algorithm, each time
asking you, If that intervention didnt work, what would you do next? Thus,
you should prepare by reviewing individual treatments and their treatment
algorithms.
SUMMARY
I hope you enjoyed this article, and I also hope that it helps you to pass your
oral boards. I firmly believe that having a sound outline and strategy, as presented in this article, can go a long way toward optimizing the power of
your practice and readings as you prepare for this important rite of passage.
Remember that everything you are studying can help you to provide better
care. Keep in mind the ultimate missionhelping othersand the time spent
in your board preparations can be surprisingly enjoyable, very rewarding,
and much more likely to result in success. Good luck!
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References
[1] Morrison J, Munoz RA. Boarding time: the psychiatry candidates new guide to the part II of
the ABPN examination. 3rd edition. Washington, DC: American Psychiatric Press Inc.;
2003.
[2] Moran M. New ABPN Executive Sees Big Changes for Board Exam. Psychiatric News
2006;41(10):10.
[3] Shea SC, Rancurello M. Faculty and resident response to an innovative mock board. Acad
Psychiatry 1989;13:13743.
[4] The Blue Tower Institute. Beat the Boards Course. Available at: www.beattheboards.com
directed by Jack Krasuski, M.D., based in Lyons, Illinois.
[5] Krasuski J. Lightning review of the psychotherapies. Lyons (IL): Blue Tower Institute LLC;
200506.
[6] Strahl N. Clinical study guide for the oral boards in psychiatry. 2nd edition. Washington,
DC: American Psychiatric Publishing, Inc.; 2005.
[7] Tasman A, Kay J, Lieberman J. Pocket companion to accompany psychiatry. Philadelphia:
W.B. Saunders Company; 1998.
[8] Shea SC. Psychiatric interviewing the art of understanding. 2nd edition. Philadelphia: W.B.
[9] Krasuski J. The ultimate step-by-step guide to the psychiatric oral board interview; 2004.
[10] Krasuski J. Special report: procrastinator proof oral board preparation. Lyons (IL): Blue
Tower Institute LLC; 2005.
[11] Krasuski J. 12 mistakes that will sink your oral boards & how to avoid them. [e-book]. Lyons
(IL): Blue Tower Institute LLC; 200205.
[12] Carlat DJ. The psychiatric interview: a practical guide. 2nd edition. New York: Lippincott
Williams & Wilkins; 2004.
[13] MacKinnon RA, Michels RM, Buckley PJ. The psychiatric interview in clinical practice. 2nd
edition. Washington, DC: American Psychiatric Publishing, Inc.; 2006.
PSYCHIATRIC CLINICS
OF NORTH AMERICA
My Favorite Tips from the

Clinical Interviewing Tip of the
Month Archive
Shawn Christopher Shea, MDa,b,*
a
Training Institute for Suicide Assessment and Clinical Interviewing (TISA), 1502 Route 123
North, Stoddard, NH 03464, USA
b
Dartmouth Medical School, Hanover, NH, USA
fter launching the Website for the Training Institute for Suicide Assessment and Clinical Interviewing (TISA) in 1999, I have had the pleasure
of editing a monthly feature of the TISA Website entitled the Interviewing Tip of the Month [1]. These interviewing gems are supplied by visitors to the Website or by participants in my workshops. Each month I choose
a favorite tip for posting and then add the past months tip to the Tip Archive. (At last count there were more than 80 tips in the archive). On the
Website I always provide a TISA Description of the Problem that frames
the interviewing problem that the tip addresses and a TISA Clinical Caveat
that further frames the use of the tip or adds another interviewing suggestion.
These sections also are included below.
I have learned so much from the tips, which visitors to the Website
shared, that it sparked the idea for this section of the Psychiatric Clinics of
North America. I thought to myself, What would happen if I asked the greatest interviewers of our time to provide two or three of their favorite interviewing tips? That answer, as further articles show, is quite remarkable.
Before touching base with the masters, here are some of the outstanding clinical interviewing tips, provided by front-line clinicians from around the world,
that started the phenomenon. Below are eight of my favorite tips from the Interviewing Tip of the Month.
INTERVIEWING TIP #1: SENSITIVELY UNCOVERING
THE CLIENTS WORK HISTORYPITFALLS AND SOLUTIONS
Description of the Problem
Many aspects of taking a social history, and even seemingly innocuous questions about demographics, sometimes can pose significant hurdles to
*Training Institute for Suicide Assessment and Clinical Interviewing (TISA), 1502 Route 123
North, Stoddard, NH 03464. (Website: www.suicideassessment.com) E-mail address:
sheainte@worldpath.net
doi:10.1016/j.psc.2007.01.006

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SHEA
engagement. A tricky engagement situation can arise when asking clients about
their employment. Mike Cheng, MD, provided the following set of valuable
tips.
Tip
After the introduction, many clinicians proceed to ask about identifying and demographic data before starting the chief complaint or taking the history of the
presenting problem. Often such inquiries start with questions about living situation and marital status. One area of difficulty is asking about occupation.
For example, the clinician should avoid asking a woman, Do you work?
because that question may imply that a woman who does not have a paid job
is not working. By implying that domestic chores and/or child rearing is not
work, the clinician inadvertently may denigrate the client on a subtle level.
On the other hand, asking, Do you have a job? or Are you working?
may tend to alienate any client who is not currently employed outside of the
home. Therefore some interviewers tactfully ask, Do you have a job or are
you between jobs? Alternatively, the following question may be the most tactful: Are you working at the moment? The addition of the words at the moment helps the client to save face.
In the last analysis, because of all of these complexities, the easiest single
question to ask is, How do you support yourself? This phrasing allows a variety of responses from the client such as: Im on disability, or I work as
a teacher, or My spouse brings in the money for us. From the start, this simple question can provide surprisingly good insights into the employment situation of the client and even how the client feels about his or her current
situation.
Clinical Caveat
The interviewing techniques described above provide a variety of thoughtful
ways for helping clients to feel comfortable when sharing job status. Another
nice question is to ask, Do you work outside of the home or in the home?
INTERVIEWING TIP #2: SEVERAL STRATEGIES
FOR UNCOVERING DRUG AND ALCOHOL HISTORIES
As clinicians all know, it frequently is challenging to uncover valid information
when first working with a person coping with alcoholism or street drug abuse.
Unconscious defense mechanisms such as denial and intellectualization, as well
as conscious distortions, minimizations, and deceit, can hinder the elucidation
of valid data. Bruce Berger, MD, provides some nice questions that can help
with this common problem.
Tip
I find the following questions useful, particularly in helping to get a feel for the
clients understanding of the extent of his or her substance abuse problem as
well as the defenses the client uses to avoid facing the impact of the abuse.
TIPS FROM THE INTERVIEWING TIP OF THE MONTH ARCHIVE
221
For the sake of simplicity, the following questions are phrased for use with
alcoholism, but they are equally useful with drug abuse.
1. When you do have periods when you stop drinking, what actually stops
you? Do any of the following ever stop you: lack of money, your own sense
of self-control, passing out, physical problems like a seizure or a coma?
2. When you are drinking, what do others say about you? Do they ever say you
are funny, mean, stupid, or anything else?
3. In your opinion what are the advantages of your drinking to you personally?
What are the disadvantages?
Clinical Caveat
With such questions it is interesting to see what the client comes up with during
the open-ended phase of the inquiry. At such points one gets a vivid chance to
see defenses, such as denial and rationalization, as well as positive characteristics, such as insight and motivation. The more closed-ended inquiries may
help stir up some data that otherwise would not be made available spontaneously by the client and also may help the client look at the consequences in
a new light.
Notice how Dr. Berger deftly uses the techniques of motivational interviewing
[2] in his two questions appearing in #3. First asking the client how drinking
helps himand accepting these benefits as realopens the door for the client to
be more open subsequently in sharing the problems attached with drinking
and perhaps more readily accepting that they, too, are real.
INTERVIEWING TIP #3: THE ONE-WORD DIFFERENCE
WHEN ASKING ABOUT SUBSTANCE ABUSE
As shown in the preceding tip, one of the classic dilemmas in clinical interviewing is the problem of minimization and denial when clients describe their substance abuse histories. The first task is to help the client to admit to the use of
the substance in the first place. The second task is to uncover the amount of
use. Kevin Rice, LCSW, addresses the first task in the following simple but effective tip.
Tip
When asking about substance abuse, I find that the word experiment almost
always elicits a more accurate response than the word use. An inquiry into
the possible use or abuse of marijuana would begin, Have you ever experimented with marijuana?
Clinical Caveat
Here is a nice example of how changing just one word can have a surprising
effect on the power of a question. Language counts. Sometimes the addition
of a small phrase can increase the likelihood of uncovering use even further:
Have you ever experimented with marijuana, even once?
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SHEA
INTERVIEWING TIP #4: HELPING CLIENTS SHARE CHILDHOOD

BEHAVIORS SUGGESTIVE OF SOCIOPATHY
Uncovering antisocial or sociopathic behaviors can be difficult, for one must
strive to collect valid data about shame-producing behaviors while attempting to maintain a strong alliance. One of the spots that can be difficult is
inquiring about antisocial childhood behaviors such as fire-setting or animal
abuse. The following tip by Terry Willey, MFT, provides a simple but
effective way of raising a difficult subject without immediately alienating
the client.
Tip
When kids are young, sometimes they dont understand their actions and
may have hurt an animal while playing with it or being rough with it. Have
you ever done something like that, even by accident?
Clinical Caveat
I like this tip because it raises the potential abuse of an animal in such a way
that the client can hint or talk about the incident without an immediately powerful shame-producing admission. Once the topic is broached, the clinician can
use skillful questioning to uncover the extent of the abuse and the presence of
sadistic pleasure or other evidence of cruelty.
Other antisocial childhood behaviors can be raised in a similar fashion with
questions such as, Little kids are often fascinated by fire and dont really understand its potential dangers. Because of this fact, they sometimes play with
fire, or accidentally start fires. Did this ever happen to you?
INTERVIEWING TIP #5: RAISING THE TOPIC
OF PHYSICAL FIGHTING
In an initial interview it also can be difficult to raise potentially shame- or guiltproducing topics with which persons have been involved as adults, such as
physical fighting, in a gentle and nonconfrontational fashion. Mustafa Soomro,
MD, proposes a nice method of raising such topics smoothly.
Tip
I find that if I want to approach the topic of physical fighting unobtrusively, it
sometimes is useful to start by raising the topic in such a way that it does not
necessarily suggest that the client was involved in the altercation. Once the
topic is raised, it is possible to investigate sensitively what role the client played
in the violence. In this regard the following question is useful: Have you ever
been in situations where fights occurred and you were affected?
Using this approach, the clinician can then proceed to flesh out the role of
the client in provoking the violence, escalating it, or perhaps merely being a victim of it.
223
Clinical Caveat
This tip is shrewd and effective. It is very nonthreatening, and it can allow
one to uncover all sorts of violence, from street fighting to domestic
violence.
It reminds me of another interviewing technique for raising a difficult topic
participation in prostitutionin a way that makes it less shame-producing to discuss by hinting that the prostitution may have been triggered by financial necessity: You told me earlier that you desperately needed to get money for
your kids. Have you ever found that, out of necessity, you turned to stealing
or prostitution? To this nonoffensive inquiry, patients have replied, You
know, I had to turn to prostitution for a couple of months, and Ill tell you
one thing, no matter what happens to me, I will never do it again.
INTERVIEWING TIP #6: HELPING THE CLIENT PINPOINT
PROBLEMATIC BEHAVIORS OR SITUATIONS
Trying to help clients recognize and focus on specific problematic behaviors
and times can be difficult, because patients may feel threatened by admitting
weaknesses or bad decisions from the past. Caryn Platt Tatelli, AM, LCSW,
has developed a nice question that addresses this issue.
Tip
When trying to focus a client on his or her role in the creation of specific problems or difficult situations (such as substance abuse or parenting problems),
I find that the following question is often gentle and effective: If you could
turn the clock back to any one point in time, what would you do differently?
Clinical Caveat
This question is simple and sensitive. It is very different in tone from asking,
What did you do wrong? because it allows the client to distance from the
behavior by taking the lead in supplying some different approaches. A variant
of the miracle question from solution-focused interviewing (see the article by
Michael Cheng in this issue of Psychiatric Clinics of North America) also can be
effective: If by some miracle, one thing you did in the past could be turned
back, what would you choose it to be?
INTERVIEWING TIP #7: HELPING PATIENTS
WHO HAVE AIDS COPE WITH DEMORALIZATION
For patients who have AIDS every day presents a multitude of difficult situations, all of which can lead to demoralization and/or depression. One demoralizing topic that does not always receive the attention it deserves is the huge
psychologic hurdle of having to take 14 or 15 pills three or four times a day.
Some of these pills are so large that many patients must, literally, gag them
down. In addition, for some patients who have AIDS the pills come not to
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SHEA
symbolize that they are beating their disease but serve as reminders that they
are diseased.
Along these lines, Ed Hamaty, DO, who has specialized in helping patients
who have AIDS, offered the following tip in a recent workshop on improving
medication interest.
Tip
As the pills become more and more problematic, patients begin to anticipate the
unpleasantness of the upcoming pill taking. In essence, they begin to play
a tape that sounds something like, Oh God, not this again, or I cant
take this anymore. By working with the patient to come up with a concrete
affirmation to say to themselves as they take their medications, this tape
can be rerecorded into something much more comforting and inspiring.
For example, a patient who has a powerful desire to continue to live to be
there for his or her grandchild may repeat the affirmation, This is for my
grandchild.
For a patient who gains a sense of satisfaction from battling back the AIDS
virus, the following simple affirmation Take that! may function almost like
a personal act of releasing defiance.
Each aphorism must be generated by the patient and have unique meaning
to the patient. For instance, a patient suffering from intractable pain, may say to
the pain as he or she takes his pain medication, Not today you wont.
Clinical Caveat
These are great tips from Dr. Hamaty, and the range of affirmations is limited
only by the imagination and unique qualities of each patient. In essence, the
range is essentially limitless.
I am finding these techniques to be very effective with certain patients dealing with psychiatric disorders. For instance, many of my younger patients who
have obsessive-compulsive disorder (OCD) find it re-affirming to say something like, This one is for you, OCD; Im gonna kick your butt today.
Such affirmations externalize the disease so that the patient does not view himself or herself as the problem. They also help the patient to focus attention on
his or her ability to control the OCD symptoms, frequently using cognitive behavioral therapy techniques as well.
INTERVIEWING TIP #8: A FAMILY THAT TAKES MEDS
TOGETHER STAYS TOGETHER
With young patients, the idea that they have been singled out as needing medications can be stigmatizing and hard to process in a healthy manner. The following insightful tip by Rory Sellmer, a fourth-year resident in psychiatry at the
University of Calgary, can be quite creative and effective in diminishing this
problem.
225
Tip
I encourage families to take their medications together to normalize the experience. This technique seems to work particularly well with young patients
who have psychosis. For example, I might ask, What would it be like for
you if you were to take your antipsychotic medications every night at the
same time your Mom is taking her blood pressure medication?
Parents also can be encouraged to make this a time to check in with
symptoms.
Clinical Caveat
Dr. Sellmer first shared this tip with me when I was presenting a workshop in
Calgary. It is a delightful way to normalize taking medications, and it can be
used frequently, because many parents take some type of medication. It helps
the family members view their illnesses, not themselves, as the problem, emphasizing that the family is working together against the illnesses with which
they all are coping. In addition, it sometimes may be useful to turn to the adolescent patient and say, You know, its also a great time for you to ask your
Mom how things are going with her heart problems. This comment further
cements the shared reality that it is us against our illnesses, not us against
each other.
CONCLUDING COMMENTS
I hope that you have enjoyed reading these interviewing tips as much as I have
enjoyed posting them as the Interviewing Tip of the Month. I encourage you
to visit the Website and see the other tips in the archive. I would also love to
receive some tips from you for posting. To me, this type of Web community
and Web sharing is exactly what the Internet was designed to do. Now lets
take a look at some of the tips that our master clinicians have provided us.
References
[1] Shea SC. Training Institute for Suicide Assessment and Clinical Interviewing (TISA). Available
at: www.suicideassessment.com. Accessed on March 21, 2007.
PSYCHIATRIC CLINICS
OF NORTH AMERICA
My Favorite Tips for Detecting

Malingering and Violence Risk
Phillip J. Resnick, MD
Department of Psychiatry, Case Western Reserve, 11100 Euclid Avenue,
Cleveland, OH 44106, USA
INTERVIEWING TIP #1: DETAILED SYMPTOM INQUIRY

The Problem
A criminal defendant may malinger psychiatric symptoms to avoid criminal
responsibility. The ability to detect malingering in a clinical interview is a challenge for even experienced clinicians. One easy symptom to malinger is hallucinations. There are few objective signs that indicate a person is genuinely
hearing a voice. For criminal defendants seeking to fake an insanity defense,
a common ploy is to allege a hallucinatory command to carry out a crime.
The Solution
The detailed symptom inquiry is a useful technique to unmask the malingerer
[1]. The naive malingerer is likely to overstate his or her symptoms based on
portrayals of mentally ill persons seen in movies and television. All malingerers
are actors portraying a part, but most malingerers do not know the subtle aspects of the phenomenology of psychiatric symptoms. The interviewer should
begin with a broad inquiry asking the evaluee to tell all the details he or she can
about the onset, course, and evolution of each alleged symptom.
I will illustrate the techniques with the symptom of auditory hallucinations.
After the evaluee has described his or her hallucinations fully, inquiry should
be made about specific details: for example, whether the voice comes from inside or outside the head; the clarity of the voices; whether the voices converse
with each other; whether the voices ever ask questions; the frequency of the
voices; whether voices instruct the evaluee to do things, and if so, whether
the evaluee feels compelled to obey the command hallucinations.
The subjects answers then can be compared with what is known about genuine auditory hallucinations. For example, 66% to 88% of patients report that
their voices come from outside their head; only 7% of auditory hallucinations
are vague or inaudible [2]. Genuine auditory hallucinations are intermittent
rather than continuous. One third of patients who have hallucinations report
E-mail address: phillip.resnick@cwru.edu
doi:10.1016/j.psc.2007.01.007

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RESNICK
having command hallucinations; the majority of persons who have command

hallucinations do not always obey them [3].
One third of patients who have hallucinations report that voices ask them
questions. If the evaluee states that he hears questions, he should be asked
for examples. Genuine hallucinated questions are not information seeking
but tend to be chastising [4]. Thus, genuine voices are likely to say such things
as, Why havent you written your essay? rather than, What time is it? or
How is the weather? Questions the interviewer can ask are:
1. Tell me exactly what the voices say.
2. Are the voices continuous, or do they come and go?
3. Do you always feel compelled to carry out the instructions of the voices?
Clinical Caveat
The interviewer should not formulate the question as, Is the evaluee malingering or genuinely ill? but instead, whether or not the evaluee has a genuine
mental illness, Is the evaluee malingering specific psychiatric symptoms? Persons who have experienced true hallucinations may still make up a hallucination
to escape criminal responsibility. These malingerers are more difficult to detect
because they can rely on their own past genuine hallucinations to answer detailed questions.
INTERVIEWING TIP #2: ENDORSEMENT OF BOGUS
SYMPTOMS
The Problem
Although most persons going to clinicians for therapy are honest in describing
symptoms, some patients malinger symptoms to gain unjust financial benefits.
An easy illness for civil litigants to fake is posttraumatic stress disorder because
virtually all of the symptoms are subjective. Another common arena is the evaluation of an alleged psychosis when interviewees are attempting to gain inappropriate eligibility for Social Security Disability.
The Solution
The examiner can ask a suspected malingerer whether he has had rare or improbable symptoms. For example, a patient may be asked whether he has ever
believed that automobiles were members of organized religion. Such questions
must be asked in the context of other questions exploring psychotic ideas so
they do not stand out as unrealistic. Some psychologic tests for malingering apply formal scoring measures to endorsing rare or improbable symptoms. The
best-validated of these tests is the Structured Interview of Reported Symptoms
[5].
A variation of this technique is to mention to another clinician, within earshot of a suspected malingerer, that a particular symptom is missing that
would clinch a psychiatric diagnosis. If the patient then volunteers that
TIPS FOR DETECTING MALINGERING AND VIOLENCE RISK
229
symptom, it provides evidence of likely malingering. Questions the interviewer can ask are:
1. When people talk to you, do you see the words they speak spelled out?
2. When you have posttraumatic stress disorder flashbacks do they occur in black
and white?
3. Do you find when you are severely depressed that your thoughts speed up?
Clinical Caveat
Evaluees who are mildly retarded or particularly suggestible might endorse
rare or improbable symptoms to please the examiner. When unusual symptoms are endorsed, the clinician must integrate this finding with other data before concluding that an individual is malingering.
It sometimes is worthwhile to confront a suspected malingerer with doubts
about his or her symptoms. The confrontation should not be done until the examiner has obtained all the information possible from the evaluee. When confronting a suspected malingerer, it is critical to allow the evaluee to save face.
INTERVIEW TIP #3: CONFRONTATION WITH A PARANOID
PERSECUTOR
The Problem
Persons who have paranoid psychotic disorders present a special risk of committing severe violence against their persecutors in misperceived self-defense.
Accurate assessment of homicidal risk in paranoid patients is important to determine if hospitalization is indicated.
The Solution
In addition to inquiring broadly about whether a paranoid person has homicidal ideas, it is effective to confront such individuals with their own specific
paranoid persecutor in a hypothetical question. For example, if a patient reports that he is intensely fearful because the Mafia has been following him
and trying to kill him, the interviewer might inquire, Mr. Jones, if you were
to see an individual walking toward you in an alley who was dressed like a Mafia hit man, and he had a bulge in his jacket, how would you respond? One
patient might say that he would not do anything because the Mafia has so
much power that they could kill him easily if they chose to. A second patient
might say that as soon as the Mafia hit man came within range, he would
take out his .357 magnum and blow his head off. If these patients were asked
simply whether they had any thoughts of killing anyone, both might honestly
answer no. They have however, different thresholds for killing in misperceived
self-defense.
Clinical Caveat
Paranoid psychotic patients are often suspicious of clinicians. Patients who are
fearful of being committed may be unwilling to provide truthful answers if they
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RESNICK
anticipate that such answers will lead to loss of their freedom. Thus, rapport
should be established before initiating a question about what the paranoid
psychotic patient would do when meeting a persecutor.
STRATEGIC TIPS AND ILLUSTRATIVE DIALOGUE
The clinician in the following reconstructed dialogue has been asked to evaluate a man who killed his mother. The defendant has had four psychiatric hospitalizations and many years of outpatient therapy for chronic undifferentiated
schizophrenia and cocaine dependence. This dialogue illustrates both the
detailed symptom inquiry and endorsement of bogus symptoms techniques
of detecting malingering.
Clinician: Tell me what led up to the killing of your mother?
Patient: I was off my medication for 2 months because I couldnt afford it.
I started hearing Gods voice telling me I should kill my mother.
Clinician: Tell me about the voice. (detailed symptom inquiry)
Patient: It was a deep voice continuously from morning until night that said, Kill
your mother because she is a demon. (Genuine voices are intermittent, not
continuous.)
Clinician: Tell me more about the voice. (detailed symptom inquiry)
Patient: Ive heard voices for 20 years. They tell me to do things, and I have to
do them.
Clinician: Have you ever disobeyed the voices?
Patient: No, I always have to obey them. (unusual response: patients rarely
always obey their command hallucinations)
Clinician: What happens if you dont obey them?
Patient: They just keep yelling at me until I do what they say.
Clinician: When is the first time you heard Gods voice?
Patient: Ive heard it for 10 years.
Clinician: Your psychiatric records indicate that you reported no hallucinations
since you have been on medication for the last 4 years. Before that, you
always reported that your voices were of your dead father.
Patient: I didnt tell my doctor about the voices lately because I didnt want him
to increase my medication.
Clinician: Do voices ever ask you any questions? (detailed symptom inquiry)
Patient: Yes they do.
Clinician: Give me an example.
Patient: God asked me the number of people who attended my church last Sunday. (atypical hallucinated question)
Clinician: Has God ever told you that you were going to succeed him as King of
the universe? (improbable symptom)
Patient. Yea. He said that. He said a lot of stuff to me.
Clinician: Has God ever told you that you should lie on the floor and tremble
when he speaks to you? (improbable symptom)
Patient: Yes. I always lie down when He talks to me.
Clinician: Did you have any other reason to harm your mother?
Patient: No, I loved my mother.
TIPS FOR DETECTING MALINGERING AND VIOLENCE RISK
231
Clinician: Your neighbor told the police that before you stabbed your mother,
she heard you arguing with her because she refused to give you $100
from your Social Security check to buy drugs (confrontation of inconsistency).
Patient: That neighbor is a busybody and a liar.
Clinician: I know that you have schizophrenia, but the voice of God you are describing now does not conform to what we know about genuine hallucinations. I dont want to write a report to the judge suggesting that you are
not being completely honest with me. Could you tell me what else actually
led to the death of your mother?
Patient: Well I didnt really hear the voice of God that day, but my mother had it
coming. Shes been treating me like a child and stealing my Social Security
money.
In this dialogue the patient has the advantage of having experienced genuine
hallucinations, so he can answer some detailed questions accurately, but he
does endorse bogus symptoms. Furthermore, witness statements and past psychiatric records are inconsistent with the story he is telling. The dialogue also
illustrates a face-saving confrontation with the defendant about inconsistencies
that result in a confession about faking Gods voice.
The next reconstructed interview illustrates the technique of confrontation
with a paranoid persecutor.
Clinician: Tell me whats troubling you.
Patient: I know that my wife is poisoning me. She and our mail carrier are getting it on and they want me out of the way.
Clinician: How do you know that this is going on?
Patient: My food has been tasting funny, so I know she is trying to poison me.
The postman also looks at me with murder in his eyes.
Clinician: Do you have any other evidence?
Patient: I can just tell by looking at her. She has also had less interest in having
sex with me.
Clinician: Have you taken any steps to try to resolve this?
Patient: I went to the police, but my wife denied it, and they say I have no real
evidence. I started carrying a gun for protection.
Clinician: What would you do if you were sitting on your porch and the mailman walked up to you and started to take something out of his mailbag?
Patient: I would have to shoot him in self-defense because I know he and my
wife are getting impatient because I am not dying fast enough from the
poison.
This dialogue illustrates that the paranoid patient has sought a nonviolent
remedy by going to the police to no avail. By learning that the patient would
make a pre-emptive strike if the letter carrier approached him directly, the clinician confirms the need to hospitalize the patient.
I have found these three interviewing tips helpful in my treatment practice in
addition to forensic evaluations. Although they are useful, no single piece of
evidence should cause an interviewer to label someone a malingerer or to conclude that a patient belongs in the hospital.
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RESNICK
References
[1] Resnick PJ, Knoll J. Faking it: how to detect malingered psychosis. Current Psychiatry 2005;4:
1325.
[2] Goodwin DW, Alderson P, Rosenthal R. Clinical significance of hallucinations in psychiatric
disorders. A study of ll6 hallucinatory patients. Arch Gen Psychiatry 1971;24:7680.
[3] Junginger J. Command hallucinations and the prediction of dangerousness. Psychiatr Serv
1995;46:9114.
[4] Leudar I, Thomas P, McNally D, et al. What voices can do with words: pragmatics of verbal
hallucinations. Psychol Med 1997;27:88598.
[5] Rogers R, Bagby RM, Dickens SE. Structured interview of reported symptoms (SIRS) and
professional manual. Odessa (FL): Psychological Assessment Resources; 1992.
PSYCHIATRIC CLINICS
OF NORTH AMERICA
My Favorite Tips for Sorting Out

Diagnostic Quandaries with Bipolar
Disorder and Adult Attention-Deficit
Hyperactivity Disorder
Daniel J. Carlat, MD*
Tufts University School of Medicine, Boston, MA, USA
ome diagnoses, such as major depression and obsessive-compulsive disorder, are fairly easy to make. When patients give histories clearly consistent with the Diagnostic and Statistic Manual of Mental Disorders, fourth
edition text revised (DSM-IV-TR) criteria, the diagnostic tasks are easy, and one
can move quickly to issues of treatment. As primary care doctors become increasingly comfortable treating basic psychiatric disorders, however, more of
psychiatrists patients are complicated. They do not always fit easily into the
neat diagnostic schema that psychiatrists depend on.
This article focuses on two disorders that frequently cause diagnostic quandaries: bipolar disorder and adult attention-deficit hyperactivity disorder
(ADHD). But first, here are two suggestions for how to get at the truth of
any diagnosis quickly when things are not straightforward:
1. Insist on obtaining past records before the first appointment. True, the patients
last psychiatrist may have gotten it all wrong, but at least the record will give
a quick sense of the diagnostic thinking that has trailed this patient and will provide diagnostic clues based on medications that have been prescribed.
2. Ask the patient for his or her diagnosis. This request can be made at the beginning, end, or somewhere in the middle of the interview. I often find it helpful to come right out and ask patients, Has anyone ever told you what your
diagnosis is? or So, what do you think your diagnosis (or problem) is?
One patient told me that he once had been diagnosed with trichotillomanianot a diagnosis that I would have embarked upon aggressively without
this information.
A reader looking for an extensive exploration of interviewing tips related to

all psychiatric disorders, may find my book useful, The Psychiatric Interview, A
Practical Guide, 2nd Edition [1].
*Corresponding author. E-mail address: drcarlat@comcast.net

doi:10.1016/j.psc.2007.02.008

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CARLAT
INTERVIEWING TIP # 1: TAKE NOTHING FOR GRANTED

IN BIPOLAR DISORDER
The Problem
Because most patients who have bipolar disorder present initially with depression, the search for mania often involves a fair amount of digging into the history. And because so many of the symptoms of mania are nonspecific,
a common pitfall is to conclude falsely that a given symptom is evidence of mania, leading to the overdiagnosis of bipolar disorder.
The Solution
Begin by asking broad screening questions and then focus in on specific DSMIV-TR criteria with questions that can differentiate depressive and anxiety
symptoms from true symptoms of mania. The following case illustrates specific
examples of such questions.
Case
A 45-year-old married father of three presented with a chief complaint of: Im
all stressed out. He worked as a construction foreman and said his workers
were driving him crazy. He felt that he had been yelling at his employees
excessively. In addition, his wife had been complaining that he was losing
his temper with the children too much. One week before the interview, he
had returned from a 2-week trip to Asia alone. This was his first trip abroad.
He had left without telling his wife, simply buying himself a ticket to Hong
Kong.
Initially, the differential diagnosis would include bipolar disorder, anxiety
disorders, depressive disorders, and substance abuse. Of these, most clinicians
would dwell on the possibility of bipolar disorder, because the patients impulsive trip to Asia sounds like the behavior of a patient experiencing a manic
episode.
A good way to begin the search for mania is to ask a high-yield screening
question. Here are some examples I have found useful:
1. Have you ever had a period of time when you felt like your mood and energy
were high and your thoughts were going quickly?
2. Did you ever go through a time when you felt too energetic and happy, so
that friends commented that you were talking too fast or behaving strangely?
3. Has there ever been a time when you felt just the opposite of depressed, so
that for a week or so you felt as if you were on an adrenaline high and could
conquer the world?
These questions are good at assessing classic, euphoric mania, but many bipolar patients experience irritability as their primary mood-state during a manic
episode. This manifestation is the bane of all interviewers, because irritability is
an incredibly nonspecific symptom and is present in depression, anxiety disorders, psychosis, substance abuse, and just about every other entity in the DSMIV-TR.
TIPS FOR SORTING OUT DIAGNOSTIC QUANDARIES
235
To understand how to assess manic irritability, it is helpful to recall how

manic patients get irritable. Often, the irritability is driven by a sense of impatience with other peoples limitations. This impatience, in turn, generally
is the result of a combination of grandiosity, excessive energy, and racing
thoughts.
Here are a couple of good questions for assessing for the presence of irritable
mania:
1. Have you had episodes when you felt that you could think so much more
clearly than other people that you became annoyed with them and felt
they were getting in your way?
2. Have you had times when you believed that you were superior and more
capable than others and got into arguments with people because they
were holding you back?
Going back to this patient, here is how the first part of the interview went:
Interviewer: Did you ever go through a time when you felt too energetic and
happy, so that friends commented that you were talking too fast or behaving
strangely?
Patient: I wouldnt say happy, but I do get revved up.
Interviewer: What do you mean by revved up?
Patient: I get a lot of energy, and I can get things done. Mainly at work. But
thats when I get stressed out, because theres always too much to do.
Interviewer: Do you enjoy that energy?
Patient: Not really. Its just there; its my personality. Ive always been hyper.
This exchange begins to lead away from mania, because although the patient
feels hyper and revved up, he indicates that these are relatively stable
personality traits. What about irritable mania?
Interviewer: Earlier, you said that youve been yelling at your coworkers and
your family. Why are you yelling at these people so much?
Patient: At work, its mainly when the guys screw up. Its just normal stuff, theyre
not bad guys, but when I get overworked, I yell. And when I come home from
work, Im tired, I want some peace and quiet, but my kids are monsters.
Thats when I yell at them.
The engine of his irritability is not grandiosity and excessive energy, but
rather stress and fatigue. So far, the interview is not particularly supportive
of bipolar disorder. But what about his impulsive trip to Asia?
Interviewer: How did you decide to go on this trip?
Patient: It was kind of weird, but one Friday, I went to a travel agent and got
a round-trip ticket to Hong Kong. That night, I just packed my bags and left.
Interviewer: What was going through your mind?
Patient: That I was fed up with everyone and everything, and I needed to escape.
Interviewer: Did you tell anyone?
Patient: I told my boss I needed a vacation. Thats it.
Interviewer: You didnt tell your family?
CARLAT
236
Patient: Nope. I just left (looks a little embarrassed).

Interviewer: So you just didnt show up at home on a Friday night, leaving your
family no idea of your whereabouts?
Patient: No, actually, I told a couple of other friends what I was doing, and I
knew they would tell my wife. I didnt want her to be worried. In retrospect,
that was pretty irresponsible, I mean I should have talked it over with her
myself first. I realize that now.
Interviewer: And what did you do while you were in Asia?
Patient: I was a tourist. I saw the sights. I relaxed. I slept a lot.
Interviewer: Did you spend a lot of money?
Patient: I spent a fair amount on the ticket, but once I was there, I didnt spend
much. I stayed in pretty cheap hotels.
Interviewer: Did you do much carousing, drinking, meeting women?
Patient: No, I kept pretty much to myself. And it actually did me good to get
away, although I had hell to pay with my wife when I got back!
Again, the story is not very impressive for a manic episode. Although the decision to go to Asia was impulsive and dramatic and fairly screams mania,
with open-minded exploration it seems to be a poorly adaptive response to
overwhelming stress. Ultimately, this patient was diagnosed with mild major
depression along with an adjustment disorder with anxious and depressed
mood.
INTERVIEWING TIP # 2: DISTRACTIBILITY IS NOT ALWAYS
ATTENTION-DEFICIT HYPERACTIVITY DISORDER
The Problem
Increasing numbers of people are presenting with the symptom of distractibility
and requesting an evaluation for ADHD. Unfortunately, distractibility is a particularly nonspecific symptom that can appear in several other psychiatric
disorders.
On one hand spotting undetected ADHD in an adult can be very rewarding.
Such patients frequently have extremely low self-esteem and may be viewed as
underachievers by both themselves and others. Comorbid depression is common. Treatment can be literally life changing, and, sometimes, life saving if
a suicide is prevented.
On the other hand, most people presenting with poor concentration and distractibility do not have adult ADHD. In such instances, an inaccurate diagnosis
of ADHD can be quite damaging, because the true underlying diagnosis (eg,
major depression, generalized anxiety disorder, substance abuse) will go
untreated.
The Solution
Assess the cause of the distractibility carefully.
Case
A 40-year-old woman, who originally had presented with anxiety and depression, came into the office one day and said, I was talking to my sister this
TIPS FOR SORTING OUT DIAGNOSTIC QUANDARIES
237
morning, and she said that Im definitely ADD. She says she just started treatment for it, and its helping her. What do you think?
Generally, with such patients the confounding causes of poor concentration
and distractibility fall into two common categories: depression and anxiety, and
usually both.
The DSM-IV-TR demands that the psychiatrist establish that there were
symptoms of ADHD in childhood before an adult can be eligible for the diagnosis, but frequently it is hard to establish this retrospective diagnosis reliably.
Nonetheless, the patient who reports absolutely no problems with schoolwork
or focus as a child is highly unlikely to have ADHD as an adult.
Here are two fishing questions that are often answered positively by patients who have true undetected adult ADHD and that may suggest that further
ADHD questioning is indicated:
1. When you were a child and adolescent, did you find that it was often a family joke or insiders joke, among your friends, that you were the nutty
professor?
People who have severe ADHD (because they are so forgetful, distractible,
and late for things) often seem somewhat zany to their friends and frequently
are the brunt of much ribbing on such matters.
2. When you were going to school, was it common for you to get into trouble
for forgetting things like your books, pencils, or homework?
Children who have ADHD usually are rushing out the door to school because they are late, and they frequently forget important items at home. Most
adults who have ADHD will recall such painful moments of forgetfulness.
Patients, who present as in the case history given previously, however, are
often hard to diagnose because their childhood reporting is vague. Most people
who had trouble with school did not have ADHD. Moreover, they may even
have had some behavioral problemsonce again not caused by ADHD. Such
self-diagnosed patients, when asked if they were ever treated with stimulants,
often say no but follow with a quick addendum, But they didnt give out
much Ritalin in those days.
I have found in these cases that the most efficient approach in ruling out
ADHD is to start by focusing on depressive and anxiety symptoms. Once those
symptoms are fleshed out, one can ask questions such as:
1. When youre feeling good, not anxious or depressed, do you still have significant problems with focus and concentration?
2. When your anxiety goes away, are you able to sit down for an hour and enjoy a book?
Patients who report that their concentration normalizes when their emotional state improves generally do not have ADHD.
238
CARLAT
It also is helpful to ask patients why they cannot concentrate. Those who
have ADHD often respond with, I dont know why, I just know that I
cant focus on any one thing without making a real effort. In contrast, patients
who have distractibility secondary to another diagnosis often respond with
something like, Once I start thinking about all my problems, I cant focus
on what Im trying to do.
Some frustrated clinicians just throw up their hands and use a stimulant trial
as a form of diagnostic testing. I believe this tactic is not a good idea, partly because even normal people report doing better on stimulants, and also because
patients who have primary anxiety may worsen, and even develop paranoia,
when taking stimulants.
Ultimately, each patient who enters the psychiatrists office is unique and difficult to diagnose in his or her own way. The best tip for diagnosing difficult-todiagnose patients is to listen carefully, take time, and avoid prematurely assuming that one has nailed the correct diagnosis. If we interview with these points
in mind, our patients will feel understood, know that we care, and, undoubtedly respond more positively to whatever treatment recommendations we
ultimately offer.
Reference
PSYCHIATRIC CLINICS
OF NORTH AMERICA
My Favorite Tips for Exploring Difficult

Topics Such as Delusions and Substance
Abuse
David J. Robinson, MD, FRCPC, FAPAa,b
a
Department of Psychiatry, London Health Sciences Center South Street Hospital,

375 South Street, London, Ontario, Canada N6A 4G5
b
University of Western Ontario, London, Ontario, Canada
INTERVIEWING TIP #1: GREASING THE WHEELS

FOR EXPLORING DELUSIONS
The Problem
It can at times be difficult for patients to discuss their delusional thoughts freely.
The reasons for their hesitancy are usually understandable: fear of being
viewed as being seriously mentally ill, fear of being hospitalized, or difficulty
discussing an emotionally painful situation [1]. At other times, reasons for concealing delusional ideas are illogical or tied to a psychotic thought process, such
as auditory command hallucinations that might be telling a patient not to speak
with the clinician. Sometimes the patient may even think that the clinician
actually is part of a plot or a conspiracy.
The Solution
When patients mention something that could be of a delusional nature, respond with curiosity. An interested, conversational manner helps to elicit detailed information because patients who harbor delusions are generally so
immersed in them that the delusions occupy the majority of their thoughts.
Your approach is threefold: (1) to grease the wheels so that the patient feels
comfortable sharing information, (2) to uncover the extent and logic of the delusional material; and (3) to determine the degree to which the delusion has become entrenched in the patients thoughts (ie, determine how much insight is
preserved or how much distance the patient has from the delusion). Examples
include:
1.
2.
3.
4.
Im interested in what you just said; please tell me more. (greasing the wheels)
How did this all start? (greasing the wheels)
What has happened so far? (uncovering the extent and logic)
Why would someone want to do this to you? (uncovering the extent and
logic)
E-mail address: dave.robinson@ody.ca

doi:10.1016/j.psc.2007.01.008

ROBINSON
240
5. How do you know that this is the situation? (determining distance)

6. How do you account for what has taken place? (determining distance)
Clinical Caveat
Regardless of an interviewers skill, delusional thoughts cannot always be elicited. Patients who have some awareness that others do not share their ideas
(preserved insight) or who have been hospitalized previously because they discussed their delusions may choose to conceal their thoughts.
Remember also that if paranoid delusions are present, you must find out if
the patient has any thoughts of hurting someone. Questions such as Do you
feel a need to protect yourself against [person in question]? and Have you
felt a need to possibly take action against [person in question] or harm [person
in question]? are essential avenues to pursue.
Illustrative Dialogue
Clinician: Some people find that, when they experience [insert appropriate
symptom, such as depression or anxiety, based on the patients story so
far], their thinking patterns become different. Has this ever happened to you?
Patient: I feel like I cant really think straight and solve everyday problems like
I used to, if thats what you mean.
Clinician: Do you have thoughts that you focus on a lot of the time and feel
strongly about? (looking for overvalued ideas or delusions)
Patient: I dont understand what you mean.
Clinician: I am asking about ideas that you have that perhaps those around you
dont share or agree with, but you know to be true and are puzzled why
others may not seem to be convinced and might even argue with you about
them.
Patient: I have an infestation with a parasite and asked my family doctor to help
me out. Initially she tried, but then seemed to give up and I couldnt understand why, so Ive spent a lot of time looking for a nonprescription treatment.
Clinician: Thats interesting. How did this start? (greasing the wheels)
Patient: I stepped on a nail about 3 months ago and got an infection. As part of
the treatment, I had to soak my foot a couple of times a day. On one occasion, a spider fell into the tub, and you know how dirty those things are.
Well, before I could get it out, the water got infected with parasites that
the spider was carrying.
Clinician: What happened after that? (uncovering the extent and logic)
Patient: Well, the parasites got into my foot because of the wound and then immediately spread throughout my body causing a variety of physical problems. I havent been well since that very moment.
Clinician: How do you know that this is the cause of your physical problems?
(determining distance)
Patient: Internet research. But before I continue, I need to ask you something?
Clinician: Whats that?
Patient: Do you believe me?
DELUSIONS AND SUBSTANCE ABUSE
241
INTERVIEWING TIP #2: HANDLING THE QUESTION DO YOU

BELIEVE ME? WITH A DELUSIONAL PATIENT
The Problem
A major concern of many patients when first sharing a delusion, as in an emergency room setting, is that they will be viewed as being seriously mentally ill.
This fear is a natural one for a person experiencing a delusion and to some degree may indicate that the patient has some distance from the delusional material. How the clinician handles this delicate moment may prove to be pivotal to
the relationship and determine how much more material the patient will be
willing to share. Clinicians do not want to be deceptive, but they need to develop enough of an alliance with patients to hear more about their thoughts.
The Solution
In such situations, you should continue to empathize actively with the patient
to preserve rapport and to facilitate the sharing of more information. In addition, you should tactfully avoid being the arbiter of reality and telling the patient whether or not you agree with the patient (or whether or not you think
the patient is right) [2]. Examples include statements such as:
1.
2.
3.
4.
Im keeping an open mind.

I cant decide without more information.
My job is to understand what your views are.
The story is an unusual one, so I really want to hear more before making a decision; tell me about . . . [refer patient back into an affectively charged detail
from the story].
Clinical Caveat
There is seldom a situation in which you would agree openly with a patients
delusional thoughts (eg, saying something like, Of course I believe you.).
Such false endorsements can undermine a therapeutic alliance and also come
back to haunt the clinician later in the interview when the patient asks the clinician to follow through on the endorsement with, Youll call the police for
me, then?
As with all principles, there are exceptions in which the clinician may need to
endorse a delusion temporarily, but these are very rare. Such a situation could
arise when the clinician believes that the patient might become violent toward
him or her if the clinician does not agree immediately with what the patient is
saying.
Patient: Do you believe me?
Clinician: I think I can understand why after such an upsetting ordeal that you
would wonder if other people believed you. (actively empathizing)
Patient: This has been a real struggle for me. At first there was a lot of concern
expressed on my behalf, but as the infestation proved untreatable, people
started to voice their disbelief.
242
ROBINSON
Clinician: When did people start becoming less supportive? (actively

empathizing)
Patient: After my GP told my family that I didnt actually have any parasites
inside of me.
Clinician: What do you think about her saying this to your family?
Patient: It made me very frustrated. I still have the infection, and she not only
doesnt believe me, but she cant treat it and now tells my family that it
doesnt exist.
Clinician: How is it that this infestation is untreatable for you?
Patient: So you agree that it is untreatable?
Clinician: I dont really know what to think at this point. It is more important that I
get a clear understanding of what has happened to you before I come to any
conclusions.
Patient: But you have access to all of my records; why cant you make a decision
right now?
Clinician: I do have access to your records and have read them, but I prefer to
ask you about the situation myself instead of reading someone elses notes.
Lets go back to what you believe makes this infestation untreatable.
Patient: Why wont you answer my question?
Clinician: Well, the story is an unusual one, so I really want to hear more before
making a decision. Tell me some more about exactly what happened after
the spider fell into the bathtub.
INTERVIEWING TIP #3: OBTAINING A MORE ACCURATE

SUBSTANCE ABUSE HISTORY
The Problem
Substance use disorders are common in psychiatric populations and have expanded to the point where they may well be considered the rule rather than
the exception. Patients often are reluctant to admit to clinicians that they use
substances in a nonprescribed fashion, fearing repercussions such as being lectured or having the information included on their medical records. Denial and
rationalization, the two most common defenses used by patients who have substance use disorders, only serves to further obfuscate a reliable history.
The Solution
A strategy to elicit a more accurate substance use history starts with waiting until at least half way through the interview to begin this inquiry. This way, the
clinician has started to develop some rapport with the patient and, one hopes, is
seen as trustworthy with sensitive information. An ideal time to begin taking
a substance use history comes after taking the medical history. One can start
by asking about legal substance use involving nicotine, caffeine, and alcohol.
The use of a structured set of questions (eg, first use, most recent use, amount,
effect, and factors perpetuating use) avoids seeming to place added emphasis on
illicit or nonprescribed substances. An example is the statement, Mr. Thompson, many of the patients that I treat did some experimenting with street drugs
DELUSIONS AND SUBSTANCE ABUSE
243
when they were younger. Often they started with [insert drug here based on
patients history] and then got curious about some others. Because it is vital
that I understand your medical health as completely as possible, Id like to
ask what your experience has been with various substances. For starters, did
you ever try pot when you were in high school?
Clinical Caveat
The Diagnostic and Statistical Manual of Mental Disorders, 4th edition revised [3]
specifies 11 different categories of substances (not including polysubstance
use or other), and it is worthwhile to ask specifically about as many as possible instead of relying on patients to be forthcoming about every experience
that theyve had. Some patients make a distinction between taking street drugs
and misusing prescription medication, viewing the latter as less significant or
tacitly sanctioned by their doctors. Also, substances such as inhalants may
not be viewed as drugs by some patients. For substances that have parenteral
routes of administration, a history of injection becomes vital to help determine
the persons risk of being exposed to HIV or a type of hepatitis.
Clinician: Mr. Jones, now that we are finishing up your medical history, Id like
to ask about your use of tobacco, alcohol, and caffeine.
Patient: I dont smoke and never did. I drink about five cups of coffee in an average day, but not after dinner because it keeps me from falling asleep. I am
a social drinker and usually have wine with dinner on weekends with my
friends.
Clinician: Did you ever go through a time where you were struggling with something and found that you were drinking a little more wine to help you cope?
Patient: Yes, I did do that for a while until my wife pointed it out, and I thought
that I should ask my doctor about ways to relieve stress. He prescribed a medication for me and told me to stop drinking alcohol.
Clinician: It is very natural for people who are struggling with psychologic stress
to try to find something that they can use to help cope better. Did you find that
this medication made a difference for you?
Patient: It sure did. It was prescribed to me a few times a day, but I found that
when things got really bad, I needed to take it more often than that. It was
like a wonder pill for the first few weeks.
Clinician: Sometimes people feel so desperate that they will do just about anything to help themselves feel better. At those times others may not understand
or approve, because they just dont know how bad it feels. Did you ever turn
to something other than what you have mentioned to help boost your mood?
Patient: I kept hearing about the medicinal effects of marijuana and how it helps
some people. I tried that a few times, but it didnt help me.
Clinician: What else did you try? (leading question to help normalize the fact
that there may have been others substances used)
Patient: I started to take my sons ADHD medication. It was a real boost for
a while, but then I had to get the refills early and knew that I was going to
ROBINSON
244
run out of excuses about why the pills werent lasting him the length of his
prescription.
Clinician: Did you ever get to the point where you were taking street drugs or
anything else to help change the way you were feeling?
Patient: No, at that point, I realized I needed help and came here.
SUMMARY
I hope that these techniques will prove valuable to you in your daily practice. I
also hope that the reader will see ways of generalizing these techniques to other
situations in which it may be difficult to engage a patient or to ferret out valid
information. I have found that interviewing is endlessly fascinating and that
with every patient there is something new to learn.
References
[1] Robinson DJ. Brain calipers: descriptive psychopathology and the psychiatric mental status
exam. 2nd edition. Port Huron (MI): Rapid Psychler Press; 2002.
[2] Robinson DJ. Three spheres: a psychiatric interviewing primer. Port Huron (MI): Rapid
Psychler Press; 2000.
[3] American Psychiatric Association. Diagnostic and statistical manual of mental disorders.
4th (revision) edition. Washington, DC: American Psychiatric Association; 2000.
PSYCHIATRIC CLINICS
OF NORTH AMERICA
My Favorite Tips for Engaging the

Difficult Patient on Consultation-Liaison
Psychiatry Services
David J. Knesper, MDa,b,c,*
a
Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA
Hospital and Community Psychiatry Section, University of Michigan Health System,
Ann Arbor, MI, USA
c
Psychosomatic Medicine Program, University of Michigan Health System, Ann Arbor, MI, USA
b
THE GENERAL PROBLEM OF DISENGAGEMENT

AND WORKING WITH THE DIFFICULT PATIENT
Disengagement is the main enemy for the consultation-liaison psychiatrist.
Hospital patients referred for psychiatric consultation often are disengaged. Inpatients who occupy a medical-surgical bed self-define their problems as
medical. After all, it was not their idea to be subjected to a psychiatric interview. Against this backdrop, the goal of the first interview is to transform
the unwilling, uncooperative, and often difficult and hostile patient into an engaged interview participant. Otherwise, the interview is an unproductive interrogation and an unpleasant power struggle. The three interview-engagement
tips or techniques described are among my favorite ways to overcome the impediments to engagement most often associated with difficult patients. Once
the difficult patient is engaged, the more typical psychiatric interview can
begin.
INTERVIEWING TIP #1: STAYING IN THE RING, MEDIATION,
AND DEVELOPING THE THIRD STORY
The Problem
Difficult patients are impossible to interview unless the consultation-liaison psychiatrist overcomes the patients initial hostility, anger, and sense of entitlement
and invalidation. These challenging patients interpersonal styles are characterized by one or a combination of several defensive character traits. Invalidating,
demanding, disruptive, attention-seeking, annoying, and manipulative behaviors are all too common. These patients believe that they are at the mercy of
*Department of Psychiatry, University of Michigan Medical School, UH 9D 9822, Box
0118, 1500 East Medical Center Drive, Ann Arbor, MI 48109-0118. E-mail address:
dknesper@umich.edu
doi:10.1016/j.psc.2007.01.009

246
KNESPER
an unfriendly professional staff and the likelihood that they may be reacting to
feelings of helplessness, fear, and disappointment explain behavior without offering a means to gain cooperation. How do you get started interviewing in this
situation? What do you say first?
The Solution
Any medical interview develops out of the clinicianpatient relationship. The
traditional interview relationship takes one of two forms: active-passive or guidance-cooperation [1]. Expert knowledge and explicit recommendations given to
willing and agreeable patients are attributes of both models. Although patients
often are told what to do, they seldom protest directly.
Here is a sequence of guidance-cooperation interactions: Im here to take
you to X-ray. is the hurried and insistent announcement from the transport aide. I wasnt told Im having an X-ray today. All I know is that
Ive been told to take you to X-ray. Im sort of annoyed, but, oh well,
lets get going. Perhaps the doctor who ordered the radiograph told the patient in a brief interaction that just did not register, or perhaps the doctor
simply forgot to mention this common procedure. Despite being a bit grumpy, most patients get transported to the radiology department without much
complaint.
The difficult patient will not go to the radiology department so quietly: Im
here to take you to X-ray. Who the hell are you? And which one of my
dumb-ass doctors sent you? All I know is that Im supposed to take you
to X-ray. Well, listen to me, Buster! You dont know a damn thing, and I
aint going no place until one of those lazy nurses gets her butt in here and tells
me whats going on! Such raw language and devaluation of professional staff
produces strong negative feelings. Typical rejoinders, such as, You cant speak
to people this way, are of no help. Chastising and blaming the difficult patient
for misbehavior seems only to make matters worse.
Difficult patients see the situation differently. The problem is, Nobody told
me about going to X-ray. Moreover, the difficult patient feels self-righteous
and thinks, How can I help getting angry when I get no respect? Now, all
of a sudden, the clinician is the one that is supposed to apologize! Predictably,
the difficult patient identifies differences that challenge the authority of the clinician, and difficult patients persist until the conflict is resolved in their favor.
Winning is motivational for difficult patients.
Where to begin? You introduce yourself and the expected reply is, Leave!
Your first instinct may be some combination of fear and anger. Get past it;
dont be intimidated. The first challenge after hearing Leave is to stay in
the ring and feel comfortable doing so. Your assertive position is made easier
by accepting a new role: that of a mediator; it is important to think and act like
one.
The key to mediation is found in developing what the Harvard Negotiation
Project calls the third story [2]. Regarding going to X-ray, there is the patients story, the staffs story and the third story. The patient thinks the staff is
CONSULTATION-LIAISON PSYCHIATRY SERVICES
247
disrespectful; the staff find the patient rude; the mediator uncovers the third
story: both parties could have acted with more courtesy, and both parties
would like the atmosphere to change. The third story often is invisible at first.
It is only after you understand the other two stories that the third story is developed. Staying in the ring and developing the third story are the most powerful engagement tools you have.
What might be the third story in going to X-ray? After peeling away the
difficult patients nasty behaviors, is there a legitimate complaint? I think so.
Failure to inform a patient about a medical procedure, however common
and painless, is disrespectful. Further, clinical staff is not above passive-aggressive behavior, especially if they have experienced the patients unpleasantness
on previous occasions.
Lets begin: you should picture entering the room, introducing yourself and
standing or sitting at a comfortable distance, without crowding the difficult patient. Following the inevitable instruction to Leave, try your own favorite
versions of the following replies:
1. Before I leave, why dont you and I talk frankly for a moment? [The interviewer can pull up a chair; after all, the interviewer is staying.] You and I
both know this is a difficult situation. Id like to help. I need to understand
what you think is going wrong here [patients story].
2. I know you want me to leave [but the interviewer moves a little closer anyway]. Thats exactly what Id like to do, but Im stuck because many of the
staff are afraid of you. Could you help me understand why staff is so fearful?
I dont understand it. There must be some good explanation.
3. Yes, I hear you. I know you dont want to see me, but I cannot leave until I
get enough facts to fill out this referral sheet [said while the interviewer
waves the sheet]. Maybe we could start by you telling me your experience
of the medical care youre getting [a less threatening place to begin].
Clinical Caveat
Sometimes the patient is so difficult that after you have tried some initial engagement strategies, it is necessary to take time out. I can see this is not going to work right now; Ill leave and talk to the physician in charge and come
back later. Thereafter, the referring physician may need to tell the patient
that a psychiatric evaluation is mandatory. Then, one of two things happens:
either the physician and the difficult patient have a heart-to-heart talk, with the
patient agreeing to behavioral improvement to avoid seeing a shrink, or the
patient agrees reluctantly to the psychiatric consultation. Either way, progress
is made.
INTERVIEWING TIP #2: NEGOTIATING, CONCESSION
MAKING, AND CONTROL SHARING
The Problem
The problem has not changed. After all, you have just started to develop the
third story. What other engagement skills are available?
248
KNESPER
The Solution
Difficult patients require power sharing, partnering, and mutual participation,
and these interview attributes must be the overall goals. To reach these goals,
the engagement interview is a process of clinical negotiation. This negotiation is
not about who is in charge, or authority, or the clinicians self-image. The interview model based on negotiation is described best by Lazare [3]. Of the several negotiation strategies Lazare recommends, concession making and control
sharing are central to engaging the difficult patient. The perceived absence of
control is the impediment, and patient empowerment is one means to overcome it.
Clinical personnel dislike any notion of making concessions with the difficult
patient. For the consultation-liaison psychiatrist, this situation is an opportunity
for liaison work. The fear is that concessions inevitably will undermine clinical
authority; staff may believe that discipline is what is needed and that it is important not to make exceptions to standard procedures. In this heated atmosphere, it is necessary to do some reframing. There are small concessions,
such as agreement and validation; and control sharing may involve simply giving the difficult patient some choices. Making more substantial concessions and
giving meaningful control are reframed as treatment. Generally, difficult patients have a comorbid personality disorder for which specialized therapy is required. Here are some examples of what I mean:
1. You are absolutely right [concession and validation]. Of course, there
needs to be a discussion with you about why youre going to X-ray. (control
sharing)
2. I think I understand how you see the situation and how you feel. Let me tell
you your story so Im sure I have it right. (control sharing)
3. Yes, it is true that sometimes patients are treated with less respect than any
one would like. I can understand why you were annoyed. (concessions and
validation)
4. Yes, you do have a better chemistry with some nurses than with others. I can
look into some preferential assignments. This is not what we usually do, but
we may be able to make an exception if you agree to be more welcoming
[agree to be more welcoming is positive; agree to improve your behavior is negative.]. (concessions and control sharing)
Clinical Caveat
There is every reason to make some nonstandard changes as part of an overall
agreement for improved behavior and cooperation. For example, one nurse or
doctor is identified who will spend 30 minutes each morning answering questions and addressing concerns. The patients room may need to be changed regardless of how inconvenient the change is to the staff. Generally, clinical
personnel are willing to make some accommodations if they come to believe
they can do a better job as a result, and if they can avoid subjecting themselves
to continued unpleasantness. Negotiations make explicit, however, that there
are limits to these accommodations and that they are part of an overall
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agreement. This process is simple contingency management and behavioral

therapy. Moreover, if the agreement falls apart, what is given can be taken
away easily as part of a contingency-management plan to improve behavior.
INTERVIEWING TIP 3: HONEST LIMIT SETTING
AND PLAYING SOFTBALL
The Problem
The difficult patient is demanding and behaving in ways that are unacceptable.
Health care services are being compromised. Engagement is impossible unless
these issues are addressed during the initial interview.
The Solution
Rather than engaging in tactless confrontation, the interviewer plays softball,
a negotiation strategy Lazare [3] calls empathic confrontation. The interviewer uses gentle confrontation tactics (ie, softball). Softball is a clear, assertive, but honest explanation of how and why the interviewer sees things
differently and of the limited options available to the difficult patient. The
tone is all good-natured.
It is important to be truthful and to establish credibility with the difficult patient. These patients know very well that their behaviors create anger and resentment, and there is no reason to gloss over the real attitudes of medical
professionals. Williams and Silk [4] explain that difficult patients sometimes
do not know what to do with this honest approach. The basic problem is
that the world does not work the way they want, and they are angry as hell
about it. Often having been raised in environments ruled by manipulation, exploitation, and hidden messages, difficult patients appreciate straightforwardness. Within reason, validation of their views provides them just enough
dignity to motivate both engagement and better behavior. Here are examples
of how this approach may be implemented during the initial interview:
1. Of course you are angry [validation], but when you yell and use raw language, the staff resent having to work with you. They are just human and get
upset too.
2. We cannot work in an unsafe environment. Some of the things you have
said, Im sure you know, frighten people.
3. I now understand how you see things. [The interviewer could restate the patients position.] Nevertheless, you can see how busy we are. When were in
a hurry, a standard set of procedures helps us all avoid mistakes.
Clinical Caveat
Unfortunately, many difficult patients are too sick to be transferred to another
facility. Unless the psychiatrist lies, what facility will take such a patient? The
clinician is stuck with the patient. What can you do if none of these tips work?
You must consider other possibilities. Is this patient psychotic? Is this frankly
sociopathic and criminal behavior? Criminals have an exquisite insensitivity
for the feelings of others. Under any of these circumstances it is important to
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KNESPER
make sure you are not trying to save the unsalvageable interview. Some interviews are unlikely to improve no matter how skilled the clinician may be.
When behaviors are beyond the techniques of negotiation and softball, it
may be time for hard ball. One option is to call the police for support and
for a choreographed show of strength. Harassment charges from the staff are
unlikely to be ignored.
The following dialogue and commentary illustrate one application of the overall strategy. For the duration of the interview, the clinician speaks calmly and is
unflappable.
Clinician: Hi. Im Dr. Richards. I am a psychiatrist. Im sure you are happy to
see me. (Negotiations might start with a try at paradoxical humor; the interviewer is being approachable.)
Patient: Youre just like all doctors and nurses; you have it all wrong. I am not
happy to see you! Who the hell sent you anyway? The last thing I need is
a shrink! Leave! Now!
Clinician: Alright. I know you were told that Id be stopping by. You have every
right to be angry. Since youve never met me, its impossible to believe I can
be of any help. Youre telling me youve been given more trouble than help
[validation and small concessions]. Try to tolerate my presence here for just
a little while [said while pulling up a chair] so I can explain how I can help.
Lets see if we can make the best of this. (The clinician is staying and just
introduced developing the third story.)
Patient: (hostile, glaring silencethe patient reacts to having no choice.)
Clinician: I know you are not happy to see me, but Ive been asked to see if there is
any way I can make your stay here more pleasant and if I can help you get the
best possible health care this hospital can provide. (control-sharing).
Patient: Id really rather you leave. (Silence ends; less hostility; deliberate
pause)
Clinician: Frankly, I dont know what is going on [concession, control-sharing],
but if it continues youre just not going to get the great care you deserve [softball]. So, tell me whats it been like for you in this hospital. (Curiosity about
the patients story)
Patient: OK. Now you listen to me! There arent enough nurses and the few
that are here are just plain rude and demeaning. And I see too many doctors! Like is someone in charge here? An army of doctors attack me every
morning and treat me like I dont know anything. They dont even want to
listen to what I have to say. Gurney-pushers show up unannounced and
want to take me to tests no one has told me about. Thats the short story.
Clinician: I cannot tell you how annoying it is to me personally whenever I hear
things like this happen. Its true that patients feel often that they are objects on
a conveyer belt over which they have no control. Im sure your feelings are
justified. (Concessions; it is too early in the interview to consider the patients misbehaviors.)
Patient: OK. So what are you going to do about it, Buster shrink? (The interviewer must not be intimidated.)
251
Clinician: Im not sure I know yet. Like you, Im just one small cog caught in
a big health care system. Now, Im not totally powerless [control-sharing]
Tell me what sort of changes might help make your stay better. (control-sharing, developing the third story)
Patient: There are too few nurses, and they are all nasty; I need some consistency in nursing care.
Hereafter is a discussion of the third story; this leads to honest limit-setting

and softball dialogue that follows.
Clinician: I need to be straight with you. I have to be more or less on the side of
the nurses. You are going to be here for no more than a week, and then you
are going to be gone. But I have to work with these nurses month after month.
I simply cannot recreate this medical unit so it runs the way you want it to
run.
Softball; or you can try an alternative softball version like this:

Clinician: If we cannot find a way to tone this down, I have to tell you that you
wont get great care. Every time you tell a nurse to f off, the word gets
around, and nurses will find all sorts of excuses to avoid giving you any extra
help. Thats just the way the world works, as Im sure you know. If I were your
public relations consultant, Id recommend we work together to see how we
can sort of clean up your act.
Patient: Me clean up my act! Hey, Ive got the names of some nurses that
should be canned; they are just that bad.
Clinician: Listen. This is a mess but Im not going to point fingers at anyone until
we [not I] know more [third story]. Ive spent the last 30 minutes getting to
know you, and I can tell you are doing the best you can under a lot of pressure [concessions]. It isnt any fun to be sick [validation].
Clinician: The professional staff wants to give you the best care they know
how. If everyone gives a little and pulls together, this thing is going to
work. (control-sharing and the beginnings of a general agreement that is
worked out during this and subsequent sessions)
Where is this all heading? The psychiatric fact-finding interview now is possible. Once engagement solidifies, the patient is accessible for a reasoned discussion of behavior. A statement something like the following might open this
portion of the interview:
Clinician: Before I leave I need to ask you just a few questions so that I can
write up that you arent crazy. [This statement might be said at the outset.]
Give me a few minutes to ask you some basic medical-psychiatric questions.
You dont need to tell me anything about your personal life. (This is a paradoxical strategy: now the difficult patient is more likely to provide personal
information.)
Clinical Caveat
For more information and examples of effective dialogue for difficult patients
and difficult conversations, my first recommendation is Brent Williams and
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Kenneth Silks [4] chapter in Primary Care Psychiatry. In Psychiatric Interviewing: the
Art of Understanding by Shea [5], I especially like the chapter, The Art of Moving with Resistance. Managing the Difficult Patient [6] is another resource. Although not geared to the psychiatric interview, Carters [7] Nasty People,
Lerners [8] The Dance of Connection, and Tannens [9] I Only Say This Because I
Love You offer excellent suggestions about how to respond to the core features
of difficult conversations.
References
[1] Szasz TS, Hollender MH. A contribution to the philosophy of medicine: the basic models of
the doctor-patient relationship. AMA Arch Intern Med 1956;97:58592.
[2] Stone D, Patton B, Heen S. Difficult conversations: how to discuss what matters most. New
York: Penguin Books; 1999.
[3] Lazare A. The interview as a clinical negotiation. In: Lipkin M Jr, Putnam SM, Lazare A, editors. The medical interview. New York: Springer; 1995. p. 5062.
[4] Williams BC, Silk KR. Difficult patients. In: Knesper DJ, Riba MB, Schwenk TL, editors. Primary care psychiatry. Philadelphia: WB Saunders; 1997. p. 6873.
[5] Shea SC. The art of moving with resistance. In: Shea SC. Psychiatric interviewing: the art of
understanding. 2nd edition. Philadelphia: WB Saunders; 1998. p. 575621.
[6] Hooberman RE, Hoberman BM. Managing the difficult patient. Madison (CT): Psychosocial
Press; 1998.
[7] Carter J. Nasty people. Chicago: Contemporary Books; 1989.
[8] Lerner H. The dance of connection. New York: HarperCollins; 2001.
[9] Tannen D. I only say this because I love you. New York: Random House; 2001.
PSYCHIATRIC CLINICS
OF NORTH AMERICA
My Favorite Tips for Uncovering

Sensitive and Taboo Information from
Antisocial Behavior to Suicidal Ideation
Shawn Christopher Shea, MDa,b,*
a
Training Institute for Suicide Assessment and Clinical Interviewing (TISA),

1502 Route 123 North, Stoddard, NH 03464, USA
b
INTERVIEWING TIP #1: THE BEHAVIORAL INCIDENT

The Problem
All sorts of resistances may predispose a patient to provide distorted information including anxiety, embarrassment, protecting family secrets, unconscious
defense mechanisms such as rationalization and denial, and conscious attempts
to deceive.
The Solution
The behavioral incident technique was delineated by Pascal [1], who defined behavioral incidents as any question in which the clinician asks about concrete behavioral facts or trains of thought. Pascal notes that to cut through patient
distortions, it often is best for clinicians to make their own judgments based on
the behavioral details of the story as opposed to the patients opinions about these
behavioral details. He cautions that it is unwise to assume that any person, when
asked for an opinion, can objectively describe matters that have strong subjective
implications. Instead, Pascal suggests focusing upon the behaviors themselves.
There are two styles of behavioral incident: fact finding and sequencing. Let
us look at the high-stakes arena of suicide assessment to see the first style of behavioral incident in action. In fact finding, instead of asking the patient for his opinion
(eg, How close do you think you came to killing yourself?, which can be easily
deflected with a quick, Oh, not that close.), the clinician asks directly about specific behavioral details: Exactly how many pills did you take? or When you
placed the gun to your head, did you take the safety off? Notice how the information gathered by these behavioral incidents may provide more valid data concerning the actual closeness of pulling the trigger or popping the pills than
provided by the question that sought only the patients opinion.
*Training Institute for Suicide Assessment and Clinical Interviewing (TISA), 1502 Route 123
North, Stoddard, NH 03464 (Website: www.suicideassessment.com). E-mail address:
sheainte@worldpath.net
doi:10.1016/j.psc.2007.02.001

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SHEA
In the second style of behavioral incidentsequencingthe clinician asks the

patient to describe what happened next (eg, What did you do then?) or
what thought or feeling came next (eg, What were you thinking at that moment?) This second style of behavioral incident provides a method for uncovering both behaviors and cognitions in a sequential fashion.
By combining both types of behavioral incidents into a series of questions,
the interviewer often can recreate the incident in question by creating
a walk-through of the dangerous event, whether it be a suicide attempt or an
act of domestic violence. Such sequential walk-throughs are remarkably good
at triggering forgotten or repressed material while decreasing patient distortion.
Once again the elicitation of suicidal ideation can serve as a prototype for
this strategy. The interviewer poses a series of questions after a patient has
reported having thoughts of shooting himself: Do you have a gun in the
house?; Have you ever gotten the gun out with the intention of shooting
yourself?; When did you do this?; Where were you sitting when you
had the gun out?; Did you load the gun?; What happened next?;
How long did you hold the gun there?; What thoughts were going through
your mind then?; Did you take the safety off or load the chamber?; What
did you do then?; What stopped you from pulling the trigger?
Further examples of fact finding and sequencing behavioral incidents include
1. When you say you threw a fit, what exactly did you do? (fact finding)
2. Did you put the razor blade up to your wrist? (fact finding)
3. After yelling at you, what did your father do next? (sequencing)
Clinical Caveat
Behavioral incidents are outstanding methods for uncovering hidden information, but they are time consuming. For tasks such as suicide assessment, the
increase in validity gained by their use is well worth the time spent. Obviously
the clinician must choose when to use behavioral incidents, with a selective
emphasis while exploring sensitive areas such as medication nonadherence,
domestic violence, sexual abuse, substance use, and suicide.
INTERVIEWING TIP #2: GENTLE ASSUMPTION
The Problem
A plethora of factors can contribute to a given patients fears of stigmatization.
Often a patient may feel that the thoughts or behaviors he or she is experiencing are so weird or bad that nobody else has ever had such thoughts. One
technique for overcoming this obstacle is called normalization [2], in which
the clinician implies that others have experienced the behavior in question
(eg, Sometimes when people are feeling very depressed, they notice that their
interest in sex drops off dramatically. Has this happened to you at all?) Normalization is a great technique, but I want to share another approach
gentle assumptionthat I have found to be particulary effective at uncovering
highly sensitive material.
TIPS FOR UNCOVERING SENSITIVE AND TABOO INFORMATION
255
The Solution
When using gentle assumption, the clinician, using a gentle tone of voice and
nonaccusatory wording, assumes that the suspected behavior is occurring. This
gentle assumption metacommunicates the reassuring message to the patient
that the clinician has already encountered the behavior in other patients.
The technique was developed by sex researchers, Pomeroy, Flax, and Wheeler
[3], who discovered that questions such as, How frequently do you find yourself
masturbating? were much more likely to yield valid answers than, Do you masturbate? If the clinician is concerned that the patient may be put-off by the assumption, it can be softened by adding the phrase if at all, as in, How often do
you find yourself masturbating, if at all? I have found very few patients to be
bothered by the use of gentle assumptions if previous engagement has gone
well and the tone of voice used with the gentle assumption is nonjudgmental.
The definition of gentle assumption can be clarified by contrasting this technique with questions that are not examples of gentle assumption. Any question
that asks whether or not a client engaged in a given behavior (eg, often beginning
with words such as Have you ever . . .) is by definition not a gentle assumption.
For example, when using a gentle assumption to uncover other street drug abuse
after having explored the patients use of marijuana, the clinician would not ask,
Have you ever used any other street drugs? Instead, the clinician, would matter-of-factly inquire, What other street drugs have you ever used, even once?
Only the latter type of question demonstrates the technique of gentle assumption.
Other examples of questions that embody gentle assumptions are:
1. What other ways have you thought of killing yourself?
2. What other problems have you had with the law?
3. In the past month how many doses of your medication do you think you may
have missed?
Clinical Caveat
No one knows exactly why gentle assumptions work, but they do. Perhaps, as
mentioned earlier, they metacommunicate that the clinician is familiar with the
area and has seen other people with similar behaviors, indirectly letting the
patient feel less odd or deviant. Gentle assumptions also may indicate that,
at some level, the clinician may be expecting to hear a positive answer, and
it is acceptable to provide one.
Gentle assumptions are powerful examples of leading questions (an attorney
on Law and Order would be on his feet objecting to each and every one of
them). They must be used with care.
More specifically, gentle assumptions should not be used with patients who
feel compelled to please the interviewer (eg, a client who has a histrionic or
markedly dependent personality disorder) or who might feel intimidated by
the interviewer (eg, a child or client with limited intelligence). In such cases
gentle assumptions can lead to patients reporting something that is not true, because they feel they are supposed to have had the experience or behavior in
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SHEA
question. I believe that gentle assumptions are inappropriate with children

when exploring potential abuse issues: in such cases gentle assumptions can
lead to the production of false memories of abuse.
Before leaving the technique of gentle assumption, it is worth mentioning
that sometimes the effectiveness of these validity techniques can be enhanced
by linking them into doublets. For instance one could link the normalization
technique briefly mentioned earlier with gentle assumption (eg, Some of my
patients tell me it is easy to forget medications, especially when taking them
several times a day [normalization]. In the past month how many doses of
the medication do you think you may have missed? [gentle assumption]).
INTERVIEWING TIP #3: SYMPTOM AMPLIFICATION
The Problem
Once an interviewer has skillfully uncovered a problematic behavior, a new
task arises: determining the extent of the problem. This task brings the
interviewer face to face with a most human, but quite problematic, penchant: minimization. Patients often downplay the frequency or degree of disturbing behaviors such as drinking and gambling. One wonders if there is a way to decrease the
distortion caused by patients minimization while maintaining engagement?
The Solution
The use of the technique of symptom amplification, developed by Shea, bypasses the patients distorting mechanism by setting the upper limits of the
quantity in the question at such a high level that, when the patient downplays
the amount, the clinician is alerted that there is still a significant problem [2].
For a question to be viewed as symptom amplification the clinician must suggest an actual number.
For instance, when a clinician asks, How much liquor can you hold in a single night? A pint? A fifth?, and the patient responds, Oh no, not a fifth. I dont
knowmaybe a pint, the clinician is made aware that there is a considerable
problem despite the patients minimization. The technique avoids creating a confrontational atmosphere in the interview, even though the client is patently minimizing behavior. Instead, almost in the same way that a martial artist allows the
sparring partners own momentum to drive the opponent to the mat, symptom
amplification allows the client to continue to use his or her natural defense mechanisms (in this case minimization) fully while the interviewer still manages to obtain a more accurate snapshot of the extent of the patients problem.
This technique often is useful in obtaining a more valid history of the extent
of violence a perpetrator is displaying (eg, in situations of domestic or predatory violence). If a perpetrator of domestic violence is asked, How many times
have you ever struck your wife?, a typical response, after a few seconds of
hemming and hawing, is, Not oftenI dont knowtwo or three times,
maybe. Contrast this information with that obtained from the very same
patient when the interviewer uses symptom amplification, asking, How
many times have you ever struck your wife, you know, in any fashion? Thirty
257
times? Forty times? Fifty times? To this question the same client might state,
Oh my gosh, not 50 times. I dont know. Fifteen times. Ten times. I dont
know. Its hard to remember.
It is worth repeating that symptom amplification is used in an effort to determine an actual quantity. It always involves the interviewer suggesting a specific
number, set high, with a patient that the interviewer suspects uses minimization
as a defense.
Other examples of symptom amplification are
1. How many physical fights have you had in your whole life? Fifty? Eighty? A
hundred?
2. How many times have you tripped on acid in your whole life? Twenty-five?
Fifty? A hundred times?
3. On the days when your thoughts of suicide were most intense, how much of
the day did you spend thinking about killing yourself: 70% of the day, 80%,
90%?
Clinical Caveat
The interviewer must be sure not to set the upper limit at such a high number
that it seems absurd or creates the appearance that the interviewer does not
know what he or she is talking about. How high the number is set will depend
on variables such as the patients history of past abuse and cultural milieu.
As we saw earlier, it sometimes is useful to combine validity techniques. Sometimes they can be linked into triplets: Some of my patients tell me it is easy to
forget medications, especially when taking them several times a day [normalization]. In the past month how many doses of the medication do you think you
might have missed [gentle assumption]10, 20, 30 [symptom amplification]?
The three techniques discussed here can be woven into a sensitive and
smoothly flowing interview. An example of such an interview, reconstructed
from an interview with a patient riddled with antisocial traits, shows these
techniques at work.
The following dialogue shows how the strategic use of validity techniques
makes it difficult for the interviewee to distort the truth through processes
such as the parsing of words or relying upon an idiosyncratic interpretation
of a word such as hit. Also, note the power of the behavioral incident to
cut away both the patients distortions and the interviewers own assumptions
and/or projections that also can cast a mist of distortion on the story being told.
In this dialogue this phenomenon is most striking when the patient uses the
phrase, I lost it on her.
Patient: My wife and I havent really gotten along well in years [pause]. Last
weekend we really went at it.
Clinician: Tell me what happened. (behavioral incident)
Patient: Well . . . She just started on me about needing to get a job, thats her big
thing now. She wants me to go down to the unemployment office today not
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SHEA
tomorrow. Today. So she starts ragging and yelling and I [pause] I just
couldnt take it anymore so I lost it on her.
Clinician: What do you mean lost it on her? (behavioral incident)
Patient: I left. Just took off in a fit of rage. I waited till she went out to the kitchen,
and I went out the back door, and I didnt come back for 2 days. I didnt call
her. I didnt look for a job. I just bagged it all. Screw her.
Many clinicians, including the author, would interpret the phrase lost it on
her as meaning physical violence. The behavioral incident dismantles this
assumption and uncovers a much less disturbing, albeit still pathologic, behavior. Although this assumption would have been off the mark here, the clinicians intuition of violence is appropriate, as is soon shown.
Clinician: Sounds like you two really do go at it. At such moments sometimes
people have a hard time controlling their emotions [normalization]. How
many times have you found yourself stressed to the point that you may
have lost your temper and perhaps hit her [gentle assumption]?
Patient: Ive not really done that.
Clinician: What do you mean not really? (behavioral incident)
Patient: Well, Ive never really ever hit her, not with my fist.
Clinician: Well, have you ever struck her in any way whatsoever? (behavioral
incident)
Patient: I slapped her a couple of times.
Clinician: Did you ever slap her hard enough that it caused some bruises? (behavioral incident)
Patient: Not really [pause]. Maybe a black eye once or twice.
Clinician: How many times do you think you have ever hit her? Thirty times?
Forty times? (symptom amplification)
Patient: Hell, not that often. Maybe six, seven times.
Clinician: Has she ever had to get stitches or go to the ER? (behavioral incident)
Patient: Oh no, shit no, never.
Clinician: Billy, you told me earlier about all the abuse your father did to you, and it
sounded really bad. Sometimes people find that with abusive parents they
have to lie to protect themselves [normalization]. Do you know what I mean?
Patient: Hell yea. After hed had a drunk on, youd tell the old man whatever he
wanted to hear and then you got your ass out of Dodge. And sometimes I
had to lie to protect my Mom or my brother.
Clinician: Some people with similar histories of abuse tell me they keep on lying,
almost out of habit, even when they are older and sometimes even when they
dont want to [normalization]. How often do you find yourself in that situation
[gentle assumption]?
Patient [smiles]: Well, Doc, I suppose I lie if I need to.
Clinician: Have you become a pretty good liar over the years?
Patient [bigger smile]: Yea, I guess you could say that.
CONCLUDING COMMENTS
The dialogue in the previous section shows the power of these techniques to
uncover domestic violence and antisocial behavior. As I stated earlier, these
259
techniques are of use in a variety of sensitive areas, from obtaining an accurate

history of substance abuse to uncovering medication nonadherence.
Perhaps the most practical and sophisticated use of these techniques is in the
elicitation of suicidal ideation and intent as used in the Chronological Assessment of Suicide Events (the CASE approach). Earlier we had seen how the
use of the behavioral incident could help the interviewer elicit suicidal ideation
more accurately. The CASE approach creates a flexible interview strategy that
weaves all of the validity techniques discussed in this article into a method of
helping patients share their inner world of suicidal turmoil. The CASE approach is designed to garner a more accurate history of the patients suicidal
ideation over time, including past behaviors, recent planning, and immediate
suicidal intent. In the CASE approach, suggestions are made not only for
what bits of information my be of use in the clinical formulation of suicide
risk, but which of the above validity techniquesand in what sequencemay
be best used for eliciting this information in a sensitive and engaging fashion.
For readers interested in learning more details about the CASE approach in
clinical practice, see Shea [46]. To learn more about its use in the arena of substance abuse treatment, I recommend consulting another article by Shea [7]. Finally, a discussion of how to train clinicians and trainees to use the CASE
approach through a method of serial role-playing (macrotraining) can be found
online in our Bonus Web Archive at www.psych.theclinics.com by selecting
the June 2007 issue, Clinical Interviewing.
I hope that you have enjoyed this brief introduction to some of the validity
techniques currently in the literature. Over the years, I have found them to be
of immense value in my clinical work. I think you will enjoy using them and I
have no doubt that they will help you to secure a more valid database in many
different areas and, quite possibly, save a life some day.
References
[1] Pascal GR. The practica l art of diagnostic interviewing. Homewood (IL): Dow Jones-Irwin;
1983.
[3] Pomeroy WB, Flax CC, Wheeler CC. Taking a sex history: interviewing and recording. New
York: Free Press; 1982.
[5] Shea SC. The chronological assessment of suicide events: a practical interviewing strategy for
eliciting suicidal ideation. J Clin Psychiatry 1998;59(Suppl 20):5872.
[6] Shea SC. The practical art of suicide assessment: a guide for mental health professionals and
substance abuse counselors. New York: John Wiley & Sons, Inc.; 2002.
[7] Shea SC. Practical tips for eliciting suicidal ideation for the substance abuse professional.
Counselor: the magazine for addiction professionals. 2001;2(6):1424.
PSYCHIATRIC CLINICS
OF NORTH AMERICA
Our Favorite Tips for Getting In

with Difficult Patients
Ekkehard Othmer, MD, PhDa,b,*, J. Philipp Othmer, MDc,
Sieglinde C. Othmer, PhDb
a
Department of Psychiatry, University of Kansas Medical Center, 3901 Rainbow Blvd.,

Kansas City, KS 66160, USA
b
Picture Hills Psychiatric Center, 5709 NW 64th Terrace, Kansas City, MO 64151, USA
c
Department of Psychiatry, VA Medical Center, 4801 East Linwood Blvd.,
Kansas City, MO 64128, USA
INTERVIEWING TIP # 1: CROSSING OVER TO THE PATIENTS

SIDE OF THE CANYON
The Problem
A patient meets the criteria for a Diagnostic and Statistical Manual, edition 4 revised Axis I diagnosis, but refuses treatment, because he or she does not agree
that there is a psychiatric disorder present.
The Solution
In such situations it often feels as if the client is standing on the other side of
a psychologic canyon from us. To bridge this divide, it may be of value for
the clinician first to try joining the client on the clients side of the canyon.
This feat can be approached by talking with the client as if the client does
not have a psychiatric disorderwalking a mile in the clients shoesbeing
nonjudgmental while trying to elucidate the patients main concerns (eg, the
practical life problems for which the patient wants help).
With sensitive interviewing, the clinician often can delineate the cause of the
clients most pressing distress and propose a solution without ever calling it
a symptom. By focusing on and reducing the clients distress rather than
quibbling over the existence of a diagnostic label, clinicians may secure the
clients cooperation more readily. We named this interviewing strategy after
a song we love, Canyons Lie Between, that just happens to have been
written by our daughter [1].
Case Illustration
Both parents bring Alicia A., a 16-year-old white teenager, to my office. Her
long, blue-dyed hair covers her face like a curtain. She has been grounded
*Corresponding author. E-mail address: eothmer@kc.rr.com (E. Othmer).

doi:10.1016/j.psc.2007.02.007

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OTHMER, OTHMER, & OTHMER
and/or without privileges for the last 2 years or so because of failing grades and
not meeting expectations at home. She states she does not want to be here because she needs no psychiatrist and no pills. Following a wrist slashing,
a brief psychiatric hospitalization did not improve Alicias mood, although
she claims she was never suicidal, and that the cutting was to gain relief. She
became disillusioned with her previous outpatient psychiatrist and clearly is
not excited about the prospects of working with me.
Patient: I dont want to be here. My parents are making me see you. They try to
make me take medications that I dont need.
Interviewer: Your mom says you had good grades up to the sixth grade. Suddenly, your grades went down, and now you have Ds and Fs.
Patient: My grades went down, because I hate school.
Interviewer: So you dont feel depressed like your mom says?
Patient: I told you I hate school.
Interviewer: Your mom also says you have trouble paying attention.
Patient: Why should I pay attention? I hate school.
Interviewer: Dr. P. treated you with medication.
Patient: I didnt want any of those pills. I dont need them.
Interviewer: I agree with you.
Patient [looks up and pushes her hair to the side, glancing at the interviewer
with one eye]: So you wouldnt make me take pills?
Interviewer: No.
Patient: Really?
Interviewer: What else do your parents say about your behavior?
Patient: I like Slipnot [a band]. My parents wont let me go to their concert because of my grades. I like Marilyn Manson. My parents hate him. They dont
want me to listen to his CD.
Interviewer: What other music do you like?
Patient: I like Rammstein. But they sing in German. I dont understand German.
Interviewer: Well, bring in the CD next time you come to see me. Ill translate
a song for you.
Patient: Youll do that? I carry many of my CDs with me. Here is a Rammstein CD.
Interviewer: Im interested in what you are listening to. When is that Slipnot
concert?
Patient: Next Friday at the Beaumont Club.
Interviewer: OK. Is it ok that I talk with your mom?
Patient: You want me to leave?
Interviewer: No. Im your psychiatrist. Not your moms. All right then, Ill get
your mom in.
Interviewer: Well, Mrs. A., Alicia says she skips medication because she does
not need it. She doesnt think that she is depressed. I would like to treat her as
if she is right. Lets hold the medication.
Mother: I know shes depressed. She doesnt talk to anybody, goes straight to
her room after school and listens only to her music. Dr. P. told us that these
are all the signs of depression. But Alicia just shrugs it off.
Interviewer: Depression means having too many bad feelings, like sadness,
irritability, and anxiousness, and too little fun. Music is the only joy Alicia
FAVORITE TIPS FOR GETTING IN WITH DIFFICULT PATIENTS
263
has left. I would love for Alicia to have more fun. Punishment can increase
negative feelings. It looks like grounding Alicia has not improved her grades.
Lets help her have more happy feelings. I suggest you go with her to see
Slipnot.
Mother [raises her eyebrows and looks at the psychiatrist with a questioning expression]: But she should earn it, I was told.
Interviewer: Youre right. Rewards can help bring about wanted behavior. But in
a down mood Alicia may not have enough interest or motivation to earn it.
Failure would increase her down feelings.
Mother: Okaaaay?
Patient looks triumphantly at her mother
Interviewer to Alicia: I would like to see you next week. But after the concert, Alicia, I would like you to tell your parents what you like about this kind of music.
At the next meeting, I show Alicia Marilyn Mansons CD Holy Wood and
I give her the translation of one of Rammsteins songs.
Interviewer: How did you do without any medication?
Patient: I tossed and turned. I couldnt sleep. I woke up early.
Interviewer: Lets fix that. It sucks to be without sleep. It may even make you irritable and cranky.
Patient: Oh, I am already.
Interviewer: Lets get rid of both, the sleeplessness with trazodone and the
cranky feelings with Zoloft.
At the next visit Alicia reports:

Patient: I slept and felt better.
Interviewer: Great. If you could reinvent yourself, Alicia, what would you
change?
Patient [looking around]: If I could . . . hmmm . . . you know I would like to be
able to stick with things. Finish them.
Interviewer: Lets try something for that. I will give you two different medications.
You will take each for 3 days and then tell me which one works better with
helping you to stay with things.
Patient: That sounds interesting.
Interviewer: One is called methylphenidate, the other Adderall. I also know
a teacher, Mr. G., who makes work fun. I will ask your parents whether
they can hire him for you.
At the next visit the patient reported:

Patient: Methylphenidate gave me headaches. Adderall made me tired, but I
could pay better attention. Mr. G. really knows how to make me like social
studies. He has fun with it himself.
Clinical Caveat
The outcome here was rewarding. The patient went on to have As and Bs with
only one C on her next report card. This was quite a turn-around!
264
Apparently, her previous psychiatrist had correctly elicited Alicias symptoms

and signs and had made the accurate diagnosis of major depression and attentiondeficit hyperactivity disorder. He had explained his diagnosis and treatment plan
but had not seen that Alicia rejected his medical model approach: from her
point of view hating everything was egosyntonic and how she felt. In her
opinion such feelings/moods and behaviors were not caused by some outside
illness.
Joining Alicia by seeing things from her point of viewcrossing to her side of the
canyonand treating her without stressing the psychiatric disorder allowed her to
feel she was being heard, admit her distress, and accept help. Let me briefly describe, in a stepwise fashion, how I managed to cross the canyon:
1. Her refusal to accept a psychiatric diagnosis: I did not demand that she have
insight into her problems as potentially being symptoms of disorders and I
even stopped her medications (especially because she said she was not taking them anyway, and she reported being nonsuicidal/homicidal). Allowing
her to stop the medicines altogether increased her feeling of control and being listened to. Further, if she notices a difference for the worse when the
medications are discontinued, she can see for herself the natural consequences of her decisions.
2. Anhedonia: Encouraging fun at a concert, talking about Marilyn Manson,
offering a translation of the Rammstein song, and getting a motivational
teacher were nonmedical treatments of Alicias anhedonia, centered around
her stated likes and dislikes.
3. Insomnia and irritability: Specifically addressing complaints reported by the
clients (such as using trazodone for sleep) builds rapport and, if successful,
boosts the stature of the psychiatrist in the clients eyes.
4. Inattention: To increase interest in her school work by finding a motivating
teacher fit Alicias view of her problems. Allowing her to pick her own medication increases her feeling of control, enhancing engagement in treatment
and likelihood for compliance.
5. Failing grades: Finding an enthusiastic teacher reduced her anhedonia.
INTERVIEWING TIP #2: CIRCUMVENTING ROADBLOCKS: THE

WHAT IF . . . QUESTION
The Problem
Patients, whether in the initial interview or in ongoing therapy, often use
everyday language to describe clinically significant psychiatric problems. If
the problem remains undiscovered because it is masked by language that
typically denotes nonclinical realms, therapeutic roadblocks can arise.
The Solution
First, identify the patients reported roadblock to social progress (between better, and where we would like to be, well). Second, using the What if . . .
question, the interviewer should ask the patient what would happen if the supposed roadblocks were, as if by magic, removed. This question often can
help clarify or discover a missed or unclear underlying cause for a situation.
265
You then strategically try to see if you, in the interview or in ongoing therapy,
can help remove the roadblock (focusing the patient on all the positive things
they can do after its removal to see if removal fixes the problem). In the following example, the problem is the patients being unemployed and not looking for
a job; the roadblock is a phobic avoidance of job interviewing rather than a desire
to be disabled and receive a disability check, as a family member assumes.
Case Illustration
Mr. Mark B. is a 31-year-old PhD student who quit attending classes during relapse of a depression that started after his parents divorce. He has finished the
majority of his course work. A final paper is nearly complete and is all that stands
between him and graduation. He is contemplating quitting all together.
He had gone on four job interviews that failed to lead to offers of employment. He became nearly housebound. After his mother left for work, he retreated into her bedroom and watched soap operas most of the day. His
father referred him for treatment. At his first visit he reported he was taking
sertraline (Zoloft), which had helped him to feel a lot less depressed. Currently,
he reported, his mood was more blah than depressed. He was pervasively
doubtful and felt hopeless regarding most issues. I added Wellbutrin to his
treatment. He missed his next appointment.
Several weeks afterward, his father, a certified public accountant, called seeking advice on what to do. He reported that his son continued to refuse to look
for work. He wants to be permanently disabled, his father said. I told the
father that, if the patient was willing, they should come in together and bring
the mother as well.
At the second visit, Mr. Mark B. was friendly and cooperative, but he
presented himself as a failure:
Interviewer: Mark, how are you doing?
Patient: Okay, I guess.
Interviewer: How is your mood?
Patient: Okay, I guess.
Interviewer: Is the Wellbutrin helping?
Patient: Yes.
Interviewer: So your Dad thinks you should get a job.
Patient: Im telling you what I told him. I already tried. Its pointless. No one will
hire me. I cant get a job [patients reported roadblock].
Father [turning to me]: See? I told you so.
Interviewer: Now, what if someone hired you, would you go to work? [the
What if . . . question]
Patient: No one will hire me. I tried four times. [patient maintains the roadblock]
Interviewer: I know, it can be hard to get a job, obviously. But, what if you had
one, would you go to work? [Clinician persistently, but gently, re-introduces
the What if . . . question in an effort to identify where the slip is between
cup and lip in Marks procuring a job.]
Patient: Yes.
Interviewer: Could you do the work and put in a full day?
266
Patient: Yes [pause]. But I really dont like interviewing for jobs [hinting at his
phobia].
Interviewer: Well, what if you could volunteer, and wouldnt even need to interview for the job, do you think you could do that? [another example of the
What if . . . question]
Interviewer: That would be great. I definitely think I could do that.
Clinical Caveat
I arranged for Mark to be given a volunteer job by a friend of the father. As
a volunteer, Mark circumvented the interviewing process. The employer
said the commercial value of Marks work would be $12 to $15 per hour. I
called Marks father and asked him to provide the company the money so
that Mark could be paid. Mark was embarrassed by this arrangement. I told
Mark that this arrangement saved him from having to beg for every penny
from his parents (which had been another point of friction between Mark
and his father). After 6 weeks, the fathers friend rejected the money from
Marks father and paid Mark directly, impressed by the quality of his work.
The company offered to hire Mark, if Mark so desired, which he did.
The What if. . . question proved to be invaluable here. Mark completed
his thesis and passed his examination. The conflict between Mark and his father over the roadblockMarks inability to get a jobhad been full of emotion.
It had led to anger, fighting, and shouting. Marks father felt Mark was trying
to have a free ride. We helped him to recognize Marks phobic response. We
developed a plan that circumvented the roadblock to Marks progress. The
transformation of the roadblock all began with the strategic use of the
What if . . . question.
A Second Illustration of the Power of the What if . . . Question
Sometimes a patients self-perceived roadblock can play a role in his or her suicide potential, as we shall soon see in the following case. By using the What if
. . . question, you can sometimes, with a little luck, help save a life. In this case,
the patient, Diane, is a 37-year-old white married woman who reports the
symptoms and signs of depression. Her depression started in puberty. She accepts the diagnosis and appreciates my empathy, but her despair is deep. She
insists suicide is the only way out of her misery, regardless of what I think
or say. Suicide may well be a symptom of her depression, but on a cognitive
level, she views suicide as an inviting solution to the meaningless quality of
her life.
Patient: My whole family is crazy and useless. They all abuse drugs. Im the only
one that does not. My marriage sucks. Im good to nobody. Its time to exit.
Interviewer: Why?
Patient: I have no power to help my family.
Interviewer: Hows that?
Patient: My niece was a crack addict.
Interviewer: She was?
Patient: Yes, she was. She was only 23 years old. Shes dead now.
267
Interviewer: What happened?

Patient: I begged her not to go to the 34th Street crack house. She laughed at
me and went anyway.
Interviewer: So?
Patient: In the crack house she witnessed the execution of a drug dealer. The executioner murdered her because she was a witness.
Interviewer: How do you know that was the scenario?
Patient: The son killed his own father.
Interviewer: Really?
Patient: Yes, the father had beaten him and thrown him out of the house. The kid
was pretty revengeful.
Interviewer: What did you do when you heard this?
Patient: I told my sister I would help her with raising her daughters two children.
But my sister got very depressed. Her younger daughter started to sleep with
her to watch out for her.
Interviewer: So hows your sister doing now?
Patient: She overdosed while her own daughter was in bed with her.
Interviewer: What a terrible story!
Patient: Thats my family for you.
Interviewer: Why do you want to follow your sister?
Patient: I wanted to adopt my nieces children, but my husband says hell leave
me if I do it. I want to do it anyway, but my lawyer said that as a single parent
I cannot adopt two children. [patients roadblockpossibly a real-world
road block]
Interviewer: I see.
Interviewer: What happened to the father of your nieces children?
Patient: Hes an addict too. Hes in prison.
Interviewer: I feel your distress. You are stuck in a deep hole. [Accepting the
patients existential crisis from her viewpoint is a way of using the first interviewing tip, crossing the canyon.]
Patient: And no way out.
Interviewer: What if you could help your nieces children, would you stick
around? [the What if . . . question]
Patient: Yes, but I cant, according to the lawyer. [patient maintains roadblock]
Interviewer: I know a single teacher who adopted two kids from Russia. I will get
you that lawyers number. [strategic attempt to circumvent roadblock]
The patient returned for a follow-up appointment.

Patient: Thanks for putting me in touch with this lawyer. The adoption is on its
way.
Interviewer: What about your husband?
Patient [shrugging her shoulders]: Hes still there. I dont care.
Interviewer: What about your depression?
Patient: I started to take your medicine. Im still depressed, but those kids need me.
Interviewer: What are your plans to kill yourself?
Patient: Im still here. Am I not?
Interviewer: Sure
Patient: I started to work out. By the way, I saw you at the YMCA the other day.
268
Clinical Caveat
The patient measured the value of her life by her power to change some things
for the better. Without that power, life appeared worthless to her. I used the
What if . . . question to help uncover a powerful reason to livethe children
of her niece. By subsequently helping remove the roadblock preventing the
adoption, I was able to help her choose life over death by suicide. You might
be interested to know that the patient currently takes care of her newly adopted
children and, in addition, keeps a full-time job. Her husband is still trying to
figure out whether he will stay around.
SUMMARY
We never cease to be amazed at the number of methods that exist for transforming roadblocks in the initial interview and in ongoing therapy as well.
We have previously described a variety of methods in our books addressing
interviewing techniques for use with difficult patients [24].
You will also notice that our techniques are similar to those described in an
article in this issue by Cheng, regarding solution-focused interviewing, motivational interviewing, and the medication interest model, interview approaches
that emphasize a collaborative method for transforming roadblocks by going
with the client. All these techniques describe methods of creatively thinking
on our feet during those crucial moments when patients seem to directly oppose us while they wait to see from where we will respondfrom an opposing
side of the canyon or from their side of the canyon.
References
[1] Othmer JC. Canyons lie between. CD: Oasis Motel track 9. 2006 Available at: www.
juliaothmer.com. Accessed February 2006.
[2] Othmer E, Othmer SC. The clinical interview using DSM-IV TR. Vol 1: fundamentals. Washington, DC: American Psychiatric Publishing, Inc.; 2002.
[3] Othmer E, Othmer SC. The clinical interview using DSM-IV TR. Vol 2: the difficult patient.
Washington, DC: American Psychiatric Publishing, Inc.; 2002.
[4] Othmer E, Othmer SC, Othmer JP. Psychiatric interview, history, and mental status examination. In: Sadock BJ, Sadock VA, editors. Kaplan & Sadocks comprehensive textbook of psychiatry, Vol. I. 8th edition. Philadelphia: Lippincott Williams & Wilkins; 2005. p. 794826.
PSYCHIATRIC CLINICS
OF NORTH AMERICA
Our Favorite Tips for Interviewing

Veterans
James Morrison, MDa,*, James Boehnlein, MDa,b
a
Department of Psychiatry (UHN 80T), Oregon Health and Science University, 3181 SW Sam
Jackson Pk Rd, Portland, OR 97239. Portland, OR, USA
b
Veterans Administration Northwest Network, Mental Illness Research, Education, and Clinical
Center (MIRECC), Portland, OR, USA
INTERVIEWING TIP #1: DIFFERENT AVENUES TO RAPPORT

The Problem
Like so many mental health patients, veterans often come to us with their defenses raised by past experience with caregivers whom they perceive as lacking
in understanding. Although health care professionals sometimes find that their
own veteran and combat status can afford instant credibility, not all providers
have wartime experience to use in developing rapport with their patients. To
connect rapidly and effectively with their sometimes suspicious patients, they
must find other ways to speed rapport.
The Solution
Of course, the best advice for the clinicians is, just be yourself. Answer questions
honestly, admit any deficiencies in your own experience if asked specifically, and
in a nondefensive manner point out those experiences you do have that can help
the patient accommodate to the treatment relationship. Veterans are just as quick
as other patients to identify and resent signs of artifice and condescension. You
dont have to know anything about combat, or even very much about the military: in all likelihood, your patient will be delighted to tell you all about it.
In fact, the clinicians willingness to learn from the patient is a powerful
builder of rapport. The clinicianpatient relationship is inherently lopsided,
and allowing the patient to redress some of the imbalance is empowering to
the point that it can help the patient feel less suspicious of the clinician and
more open and willing to share intimate information. Also, you never know
what you will learn about the military serviceor any other field of human endeavorthat will help you understand the patients current situation.
Max, an illustrative case
Max, a 58-year-old Vietnam veteran, presented to the clinic with the chief complaint of nightmares that had been occurring approximately 3 nights per week.
*Corresponding author. E-mail address: morrjame@ohsu.edu (J. Morrison).
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After many years of virtually no nightmares, they had increased in frequency

and intensity dramatically with the onset of the Iraq war. Reading about the
deaths of Iraqi civilians had triggered Maxs memories of Vietnamese civilian
deaths, particularly a family with which he and his unit had become friendly
during his year-long tour in 1969 and 1970. These memories in turn had led
to nightmares that contained both literal and symbolic images of loss and
death. The nightmares and memories had contributed to sadness, irritability,
and increased alcohol use over the previous 3 months.
Over the years Max had kept in close contact with several Marine buddies,
but they had rarely discussed their Vietnam experiences or subsequent symptoms that they might have had during times of stress. In fact, at the first appointment, Max respectfully told the 40-year-old therapist that he did not
want to go into detail about his Vietnam experiences or the content of his nightmares because discussing them made him feel worse. Besides, how could any
therapist who was not a veteran and had never seen combat relate to them?
The therapist replied that, despite a lack of veteran status, 10 years of experience working in the Veterans Administration (VA) with veterans of World
War II, Korea, and Vietnam had afforded an appreciation of both the unique
and universal issues that veterans of all wars face after they return home. Moreover, the therapist mentioned that the confidentiality of the therapeutic relationship might allow the veteran to talk about some sensitive issues or doubts that
he had been reluctant to discuss even with his wife or trusted Marine friends.
By action rather than by words, in regular sessions over the following several
months the therapist communicated to the veteran an ability and willingness to
listen, without judgment, to the veterans painful memories and tearful expressions of loss, mourning, and guilt associated with those left behind in Vietnam.
There is a corollary that even professionals who work for the VA lose
sight of from time to time: veterans experiences may differ, depending upon
the era of service. For example, many World War II veterans served for the
duration of the war, whereas most Viet Nam draftees returned home after
a year. When interviewing veterans, it is always a good idea to ask some
open-ended questions [1] to elicit even a brief overview of the patients wartime
experiences and their effect on the individual: What was your job when you
were in combat?; How often did you come under fire?; How did you deal
with your long separation from home and family?
Clinical Caveat
Like our next tip, this one has virtually no downside. It urges the use of techniques and attitudes that promote a melding of the clinicians desire to gain information with the patients desire for help.
INTERVIEWING TIP #2: KEEP AN OPEN MIND
The Problem
It happens so often that most clinicians probably have experienced it at one
time or another: although the patients story gradually becomes clearer as
TIPS FOR INTERVIEWING VETERANS
271
time passes and more information comes to light, the clinicianby now invested in a particular theory or favorite treatmentis slow to recognize the
emerging picture. Such a blind spot may be especially likely in the face of obvious precipitants such as time spent in combat or a civilian calamity.
The Solution
Throughout history taking, we have found that it is vital not to surrender to
complacency but to keep a fully open mind as to the possible causes of a patients
difficulties. Doing so can be a challenge, especially in the face of a patient who
has posttraumatic stress disorder with a compelling history of combat trauma.
Burt, an illustrative case
At Burts first appointment at the mental health clinic, he was queried closely
about his combat experiences. He had had more than a sufficiency of war,
as he put it, and the images of explosions, wounds, and dying continued to haunt
his dreams. At the end of this evaluation, Burt was assigned to group therapy for
posttraumatic stress disorder, and he attended the meetings faithfully for weeks
afterwards. Because he continued to have symptoms, the group leader finally
asked in private about his marriage. It came out that Burts wife was complaining
about his drinking, as she had done off and on since they were first married, well
before he joined the Army. Once his clinicians stumbled onto the fact that something in addition to combat stress might be contributing to Burts difficulties, it
was relatively easy to design a more effective therapy program.
Clinical Caveat
Of course, not all possible causes are equally likely, and one of the clinicians
responsibilities is to winnow the list. Doing so too early risks the loss of valuable data; doing so too late can mire the interview in irrelevant material.
The bottom line, and one of our central recommendations is to cast wide the
net and consider all diagnostic possibilities [2], even those that initially might
seem highly unlikely or even ridiculous. Every once in a while, one of your
unlikely possibilities will redeem your faith in a broad-ranging differential diagnosis. When interviewing, dont close off any conceivable avenue of inquiry
by making assumptions. The same importance attaches to a careful developmental history: childhood loss or trauma may contribute to the frequency
and severity of military-related symptoms of posttraumatic stress disorder.
INTERVIEWING TIP #3: DEALING WITH QUESTIONS ABOUT
YOUR PERSONAL ISSUES
The Problem
How should you respond when a veteran (or any patient) raises issues or opinions about politics, religion, or other closely held beliefs? This question arises
commonly in VA settings, especially with combat veterans, who are often given
to expressing their feelings strongly. The answer can pose significant challenges
for clinicians. Whereas some patients undoubtedly could handle the give and
take of a frank discussion that includes the therapists own beliefs, it is hard
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MORRISON & BOEHNLEIN
to identify these patients in advance. Thats why conventional wisdom prohibits any such discussion in the therapeutic environment.
There are all sorts of ways to deflect such a conversation gambit, some of
which only create further problems. Ignoring the question sets you up as someone who either does not listen or does not respond. The simple statement, I
never discuss personal matters, although it might be truthful and is certainly
succinct, risks stanching the flow of other, vital information. A seemingly simple and direct response would be to provide the information requested, especially if it is about a belief you and the patient share. These things, however,
have a way of leaking out to other patients in the system, and a response
that wins you points with one patient might lead later to a more spirited defense
than you would like with another, less sympathetic patient. Why do you
ask? is the tried and true, if hackneyed, response familiar to everyone, but
its answer still requires you to craft a response. Reflecting back what the patient
has just said (You seem to feel ) can be annoying, and some patients might
think you are mocking them. There must be a better way.
The Solution
Regardless of how provocative (or how far from your own views) the patient
seems to be, it is honest to acknowledge the emotion behind the statement:
You really care a lot about this issue; I can appreciate how strongly you
feel. Then, you can invite further discussion: How did you come to feel
that way? These responses all have the effect of turning the discussion
away from your own preferences and back to the patients.
If pushed to the point that there is no way outDont you think so,
Doc?you should respond honestly: Of course, I have my own feelings
about politics, but what I really care about is how you feel. My experience tells
me that it is much more important and helpful to focus on the thoughts, needs,
and opinions of my patients. Maybe you could tell me what was happening
when you first started feeling that way. This forthright statement accomplishes two things: it portrays you as attentive and empathetic, not uncooperative, and it guides the conversation back to the patients own situation.
Clinical Caveat
It would be counterproductive to proscribe all expressions of personal preference. We generally prefer to be as candid with our patients as possible, which
may occasionally include mention of a certain fondness for Savannah, the Sopranos, or salsa verde. It would seem especially pointless to avoid admitting to
ideas you have already expressed previously, whether directly to the patient or,
perhaps, in a journal article or public lecture. Also, other than religion and politics, the number of topics that you should strictly avoid is small. Even in such
contentious topics as electroconvulsive therapy and assisted suicide, your own
views can (and should) have a bearing on the counsel you give your patients.
It also is important not to confuse the statement of personal preference with
an honest attempt to help clarify the patients own ideas about matters such as
responsibility, guilt, and forgiveness.
TIPS FOR INTERVIEWING VETERANS
273
STRATEGIC TIPS AND ILLUSTRATIVE EXAMPLES

The explicit subject matter of Tip #3 would seem to render further illustration
superfluous. Both Tips #1 and #2 were needed in the following case, however:
by focusing on what the interviewer wanted to know about rather than what
Amy needed to talk about, the questions from Amys initial interview (reconstructed long after the fact) conveyed the message that she was right to withhold
the meaningful part of her story, which for months she had been afraid to discuss.
Amy, an Illustrative Case
Amys tour of duty in Iraq had changed her. All my friends tell me that, she
said, wiping away tears. I guess thats what comes of being a soldier. After
that, she grew quiet, volunteering little more about her experiences. The later
part of that first interview included this exchange, which illustrates the use of
openly admitting a deficiency in knowledge and asking to be taught as a different avenue to rapport:
Clinician: I cant even imagine a situation where youre at risk for being blown
up just driving down a main thoroughfare.
Amy: Well, after just 3 weeks in the country, I was with several people in my unit
when our Humvee hit an IED. My best friend lost the use of her arm, had to be
air evac-ed out.
Clinician: A terrible experience. How did the rest of your patrol handle it?
For several minutes Amy spoke of her tour in Iraq, information about improvised bombs, how she had been taught to scan the roadside for signs that they
were there. She also divulged important details about her deepening depressionthe crying spells, sleeplessness, feelings of despair. She received a prescription
for an antidepressant and was assigned to a group for combat trauma survivors.
In group therapy, Amy mostly just listened. Finally, after weeks of silent
attendance, she stopped coming. Within a few days, a senior clinician interviewed her. This exchange includes an example of keeping an open mind as
to what else might explain the symptoms:
Amy: It wasnt helping at all.
Senior Clinician: What were you feeling?
Amy: I just couldnt seem to relate to what the others were saying.
Senior Clinician: Maybe you should tell me what else happened over there.
What came pouring out was a tortured tale of sexual harassment by a few of
her fellow soldiers, capped by rape in an empty mess hall by a first sergeant.
He said, if you ever tell about this, your parents are going to get a home visit
by two officers in uniform.
References
[1] Morrison J. The first interview. Second edition. New York: Guilford; 2007.
[2] Morrison J. Diagnosis made easier. New York: Guilford; 2007.
PSYCHIATRIC CLINICS
OF NORTH AMERICA
Our Favorite Tips for Interviewing

Couples and Families
John Sommers-Flanagan, PhD*, Rita Sommers-Flanagan, PhD
Educational Leadership and Counseling, The University of Montana, 724 Eddy Street,
Missoula, MT 59812, USA
ndividual interviewing differs from couple and family interviewing in one

clear and encompassing way: although individual interviewing often includes a focus on or discussion about relationships, couple and family assessment always includes relationships as a primary focus. When interviewing
individual patients, the clinician may talk about relationships and relationship
dynamics, but when interviewing couples and families, one inevitably observes,
experiences, and often is pulled into here-and-now relationship dynamics.
INTERVIEWING TIP #1: RADICAL ACCEPTANCE
The Problem
The problems and beliefs couples and families bring to treatment can be particularly disturbing to clinicians, sometimes causing clinicians to have strong
negative emotional reactions to specific couple and family behaviors or statements. These reactions may be reflected in the clinicians nonverbal behaviors
or in judgmental statements that, in turn, can reduce patients openness and
cooperation with the interview process.
The Solution
Radical acceptance is a technical modification of Carl Rogerss core attitude of
unconditional positive regard. Rogers [1] was comfortable with therapists using
techniques as long as these techniques rise up within the therapist in a spontaneous or unplanned way. In keeping with this obvious paradox, we recommend that interviewers use radical acceptance whenever the need for it
arises spontaneously. The purpose of radical acceptance is to welcome graciously even the most absurd or offensive patient statements. For example,
in response to a potentially disturbing patient statement, one might say, Im
very glad you brought that [topic] up. Variations of radical acceptance are
provided later.
Radical acceptance is especially warranted when patients say something the
clinician personally or philosophically opposes. These statements may be
*Corresponding author. E-mail address: john.sf@mso.umt.edu (J. Sommers-Flanagan).
doi:10.1016/j.psc.2007.02.003

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SOMMERS-FLANAGAN & SOMMERS-FLANAGAN
unusual, disagreeable, racist, sexist, or insensitive. Three examples of provocative client statements that might stir negative feelings in the clinician are listed
here, followed by illustrations of the radical acceptance technique:
1. Parent [in a parent consultation situation, without children present]: I believe
in discipline. Parents need to be the authority in the home. And yes, that means
I believe in giving my kid a swat or two if he (she) gets out of line.
Clinician: Im very glad you brought up the topic of spanking.
2. Husband: We need to stay together because divorce is against Gods law.
Clinician: Thank you so much for speaking your mind in here.
3. Parent [speaking to an adolescent in a family therapy situation]: I cant accept your homosexuality. You have to resist it. I wont tolerate sinful behavior.
Clinician: Many parents share views similar to yours but wont say them in
here, so I especially appreciate you sharing your beliefs so openly.
Clinical Caveat
Radical acceptance involves actively welcoming any and all comments from
couples, parents, and children. To use this technique, the clinician must
move beyond feeling threatened, angry, or judgmental about what patients
say and embrace whatever comes up.
Radical acceptance, as illustrated in the preceding examples, is more active,
directive, and value-laden than traditional person-centered therapy approaches.
The goal is for the clinician to communicate his or her personal and professional commitment to openness during the assessment and treatment process.
Without such openness, patients may hold underlying beliefs that never get articulated. This perspective relies on the clinicians deep conviction that patients
are unlikely to experience insight or be motivated to modify their beliefs unless
they expose those beliefs to the light of personal and professional inspection.
Radical acceptance involves letting go of the need to teach the patient a new
way. Instead, the interviewer invests in a process that allows unhealthy beliefs
to shrink, melt, crumble, or deconstruct with the light and heat of family, couple, or therapist inspection and analysis. For example, in the case of parents
who express a need to use corporal punishment, it may be very important
for patients to articulate their beliefs in a public/professional setting. Then, after
proclaiming such a position and having their rights to have that position affirmed, they may be able to let go of it more completely or use it less often.
Similarly, the parent who is unable to accept his or her teenagers homosexuality may need to have painful (and maladaptive) feelings affirmed before moving beyond those feelings and recovering other (more constructive) feelings of
love and affection for the child.
When we share the attitude or technique of radical acceptance with clinicians, the first question that arises is typically, How can I radically accept
what the patient says and believes when I also want immediately to help
him or her change those beliefs?
This question gets to the heart of paradox and dialectic in therapy, which
Rogers never addressed directly. More recently, however, Linehan [2] and
TIPS FOR COUPLES AND FAMILIES
277
Hayes and colleagues [3] articulated this paradox and integrated it into their
specific therapeutic approaches (ie, dialectal behavior therapy and acceptance
and commitment therapy). These approaches emphasize that patient change
or progress is stimulated when the patients emotional condition is completely
embraced or accepted. In essence, the interviewer says (and believes), I accept
you as you are, and I am simultaneously committed to helping you change [4].
In summary, clinicians using radical acceptance welcome and explore all patient statements. Despite this attitude, clinicians using radical acceptance do
not endorse all patient statements and beliefs. Instead, after affirming the patients
right to his or her personal beliefs, the clinician may openly question the usefulness or helpfulness of the patients beliefs or behaviors. The underlying message
is that in couple or family therapy clinicians are open to hearing, accepting, and
analyzing the utility of anything and everything patients have to say.
INTERVIEWING TIP #2: THE ROMANTIC HISTORY
The Problem
Often, when couples arrive for an initial interview, they are in deep relational
conflict and pain. This conflict and pain usually produces negative affect and
negative expectations. Consequently, hostile interactions between romantic
partners may occur immediately upon the couples entry into the consulting
office and interfere with clinical assessment and treatment outcome.
The Solution
The romantic historyasking how the couple met and fell in loveis a specific interviewing strategy designed to gather information and, at least temporarily, shift
couples into a more positive affective state [5]. Shifting couples from a negative to
a positive emotional state also can produce more positive exchanges during the
initial session. Introducing the romantic history often requires an explanation:
All couples have both positive and negative feelings toward each other.
Right now, like many couples, you may be feeling more negativity than usual,
and youll certainly get a chance to talk about your negative feelings in here.
Right now, however, Id like to hear a detailed story about how the two of you
met, what attracted you to each other, and some pleasant memories from the
very beginning of your romantic relationship. Either one of you may go first,
but remember, I want to get a feeling for your initial meeting and early
romance and so Ill be asking you each a number of follow-up questions.
Clinical Caveat
The purpose of the romantic history is twofold. First, as noted, shifting into
a romantic history-taking format can help couples shift into more positive
emotional states. Second, research indicates that when couples (or individuals)
experience a more positive mood or affect, they can more easily recall other
positive experiences and more effectively solve problems [6].
Some individuals resist the romantic history, principally because they want
to continue feeling justified in their negative affect or conflict. Additionally,
278
some couples may engage actively in the romantic history but quickly shift
back into a negative affect or new or old conflict. Sometimes couples even
get into a conflict over their initial romance or share/uncover hidden negative
feelings about their early romance. When these situations arise, the following
statements may be helpful:
1. When people are upset or in a bad mood, it can be very hard to remember
anything positive, so Im not sure if you can do this right now. (This statement provides the patient with a small challenge.)
2. It seems like maybe you dont really want to think of anything positive about
your relationship right now, and thats perfectly okay. Whether or not you
talk about your romantic history is totally up to youits your choice.
(This statement affirms the patients personal control.)
INTERVIEWING TIP #3: TRANSFORMING

WISHES INTO GOALS
The Problem
Many couples and families struggle to identify and express their treatment
goals. This struggle arises in part because some family members and romantic
partners are reluctant therapy participants and have difficulty admitting to
problems or believing that treatment will be helpful. Additionally, despite the
need for specific goals for insurance and managed care purposes, couple and
family therapy patients often, when asked directly, What are your goals for
therapy?, respond with quizzical looks and shoulder shrugs.
The Solution
Early myths, including Aladdin and his magical lamp, speak to the archetypal
nature of wishing. Consequently, virtually all patients inherently understand
the language of wishes and can identify specific ways in which they might
wish their lives were different.
In this technique, the clinician asks the family members to share wishes. The
resulting wishes may be transformed easily into treatment goals that are readily
agreeable to the family, because they came up with the wishes in the first place.
This technique, designed for use when interviewing couples or families, is essentially the same technique as the miracle question in solution-focused interviewing described earlier in the Michael Cheng article in this issue of the
Psychiatric Clinics of North America.
Clinical Caveat
When child or adolescent patients are involved in a family interview, we
recommend structuring the wishes into three components [7]. Doing so provides a broader sense of the patients world and what parts of that world are
most troubling:
If you had three wishes, or if you had a magic lamp like in the movie Aladdin, and you could wish to change something about yourself, your family,
or your school, what would you wish to change?
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This question structures goal setting into three areas: self, family, and school.
It gives the young patient a chance to identify personal goals in any or all three
categories. Depending upon the child and on the parents influence, there may
still be no constructive response. In this case the clinician might try amplifying
the question:
You dont have any wishes to make your life better? Wow! My life isnt
perfect. Maybe I should wish to change places with you. How about
your parents? Isnt there a little thing that you might change about them if
you could? [pause for answers] How about yourself? Isnt there something
small, that you might change about yourself?
Nervous or shy children/adolescents may continue to resist this questioning

process. If so, a chance to pass should be provided.
When using the wishes-into-goals strategy with couples, clinicians must proceed with caution. Specifically, as is generally the rule in couples work, the clinician should avoid giving one partner an opportunity to criticize or suggest
that the other partner should make some personal changes:
If you had three wishes, but your wishes were restricted to ways in which
you might change yourself, ways in which you might improve yourself,
what would you wish for? Let me emphasize: these wishes cannot be
used to wish for your partner to change in any way. They can only be
used to wish for ways in which you might change or improve yourself.
Note that in the preceding example the clinician repeats the limit or rule by
which each partner must abide. This repetition or limit setting with couples is
strongly recommended because of their tendency to deteriorate quickly into
cross-criticism.
Patients who are resistant to treatment typically refuse the opportunity to
generate wishes for how their lives might change for the better. They may
say things like
1.
2.
3.
4.
Everything is fine.
I cant think of any wishes.
This is stupid.
I dont believe in wishes.
The clinician can use the following statement if patients refuse to generate
wishes during an interview:
Thats okay. Sometimes its hard to think of wishes, or sometimes people
dont want to think of any wishes. Lets skip the wishes for now. But, if, at
any point, you change your mind and decide youd like to describe
a wish or goal you have for therapy, feel free to speak up.
Additionally, couples often want to wish only for their partner to change. Of
course, as noted before, this impulse should be avoided diligently, because usually couples have already been making many statements to each other like, If
280
only you would listen to me more, or If you would just accept me for who I
am, then wed both be so much happier. In the end, couples often are relieved
to discover their therapist will not let them engage in cross-criticism.
The three tips described in this article may be used independently or woven
together into a couple or family interview. Obviously, the romantic history
is appropriate only within couple counseling interviews. Radical acceptance
and wishes into goals may be used during couple, family, or individual
interviewing.
The following clinician-patient vignette illustrates the use of radical
acceptance, wishes into goals, and the romantic history within the context of
a reconstructed single initial couple therapy interview:
Clinician: Id like to begin by asking each of you about your goals for therapy.
Husband: I dont have any goals. She drug me here. I think this is totally stupid.
I dont believe in counseling.
Clinician: Well let me thank you for being so open. Its good to hear exactly
what youre thinking and feeling about this [radical acceptance]. Im especially impressed that youve come for this meeting even though youre totally
against it. It says something good about your commitment to your marriage
[reframing resistance into commitment].
Husband: Thats right. I aint giving up on this.
Clinician: That makes me think we should begin at the beginning. Id like both of
you to tell me, in your own words, exactly how you first met, what attracted
you to each other, and some pleasant memories from the very beginning of
your romantic relationship. Either one of you can go first, but remember, I
want to get a feeling for your initial meeting and early romance, and so
Ill be asking you each a number of follow-up questions [romantic history].
Wife: Id like to start [at this point, both patients describe their romantic history].
Clinician: Thanks to each of you for telling me about how you got together. Now
Id like to find out more about what youd like to do to improve your relationship. But first, lets begin with each of you talking about ways you might improve yourselves. If you had three wishes, but your wishes were restricted to
ways in which you might improve yourself, what would you wish for? Let me
emphasize: these wishes cannot be used to wish for your partner to change
in any way. They can be used only to wish for ways in which you might
change or improve yourself [wishes into goals].
SUMMARY
We hope the reader has found this brief description of how to use radical acceptance, the romantic history, and wishes into goals interesting and stimulating. In many ways, we find interviewing couples and families to be the most
overwhelming and fearsome of all clinical situations. We have found these
techniques are very helpful to couples and families and also helpful to clinicians
as they cope with their own feelings and reactions as they interview couples
and families.
281
References
[1] Rogers CR. A way of being. Boston: Houghton Mifflin; 1980.
[2] Linehan M. Cognitive behavioral therapy of borderline personality disorder. New York: Guilford Press; 1993.
[3] Hayes SC, Strosahl KD, Wilson KG. Acceptance and commitment therapy: an experiential
approach to behavior change. New York: Guilford Press; 1999.
[4] Sommers-Flanagan J, Sommers-Flanagan R. Counseling and psychotherapy theories in
context and practice: skills, strategies, and techniques. New York: Wiley; 2004.
[5] Young-Eisendrath P. Youre not what I expected: breaking the he said-she said cycle. New
York: Touchstone; 1993.
[6] Isen AM. Advances in experimental social psychology. In: Berkowitz L, editor, Positive affect,
cognitive processes, and social behavior, Vol 20. New York: Academic Press; 1987.
p. 20353.
[7] Sommers-Flanagan J, Sommers-Flanagan R. Tough kids, cool counseling: user-friendly
approaches with challenging youth. 2nd edition. Alexandria (VA): American Counseling
Association; 2007.
PSYCHIATRIC CLINICS
OF NORTH AMERICA
Designing Clinical Interviewing

Training Courses for Psychiatric
Residents: A Practical Primer
for Interviewing Mentors
Shawn Christopher Shea, MD*, Ron Green, MD,
Christine Barney, MD, Stephen Cole, PhD,
Graciana Lapetina, MD, Bruce Baker, EdD
Training Institute for Suicide Assessment and Clinical Interviewing (TISA),
1502 Route 123 North, Stoddard, NH 03464, USA
THE EXTENT OF THE CHALLENGE

The psychiatric expert is presumed, from the cultural definition
of an expert, and from the general rumors and beliefs about
psychiatry, to be quite able to handle a psychiatric interview.
Harry Stack Sullivan, 1954 [1]
Performing a sensitive and thorough initial interview in 50 minutes is one of

the greatest challenges in clinical practice. Teaching a young psychiatric resident how to do so is, arguably, an even greater challenge.
As psychiatric educators, we realize that interviewing is the foundation from
which all psychiatric care unfolds. It demands psychopathological knowledge,
interpersonal skills, and intuitive abilities. Thus, it is a true blending of science,
craft, and art. It also is a dynamic and creative process requiring a somewhat
elusive set of skills that, frankly, as Sullivan wryly alludes in our opening epigram, may not be part and parcel of every psychiatric graduates practice.
The importance of this set of skills has been highlighted by Langsley and Hollender [2]. Their survey of 482 psychiatric teachers and practitioners revealed
that 99.4% ranked conducting a comprehensive interview as an important requirement for a psychiatrist. This represented the highest ranking of 32 skills
listed in the survey. Seven of the top 10 skills were directly related to interviewing technique, including skills such as the assessment of suicide and homicide
risk, the ability to make accurate diagnoses, and the ability to recognize countertransference problems and other personal idiosyncrasies as they influence interactions with patients. These results were replicated in a follow-up survey [3].
*Corresponding author. Website: www.suicideassessment.com. E-mail address: sheainte@
worldpath.net (S.C. Shea).
doi:10.1016/j.psc.2007.02.004

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SHEA, GREEN, BARNEY, ET AL
Since the time of these surveys, interviewing, if anything, has become even
more challenging, for our time constraints have become more rigid under managed care, our paperwork demands more daunting, and the diversity of cultures
from which patients ariserequiring an increased flexibility and sophistication in
our interviewing styleshas jumped enormously as we experience new waves of
immigration. In like fashion, the designing of clinical interviewing training has become more demanding secondary to factors such as the ever-increasing complexity of the field and our decreasing resources in academia. In addition, some
internationally trained residents may require an increased amount of attention
as they adapt to the cultural nuances of psychiatric practice utilizing a language
that may not be the primary language of their country of origin.
As contemporary psychiatric educators (as well as educators in graduate programs in counseling, clinical psychology, psychiatric social work, and psychiatric nursing) we are facing two core challenges with regard to interviewing
training. First, programs must be developed that foster the trainees ability to
handle a wide diversity of clinical interviews with flexibility. The range of interview types includes 50-minute initial assessments, diagnostic interviews,
emergency room assessments, consultation and liaison evaluations, medical
and psychotherapy assessments, medication checks, and other more specialized
tasks, such as forensic evaluations or assessments of trauma victims.
To accomplish this goal, programs must be developed that help residents understand a core set of interviewing principles, that they can then generalize to
nurture competence in all of the interview formats described above. These
core interviewing principles must help the resident to naturally integrate
a wide range of interviewing skills such as engagement techniques, recognition
of defense mechanisms and dynamic conflicts, techniques for sensitively structuring interviews, approaches for performing a biopsychosocial assessment
that includes the exploration of cultural and spiritual themes, and methods of delineating diagnoses according to the Diagnostic and Statistical Manual, Fourth Edition, Text Revision (DSM-IV-TR) and the prospective DSM-V. To top it all off,
this massive data-gathering task must be performed in such a way that the patient
feels that he or she is having a conversation with a caring professional as opposed
to being interviewed by some guy with a clipboard. This is no easy task.
The second major challenge consists of developing interviewing training
courses that are individualized to the specific learning needs of the trainee,
for residents vary remarkably in the skill base they bring to their training
and in the fashions in which they learn best. It is our experience that the effectiveness of educational techniques may vary significantly with each resident.
High resident satisfaction with an individualized approach to learning interviewing has been empirically demonstrated [4].
For instance, some residents may require modeling experiences in order to
improve, while others may benefit more powerfully from readings or videotape
supervision. We believe that longitudinal, individualized training helps residents secure their newly acquired skills more effectively. This is important,
as at least one study suggests that interviewing skills can be easily lost over
DESIGNING CLINICAL INTERVIEWING TRAINING COURSES
285
time [5] and that the intensity of the training has a positive impact on interviewing skill acquisition [6].
This article was written to fill a gap in the literature. Despite the enormous
amount of material that has appeared over the years regarding clinical interviewing research (the interested reader can see a review of the literature [7]
and an annotated bibliography [8] of recommended readings for psychiatric
residents and educators regarding clinical interviewing), we have never come
across a no-nonsense primer on how to design clinical interviewing programs.
Such a primer would ideally provide core principles that might help a residency director, course director, or interviewing mentor design a practical clinical interviewing course. Moreover, to be effective, the primer should provide
principles that can allow each program designer to create a program that fits the
specific needs of his or her trainees within the limiting factors (and there always
are limiting factors) of his or her specific residency program.
It is our hope that we have created such a primer and that it will prove to be
immediately practical for the busy residency director. If successful, hopefully it
will also be fun to read, for, in our opinion, interviewing and the training of the
next generation of interviewers should always be fun. The article is informal,
and by its very nature, it is a reflection of our personal opinions. It is not presented as the right way to teach interviewing but merely as a generator of
potential solutions and guidelines.
For those readers who already have outstanding interviewing courses in place,
it is our hope that a few nuggets can be culled from this article that may enhance
them further. We would also love to hear from you and learn from your own experiences and successes. For those readers who are just starting up a course or are
trying to improve their current program, hopefully, this article will provide
a sound foundation for further design and implementation.
Throughout this article, I am sharing the considerable expertise of my coauthors who have been intimately involved as interviewing mentors at the Dartmouth Interviewing Mentorship Program (DIMP) that has been running
successfully at the Dartmouth psychiatric residency for more than 16 years.
Put simply, we are sharing our very best tips on interviewing training design
culled from the over 60 years of our combined experience as interviewing
mentors.
On a more personal note, it has been my privilege to devote more than 25
years to the study and training of psychiatric residents and other mental health
professionals in clinical interviewing, as well as founding the Training Institute
for Suicide Assessment and Clinical Interviewing (TISA). Having given over
500 workshops on clinical interviewing and interviewing training design in different academic and clinical settings, I have been able to learn, from clinicians
and trainers throughout North America, their best design ideas which I will
share in the following pages.
I was also fortunate to be the lead designer in two successful interviewing
training programs at psychiatric residency programs. The first interviewing
program was in the decade of the 1980s at Western Psychiatric Institute and
286
Clinic (WPIC) at the University of Pittsburgh, Pennsylvania [4,9]. The second

was the DIMP mentioned earlier, which we are describing for the first time in
this article. In addition to the innovations of these programs, we also intend to
share the mistakes made in each program from which we have learned some
painful lessons. Hopefully, we can pass on to you the solutions to these problems, so that you dont have to learn them the hard way, as we did.
Our approach in this primer is four-pronged in nature:
1. Delineate the core principles for designing and successfully implementing interviewing training programs
2. Describe the programs at WPIC and DIMP, thus providing the reader with
two distinctly different ways of successfully implementing the core principles
in settings where there were radically differing resources and limitations
3. Address some potential problem areas in design and how to avoid them
4. Include, as appendices, some key practical educational tools such as a list of
educational goals (regarding the acquisition of clinical interviewing skills)
and a sample course syllabus
These tools are not presented as the final word, but merely as springboards for your own creative design purposes.
THE SEVENTEEN GOLDEN PRINCIPLES FOR DESIGNING
INTERVIEWING TRAINING PROGRAMS
Principle #1: Use Direct Observation and Mentorship
If the reader were to remember only one principle from this article, the following is the most important thing we have to say: to ensure that a resident has
learned an interviewing technique, one must directly observe the resident demonstrating the technique. Direct observation (by being present in the room, behind a one-way mirror, or videotape) is essential for a sound interviewing
program. Direct observation is optimized when combined with immediate feedback, coaching, and role-playing until the resident gets it right. We call this
process of ongoing observation and corrective coaching mentorship.
Clinical interviewing is a profoundly complex procedure. One cannot teach
a student how to drive a car by giving a lecture or telling the student to read
a book. These educational venues can help, but the bottom line is simpleto
teach driving, you must watch the student drive. There is no other way. So
it is with clinical interviewinga behavioral task vastly more complex than driving a car.
By way of perspective, in the state of New Hampshire, where Dartmouth is
located, student drivers must have a parent watch them drive at least 20 hours
(in addition to taking a drivers education course) before even attempting a driving test. How many psychiatric residents have had 20 of their 50-minute
outpatient intakes watched in their entirety by a seasoned clinician before graduating? Bottom linethe more direct supervision you can provide, the better.
We have been consistently surprised at how badly a resident may translate
what is an excellent interviewing technique they heard in lecture or read about
287
in a book, into a poor interaction when the resident subsequently tried to utilize
the technique with a real patient. Perhaps this fact should not be so surprising,
for so much of the power of interviewing techniques depends on nonverbal
communication and sensitive timing. Nevertheless, there is only one way to
know whether interviewers are translating interviewing techniques from the
classroom to the interview room successfully: watch them do it.
It has been a welcome development that residency programs recently have
introduced practice oral boards where the mock board interview is observed.
In no way shape or form, is such an exerciseuseful as it may be in the context
for which it was designed (preparing one for the oral boards)a replacement
for clinical mentorship in which an experienced coach, familiar with the residents strengths and weaknesses, sits in the room and directly observes the resident doing actual clinical interviews longitudinally over time.
Principle #2: Focus Upon Learning a 50-Minute Intake
We suggest that, when designing an interviewing training program, you focus
upon ensuring that a resident, before graduation, can adequately perform
a standard 50-minute outpatient initial assessment. Such interviews are, arguably, the most difficult to perform because of the massive database required
while developing a powerful alliance with the patient. More importantly, the
interviewing principles used to perform such interviews can be applied easily
to other interview tasks. In addition, such an interview may represent the single
most common interview that a resident will need to utilize upon graduation being the cornerstone interview required in community mental health work and
in private practice.
Principle #3: Model a Complete Initial Interview
Before a trainee can do an initial interview effectively, they must see one done
effectively by an experienced clinician from beginning to end. Toward this
goal, when beginning a mentoring program with a resident, we often have
the mentor perform the very first scheduled interview. It allows the resident
to observe a full intake, and it offers, in the post-interview discussion, a chance
for the mentor to share things he or she would have done differently if given
another chance. This sharing often goes a long way toward breaking the ice
in supervision. Another option is to have a skilled clinician make a videotape or
DVD of a nicely performed outpatient intake, which can then be reviewed by
all trainees.
Principle #4: Use Multiple Educational Formats to Provide a Sound
Theoretical Framework
A sound theoretical understanding of interviewing goals, techniques, and strategies should be provided either by didactics or book, and we strongly suggest
the use of both approaches. Reading can provide a powerful means of consolidating didactic information. It also allows for further exploration of topics that
have piqued the students interest. There are many outstanding major texts,
and you cant go wrong with any of the following, which I shall list by
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alphabetical order of author: Carlats The Psychiatric Interview: a Practical Guide

(2nd edition) [10], The Psychiatric Interview in Clinical Practice (2nd edition) by
MacKinnon et al [11], Morrisons The First Interview: Revised for DSM-IV [12],
Othmer and Othmers The Clinical Interview Using DSM-IV TR (Vol. 1: Fundamentals) [13], Sheas Psychiatric Interviewing: the Art of Understanding (2nd edition)
[14], and Sommers-Flanagans Clinical Interviewing (3rd edition) [15].
Principle #5: Create an Educational Goals List (EGL)
It is very useful to have a listing of the educational goals, with regard to interviewing skills, which you expect the resident to have addressed by the end of
the interviewing course. This educational goals list (EGL) provides the resident
with a clear understanding of what is expected and also motivates residents to
read more aggressively from the selected textbook, for they can readily see
what they know and what they dont know. Equally important, the EGL provides a concrete checklist for mentors to track the development of the trainees
progress, to identify weak areas, and to address these weak areas effectively.
Appendix A of this article provides a sample EGL.
Principle #6: Integrate Diverse Mental Health Disciplines
Residents seem to respond enthusiastically to courses that integrate interviewing techniques developed by experts from diverse mental health disciplines.
We have found that residents enjoy learning about techniques developed by
psychologists, counselors, social workers, and nurses as well as those created
by psychiatrists (indeed, some of the most powerful interviewing techniques
have come from nonpsychiatric disciplines, such as the behavioral incident
by Pascal [16] and motivational interviewing by Miller and Rollnick [17]).
Such training also prepares residents to work effectively in multidisciplinary
teams. Nothing helps to cement a sound working relationship with the outpatient psychotherapists in a community mental health center than a psychiatrist
who talks glowingly about a technique learned in her or his residency that was
designed by a psychologist or counselor.
We recommend describing such techniques in your didactics or choosing
a book on clinical interviewing that specifically pulls on multiple disciplines
[14]. Note that the presence in the class of different disciplines among the
trainees, or the mentors, can significantly enhance this process as well, but is
not necessary. In this regard, two of our most popular mentors with psychiatric
residents have been clinical psychologists.
Principle #7: Emphasize the Integration of Interviewing Skills
When teaching, it is valuable to emphasize the integration of numerous skills
into a single clinical tapestry by modeling engagement techniques, differential
diagnoses, and psychodynamic principles in integrated tasks as they appear
in actual clinical practicenot as isolated skills. Such integration is enhanced
by making sure that the resident knows, while being observed interviewing,
the specific interviewing task at hand and is urged to use all available skillsets to do it well. Thus, the trainee may be told to demonstrate a differential
289
diagnosis by the DSM-IV-TR, but will be pushed to do so while using specific

engagement skills and understanding the psychodynamics needed to help the
patient feel comfortable and to increase the likelihood of uncovering valid data.
Principle #8: Place Course in the Real World
The course should occur in a setting or clinical rotation in which the importance of the interviewing skills is immediately evident to the resident because
they are the exact skills that the resident must use to complete his or her daily
work. Thus, the training of an outpatient initial interview should, preferably,
be taught on a rotation in which the resident is doing outpatient intakes, not
while the resident is solely on an inpatient unit. If at all possible, the observed
interviews should be with actual patients that the resident is performing a clinical task and for which the resident will be responsible for the subsequent writeup and triage.
Principle #9: Individualize the Training
We feel that the most effective interviewing training is individualized. In individualized training, the mentor becomes aware of the residents strengths and
weaknesses, and the resident and the mentor have mutually agreed on which
interviewing skills are being focused upon in each session of mentoring.
Principle #10: Maximize Learning by Using a Well-defined Supervision
Language
It is useful to define the interviewing skills and educational goals with a concise
and clarifying supervisory language. The past two decades have seen significant advances in the development of reliable and operational supervisory languages that can greatly enhance the learning of interviewing skills by residents.
Naturally, you should choose whatever supervision languages and terms fit
best with your own interests and goals.
As an example, I will describe a supervision languagefacilics [4,9]developed years ago that we have found to be quite useful in transforming an almost
universal problem with young residents: how do you sensitively uncover the
huge database of an initial assessment in 50 minutes, while trying to engage
the patient in a conversational mode? Errors range from serious gaps in important data to interviews where rapid-fire questions create a disengaging Meet
the Press interview style. Of course there are also the one-hour-intakes that
run two or more hours in length!
Facilics, a term derived from the Latin root facilis meaning ease of movement, is the study of how clinicians gather data and utilize time while trying to
engage patients effectively. The language allows the resident to recognize,
within his or her own interviewing style, seven different methods (called
gates) of making transitions from topic to topic in an interview. This gating
has a lot to do with whether or not a residents interview feels smooth and conversational to the patient as opposed to stilted and artificial.
Facilic supervision also addresses the interviewers method of exploring specific data regions with an emphasis on creating a thorough, yet engaging
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interview style. It further provides the resident with an objective and clarifying
look at how he or she uses time constraints effectively or poorly. We have
found that facilic principles can be used to better understand, and to more effectively perform, all interview formats from a 50-minute standard intake to
a 20-minute emergency room assessment. As an added bonus, an understanding of facilic principles can help the resident to pass the oral boards after
graduation.
The supervision system was designed to be easily learned. It also has a set of
specific symbols that supervisors use to map out the residents structuring
maneuvers as the interview proceeds. This shorthand system was designed
to clarify educational concepts and to highlight structuring problems and skills,
while presenting an immediately understandable visual record of what took
place in the interview.
In addition to being useful in coaching the resident immediately after the interview is completed, the graphic system has been useful in videotaped supervision and as a visual springboard for group discussion during class sessions. It
also provides a permanent record of the residents progress over time.
When residents in the WPIC program [4] were asked to rank 12 different
educational tools including didactics, role-playing, direct supervision, textbooks, and videotaping, facilic supervision received the most votes as being
valuable in learning the art of interviewing. Facilic supervision now is used
across mental health disciplines, both nationally and internationally, and has
been translated into Spanish, French, and Chinese.
In the DIMP, residents have shown a robust appreciation for the use of facilic supervision. For your convenience, we have provided a guide (and a programed text) to the use of facilic supervision and its schematic shorthand in the
electronic version of the article by Shea and Barney, (Facilic Supervision and
Schematics: The Art of Training Psychiatric Residents and Other Mental
Health Professionals How to Sensitively Structure Clinical Interviews) in this
June issue of the Psychiatric Clinics of North America in our Web Archive at
www.psych.theclinics.com. We hope that you enjoy it and find it useful.
Principle #11: Use the Elicitation of Suicidal Ideation as a Prototypic
Interviewing Skill
We believe that all graduates of a psychiatric residency should be able to demonstrate proficiency in the critical art of eliciting suicidal ideation. Indeed, we
feel that this skill should be addressed early in the residency, before their oncall duties begin, if possible. In our opinion, a good place to start such training
is with the Chronological Assessment of Suicide Events (CASE) Approach,
a widely utilized interview strategy that can be taught easily and in which
the residents competency can be tested objectively [14,1820].
The CASE Approach is a flexible and practical interview strategy for eliciting
suicidal ideation and behaviors over four chronological time frames. These
four time framesPresenting, Recent, Past, and Immediate Suicidal Ideation/
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Behaviorsare explored using four specific interviewing validity techniques.

These four validity techniques: the behavioral incident, gentle assumption,
symptom amplification, and denial of the specific, were culled from the pre-existing clinical interviewing literature in the fields of counseling, clinical psychology, and psychiatry.
Because the strategies of the CASE Approach are based on identifiable interviewing techniques, the residents skills can be easily observed, monitored
over time, and objectively tested, ensuring that the resident can effectively
elicit suicidal ideation using a reasonable method before graduating the
residency.
We recommend the CASE Approach because it has been described extensively
in the literature [14,1820] and has been enthusiastically received among mental
health professionals, substance abuse counselors, school counselors, primary
care clinicians, and clinicians in the correctional system [2127]. It is routinely
taught as one of the core clinical courses provided at the annual meeting of the
American Association of Suicidology (AAS). It is also one of the techniques described in the one day Assessing and Managing Suicide Risk Course, co-sponsored by the Suicide Prevention Resource Center (SPRC) and the AAS.
From an administrative perspective of a residency director, it is reassuring to
know that all ones residents have been trained in a reasonable method of eliciting suicidal ideation, that has extensive face and construct validity, that may
hopefully save lives, and that also might significantly decrease the likelihood of
malpractice suits. Once again, for your convenience, more information about
the CASE Approach, including a method of teaching it called macrotraining,
appears in the electronic version of the article by Shea and Barney, (Macrotraining: A How-To Primer for Using Serial Role-Playing to Train Complex
Clinical Interviewing Tasks Such as Suicide Assessment) in this June issue of
the Psychiatric Clinics of North America in our Web Archive at www.
psych.theclinics.com.
Principle #12: Monitor Ongoing Progress
The residents progress should be monitored in an ongoing and continuous
fashion. You may find that a self-monitoring log or journal of what the resident
is working on, and their progress to date, can be useful.
Principle #13: Flexibly Utilize Educational Tools
It is valuable to provide access to a range of educational techniques and resources such as a core textbook, supplemental reading list, and various combinations of direct and indirect supervision, always creatively changing
educational approaches to the learning needs of the trainee.
Principle #14: Ask for Ongoing Feedback
Ongoing feedback from your residents during the mentorship, including his or
her attitudes toward how much they like specific techniques (role-playing,
videotaping, etc.) can help you to individually shape the learning experience
as it unfolds, maximizing the residents growth.
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Principle #15: Organize a Monthly Mentors Meeting

If your program utilizes more than one mentor, we feel that it is very important
for them to meet routinely as a group, about once a month, for a two hour block.
Over the past 16 years, we have found these meetings to be fun and also important for the success of the program. During the mentor meetings, the mentors review the videotapes made by all the trainees, thus offering an opportunity for
each of us to spot points for supervision that the trainees own mentor may
have missed. In essence, each trainee gains the input of a handful of different
mentors all observing the same tape. It is a uniquely rich training opportunity.
In these sessions, mentors can review the supervision language, ensuring that
there is a consistent use of terminology among mentors. We also role-play
training techniques with each other. Such role-playing ensures two quality assurance factors: (1) our fidelity to the teaching model and (2) consistency
among mentors in the use of the various supervision languages, such as facilics,
and in the teaching of interview strategies, such as the CASE Approach.
Also, specific problems with trainees, including resistance to training and
problematic attitudes, can be addressed, with creative solutions often resulting.
During these meetings, we also make design changes in the course based on
resident feedback or changes in resources. Finally, the mentor meetings give
a cohesiveness to the group and an identity that helps keep us fresh, so that
mentors often stay with the program for years (three DIMP mentors have participated in the program over 15 years).
Principle #16: Update Didactic Classes
Keep an eye on updating didactic classes, for although interviewing techniques
and strategies do not change with the ferocious rapidity of psychopharmacological interventions, new ideas do indeed appear. Sometimes entirely new topics
emerge in which significant advances have been made with regard to interviewing
strategies and techniques. For instance, we have currently added an hour-andone-half workshop on How to Talk with Patients About Their Medications
based on new work in this critical, yet often overlooked area. The workshop focuses on the use of specific questions and statements to enhance medication adherence rates while further solidifying the therapeutic alliance [28].
Another interviewing area that has emerged recently which warrants, in our
opinion, a class in an interviewing course syllabus, is the topic of cultural diversity. Although attention to this pivotal topic is now required in residency training, we think a specific lecture on interviewing questions and attention to
nonverbal differences in culture (from seating arrangement to the role of eye
contact) can be valuable.
In addition, we feel that a class devoted to interviewing techniques for sensitively exploring the spiritual beliefs and worldview of patients is important.
Josephson and Peteet [29] and Griffith and Griffith [30] have written very practical and informative books on this subject. Be sure to check out Josephson and
Peteets outstanding article on this exact topic in this issue of the Pyschiatric
Clinics of North America.
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Another topic that warrants a class, in our opinion, is the rich arena of how
to talk with the family members of patients dealing with severe and persistent
mental illnesses such as schizophrenia and bipolar disorder, as well as difficult
personality processes such as borderline personality disorder. Topics in such
a class can describe specific questions and statements that help family members
to understand these illnesses, to decrease their stigmatization, to feel comfortable getting their needs met by staff, to ease feelings of guilt and shame, and
to learn how to respond appropriately to the symptoms of their loved ones
from hallucinations to self-cutting or suicidal behaviors. The article in this issue
by Murray-Swank, Dixon, and Stewart is a superb introduction to these interviewing topics.
Principle #17: Use Your Interviewing Course as a Recruitment Tool
Both at WPIC and Dartmouth, we found that our comprehensive interviewing
training programs were powerful recruitment tools for attracting high-quality
residents. Resident applicants were well aware that interviewing skills were critical to their training and were impressed by the presence of interviewing mentorship, in addition to psychotherapy supervision, at both the WPIC and the
Dartmouth programs.
TWO SAMPLE INTERVIEWING TRAINING PROGRAMS:
STRENGTHS AND WEAKNESSES
We doubt that an ideal interviewing training program can ever be created. Resources in contemporary residency training are simply far too scarce to do so.
Moreover, an ideal interviewing training program that cannot be implemented is not ideal; it is foolish. Thus, we are all faced with the tough task
of designing the best interviewing training programs that we can with the resources we have available. In some instances, the program that is designed
may be fairly minimal, but a well-thought-out minimal program is still much
better than no program at all, especially if (1) it sparks the interest of the resident to further improve his or her interviewing skills and (2) provides the theoretical framework from which the resident can do so.
On the bright side, we dont think that most programs must be minimal in nature, nor should they be minimal considering the immense importance of clinical
interviewing skills. Armed with a sound theoretical approach to designing interviewing training programsas we are trying to provide in this primerwe feel that
surprisingly robust programs can be developed even with limited resources.
In the following section, we will show two widely differing programs that we
feel have been very successful, as indicated by resident satisfaction and longevity of the programs. It is hoped that they will provide models from which the
reader can pick and choose bits and pieces to create a viable and lively program
in their own psychiatry department.
For the most part, each of the programs implements all the core principles
listed above. Naturally, each program implements them with varying degrees
of efficacy secondary to limitations on the number of mentors, institutional
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politics, residents schedules, and the availability of clinical rotations willing to

support the training. Consequently, the strengths and weaknesses of each program will be addressed as well.
We want to emphasize that a high-quality interviewing training program
does not have to incorporate all 17 principles described in the previous section.
Rather, we are saying that by incorporating as many of the principles as resources allow, you are likely to maximize the benefits of your program and
minimize its weaknesses.
Western Psychiatric Institute and Clinic (WPIC) Interviewing Course
(19831988)
The biggest challenge for this program designand it was a big onewas that
only one faculty member (myself) was available to teach a course on interviewing
while trying to provide mentorship to more than 40 residents (slightly more than
ten a year). Such a limited teaching force is fairly common, and this program
demonstrates some methods that might help you navigate such a challenge.
To begin with, in order to offset the obvious decrease in time that could be
devoted to mentoring, this course emphasized the use of didactic material, but I
tried to make sure that all the didactic material could be immediately applied to
the direct clinical experience and supervision of the residents. Consequently,
placement of the course became critical, and I looked for a spot where, even
though I could only provide two or three sessions of direct mentoring, the resident might be able to observe interviewing by other experienced faculty and
perhaps receive some feedback from them as well.
The training program subsequently was integrated into the three month
rotation at the Diagnostic and Evaluation Center (DEC) at WPIC, of which
I was the medical director. Residents usually hit this rotation during postgraduate year (PGY) II or PGY III. This unit functioned both as a full intake
assessment center and as a psychiatric emergency room. Several times a day
while on this rotation, residents were required to conduct two significantly
different styles of interview tailored to the clinical task at hand, classic 50minute intakes and 20- to 30-minute emergency room assessments. After
the resident interviewed the patient and presented to a faculty psychiatrist,
the patient was also interviewed briefly by the faculty, providing the resident
a chance to observe the faculty members interaction with the patient.
During the rotation, residents attended 17 1.5-hour classes dedicated to interviewing techniques (In Appendix B, a prototype of a class syllabus is provided
for your use that has been further expanded and improved upon from my subsequent experience over the years). The first 30 minutes was devoted to lecture. In the second 30 minutes, one of the trainees interviewed a patient
from the DEC (or from an inpatient unit if no clinic patient was available) in
front of the class with all participants in the same room as the interviewing
dyad. In the last 30 minutes, the group discussed the interview and provided
constructive feedback (partially compensating for the lack of direct
mentorship).
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Classes were composed of 6 to 14 mental health trainees including psychiatric residents, clinical psychology interns, psychiatric nurses, social work interns, family practice residents, emergency medicine residents, counseling
students, and medical students. This multidisciplinary learning cohort provided a rich arena for personal growth and learning. The lectures and readings
(a draft of my eventual textbook, Psychiatric Interviewing: the Art of Understanding,
which evolved from the lectures themselves) provided a theoretical overview
covering the Educational Goals List (EGL), while integrating numerous
schools of thought and disciplines including descriptive psychopathology, psychoanalysis, counseling, and clinical psychology.
From an experiential perspective each resident had to observe at least two
videotaped intakes from our experienced staff. I only had time to provide direct
supervision (mentorship) to the psychiatric residents. Two forms of direct supervision were used. Each resident videotaped an initial intake, which I then
reviewed alone first, and then reviewed together with the resident to pick
out a few areas for improvement. Subsequently, I sat in and directly observed
the residents entire interview (sometimes demonstrating specific techniques)
on two or three occasions.
The strengths of this program are obvious. For a more detailed description,
including empiric data on resident satisfaction, the following papers [4,9] will be
of value.) In my opinion, the theoretical framework provided by the lectures
and the textbook was pivotal to the success of the program. Having this material immediately amplified by watching another trainees interview, and then
discussing it as a group, enhanced both enthusiasm and understanding. It
was also hard to beat the rich multidisciplinary milieu, and it was gratifying
to see the interdisciplinary walls fall as the course proceeded and genuine
cross-discipline respect grew.
Residents also reported benefiting greatly from the review of their videotape,
which was completely mapped out using facilic schematics. The majority of residents reported that one of the most powerful learning experiences was the two
or three sessions of subsequent direct mentorship with me sitting in the room as
the interview proceeded, once again noting the facilics of their interview. Residents strongly urged that the number of direct mentorship sessions be markedly increased. Alas, I could only do 2-3 because of time constraints, which
was the most striking deficit of the program, a deficit that in the DIMP would
be dramatically addressed.
Dartmouth Interviewing Mentorship (DIMP) Program (19892004)
In the Dartmouth interviewing program, we were able to capitalize on all
that had been learned at WPIC, but we also had some new limiting factors.
Specifically, since I was an adjunct faculty and lived 1.5 hours from the
Dartmouth Medical Center, it was not feasible for me to both teach a 17class course and to attend monthly mentors meetings. Thus, we had to
come up with a different way to approach the didactic teaching component
of the program.
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From the experiences at WPIC, it was clear, from the empirical resident feedback, that the most popular learning came from direct mentorship. Consequently, we wanted to turn the thrust of our resources towards providing
a longitudinal mentorship experience for the residents.
By presenting at Grand Rounds outlining the core principles of designing an
ongoing interviewing mentorship program (which included a description of facilic supervision, elements of the CASE Approach, and my experiences at
WPIC), we had over 10 faculty who wanted to become interviewing mentors.
By the time we were done training the volunteer faculty over the next year we
had a solid core of six committed interviewing mentors, for the most part allowing each mentor to work with one resident per year.
To address the absence of an ongoing didactic class, as had been present at
WPIC, we decided to emphasize the textbook [14] as the cornerstone of the
ongoing didactics, for it comprehensively covered almost all of the material
in our EGL as well as introducing the student to facilics, the CASE Approach,
and several other interviewing languages that had proved popular at WPIC
(eg, the teaching of validity techniques including the behavioral incident, shame
attenuation, gentle assumption, symptom amplification, and denial of the specific, as well as a supervision language called the Degree of Openness Continuum (DOC) that gave residents an objective awareness of the style of
questions they were using.)
In addition, the year-long mentorship, placed into the PGY III year when residents were doing their outpatient clinics, was kicked-off with two full-day
workshops given 1 week apart. Each day had four workshops of 1.5 hours.
Topics covered included
Day 1:
1. The Initial Interview; Traps, Roadblocks, Strategies and Solutions (which included a complete experiential introduction to the facilic system and schematics that the mentors would be using)
2. Videotape Demonstration of a Complete Initial Interview done by myself
which was meticulously torn-apart and analyzed (mapping the entire interview out on a large whiteboard with facilic symbols)
3. Videotape Demonstration Continued
4. Understanding the Power of Our Words (an introduction to the DOC supervision system that the mentors would be using to help the residents achieve
an objective understanding of their frequency of open-ended questions, frequency of leading questions, and style of empathic engagement)
Day 2:
1. The Creative Use of Object Relations in the Initial Interview: The Importance
of Psychodynamics
2. Interviewing Techniques for Uncovering Personality Dysfunction on Axis II of
the DSM-IV (with video demonstration)
3. Uncovering Sensitive and Taboo Material: An Introduction to Five Interviewing Techniques for Improving Validity (with video demonstration)
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4. Uncovering Suicidal Ideation and Intent: The Chronological Assessment of

Suicide Eventsthe CASE Approach (with video demonstration)
At the end of the year-long mentorship, there was a third all-day workshop
that was hosted at the residency directors house and was handled more as a retreat. In its final format it included three workshops: (1) Transforming Confrontational Resistance: Angry Exchanges and Awkward Personal Questions
from Patients, (2) An interactive group session focusing on an understanding
of the personal impact and meaning of suicide on families, staff, and oneself (we
pushed the residents to uncover their personal biases about suicide and how
these biases could impact on their interviewing styles and their ability to spot
suicidal patients), and (3) How to Talk with Patients About Their Spirituality. We made a point of familiarizing residents with a variety of appropriate
responses for handling difficult questions such as, Dr. Shea, do you believe
in God? We felt that unless residents felt comfortable handling this question,
they would be hesitant to ask patients about their religious beliefs. At the end of
the retreat, we spent an hour garnering feedback from the residents on how we
could improve the year-long mentorship.
The mentorship began with the mentor and resident meeting for an hour to
discuss what the mentorship would be like and agreeing on a set time to meet
for 2 hours every other week. Then the resident would make a videotape of an
initial 50-minute intake. The mentor would review the intake by himself or herself
and carefully map the interview out using facilics, noting such things as the use of
empathy and engagement skills, the degree of open-endedness, the residents
nonverbals, and the residents approach to specific clinical tasks such as eliciting
suicidal ideation and performing a differential diagnosis using the DSM-IV.
At this point, the mentor and resident would meet for 2 hours to go over the
videotape and develop an individualized learning program with two to four
specific, mutually agreed-upon interviewing techniques, as areas for focused attention. Learning goals were operationalized and described by specific terms
such as decreasing the number of phantom gates, increasing the number
of natural gates, and utilizing gentle assumption, etc.
The specificity of the supervision terms was greatly appreciated by residents.
They reported that the well-defined supervision language made it easy for them
to see what specifically needed to be done. Moreover, once they did it they
could subsequently see their progress, providing a positive feedback loop
which further motivated them to work harder on their interviewing. After goals
were set in the initial meeting, it was agreed that the mentor would subsequently help the trainee master these skills. As the year progressed, once mastery was accomplished, new goals were set. Both in the initial videotape review
and in ongoing mentorship, we emphasized positive re-enforcement.
From this point onwards, the mentor and trainee began to meet during the
agreed-upon 2-hour blocks every other week. In the first hour of the sessions,
the mentor would observe the resident doing a full initial intake interview in
the clinic with the mentor in the room.
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As the interview proceeded, the mentor would map out the interview with
facilics and note everything from psychodynamics and structuring techniques
to the residents nonverbals and style of questioning using the DOC language,
always carefully attending to the agreed-upon areas for improvement. By being
in the room, the mentor could have the opportunity to demonstrate a specific
interviewing strategy for the resident with the actual patient, providing a powerful learning experience. In the second hour, the mentor would provide feedback and coaching on what had just occurred. Role-playing was used to help
consolidate specific interviewing techniques.
The resident was urged to continue to focus upon their agreed-upon interviewing goals in all subsequent interviews between mentoring sessions (a 2week span). Some residents did this informally; others actually kept a behavioral self-monitoring form of their progress in the interviews performed
between mentoring sessions. The self-monitoring form was then reviewed by
the mentor at the beginning of each 2-hour block.
This self-monitoring approach helped residents understand that much of the
work of the training programpracticing techniquesactually would occur outside the mentoring sessions, during their clinical interviews between sessions. It
would be during these between-session interviews that much of the most productive work and improvement would occur, a process that parallels a psychotherapy patients learning that much of the real work of therapy occurs between
sessions (a point not missed by residents interested in doing psychotherapy).
Unlike the WPIC program, the very first interview was done by the mentor so that the resident would see a second clinician (my videotape presented
in the First Day workshop being the first clinician) perform an initial interview from front to back, including observing nitty-gritty details such as
how the mentor takes notes and why. As mentioned earlier, the willingness
of the mentor to put herself or himself on the spot frequently helped break
the ice in the mentorship dyad, especially if the mentor made some mistakes
and openly discussed how she or he could have done the interview
differently.
Throughout the year-long coaching, the mentor would refer the resident
back to readings from the textbook that seemed particularly germane to the patient just interviewed or could help clarify or consolidate a technique that
seemed confusing. For instance, if the patient exhibited subtle signs of psychosis that the resident did not recognize, then the resident would be referred to
the chapter on interviewing techniques for uncovering psychotic process. In
the next session of role-playing (as described below), the mentor and trainee
could discuss aspects of the chapter and then role-play appropriate techniques.
If a patient did not show up as scheduled (happened about one third of the
time), the 2 hours would be devoted to role-playing the specific techniques the
resident had chosen to develop or that patient interactions had brought to light
as areas of interest.
It was also during one of these no-shows that the mentor could conveniently role-play a patient with suicidal ideation and ask the resident to
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demonstrate the effective use of the CASE Approach to ensure that residents
were competent in eliciting suicidal ideation (in future weeks, as the mentor
observed the resident interviewing actual patients, the mentor could note
whether the resident had successfully incorporated the CASE Approach
into their ongoing work). Over the course of the year, most residents were
observed doing about 10 to 15 actual interviews, with the other sessions being filled with role-playing.
The biggest disadvantage of the DIMP program was the loss of an ongoing
multidisciplinary class, where trainees observed each other interviewing and
shared feedback. Fortunately, the textbook emphasized multidisciplinary techniques, but the actual class interaction was a definite loss when compared to the
WPIC program.
In our opinion, this loss was far outweighed by the significantly more comprehensive nature of the mentoring process, which received high praise from
the residents. The longitudinal mentoring and diversity of patient presentations, the development of specific goals for improvement, the ability to practice
and consolidate these goals by role-playing, and the richness of the relationship
that developed over the year between mentor and resident were invaluable. To
boot, providing mentorship was great fun, with most mentors finding the vivid
interactive quality and the ability to actually see the residents skills improve in
front of them, highly enjoyable.
In addition to concrete improvements in interviewing skills, many of the residents seemed to gain a variety of intangibles such as increased confidence, increased excitement about interviewing, and, in many cases, an improvement in
his or her ability to have an observing ego while interviewing (an ability that
proved to be a boon to their development as psychotherapists as well).
In the 15 years of running the program, only a handful of residents balked at
the process. In these cases, issues such as insecurity, social anxiety, or passiveaggressive tendencies seemed to make direct supervision more threatening.
Fortunately, the longitudinal quality of the mentorship sometimes allowed
the mentor to help the resident overcome these obstacles, while in a few instances, important deficiencies in the residents skill or attitude were uncovered
and brought to the attention of the residency director for intervention.
POTENTIAL MISTAKES IN COURSE DESIGN
AND HOW TO AVOID THEM
Required Course Versus Optional
From our experience we have become convinced that you should always make
sure that the clinical interviewing course and mentorship is required. At both
WPIC and Dartmouth, an optional format was tried briefly. In both instances,
the results were dismal. If the course is made optional, it can metacommunicate
that interviewing is not that important. It is obvious to residents that the residency course in psychopharmacology is not optional, and if the interviewing
course is optional, the resident has to wonder about the importance of the topic.
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Moreover, even the most motivated of residents can be appropriately hesitant about being directly observed, and they are also frequently dealing with
heavy workloads. Consequently, even some of the better trainees may not
sign up or may slowly drop out because Im just so busy right now. Finally,
the residents who may most need the trainingresidents with weak interviewing skillswill probably be the least likely to sign up for the course.
PGY-I versus PGY-II versus PGY-III
From our set of core principles, you will recall the importance we placed on
scheduling the program at a time when residents are doing outpatient assessments (one of the single most critical factors for success of the program).
The first year that we implemented the course at Dartmouth, we placed it in
the PGY-II, thinking the sooner the better with regards to providing residents training in interviewing. At Dartmouth, these residents were primarily
on inpatient units, and we found that they just didnt quite get the tight
time constraints of a 50-minute hour nor the specific difficulties unique to
outpatient settings. Moreover, they were still so early in their training that
they were somewhat flooded with information to learn and also lacked much
of the observing ego that is useful for maximizing direct supervision. We
then took this exact same group of residents and gave them interviewing mentors in PGY-III. Almost all of them said this time frame provided a significantly
better learning experience.
If your outpatient experience is primarily in PGY-II, then the mentoring program is best suited there. It simply depends on the scheduling of this type of
clinical experience in your residency program.
On the other hand, we now lean towards placing some components of interviewing training at differing time points in the residency. For instance, very
shortly after completing their medical internship, as they begin their actual psychiatric training, we think it is a great time to give the residents the didactics
(including video demonstrations if available) on validity techniques and the
elicitation of suicidal ideation by methods such as the CASE Approach, as
they are beginning their on-call duties.
First, this early exposure to key interviewing skills may significantly improve their ability to deliver quality emergency room care or quality interventions on inpatient units late at night while being on-call. Second, it
provides the resident, firsthand, with personal experience that interviewing
techniques can be immensely practical and useful in their everyday work,
thus priming them to be interested in interviewing as the residency continues. This may also be a good time to give the residents whatever textbook you choose on psychiatric interviewing, so that interested residents
can read and obtain a theoretical framework for their early interviewing
practice.
In PGY-II, if you have the capabilities to have a series of didactic classes as in
the WPIC program, this can provide valuable information while stoking interest in learning about interviewing. Chapters from the book can be given as
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required reading, week by week, and discussed in the course. Such a structured
setting greatly increases the likelihood that the trainees will both do and enjoy
the reading as well as learn from each other.
If an appropriate outpatient experience also is available during PGY-II, then
you could simultaneously run the year-long mentorship program. If not, the
PGY-II classroom course would be followed by the mentoring program in
PGY-III. Such a set-up might almost be ideal, providing residents with an extended interviewing focus that moved with the resident throughout the first
three years of training.
PGY-IV residents, who were particularly excited about interviewing, can be
trained as interviewing mentors and attend the interviewing mentors monthly
meetings. This was done at Dartmouth and the residents found it to be a powerful experience, some of whom later became full-time faculty and official mentors. Once again there is no right way, but these are suggestions to get you
started.
One Mentor Versus Multiple Mentors
At the WPIC program there was only one teacher and mentorme! This
greatly limits the number of hours of mentoring each resident receives. It
also jeopardizes the longevity of the program if your mentor leaves. Keep in
mind, you can still provide an excellent experience with just one person, as
was done at WPIC, and you may not have a choice because of limited faculty
availability.
On the other hand, if at all possible, try to utilize multiple mentors, which
can greatly increase the amount of direct supervision. If you do this, remember
the importance of providing for the ongoing recruitment and training of new
mentors, for suddenly a group of mentors may disappear, leaving the program
precariously short-staffed, a problem we encountered at Dartmouth. We now
realize that ongoing recruitment must be built into the program. Having PGYIV residents (often chief residents) become mentors is one way of approaching
this problem, for some residents stay to become faculty, often subsequently volunteering to become interviewing mentors.
Also remember the importance of the monthly mentor meetings. Although
requiring time, we view these meetings as critical for maintaining the viability
of the program over time. Mentorship is time consuming and can be frustrating
in those rare occasions when you have a problematic resident. The camaraderie, cohesiveness, and joint problem- solving of supervision problems provided
by the monthly mentor meetings is valuable in attracting and keeping mentors.
All mentors must be required to attend.
SUMMARY
Always keep in mind the value of flexibility. Each residency brings with it, its
own limitations in resources and its own potentials for creative solutions to
those limitations. In any given residency one must determine which educational techniques may be most cost effective. Depending on the availability
302
of resources, the core principles outlined in this article can be implemented in

varying fashions. For instance, one program might meet the need for a wellgrounded theoretical foundation through the use of didactics, a textbook,
and supplemental readings. Another program might meet this need without
the use of lectures, using a small-group seminar format and a textbook instead.
In the long run, one of the major goals of any interviewing training program is
to stimulate intellectual excitement about the interviewing process. It is hoped
that this excitement will involve residents in an ongoing exploration of their interviewing styles, that will continue until the very last interview of their careers.
Only if this openness for future learning has been achieved can a clinical interviewing program fulfill its promise. As Sir William Osler [31] astutely observed,
The hardest conviction to get into the mind of a beginner is that the education
upon which he is engaged is not a college course, not a medical course, but a life
course, for which the work of a few years is but a preparation.
APPENDIX A
EDUCATIONAL GOALS LIST FOR PSYCHIATRIC INTERVIEWING
SKILLS
In the following educational goals list (EGL), we have tried to present a stateof-the-art and comprehensive listing of the key concepts and techniques related
to interviewing skills that we feel can be of immediate use to a resident in everyday clinical practice. The list is garnered from various readings and has
been derived across various mental health disciplines.
We hope that it provides an unusually rich, one-stop-shop for both mentors and residents to become aware of all the exciting developments that are
occurring in clinical interviewing. The list can be used throughout the mentorship to help the resident become aware of areas of interest that can be tapped as
personalized interviewing goals, while suggesting resources for achieving those
very same goals. As the year proceeds, the mentor and resident can review the
list to check on progress. We also find that mentors sometimes discoveras we
didideas and strategies on the EGL that are also new to them and prove to be
useful areas for further exploration.
We also feel that you will find that some of the skill sets are particularly amenable to role-playing for acquisition and consolidation. For example, under G:
Handling Confrontational Resistance and Intense Affect, role-playing may be
the single best modality for training the resident. Other interviewing skills that
are particularly amenable to role-playing include: handling awkward questions
or demands, handling challenges to clinician competence, working with hostile
comments, recognizing and calming the potentially violent patient, working
with tearful patients, reassuring the anxious or frightened patient, and working
with patients exhibiting guarded or paranoid affect.
It is not expected that every resident, at the time of graduation from the residency, will be competent in using all of the interviewing skills listed under each
goal category, but we do feel that by the time of graduation a resident should
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be competent in all of the lettered goals, choosing whichever specific techniques

they and their mentors find necessary to achieve this competence. The EGL
provides a resource where residents can become familiar with the many techniques designed to accomplish these goals, be aware of their personal strengths
regarding their use, and spot areas for ongoing improvement within these core
skill groups. In short, the EGL provides the resident with a convenient listing
of key interviewing skills for ongoing growth both during the residency and
throughout his or her career.
A. Psychodynamic interviewing skills
1. Recognition of defense mechanisms
2. Techniques of unstructured interviewing
3. Elicitation of psychogenetic history and dynamic diagnosis
4. Recognition of the seeds of transference and countertransference
5. Assessment for psychotherapy
6. Ability to recognize and use ones own feelings, associations, and fantasies
7. Development of the clinicians observing ego
8. Use of object relations and the psychology of the self in the initial interview
9. Familiarization with key authors such as Sigmund Freud, Harry Stack Sullivan,
John Whitehorn, Roger MacKinnon, Robert Michels, Leston Havens, Otto Kernberg, Heinz Kohut, Aaron Lazare, and others
B. Basic engagement skills
1. Use of empathic statements
2. Use of stroking and supportive statements
3. Nonverbal facilitatory techniques (such as head nodding and eye contact)
4. Study of proxemics (use of space)
5. Study of kinesics (use of gesturing and body movement)
6. Paralanguage skills (tone of voice and other speech characteristics)
7. Recognition of weak or pathologic engagement
8. Note taking
9. Familiarization with key authors such as Edward Hall, Gerard Egan, Alfred
Benjamin, Carl Rogers, Rita and John Sommers-Flanagan, and others
C. Advanced engagement skills
1. Familiarity with leading theorists in collaborative interviewing such as Borden
and Prochaska (four stages of change: 1. Precontemplation, 2. Contemplation,
3. Preparation, and 4. Action)
2. Solution-focused interviewing
3. Motivational interviewing (Miller and Rollnick)
4. Medication interest model (Shea): how to talk with patients about their medications in a fashion designed to improve medication adherence
5. Counterprojection and soundings (Leston Havens)
D. Understanding response modes: how clinicians phrase questions and statements
1. Familiarity with major theorists in response mode clinical research such as
Clara Hill
2. Familiarity with the degree of openness continuum (DOC) Shea: open-ended
questions, gentle commands, swing questions, qualitative questions, statements of inquiry (leading questions), empathic statements, facilitatory statements, closed-ended questions, and closed-ended statements
304
E. Basic and advanced structuring techniques

1. Facilic supervision and schematics (Shea)
2. Creating a conversational style while gathering large databases
3. Understanding regions (content and process regions)
4. Understanding transitions called gates (spontaneous gates, natural gates,
referred gates, implied gates, phantom gates, and introduced gates)
5. Attending to the changing needs of the patient depending on the structural
phase of the interview (eg, introduction, opening, body of the interview, closing, and termination)
6. Flexible strategies for structuring the interview depending upon time constraints
and clinical tasks
F. Handling stylistic resistance
1. Focusing loquacious and/or wandering patients
2. Opening up reticent or shut-down patients
3. Derailing rehearsed or manipulative interviews
4. Effectively engaging patients with a formal thought disorder or mania
G. Handling confrontational resistance and intense affect
1. Handling awkward questions or demands
2. Handling challenges to clinician competence
3. Working with hostile comments
4. Recognizing and calming the potentially violent patient
5. Working with tearful patients
6. Reassuring the anxious or frightened patient
7. Working with guarded or paranoid affect
H. Minimizing bias created by the interviewer
1. Avoiding phrasing bias as seen with negative questions, cannon questions,
leading questions, or overly wordy questions
2. Avoiding nonverbal bias
I. Maximizing validity while probing sensitive areas
1. Use of behavioral incidents (Gerald Pascal)
2. Use of other validity techniques such as: gentle assumption (Pomeroy et al), induction to bragging (Othmer and Othmer), shame attenuation (Shea), normalization (Shea), symptom amplification (Shea), and denial of the specific (Shea)
3. Familiarization with the uncovering techniques of neurolinguistic programming
(Grinder and Bandler)
J. Phenomenologic inquiry (Jaspers) and descriptive psychopathology
1. Basic techniques of phenomenological interviewing
2. Understanding the patients core psychologic pains
3. Understanding the phenomenology of common forms of psychopathology such
as organic syndromes, psychosis, mania, depression, obsessions and compulsions, posttraumatic stress disorder, substance abuse, eating disorders, and
characterological problems
K. Exploring religion, spirituality, worldview, and framework for meaning
1. Importance of exploring spirituality
2. The potential impact of the interviewers worldview on the interview
3. The propriety of sharing ones own worldview with the patient: the advantages
and disadvantages of self-disclosure
4. Indirect methods of raising worldview
5. Direct methods of raising worldview
305
6. Interviewing techniques for an in-depth exploration of worldview

7. Gracefully handling the patients question, Do you believe in God?
8. Familiarity with leading theorists such as Allan Josephson, John Peteet, and the
Griffiths
L. Diagnostic skills
1. Familiarity with multiaxial approaches in general and particularly the DSM-IV-TR
2. Familiarity with DSM-IV-TR diagnostic criteria
3. Ability to elicit symptoms relevant to specific DSM-IV-TR diagnoses on both Axis
I and Axis II thoroughly but naturally
4. Ability to recognize diagnostic leads
5. Ability to use time constraints effectively and flexibly while exploring diagnostic criteria sensitively
6. Ability to elicit an organized and accurate chronology of the history of the
present illness
7. Ability to uncover characterological disorders
8. Ability to uncover family psychopathology
9. Familiarity with key diagnostic interviewing theorists: Danny Carlat, Othmer and
Othmer, David Robinson, James Morrison, and Shawn Christopher Shea
M. Content exploration
1. Delineating the chief complaint, referral source, the history of the present illness, past psychiatric history, social history (including occupational, educational, relationship and childhood abuse histories), family history, general
medical history, and review of physical systems
N. Suicide assessment
1. Eliciting risk and protective factors
2. Understanding and using the Chronological Assessment of Suicide Events
(CASE) Approach (Shea, 1998)
a. Presenting suicide events (last 48 hours)
b. Recent suicide events (last 2 months)
c. Past suicide events
d. Immediate suicide events (now/next)
O. Assessment of sensitive and taboo material
1. Rape and assault
2. Spouse, parent, and child abuse
3. Antisocial behavior
4. Normal and pathologic sexual/gambling history
5. Drug and alcohol history
6. Treatment and medication nonadherence
P. Interviewing techniques related to cultural diversity issues
1. Nonverbal considerations related to culture and the interview
2. Differences in greeting related to culture
3. Varying taboos about sharing psychiatric concerns related to culture and questions used to sensitively explore such issues
4. Differing approaches to discussing treatments and medications related to culture
Q. Talking with family members of patients who have severe mental illnesses
1. Interviewing techniques for decreasing stigma
2. Interviewing techniques for decreasing shame and guilt
3. Interviewing techniques for decreasing biases and fears about mental health
professionals
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4. Interviewing techniques for helping family members understand and respond

appropriately to patient symptoms such as obsessions and compulsions, nonlethal self injury such as self-cutting, and suicidal behavior
5. Interviewing techniques for helping family members deal with the death of
a loved one by suicide
6. Interviewing techniques for psychoeducation about mental illnesses and treatment interventions from medications to psychotherapy
R. Interviewing techniques related to the mental status
1. Familiarization with key descriptive terms such as loosening of associations,
tangential speech, circumstantial speech, restricted affect, inappropriate
affect, flat affect, the difference between mood and affect, among others
2. Techniques used for cognitive testing including the Folstein Mini-Mental Status
3. Techniques for helping patients to feel less shame and guilt related to deficits
uncovered during cognitive testing
4. Familiarization with key theorists such as Strub and Black, David Robinson,
Trezpacz and Baker
APPENDIX B
CORE COURSE OUTLINE FOR PSYCHIATRIC INTERVIEWING
The following course syllabus is an example, in our opinion, of a comprehensive and powerful introduction to the art of clinical interviewing. If you have
the resources it can be used as a direct model for your own curriculum.
Naturally, resources are limited, and they can even change, within a single institute over time, as faculty come and go. Consequently, we also designed this curriculum to provide a practical platform for helping course designers to create
shorter courses in an organized and informed fashion. This list can help the designer to pick and choose classes, having a better idea of the pros and cons (eg,
what exactly will be lost) by the deletion of certain topics. A review of the list
may also suggest how some classes, for the sake of time limitations, might be combined. For example, the two separate classes on cultural diversity and exploring
spirituality might be combined comfortably into a single class.
We feel that, when guided by an organized decision-making process, a director
can create a sound introductory course on clinical interviewing in as few as 10
classes. If you are faced with such a tough decision, we hope this model curriculum can help you to creatively design a course syllabus that nicely fits the needs
and limitations of a particular institute. (By the way, anytime you can use videotape or DVD demonstrations of your techniques, the class is invariably
improved).
Section 1: Cornerstone Principles of Clinical Interviewing
Class 1: Introduction: the primary importance of engagement
Key topics include:
Goals of clinical interviewing
Engagement
307
Blending; unconditional positive regard (Carl Rogers)

Sullivans engagement question and his concept of the self-system
Collaborative interviewing strategies including solution-focused interviewing
Motivational interviewing (Miller and Rollnick)
Class 2: The language of interviewing

Key topics include:
Facilic supervision (a language for understanding how to structure the interview
sensitively)(Shea)
The Degree of Openness Continuum (DOC)a language for understanding
nine different types of clinician responses (open questions, statements of gentle command, swing questions, qualitative questions, facilitatory statements,
statements of inquiry, empathic statements, closed questions, and closed
statements)(Shea)
Class 3: The structure of the interview: traps, roadblocks, strategies and solutions
Key topics include:
Five phases of the interview
Scouting phase
Clinician analysis during opening minutes of the interview
Issues during the introduction and closing phase
Transforming initial resistance
Sensitively structuring the interview
Creating a conversational mode
Cross-sectional facilic diagrams (strategies for managing the four quadrants of
time used for gathering information)
Recognizing problematic interview such as the shut-down interview and the
wandering interview
Class 4: Videotape/DVD demonstration of an initial interview: part I (requires about

1.5 hours)
This class is a videotaped demonstration of an entire initial interview, done by
one of the mentors, which the class analyzes and discusses by collaboratively
mapping out the interview on a large whiteboard using facilic schematics. All
aspects of the interview are discussed, including:
Engagement techniques
Psychodynamic issues
Differential diagnosis by the DSM-IV-TR
Gathering of all major content regions from social history to the medical history
Mental status
Lethality assessment
Nonverbal communication
Class 5: Videotape/DVD demonstration of an initial interview: part II (requires

about 1.5 hours)
This class is a continuation of Class 4, focusing on the second half of the demonstration interview
308
Class 6: Transforming the shut-down interview

Key topics include:
Differing reasons the shut-down process emerges, ranging from anxiety to oppositional behavior
Use of the principles of the DOC to transform shut-down interviews
Specific methods for engaging reticent patients
Role-playing exercises
Class 7: Sensitively structuring the wandering patient

Key topics include:
Differing reasons for wandering to emerge, ranging from histrionic process to
hypomania
Use of the understanding of the DOC and closed-ended techniques to focus the
patient
Appropriate use of cut-offs
Avoiding the dead zone for data gathering
Effective use of time as related to clinical tasks
Role-playing exercises
Class 8: Nonverbal behavior

Key topic include:
Proxemics (Edward Hall)
Kinesics (Ray Birdwhistell)
Paralanguage and tone of voice
Facial expression
Eye contact
Clues to deceit
Seating arrangement
Note taking
Displacement activities
Postural echoing
Section 2: Psychopathology and the Interview Process

Class 9: Exploring depression and mania
Key topics include:
Phenomenology of mood disturbance
Critical data for DSM-IV-TR diagnosis
Techniques for eliciting data about mood symptoms including depression, mania, and mixed states
Questions for uncovering hypomania as seen in bipolar types II, III, and IV
Class 10: Exploring anxiety symptoms

Key topics include:
Phenomenology of anxiety symptoms
309
Techniques for eliciting data about anxiety symptoms, picking up atypical panic
attacks and atypical flashbacks in posttraumatic stress disorder, sensitive
questions for screening for obsessive-compulsive disorder
Class 11: Exploring substance abuse and eating disorder symptoms

Key topics include:
Phenomenology of substance abuse
Approaches to minimization and denial
The CAGE: a four-question quick screen for alcohol abuse
Interviewing techniques for delineating a DSM-IV-TR diagnosis
Phenomenology of eating disorders
Techniques for delineating a DSM-IV-TR diagnosis of an eating disorder
Class 12: Exploring psychotic process

Key topics include:
Phenomenology of psychotic process
The life cycle of a psychosis
Schneiderian first rank symptoms and questions for spotting them
Soft signs of psychosis
Engagement techniques for eliciting data pertinent to psychotic symptoms
Class 13: Exploring personality dysfunction

Key topics include:
The role of the social history in the diagnosis of Axis II disorders
Deflecting defensive resistance typical of some people who have Axis II disorders in the initial interview
Typical defense mechanisms
Signal signs
Signal symptoms
Probe questions
The two-step strategy for delineating diagnoses on Axis II of the DSM-IV-TR
Class 14: The cognitive mental examination as related to delirium and dementia
Key topics include:
Orientation techniques
Digit spans
Vigilance test
Trails test
Four-object recall
Constructions
The Folstein Mini-Mental Status
Humanistic concerns during the cognitive examination
310
Section 3: Advanced Interviewing Techniques and Psychodynamic

Interviewing Perspectives:
Class 15: Vantage points: bridges to psychotherapy
Key topics include:
Attentional vantage point
Use of fantasy and clinician countertransference
Harry Stack Sullivan and participant observation
The observing ego and self-remembering
Conceptual vantage points
Class 16: Validity techniques: interview techniques for uncovering sensitive and taboo
topics
This class describes interviewing techniques for uncovering the truth about domestic violence, incest, antisocial behavior, substance abuse, suicide and homicide, and medication nonadherence including:
The behavioral incident
Normalization
Shame attenuation
Induction to bragging
Gentle assumption
Symptom amplification
Denial of the specific
The uncovering techniques of Grinder and Bandler
Class 17: Interviewing techniques for sensitively eliciting suicidal behaviors, ideation,
and intent
Key topics include:
Phenomenology of suicide
Uncovering risk and protective factors
Interviewing techniques for probing dangerous material
Chronological Assessment of Suicide Events (CASE) approachan interview
strategy for eliciting suicidal ideation, intent, and behaviors (Shea)
Triad of lethality
Documentation of suicide assessments
Class 18: Role-playing workshop on transforming resistance and gracefully handling

awkward patient questions
Key topics include:
Strategically sliding on the oppositional continuum
Natural methods of transforming anger
Pulling resistance
Strategic empathy
Avoiding the paranoid spiral
Leston Havens counterprojection
311
Side-tracking
Content responses
Process responses
Class 19: Assessment for dynamic psychotherapy

Key topics include:
Desirable patient characteristics
Understanding the process of patient behavior and the patients response to
interpretive questions
Use of reflecting statements
Questions that help one choose the time-limited psychotherapy best suited to the
unique characteristics of the patient
Class 20: Introduction to the role of the psychodynamic formulation

Key topics include:
Psychogenetic history
Spotting defense mechanisms
Identifying unconscious conflict
Identification
Projective identification
Introjection
Incorporation
Kernbergs structural interviewing
Class 21: The use of object relations and the psychology of the self in the initial
interview
Key topics include:
Normal and abnormal development of the self
Part-self/part-object
Merger object
Self-objects
Split affects
Otto Kernberg
Heinz Kohut
The bipolar self
The effective use of complementary shifts
Section 4: Special Topics Requiring Specific Interviewing Skills

Class 22: Interviewing techniques related to cultural diversity
Key topics include:
Nonverbal considerations
Differences in greeting related to culture
Varying taboos about sharing psychiatric symptoms and how to navigate them
Differing approaches to discussing treatments and medications related to culture
312
Class 23: Exploring religion, spirituality, worldview, and framework for meaning
Key topics include:
Familiarity with leading theorists such as Allan Josephson, John Peteet, and the
Griffiths
Importance of exploring spirituality
Potential impact of the interviewers worldview on the interview
Advantages and disadvantages of self-disclosure
Indirect methods of raising worldview
Direct methods of raising worldview
Gracefully handling the patients question, Do you believe in God?
Chapter 24: Improving medication adherence: how to talk with patients about their
medications
Key topics include:
Why patients dont take medications
The medication interest model (Shea)
The choice triad
Interviewing techniques based on the medication interest model such as
The inquiry into lost dreams
The inquiry into medication sensitivity
The trap-door question
Dismantling the crutch myth
The question of efficacy
The question of cost
The question of what taking medications symbolizes to the patient
Chapter 25: Talking with family members of patients having severe mental illnesses
Key topics include:
Interviewing techniques for reducing stigma
Interviewing techniques for decreasing shame and guilt
Interviewing techniques for decreasing biases and fears about mental health
professionals
Interviewing techniques for helping families understand and respond appropriately to patient symptoms such as obsessions and compulsions, nonlethal selfinjury such as self-cutting, and suicidal behaviors
Helping family members deal with the death of a loved one by suicide
Familiarity with leading theorists including Aaron Murray-Swank, Lisa Dixon,
Bette Stewart, Robert Drake, and Kim Mueser
References
[1] Sullivan HS. The psychiatric interview. New York: W.W. Norton company; 1970.
[2] Langsley DC, Hollender MH. The definition of a psychiatrist. Am J Psychiatry 1982;139:
815.
[3] Langsley DC, Yager J. The definition of a psychiatrist: eight years later. Am J Psychiatry
1988;145:46975.
[4] Shea SC, Mezzich JE, Bohon S, et al. A comprehensive and individualized psychiatric interviewing training program. Acad Psychiatry 1989;13(2):6172.
313
[5] Engler CM, Saltzman CA, Walker ML, et al. Medical student acquisition and retention of
communication and interviewing skills. J Med Educ 1981;56:5729.
[6] Levinson W, Roter D. The effects of two continuing medical education programs on communication skills of practicing primary care physicians. J Gen Intern Med 1993;8:
31824.
[7] Shea C. Contemporary clinical interviewing: integration of the DSM-IV, managed care concerns, mental status, and research. In: Goldstein G, Hersen M, editors. Handbook of psychological assessment. 3rd edition. New York: Pergamon; 2000.
[8] Shea SC. Psychiatric interviewing. In: Sledge WH, Warren C, editors. Core readings in psychiatry. Washington, DC: American Psychiatric Press, Inc.; 1995.
[9] Shea SC, Mezzich JE. Contemporary psychiatric interviewing: new directions for training.
Psychiatry, Interpersonal and Biological Processes 1988;51(4):38597.
[11] MacKinnon RA, Michels RM, Buckley PJ. The psychiatric interview in clinical practice. 2nd
edition. Washington, DC: American Psychiatric Publishing, Inc.; 2006.
[12] James M. The first interview: revised for DSM-IV. New York: Guilford; 1995.
[13] Othmer E, Othmer SC. The clinical interview using DSM-IV TR. Vol 1: fundamentals Washington, DC: American Psychiatric Publishing, Inc.; 2002.
[14] Shea SC. Psychiatric interviewing: the art of understanding. 2nd edition. Philadelphia:
W.B. Saunders Company; 1998.
[15] Sommers-Flanagan R, Sommers-Flanagan J. Clinical interviewing. 3rd edition. New York:
John Wiley & Sons, Inc.; 2002.
[16] Pascal GR. The practical art of diagnostic interviewing. Homewood (IL): Dow Jones-Irwin;
1983.
[19] Shea SC. The chronological assessment of suicide events: a practical interviewing strategy
for eliciting suicidal ideation. J Clin Psychiatry 1998;59(Suppl 20):5872.
[20] Shea SC. The practical art of suicide assessment: a guide for mental health professionals
and substance abuse counselors. New York: John Wiley & Sons, Inc.; 2002.
[21] Shea SC. The chronological assessment of suicide events (the CASE approach): an introduction for the front-line clinician. NewsLink [the Newsletter of the American Association of Suicidology]. Fall 2003;29,2.
[22] Available at: EndingSuicide.com. [a centralized suicide prevention education site funded
by the National Institute of Mental Health, contract #N44MH22045] provides details on
the use of the CASE Approach.
[23] Magellan behavioral health care guidelines. CASE approach recommended to participating clinicians. 2002.
Counselor, the Magazine for Addiction Professionals 2001;2(6):1424.
[25] Shea SC. Tips for uncovering suicidal ideation in the primary care setting. In: Hidden diagnosis: uncovering anxiety and depressive disorders (version 2.0) [four-part CD-Rom series].
GlaxoSmithKline; 1999.
[26] Innovations in the elicitation of suicidal ideation: the chronological assessment of suicide
events (CASE approach). Presentation for the Federal Bureau of Prisons Annual Meeting
of Chief Psychologists. Tucson (AZ), 2001.
[27] Innovations in the elicitation of suicidal ideation: the chronological assessment of suicide
events (CASE approach). Presentation for the Federal Bureau of Prisons Annual Meeting
of Psychiatrists. Atlanta (GA), 2003.
314
[29] Josephson A, Peteet J, editors. Handbook of spirituality and worldview in clinical practice.
Washington, DC: American Psychiatric Publishing, Inc.; 2004.
[30] Griffith JL, Griffith ME. Encountering the sacred in psychotherapy: how to talk with people
about their spiritual lives. New York: Guilford; 2002.
[31] Osler W. Aequanimitas. 3rd edition. Philadelphia: Blakiston; 1945.
Psychiatr Clin N Am 30 (2007) e1e29
PSYCHIATRIC CLINICS
OF NORTH AMERICA
Macrotraining: A How-To Primer

for Using Serial Role-Playing to Train
Complex Clinical Interviewing Tasks
Such as Suicide Assessment
Shawn Christopher Shea, MDa,b,*, Christine Barney, MDb
a
Training Institute for Suicide Assessment and Clinical Interviewing, 1502 Route 123 North,
Stoddard, NH 03464, USA
b
DEDICATION
This monograph is dedicated to Allen E. Ivey.
Teach by doing whenever you can, and only fall back upon words when
doing it is out of the question.
Rousseau (1712-1778), Emile; or, Treatise on Education
There are few clinical tasks in all of medicine and mental health more complex, nuanced, and of immediate consequence to the care of our clients than
clinical interviewing. And there are few clinical tasks more daunting to learn.
To learn how to effectively interview, the student must attentively watch someone who knows how to do it well, then do it themselves repeatedly while having
someone who knows how to do it well coach them so that the student can learn
how to do it even better. There is no other way. Whether we are doing the
doing or the student is doing the doing, Rousseau got it right almost three
centuries ago.
As we stated in an earlier article on designing interviewing training programs
in this issue of Psychiatric Clinics, clinical interviewing is a profoundly complex
procedure. One cannot teach a student how to perform a procedure from
a podium. By way of example, lets look at a very common procedure that
we must all learn, a most useful, yet potentially dangerous proceduredriving
a car. You cant teach someone to drive a car by giving a lecture or telling the
student to read a book. These educational venues can help, but the bottom line
is simpleto teach driving, the student must watch you drive first; then you
must watch the student drive. So it is with clinical interviewinga behavioral
*Corresponding author. (Website: www.suicideassessment.com). E-mail addresses: sheainte@
worldpath.net (S.C. Shea).
doi:10.1016/j.psc.2007.03.002

e2
SHEA & BARNEY
task vastly more complex than driving a car, and when it comes to tasks such
as performing a suicide assessment, equally critical to master.
Unfortunately, when one is attempting to master the myriad of specific interviewing tasks in which a good clinician must show proficiency (such as eliciting
a drug and alcohol history, exploring domestic violence and incest, performing
a differential diagnosis, eliciting suicidal ideation, taking a sexual history, and
talking with patients effectively about their medications and providing other
psychoeducation), interviewing training is often a bit of a haphazard process.
A young clinician may or may not get a chance to see a specific interviewing
task, such as exploring incest, done well. Even if they do, students may go
months or years, if ever, before an experienced clinician watches them do
the task while providing effective feedback and subsequently makes a determination that the student has performed the interviewing task competently.
Even mock oral boards do not guarantee adequate observation of the trainees
skill level by the residency. For instance, essentially every patient in a mock board
will require a differential diagnosis, providing an opportunity for this interviewing skill set to be directly observed. But not every mock board patient has a complicated history of incest requiring a sensitive inquiry by the interviewer.
Consequently, a resident could graduate from a psychiatric residency program
without ever being observed performing this specific skill set by an experienced
faculty memberthe level of competency of the resident being both untested and
unknown. Macrotraining was created to address these problems.
Macrotraining is an educational strategy for training complex clinical interviewing skills in a single session to such a degree of clarity that the trainee can
perform the task to a level of predetermined competency by the end of the session. The foundation of macrotraining is the use of serial role-playing both to
teach the skill and then carefully and methodically consolidate the skill for the
trainee so that, at the end of the session, the trainee clearly gets it and can
readily demonstrate the skill. It is the doing, as Rousseau would state, that
makes macrotraining so effective. In short, in a macrotraining session the students not only learn the skill, they practice it to the point of competency and
are then tested on it. Depending on the complexity of the task, a macrotraining
session usually lasts from a half hour to 4 hours.
Macrotraining can be used to train any clinician, ranging from a novice student (to get the critical basics down) to an experienced clinician (to perfect advanced nuances of the desired interview strategy) in any of the aforementioned
interviewing tasks and many more. As long as the interviewing skill set has the
following criteria, then macrotraining can be used to train the student to a level
of competency: (1) There is a specific goal with a concrete optimal database to
be uncovered (such as exploring incest or eliciting suicidal ideation); (2) Specific
questions or statements, which are well defined and can be modeled for the student, are delineated; and (3) Effective ways of flexibly sequencing the questions
or statements are clearly operationalized for the student (a flow sheet can be
created to help the student understand the how and why of the sequencing
of the questions).
MACROTRAINING FOR SUICIDE ASSESSMENT
e3
Originally designed to train psychiatric residents and other mental health

graduate students, including counselors, social workers, substance abuse specialists, and clinical psychologists, as well as to train any staff handling crisis
calls, macrotraining can also be used with medical students, nursing students,
physician assistant students, and clinical pharmacy students. In fact, its use may
not be limited to the helping professions, for we feel it could be equally useful
in the training of newspaper reporters, employment interviewers, lawyers, and
police.
In addition to our belief that macrotraining can be unusually effective for
training clinicians to perform complicated interviewing tasks, on a more personal note, we should add one more thingmacrotraining is one of the most
fun and rewarding styles of training the authors have ever had the pleasure
to employ. The sessions are often peppered with laughter, shared learning,
and the pleasure (for both trainer and student) of directly observing the trainee
gain skills right before ones eyes. This is a monograph for all those who love
to teach.
The monograph is intended to pass on, in a no-nonsense fashion, the nittygritty on how to use macrotraining in your psychiatric residency or graduate
program or at a clinic or call center. It is neither a research paper nor an academic review. It is written to be an informal and immediately practical
primer for anyone interested in trying out macrotraining as an educational
tool. If you have any questions (or if you discover ways of improving
macrotraining or new uses for it), please contact us at the website for the
Training Institute for Suicide Assessment and Clinical Interviewing at
www.suicideassessment.com. It is also our hope that the monograph will
spur research on macrotraining, for although the seed research has been quite
promising, macrotraining is ripe for comprehensive empiric study, especially
regarding its efficacy in passing on critical skills such as eliciting suicidal
ideation.
In the following article, we hope to provide a clear enough description of the
macrotraining paradigm that an interested reader could actually begin to use
the technique. To enhance the process, we decided to actually pick a specific
and critical interviewing skilleliciting suicidal ideationas a model for illustrating the use of macrotraining. Indeed, macrotraining was originally developed
to train clinicians in this specific skill, and the authors have more than 25 years
of experience in using macrotraining to teach the elicitation of suicidal ideation,
planning, intent, and behavior.
To accomplish our task, we will use a five-point approach: (1) provide a brief
history of macrotraining; (2) delineate the core principles of macrotraining;
(3) describe an innovative method of eliciting suicidal ideationthe Chronological Assessment of Suicide Events (the CASE Approach)that nicely illustrates
an interviewing strategy that can be readily taught by macrotraining; (4) illustrate the step-by-step use of macrotraining to teach the CASE Approach; and
(5) provide specific tips on how to use macrotraining more effectively to teach
suicide assessment skills and other interviewing tasks.
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HISTORY OF MACROTRAINING
To understand the history of macrotraining, one must go back 4 decades to the
highly innovative work of Allen E. Ivey [1,2], who developed a methodology
called microcounselingthat has revolutionized interviewing training. Ivey
quickly realized that, as Rousseau described in our opening epigraph, the secret
to teaching was doing. He also realized that interviewing was a procedure composed of innumerable smaller proceduresindividual questions or statements.
He decided that, to effectively teach interviewing, one must start by training
the student at the smallest level of procedure (for example, an open-ended question or a reflecting statement). He further realized that providing didactic teaching would not be sufficient to pass on a behavioral skill; one must also address
the skill through the use of modeling and role-playing, while ensuring competency in the skill by direct observation of the student demonstrating it.
Because of the focus on the training of single interviewing techniques, the
isolated educational format used in the overall process of microcounseling is
sometimes called microtraining. In classic microtraining, the interview question or behavior to be trained must be behaviorally well defined and is usually
described in a manual as well as modeled on videotape. Some students may be
able to test out of the session, if they can already demonstrate the skill in
question. But for those who do not know the skill, a microtraining session is
used. In the specific session, the trainer focuses on a single skill. After a brief
reading and a few minutes of didactics enhanced by modeling (often by watching a videotape), the trainee learns the specific skill via the use of role-playing
until the trainer is comfortable that the trainee can demonstrate the skill to
a level of competence. In a brief period, often 6 to 7 minutes, the trainee will
practice the newly acquired skill using role-playing as many times as possible
to consolidate the skill. At other times, new role-plays with different types of
clients are introduced subsequently to see if the trainee can generalize the newly
acquired interviewing skill to different types of clients.
Subsequent research has shown that these skills, if consolidated well during
the microcounseling session, can be further generalized into later interviews
with real clients [3]. This ability to use various types of clients in role-plays
has also been advantageously used to help teach culturally specific interviewing
techniques [4].
In my residency and early years as an interviewing mentor at Western Psychiatric Institute and Clinic in Pittsburgh, Pennsylvania, I was utterly fascinated
by the work of Ivey, for I feel one would be hard pressed to find an educational
technology that has been better studied empirically. Microcounseling works.
To be more specific, the evidence base for microcounseling has been building for decades [5]. A review paper by Daniels [6] describes the results of more
than 450 different studies done on microcounseling. In addition, nicely designed models for conceptualizing the use of microcounseling in supervision
have been developedsuch as the Microcounseling Supervision Model
(MSM) of Russell-Chapin and Ivey [7]to provide guidance in the everyday
use of microcounseling by interviewing mentors.
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We have spent some time emphasizing the impressive research behind

microtraining because microtraining is the fundamental building block in macrotraining. Indeed, macrotraining is the serial use of microtraining techniques to
train clinicians to perform complex interviewing sequences. Although macrotraining has not been studied empirically, it is our hope that this paper will
jump-start its study both qualitatively and quantitatively. As we await the results of such research, it is reassuring to know that the key component of macrotrainingmicrotraininghas been repeatedly proved to be effective, a fact that
lends support to our seed research and our direct observation that macrotraining is also highly effective. The beauty of macrotraining is that each training
session is, in essence, its own qualitative research study, for the trainee can
either do the interview strategy correctly or not by the end of the session. If
the trainee can, then it has been proved that macrotrainingwith this particular
traineehas worked. Let us see what it is all about in more detail.
At Western Psychiatric Institute and Clinic, I was the Director of the Diagnostic and Evaluation Center (DEC) from 1984 through 1988. The DEC was
both an emergency department and an assessment center that also contained
a telephone triage center. We ran a comprehensive interviewing training program, as described elsewhere in this issue of the Psychiatric Clinics. As we studied
the art of clinical interviewing, we began to realize the complexity of the art itself. Although an interview is composed of individual techniques, these techniques do not exist in isolation in the real world of clinical interviewing;
they are always integrated into specific interviewing tasks.
Such tasks often, though not always, revolve around the gathering of a specific database while maintaining engagement with the client. Typical interviewing tasks might include gathering a symptom picture to make a differential
diagnosis, eliciting information related to a drug and alcohol history, uncovering information related to interpersonal functioning and social history, and eliciting suicidal ideation. Especially with sensitive topics such as domestic
violence, incest, and suicidal ideation, it becomes critical for the clinician to
be able to ask questions about difficult-to-share material while at the same
time carefully attending to and nurturing the therapeutic alliance.
While watching trainees from psychiatry to clinical psychology, we found
some trainees who would approach these challenging interviewing demands
in a fashion that was highly engaging, but very poor in uncovering the information needed to help the patient. On the other end of the continuum, we
found trainees who seemed to cover the right bases with regard to the critical
database, but did so in a fashion that was painfully disengaging (often yielding
invalid data as well). The trick was to train students to do both wellto
uncover a comprehensive, valid, and useful database while simultaneously
carefully attending to and enriching their engagement with the client.
Microcounseling is effective at teaching individual interviewing techniques,
especially those techniques vital to engagement, such as attending behavior,
communicating empathy, and using open-ended questions, reflecting statements, and summarizing statements. We began to wonder if one could delineate
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a complex interviewing tasksuch as eliciting suicidal ideationinto single small

steps that eventually flowed into a larger sequence of questions and ultimately
blended into collections of sequences that would uncover a specific database
in a valid and sensitive fashion. If so, could this operationalization of the complexities of a real-life interviewing tasksuch as uncovering incestbe amenable
to the serial use of microtraining on each of the steps of the process, until the
trainee could perform the entire interview flexibly and accurately?
The promise of such a training strategybuilt directly on the shoulders of an
educational technology (microtraining) that was already well established as effectivewas enticing. We felt that with regards to some taskssuch as eliciting
suicidal ideation and uncovering domestic violencewe might be able to help
clinicians save lives by training them to be more effective interviewers in traditionally difficult arenas. Macrotraining was born.
For macrotraining to work, several questions needed to be answered in the
positive: (1) Could complex interviewing tasks such as eliciting suicidal ideation (which sometimes might require many questions by the clinician, whose
wording and sequencing could have critical impacts on uncovering valid information while securing ongoing engagement) be simplified and clarified into
a language that could be easily picked up by trainees? (2) Would the use
of serial microtraining steps allow the trainee to master and remember complicated interviewing strategies that might contain more than 30 questions? (3)
Could macrotrainers maintain the sharpness and clarity of mind to intensively
train a single student in sessions that might prove to be hours in length, as
might be the case when training particularly complicated interview strategies?
and (4) Would the student be able to maintain concentration and enthusiasm
over such extended periods of time and enjoy the process while doing so? We
were intent that the macrotraining sessions be fun and unfold within a safe
interpersonal space, for the first priority of any supervisor must be to ensure
the welfare of the trainee [8].
Thankfully, the answers to all of these questions proved to be yes. Let us
take a more detailed look at the art of macrotraining.
CORE PRINCIPLES OF MACROTRAINING
Macrotraining was developed to train clinicians to perform specific complex interviewing tasks flexibly. It not only allows the trainer to teach specific types of
questionsboth their wording and sequencingbut also allows the trainer to ensure that the questions are asked in an engaging fashion (by directly observing
the interviewers timing, tone of voice, and use of other nonverbal communications). Thus, while teaching the sequencing of a complex interview strategy,
the trainer can ensure that all of the critical basic engagement skillsthose classically taught in microtrainingare still employed effectively. If a specific sequence of questions is used correctly, but not in an engaging fashion, then
the role-play is repeated until the trainer is comfortable that engagement skills
are used routinely by the student throughout the specified sequence of
questions.
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Naturally, the specific questions, their sequencing, and the frequency with
which it is expected each question should be used are completely determined
by the trainer. Each of us might come up with a slightly different way of eliciting a drug and alcohol history, for there are many effective ways to do so. Generally speaking (there may be exceptions when a rigid ordering of questions is
demanded), it is important to communicate to the trainees that they are not being taught the right way to elicit a specific database, but a reasonable way.
It is expected that they will learn to perform this reasonable way to a level of
competence and will then be urged to flexibly change the questioning as meets
the needs of each unique client and interview situation encountered in the future. In a similar fashion, medical students learn how to do a complete physical
examination to a reasonable level of competence. They subsequently learn how
to adapt the extent and style of the physical examination to the needs of the
patient and his or her presentation of symptoms. Macrotrainers consistently
communicate that engagement, flexibility, and creativity are the cornerstones
of clinical interviewing.
Three definitions are of immediate value at this point. An interview technique is a single question or statement, such as an open-ended question
or a behavioral incident (a specific style of question used to improve the likelihood of receiving a valid answer from a client, which we will describe later in
this article). An interview sequence is a series of two or more interview techniques in which the style of the questions (which may include their content
and/or their exact wording) and their sequencing (the order in which they
are asked) is clearly delineated. An interview region is a specified database
pertaining to the interviewing task at hand. An interview region could be composed of a single interview sequence or multiple interview sequences strung together to obtain the necessary clinical information. Thus an interview region
could be as short as two questions (a region that contains only a single twoquestion interview sequence) or could contain 10, 20, or more questions (a series of interview sequences). Armed with these three simple definitions, one can
readily understand the core principles of macrotraining.
For the purposes of illustration, let us assume that we are trying to train a student in how to elicit a history of physical and sexual abuse in a comprehensive
and sensitive fashion. Let us assume that the prototypic strategy we are proposing has three contiguous databases that we have delineated as three specific interview regions: Region #1current abuse; Region #2recent abuse over the
past year; and Region #3past abuse. Let us further suppose that within each
of our regions we have two or more interview sequences of questions that we
feel are important in sensitively uncovering a valid abuse history. Using this
prototype, let us see how a macrotraining session might proceed.
In the first step, the macrotrainer will provide a succinct, and hopefully interesting, overview of the entire interview strategy. (If the macrotrainer has
an article describing the interview strategy for uncovering physical and sexual
abuse, he or she will have asked the student to have read it before coming to
the macrotraining session.) The trainer might choose to discuss why the
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elicitation of an abuse history is both so important and so sensitive in nature.

The trainer would show the overall flow of the three regions, moving from
immediate to recent to past experience, and why this flow is viewed as useful.
A brief description of some of the information to be gathered in each region
might be offered.
In the next step the macrotrainer will focus entirely on teaching the skills
used in Region #1 (current abuse). The trainer will describe in detail each of
the interview questions/statements that are to be used in each of the interview
sequences found in Region #1. Flip charts, whiteboards, etcetera may be particularly useful in enhancing this interactive didactic section.
After the didactics, the macrotrainer will ask questions to test whether the
trainee really understands the interview techniques and their sequencing.
Any areas of fogginess regarding the theory and the sequencing of the interviewing techniques are then immediately clarified by the trainer.
Following testing/clarification, all the interview sequences for Region #1 (we
will assume that there are just two interview sequences in Region #1 of our prototype) are modeled by the trainer. The best method is to have a premade videotape of a skilled interviewer competently and sensitively doing Region #1 with
an actual patient. This videotape metacommunicates to the trainee that the interview strategy is both engaging and effective in gathering the desired information
in the real world of everyday practice. The videotape also provides a powerful
mental model for the trainee, which can work as both a conscious and unconscious visualization (much as a professional golfer visualizes his or her swing before actually striking the ball) and can help guide the student during the
subsequent role-playing. This videotape can also be viewed again, later in the
macrotraining session, at any point where clarification of interviewing technique
or more modeling is deemed useful. If no video is available, the interview region
can be demonstrated by role-playing, although this is far less desirable (a significant down-side is that the trainees attention must now be shared between creating the role of the client and trying to observe effective technique).
After the videotape has been observed, the first role-play is done, focusing on
just the first interview sequence of Region #1. This sequence is performed until it is
done to a level of competency.
Active feedback is provided in two ways. If an error is made, the role-play
can be interrupted by the trainer with a time out, signified by an agreedon hand signal. At this point the training dyad breaks out of role and discusses
what is going on, and errors of technique are corrected. Occasionally, a trainer
may take a moment to reverse roles in the role-play to model the correct technique directly (this exercise, called a reverse role-play, not only accomplishes
its primary goaldemonstrating the technique correctlybut also often allows
the trainee to see how the technique feels to the client, providing a powerful
experiential demonstration to the student that engagement can be enhanced
even while data is being gathered). The dyad then returns to the role-play to
implement the now-corrected interview techniques. A second time to provide
feedback is at the end of the role-play.
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In either case, once the student effectively demonstrates the first interview
sequence of Region #1, it is important that a new role-play be done in which
the student must now correctly perform the first interview sequence from front
to back (remember that such sequences are usually only about two to five questions in length), thus consolidating the learned skill.
It is now time for the macrotrainer to teach the second of the sequences in
Region #1. (If you will recall, in our prototypic interview strategy, Region
#1 has only two interview sequences.) A brief verbal description and rationale
of the second interviewing sequence are given (notice that, if the student appears unclear, you can always watch the videotape of this sequence again).
A role-play is now performed with the same originally role-played patient,
picking up where the first interview sequence of Region #1 stopped. The exact
same procedures are done as in the training of the first interviewing sequence,
until the student can do the second sequence correctly.
After much positive feedback, the student is then asked to perform the two
sequences of Region #1 back to back, without stopping, with an entirely new
role-played client provided by the macrotrainer. Feedback is given until the student can do Region #1 to a level of competence. The training of Region #1 for
eliciting the current abuse history is now completed. Not only does the student
understand the interviewing strategy for eliciting a current abuse history, but
the student has demonstrated that he or she can actually do the strategy in
an engaging fashiona vastly different proposition altogether.
Notice how many times the student has repeated the specific interview sequences with different role-played patients. This repetition firmly consolidates
the skill set for the trainee. Repeated role-plays of already learned interview sequences are the heart and soul of macrotraining. It is this serial repetition that allows students to learn complex interview skills in such a fashion
that the skills stick and the likelihood of the students demonstrating
continued competency months and years later is, in our opinion, greatly
enhanced.
Doing role-plays so that they appear natural and prove to be effective
whether as isolated illustrations or in systematic microtraining or macrotraining
is no easy task. It is both a set of skills and an art. Consequently, we have
provided online in this issue of the Psychiatric Clinics an entire article devoted to
tips for improving and mastering role-playing as an educational tool, should
a more in-depth knowledge be of interest (See The Art of Effectively Teaching
Clinical Interviewing Skills Using Role-Playing: A Primer at www.psych.
theclinics.com).
The macrotrainer is now ready to teach the student how to explore Region
#2recent abuse (over the past year). Let us assume that this region is composed of three interview sequences. The exact training flow, as illustrated earlier in teaching Region #1, is used until the student can do all three sequences
of Region #2 in a row (and without stopping) to a level of competency.
At this point, if things have gone well, we have had a lot of success. The
student has learned and demonstrated that, as Rousseau would say, they
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can do in a sensitive and reliable fashion two entire regions related to uncovering an abuse history. And it is here that our emphasis on consolidating skills
through serial role-playing once again plays a critical part in effective
macrotraining.
At this stage, the trainee is asked to do Region #1 followed by Region #2
without error and without stopping with a newly created role-play. This is
done until the student performs the task to a level of competence. Most students by this point in macrotraining are having a blast. It is empowering
to be able actually to see oneself gaining interviewing skills in the immediate
here and now. Moreover, good macrotrainers are gifted at providing positive
feedback and using humor effectively.
We are now ready to teach Region #3. The exact same training flow is used
as in Regions #1 and #2. Once competence is gained in Region #3, the student
is asked to pass the test. In short, the student must now demonstrate how to
do all three regions of the elicitation of an abuse history sequentially, without
stopping and without mistakes, while demonstrating effective engagement
skills. Any errors are corrected and sound technique consolidated until the student can demonstrate the entire series without flaw. Thus the length of a session
of macrotraining is dependent not only on the complexity of the skills being
taught but on the rapidity with which a specific trainee picks them up. Sometimes a second macrotraining session must be set up because the student cannot
demonstrate competence in a single session, but this is rare.
At this stage, let us move from the use of macrotraining to teach a theoretic,
prototypic interview to the real McCoyan interview strategy designed to accomplish a critical clinical task (uncovering suicidal ideation and intent) that has
been operationally defined, that has been refined over the course of 20 years,
that has been presented in the clinical literature, that has demonstrated sound
construct and face validity, and that can be readily taught to your own traineesthe Chronological Assessment of Suicide Events (the CASE Approach).
INTRODUCTION TO THE CHRONOLOGICAL ASSESSMENT
OF SUICIDE EVENTS (THE CASE APPROACH)
The CASE Approach is a flexible, practical, and easily learned interview strategy for eliciting suicidal ideation, planning, and intent, designed to help the interviewer explore both the inner pains of the client and the suicidal planning
that often reflects these pains. The CASE Approachalong with macrotrainingwas first developed at the Diagnostic and Evaluation Center of Western
Psychiatric Institute and Clinic at the University of Pittsburgh, Pennsylvania,
in the 1980s for use in emergency rooms, assessment centers, inpatient and outpatient settings, or any type of crisis intervention done over the phone. It was
further refined at the Dartmouth Medical School, Hanover, New Hampshire,
and in front-line community mental health center work during the 1990s. Final
development and refinement of the CASE Approach (and of macrotraining)
were done at the Training Institute for Suicide Assessment and Clinical Interviewing [9].
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The CASE Approach was first described in the literature in 1998 by Shea
[10,11] and has subsequently been received enthusiastically by mental health
professionals, substance abuse counselors, school counselors, primary care clinicians, and the correctional profession [1218]. The CASE Approach is presented routinely as a core clinical course at the annual meetings of the
American Association of Suicidology [19]; it is described in the 1-day suicide
assessment competency course (Assessing & Managing Suicide Risk) co-sponsored by the Suicide Prevention Resource Center (SPRC) [20] and the American Association of Suicidology, and it is recommended as a resource for
telephone crisis workers by the National Suicide Prevention LifeLine [21].
It was designed to increase validity, decrease errors of omission, and increase
the clients sense of safety with the interviewer while discussing intimate details
regarding suicidal ideation, intent, and behaviors. In the CASE Approach,
clinicians are trained to flexibly uncover suicidal ideation and intent using
a sophisticated set of questions and interview strategies, as opposed to asking
a simplistic set of rote questions on the presence of suicidal plans. The
techniques and strategies of the CASE Approach are concretely behaviorally
defined; consequently it can be taught readily, and the skill level of the clinician
may be tested easily and documented for quality assurance purposes.
In the CASE Approach, the interviewer explores the suicidal feelings, ideation, plans, intent, and actions of the client over four contiguous time regions
hence its name. First, the clinician begins by sensitively and carefully
exploring the clients presenting suicidal ideation/actions during the last
48 hours (Region #1Presenting Suicide Events). Second, the clinician explores the clients suicidal ideation/actions during the previous 2 months
(Region #2Recent Suicide Events). After the clinician completes this exploration, Region #3 (Past Suicide Events), consisting of the past suicidal ideation/
actions, is explored. Finally, the clinician explores Region #4 (Immediate Suicide Events), consisting of the clients immediate suicidal ideation/actions/intent. This region of immediate ideation is defined as those suicidal thoughts
potentially arising during the interview itself and the clients views on possible
future suicidal thoughtsand what to do if they arise (Fig. 1).
A hallmark of the CASE Approach is the flexible use of four specific interviewing techniques, designed to increase the validity of the elicited data while
Fig. 1. Chronological Assessment of Suicide Events (CASE) Approach.
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exploring each of the four chronological regions just described. These four validity techniquesthe behavioral incident, gentle assumption, symptom amplification, and denial of the specificwere culled from the pre-existing clinical
interviewing literature in the fields of counseling, clinical psychology, and
psychiatry.
There is no space in this article to describe the details of the CASE Approach
(appropriate resources for a complete review of the approach will be provided
later). But we want to share enough of the strategy so that the reader can see
how macrotraining can be effectively employed to train clinicians in its use. To
accomplish this goal, let us look at one of the validity techniques used in the
CASE Approachthe behavioral incidentand how it is used in Region
#1 of the CASE Approach (eliciting suicidal ideation, intent, and behaviors
in the last 48 hours).
Regarding any type of sensitive materialnot just suicidal ideationa client
may provide distorted information for a number of reasons, including anxiety,
embarrassment, protecting family secrets, unconscious defense mechanisms,
conscious attempts at deception, and fears of the possible consequences if
one tells the truth (such as hospitalization or the contacting of social service
agencies if abuse is uncovered). These distortions are more likely to appear
the more the interviewer asks a patient for opinions rather than behavioral
descriptions of events.
Behavioral incidentsan interviewing technique originally described by
the clinical psychologist Gerald Pascal [22]are questions that ask for specific
facts, behavioral details, or trains of thought, as with How many pills did
you take? or that simply ask the patient to describe what happened sequentially, as with What did you do next? By using a series of behavioral incidents, the interviewer can sometimes help a patient enhance validity by
recreating, step by step, the unfolding of a potentially taboo topic such as a suicide attempt or an act of domestic violence.
As Pascal states, in general, it is best for clinicians to make their own clinical
judgments based on the behavioral details of the story itself, rather than relying
on clients to proffer objective opinions on matters that have strong subjective
implications. Some typical behavioral incidents are listed below as they might
appear when uncovering any area of sensitivity, such as a history of incest,
a substance abuse history, or the elicitation of suicidal ideation:
Prototypes:
1. Did you put the razor blade up to your wrist?
2. When you say that you taught your son a lesson, what did you actually
do?
3. Have you ever missed a day of work because of a hangover?
4. What did your father say then?
5. Tell me what happened next.
Lets see how this specific interviewing techniquethe behavioral incident

is used to form an interviewing sequence for use in Region #1 of the CASE
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Approach. This interviewing sequence can be easily taughtvia macrotraining

in the same fashion that we taught the two interviewing sequences in Region
#1 of our prototypical interview for uncovering abuse, described earlier.
In the CASE Approach, during the exploration of Region #1 (the Presenting
Events), the interviewer asks the patient to describe the suicide attempt incident
from beginning to end. During this description the clinician gently, but persistently, uses a series of behavioral incidents, guiding the patient to create a verbal videotape of the attempt step by step. Readers familiar with cognitive
behavioral therapy will recognize this strategy as one of the cornerstone assessment tools of CBTbehavioral analysis.
If an important piece of the account is missing, the clinician returns to
that area, exploring with a series of clarifying behavioral incidents, until
the clinician feels confident that he or she has an accurate picture of
what happened.
This serial use of behavioral incidents not only increases the clinicians understanding of the extent of the patients intent and actions but also decreases
any unwarranted assumptions by the clinician that may distort the database.
Creating such a verbal videotape, the clinician will frequently uncover a more
accurate picture of the suicidal behavior and the suicidal intent it may reflect
in a naturally unfolding conversational mode, without much need for memorization of specific questions.
When there has not been a specific suicide attempt, the serial use of behavioral incidents can be particularly powerful in uncovering the extent of action
taken by the patient regarding suicidal planningan area in which clients frequently minimize. Keep in mind the goal of the interviewerto uncover a valid
understanding of how close the client came to actually attempting suicide, a realization that the client may not want to admit to the interviewer (or perhaps
even to himself or herself) because of stigmatization or shame. The resulting information can have critical implications for safe triage and collaborative planning to help the client be safe in the days to come.
For example, the series of behavioral incidents used to create the verbal videotape may look something like this, in a patient who actually took some actions with a gun: Do you have a gun in the house? Have you ever gotten
the gun out with the intention of thinking about using it to kill yourself?
When did you do this? Where were you sitting when you had the gun
out? Did you load the gun? What happened next? Did you put the
gun up to your body or head? Did you take the safety off or load the chamber? How long did you hold the gun there? What thoughts were going
through your mind then? What did you do then? What stopped you
from pulling the trigger?
In this fashion, the clinician can feel more confident of getting an accurate
picture of how close the patient actually came to attempting suicide. The resulting scenario may prove to be radically differentand more suggestive of imminent dangerfrom what would have been relayed by the patient if the
interviewer had merely asked, Did you come close to actually using the
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gun?to which an embarrassed or cagey patient might quickly reply, Oh no,

not really.
Also note, in the aforementioned sequence, the use of questions such as
When did you do this? and Where were you sitting when you had the
gun out? These types of questions, also borrowed from CBT, are known
as anchor questions, for they anchor the patient in a specific memory as opposed to a collection of nebulous feelings. Such a refined focus will often bring
forth more valid information as the episode becomes more vivid to the patient.
The exploration of Presenting Suicide Events can be summarized as follows.
The clinician begins with a statement such as It sounds like last night was
a very difficult time. It will help me to understand exactly what you experienced if you can sort of walk me through what happened step by step. Once
you decided to kill yourself, what did you do next?
As the patient begins to describe the unfolding suicide attempt, the clinician
will use one or two anchor questions to maximize validity. The interviewer will
then proceed to use a series of behavioral incidents that make it easy for the
clinician to picture the unfolding eventsour so-called verbal videotape.
The strategy and the metaphor of making a verbal videotape have been quite
popular with residents and graduate students, for the clinical task seems clear
and is easily remembered even at 3:00 AM in a busy emergency department.
Perhaps one of the most sophisticated uses of the validity techniques (and,
we think, one of the most useful) occurs in Region #2 (Recent Suicide Events
including suicidal thoughts, plans, and behaviors over the past 2 months).
In this region of the CASE Approach, all four of the validity techniquesthe
behavioral incident (BI), gentle assumption (GA), denial of the specific (DS),
and symptom amplification (SA)are flexibly interwoven to uncover hidden
suicidal intent and behaviors (Fig. 2).
Without a knowledge of the definitions and uses of all the validity techniques, Fig. 2 may not make a lot of sense, but all the reader needs to glean
from it, for our purposes, is that a series of interviewing sequences is used
that are composed of well-defined interviewing techniques, making the region
amenable to macrotraining.
By the way, if you are not familiar with the CASE Approach, it cannot be
emphasized enough that it is not presented as the right way to elicit suicidal
ideation. It is presented merely as a reasonable way. Once they have learned
how to use the CASE Approach, clinicians can subsequently adopt what they
like and reject what they do not like.
Moreover, the CASE Approach is intended to be creatively and flexibly
altered to fit the needs of each unique client and his or her presentation. In complicated presentations of suicidal potential, the entire CASE Approach may be
valuable. When the interviewer is less suspicious of suicidal potential, bits and
pieces of the CASE Approach can be used as indicated. The goal is not to present a cookbook way of interviewing but to excite the clinician to discover his or
her own way of strategically eliciting suicidal ideation and to provide the clinician with the toolsthe validity techniquesto do so.
Fig. 2. Exploration of recent suicidal ideation.
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To become familiar with the CASE Approach, your psychiatric residents,

graduate students, and staffwhether face-to-face clinicians or phone staff
have a variety of options. We believe that the best single article on the practical
use of the CASE Approach is The Delicate Art of Eliciting Suicidal Ideation
[23], an excellent introduction to be read before a session of macrotraining on
the CASE Approach. The most comprehensive description of its use, which
also shows how to effectively integrate the CASE Approach with all the other
critical aspects of suicide assessment, from risk factors and clinical formulation
to documentation, can be found in the book The Practical Art of Suicide Assessment:
A Guide for Mental Health Professionals and Substance Abuse Counselors [24].
We will now use the teaching of the CASE Approach as an illustration of
how to use macrotraining in the real world. It is our hope that such training
can provide a psychiatric resident or graduate student with the tools to competently elicit suicidal ideation. Macrotraining of the CASE Approach also allows
a residency director to rest assured that the trainee has been directly observed
applying a reasonable method of eliciting suicidal ideation by an experienced
faculty member, a quality-assurance measure that may someday save a life.
MACROTRAINING THE CHRONOLOGICAL ASSESSMENT
OF SUICIDE EVENTS APPROACH: HOW TO DO IT
The macrotraining of the CASE Approach begins before anyone enters the
room. As a prelude to the training, the student is asked to read the article
The Delicate Art of Eliciting Suicidal Ideation, mentioned earlier. The article
is easy to read and lays out the fundamentals of the CASE Approach clearly.
The article also contains a sectionThe Importance of Eliciting Suicidal Ideationthat goes beyond the obvious reasons, providing some surprising and sophisticated beneficial ramifications of gathering a thorough database on suicidal
ideation, intent, planning, and behaviors. We have found this section tends to
motivate students and generates an excitement about the upcoming macrotraining session.
After appropriate introductions and a settling in period (often accompanied
by some coffee and doughnuts), the trainer asks about questions concerning the
article and shows how each of the trainees questions will be addressed carefully and experientially in the training session.
In the next step, using a 46 whiteboard, the trainer maps out the four regions of the CASE Approach (Region #1Presenting Suicide Events over the
past 48 hours; Region #2Recent Suicide Events over the past 2 months; Region #3Past Suicide Events; and Region #4Immediate Suicide Events during the interview). The naturalness of the flow between regions is described.
We also emphasize that frequently we see an increase in engagement as the
CASE Approach is performed with clients. This beneficial increase in rapport
seems to occur because clients are sharing material they have often kept to
themselves because of shame, and the fact that the CASE Approach interviewer
neither underreacts nor overreacts to the clients suicidal thoughts is often
reassuring.
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The trainer then briefly addresses the structure of the day, indicating that
each of the four regions will be addressed individually. Within each region
the trainee will learn what data bits are important to gather, see suggested validity techniques for uncovering this information, and even be able to learn
methods of sequencing these validity techniques that might help uncover potentially dangerous hidden information.
The trainer subsequently turns attention solely to the teaching of Region #1
(Presenting Events). A brief didactic is given using the whiteboard and flip
charts to review the validity techniques used in this region (there is only
onethe behavioral incident) and the interview sequences used in Region #1
(there is only onethe creating of a verbal videotape using sequential behavioral incidents). The presence of only one validity technique and one type of
interviewing sequence in Region #1 turns out to be an unplanned blessing
in macrotraining the CASE Approach. Learning this region is simple enough
that it almost functions as a warm-up for the trainee. Success in it is almost
guaranteed, resulting in an increased confidence and excitement as the trainee
moves into Region #2.
After providing the didactics, the macrotrainer asks some questions to test
the trainees understanding. Any areas of fogginess are clarified before proceeding. Once the trainer is comfortable with the students understanding of
the structure of the behavioral incident and its sequential use to create a verbal
videotape, the student is shown a videotape of a skilled clinician doing Region
#1. It can be a videotape of you or any faculty member who knows the technique, but it should be with an actual patient. After answering any questions
regarding the tape, the trainer moves on to the first role-play.
Given that there is only one sequence in Region #1, after reviewing the behavioral incident sequence used to create a verbal videotape, the trainee is asked
to perform this interview sequence in a role-play in which a client has overdosed. Any errors are corrected either by timing out during the role-play
for immediate feedback or after the role-play is completed. Role-plays are sometimes timed out to provide purely positive feedback, such as You just did
a great section using behavioral incidentscouldnt be done any better. Lets
pick up where we left off and see what else you uncover as you continue the
verbal videotape. Great job!
Once the behavioral incident sequence has been done to perfection with
a client considering an overdose, we suggest two consolidating role-plays
be performed: a client with a gun at home and a client considering hanging.
Each is done to a level of competency before one moves to the next one.
These role-plays also allow you to see how well the trainee can generalize
the use of the behavioral incident to other methods of suicide. At this point
we recommend repeating the role-play of a patient contemplating an overdose (using a new patient) to see how well the trainee has maintained the
skill level.
At this juncture in the macrotraining, trainees are often enthusiastic. Its fun
to succeed. They realize that what they are learning may help them to save
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a life. Motivation levels are usually high as we enter the training of Region #2,
arguably the most complex arena of interviewing in the CASE Approach.
But training in Region #2 is not really as hard as it looks at first glance. Take
a look at Fig. 2 again. You will see that Region #2 is actually composed of three
discrete interviewing sequences. The first sequence is composed of the use of
a gentle assumption (GA)such as What other ways have you thought of killing yourself?followed by the creation of a verbal videotape of the extent of
planning and action taken on another method, if one is reported by the client.
The trainer portrays a client until the trainee shows competence in this interviewing sequence, exactly as was done in Region #1.
Note that part of this simple first sequencemaking a verbal videotapeis actually composed of an interviewing sequence in which the trainee has already
gained competence, for making a verbal videotape was the core interviewing
sequence used while exploring Region #1.
The second interviewing sequence in Region #2 is nothing more than the first
sequence repeated multiple times. (Please refer to Fig. 2.) Specifically, the clinician
repeatedly uses a gentle assumption followed by a series of behavioral incidents to
create a verbal videotape, until the client responds to the gentle assumption of
What other ways have you thought of killing yourself with a negative such as
None. At this point the trainer and trainee return to the role and pick up where
they left off. The trainer portrays a patient who has been contemplating multiple
methods of killing himself or herself, and the trainee is expected to keep posing
gentle assumptions with follow-up verbal videotapes until this second interviewing sequence is performed to a level of competence.
In the third interviewing sequence (please refer to Fig. 2), the interviewer employs a series of denials of the specific, which are followed by the making of
a verbal videotape if a new method of suicide is proffered by the client. Finally,
a different validity techniquesymptom amplificationis used to figure out the
intensity and frequency of the suicidal ideation across all contemplated plans.
At this point, this third and final interview sequence of Region #2 is role-played
to competence by returning to the same spot where this patients role-play was
interrupted.
You will readily understand the nature of and reasoning behind all these specific validity techniques and their sequencing after you read the article The
Delicate Art of Eliciting Suicidal Ideation. What is important now for our understanding of macrotraining is merely that even this relatively complex series
of interview questions can be conceptualized as three simple interview sequences, which are very amenable to microtraining. It is now time to ask the
student to do all three sequences of Region #2 in order and without stopping
to ensure their competence and to further clarify and consolidate the learning
so far in Region #2.
Once the student has mastered Region #2, and after much positive reinforcement (students are often quite impressed that they have been able to master
a relatively complex interview strategy so easily), we have reached a critical
juncture in the macrotraining. As stated earlier, the heart and soul of
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macrotraining is the serial repetition of learned interview sequences until perfected. The trainer now creates a completely different patient, who has been
thinking of multiple suicide methods and taken some action on at least three
of them in the past 2 months. In this role-play, the student is asked to do
both Region #1 and Region #2 back to back and without stopping until a level
of competence is reached.
It may be close to an hour since the student was microtrained on Region #1,
so requiring the student now to do both Regions #1 and #2 contiguously not
only offers a chance for the student to consolidate his skills but also allows the
trainer to ascertain whether the student has retained what was taught earlier.
Any decrement in the techniques for Region #1 can be addressed if necessary.
Also notice how often, in the course of the macrotraining thus far, the student has practiced making a verbal videotape, using behavioral incidents
with a variety of different types of clients to ensure generalization of the skill
set. We find the consolidation effect of these repeated role-plays to be powerful,
hopefully enhancing the likelihood that months and years later the student will
still be employing this strategy with skill.
The rest of the macrotraining session follows the exact same protocol. After
successfully demonstrating the ability to do Regions #1 and #2 contiguously,
the student is trained to do Region #3 (past suicidal ideation, plans, and behaviors) to a level of competence.
It is then critical that the student be asked to do a serial consolidation roleplay in which a brand-new patient is presented and the student does Regions
#1, #2, and #3 without stopping and to a level of competence. We think
you will be pleasantly surprised at how many students can do this well.
The macrotrainer now proceeds to teach Region #4 (immediate suicidal
thoughts and intention during the interview itself), once again starting with
a brief didactic, followed by watching the model videotape and proceeding
with the serial role-playing. Once the student has demonstrated the ability to
explore Region #4 to a level of competence, the macrotraining is over, except
for one major part.
As one would expect, it is now time for the student to pass the test by demonstrating the ability to do the CASE Approach through all four regions without stopping and to a level of competence with yet another role-played client.
We have found that the vast majority of trainees find the macrotraining sessions to be both fun and valuable. Many are surprised at how much they learned
and how much of it will be of immediate practical use to them. It also tends to
stir excitement about the interviewing process, convincing residents of something that experienced clinicians already know about clinical interviewingnamely, technique counts. In addition, there is a perk to the macrotraining
session. Psychiatric residents are very appreciative of the time spent with the faculty (or chief resident) during the training. It may prove to be the most intensive
one-on-one attention they will get in their residency experience.
The time spentroughly 3 to 4 hours (including breaks)may at first glance
look substantial, but when put in perspective, it is well worth the investment.
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To devote 3 to 4 hours of time, in a 4-year psychiatric residency or graduate

program in counseling, to one of the most critical of all clinical skills (and
a forensically high risk area) is hardly inordinate. Moreover, the macrotraining
achieves a level of behavioral competence in eliciting suicidal ideation that is
simply unobtainable using lectures and readings.
If you are at a clinic, hospital, substance abuse center, or crisis call center and
want to train your staff to a level of competency in eliciting suicidal ideation
(or perhaps other interview strategies of particular interest to your needscrisis
intervention techniques, eliciting a substance abuse history, uncovering the
extent of domestic violence), macrotraining can be invaluable and fun.
A particularly clever occasion to do macrotraining is with newly hired staff
during their orientation. Orientation periods are frequently viewed as sort
of boring by many personnel. The inclusion of a macrotraining session is often quite refreshing and also helps ensure the quality control of your program.
For both quality-control and forensic purposes, it is nice to have documented
that all new staff has been trained in eliciting suicidal ideation in a rigorous
fashion. Such orientation macrotraining sessions also provide an early and
close-up look at a new employee and how readily he or she responds to
supervision.
A FEW FINAL TIPS FOR EFFECTIVELY USING MACROTRAINING
Tip #1: Establishing Buy-In to MacrotrainingThe Real First Step
Macrotraining represents a significant investment in time for the student, no
matter what interview task is being taught. It also involves role-playing, which
can be intimidating to some students, for the trainees errors are made immediately apparent to an observer. Consequently, it is critical to address these issues before beginning to teachto establish the students buy-in before
proceeding with actual training. A good macrotrainer knows how to pitch
the product. The goal is to establish early on a sense of safety, excitement,
and motivation about the session itself, creating in the student a belief that
I am about to do something special that few students ever get a chance to do.
After chit-chat and a doughnut or two, we like to begin by asking what, if
anything, the student has heard about macrotraining. Once you have been doing macrotraining at your center successfully, many students will arrive already
excited about the session, for they will have heard good feedback about the experience from colleagues. By contrast, if for some reason they heard something
negative, it is best to have this hesitancy out on the table immediately so that
one can potentially transform it.
Selling the product effectively can be enhanced by remembering three goals:
(1) Establish credibility and excitement about macrotraining by giving a bit of
its history; (2) Establish credibility and excitement about you as a macrotrainer
by sharing some of your personal successes with the method; and (3) Decrease
any anxiety related to the unknown by concisely outlining the day.
With regard to the first goal, consider sharing with the students information
about Allen Ivey and microtraining, emphasizing the large amount of
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research supporting the power of microtraining. Proceed to emphasize how

macrotraining is based on the serial use of Allan Iveys microtraining. Let
students know a little bit about how macrotraining was developed at a leading
interviewing training center (WPIC) and has been in ongoing refinement for
more than 20 years. Credibility is also enhanced by sharing that macrotraining
was developed by the author of several popular textbooks for psychiatric residents and graduate students across all disciplines [10,24,25], some of which the
students may already be using in their graduate program, a fortuitous circumstance that can greatly enhance pre-session enthusiasm.
If you happen to be macrotraining the CASE Approach, give a little information on its wide acceptance both nationally and internationally. Touch on how
important eliciting suicidal ideation can be. And perhaps the most powerful endorsement is a personal oneif you have onesuch as I have found the CASE
Approach to be invaluable for me in my own practice. I think it has helped me
to save a life or two.
One can achieve the second goalestablishing ones own credibilityby sharing some of your successes in macrotraining and your own pleasant surprise
at its power. Perhaps even more importantly, share how much fun you have
doing it and that you too will learn from the process, for it always involves
a shared learning experience.
Concerning the third goaldecreasing the fear of the unknownlay out the
day in a concise form. Be sure to emphasize that the day is designed to be
enjoyable. Moreover, We will move together at whatever pace is comfortable
to you.
Finally, keep in mind that in the long run, the single most powerful tool you
have for establishing buy-in is not the content of the approaches just described, but the warmth and personal excitement with which you communicate
them.
Tip #2: Proactively Transforming Fears About Role-Playing
To a student who has not done a lot of role-playing (or to a student who has
experienced role-playing done poorly), the idea of doing 3 hours of it is not exactly appealing! Causes of hesitancy can include the idea that role-playing is
threatening (as mentioned earlier), is hokey, is silly, is not realisticor all of
the above.
During the introduction to the macrotraining session, we suggest routinely
asking whether the trainee has ever done role-playing and, if so, what the experience was like. Responses vary remarkably, from students who love it to
those who dislike it intensely. If you find a student who voices significant dislike of role-playing, we often begin by going with the resistance, using comments such as Well, to tell you the truth, sometimes role-playing is
frustrating. Ive had some role-plays done when I was a student that didnt
seem to work for me either. You know, the trick is that role-playing can be
done well or done poorly by a trainer. Ive had some good luck with it over
the years, and Ive gotten better and better at making it feel more real. And
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there is one thing I know it provides that no other training situation can match.
It allows us to look repeatedly at a specific difficult interview situation so that
we can try new ideas, something you just cant do repeatedly with a real
patient. Youll have to see what you think, and let me know as we go along,
because I want this to be enjoyable for you as well as being a great way to learn
how to elicit suicidal ideation. By the way, if you think that my acting skills are
not the stuff of Oscars, just let me know. This last statement, said with a gentle
smile and a twinkle in the eye, can result in a real breaking of the ice. The
use of humor is crucial to successful macrotraining throughout the session.
And here we come to one of the single most important tips for successful
macrotraining: Remember that the main goal of the very first role-play is to make
sure that the trainee is comfortable with role-playing and enjoyed the experience with
you. Actual learning about interviewing technique takes a distant second place
in the first role-play. The goal is to establish a safe learning environment for
the trainee.
You may encounter a few trainees who have significant anxiety related to
role-playing. And, in a rare instance, a trainee may have a true social phobia
with an intense fear of performing any task in which he or she will be observed directly. If you ever encounter such a situation, macrotraining may
be counterproductive; the teaching of the intended interview strategy may be
best approached in less directly observed ways, while you help the trainee to
seek professional help for the ongoing social phobia.
Tip #3: Using Role-Plays Designed to Generalize Skills to Different
Interview Tasks
So far in this article, role-playing has been used to teach a new interviewing
skill, to consolidate the learning of an immediately learned skill, or to see if
the skill can be transferred to a new patient, a situation in which the same
skill needs to be used for the same task but with a patient who presents a bit differently.
Every once in a while it can be useful to do a role-play that has nothing whatsoever to do with the stated goal of the macrotraining session. The need to generalize the skill to a new type of clinical task can, paradoxically, enhance the
learning of the skill for which the macrotraining is being done, for such radical
generalization can ensure that the trainee understands why the interviewing
technique or strategy works.
Let me clarify with an example from macrotraining the CASE Approach.
When teaching the student how to make a verbal videotape during the exploration of Region #1, if time permits, I might suggest the student make a verbal videotape of a completely different situation so that he or she can see the
power of the behavioral incident to uncover the truth.
For instance, I might ask the student to use behavioral incidents to create
a verbal videotape regarding an act of domestic violenceone that is being reported by a victim of the violence, who may be prone to minimizing its extent
(perhaps to protect the perpetrator). I will then role-play the victim and share
more and more of the truth of the extent of the violence as the interviewer
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gently walks me through what happened step by step using behavioral incidents, an exercise that can vividly show the trainee the power of using
behavioral incidents.
Such off-task generalizing role-plays can provide a series of benefits: (1) The
trainee learns to apply the interviewing technique or sequence even more effectively, because the exercise forces the trainee to think more creatively about how
to use the technique (the trainee will have seen no model of this use of the creation of a verbal videotape); (2) The unusual role-play brings a refreshing break
in the focus of the format; (3) The student learns through personal experience
that this particular validity techniquethe behavioral incidentmay be useful
in many clinical situations other than eliciting suicidal ideation (and is much
more likely to try using it in creative ways once the macrotraining session is
over); and (4) The discovery of the new uses of the behavioral incident (or
any of the other validity techniques, such as gentle assumption and symptom
amplification) in other clinical situations frequently enhances immediate enthusiasm about the macrotraining of the CASE Approach, for the resident now sees
unexpected benefits coming from the session.
Tip #4: Communicating the Critical Importance of Flexibility
Many of the interview strategies that can be taught using macrotraining, such
as eliciting a drug and alcohol history or uncovering incest, are creatively
adapted and modified to the unique circumstance of the client at hand and
the variables of the interviewing environment and immediate goals of the
interview. For instance, with a seasoned street junkie, one is going to lean toward using a detailed uncovering of substance use, abuse, and experimentation.
Validity techniques such as gentle assumption (What other street drugs have
you used, even just one time?) may be repeatedly used by the interviewer.
By contrast, if, as the history unfolds, the interviewer sees little supporting
evidence of street drug abuse, and the patientwhen asked several prompting
questions about street drug usecomments, No, Ive never even smoked a cigarette; I dont believe in using street drugs and never have, then there is no
need to continue with an exhaustive inquiry about all the classes of street
drugs. Obviously, such a detailed inquiry could seem odd to the client and potentially be disengaging.
Although flexibility is taught throughout any macrotraining session, after the
student has mastered the interview strategy, we believe it is important to reemphasize the need for flexible application of that strategy, providing concrete
examples (as I just did) of circumstances where it should be markedly
decreased in scope.
We find this to be particularly true with the macrotraining and subsequent
use of the CASE Approach. After the student has passed the test of demonstrating the entire CASE Approach, emphasize the critical importance of flexibly adapting the technique to the unique client being interviewed, whether the
interview is taking place in an outpatient setting or emergency room or during
the handling of a crisis call.
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By way of illustration, as we near the end of a session of macrotraining the

CASE Approach, we point out that we have been role-playing patients who
present with multiple thoughts of suicide, who have taken action on at least
one of these methods, who show significant risk factors, who report few buffering factors, and of whom we have an intuitive suspicion thatsecondary to
feelings of shame or fears of stigmatizationthey are hesitant to share the vital
information we need to ensure safety and effective collaborative treatment
planning. In our opinion it is here, in these particularly dangerous (and relatively infrequent) situations, that the full implementation of the CASE
Approach may be life saving.
Point out to the trainee that the CASE Approach is greatly modified and
shortened in most other situations. We leave nothing to chance here, and
make a point of providing clear examples of what we mean. Thus we describe
a situation in which a client speaks earlier in the interview of being quite distressed (and may be intermittently tearful) but relates minimal risk factors
for suicide and describes excellent buffers (perhaps speaking spontaneously
of future plans and a strong social support system). In such a situation, the
screening for suicidal ideation may go as follows:
Clinician: With all of the stress and pain youve been going through, have
you had any thoughts of killing yourself?
Client: No, I havent.
Clinician: How about recently, over the past couple or so months: Have
you had even fleeting thoughts of killing yourself?
Client: You know, it just doesnt cross my mind.
Clinician: How about in the past? You had told me about some very serious episodes of physical abuse when you were growing up; have you ever had
any thoughts of killing yourself or perhaps even tried?
Client: You know, with all Ive been through, you would almost think that
I would have, but for some reason it has just never seemed like an option to
me, thank God.
The entire screening with the CASE Approach was completed with this client with just three questions in less than a minutes time. It would be inappropriate to use gentle assumptions, denials of the specific, and symptom
amplification in Region #2 of the CASE Approach (recent ideation over the
past 2 months). Its just not necessary, and would appear odd to do so. Also
note that Region #4 (immediate suicidal ideation in the interview itself) is
not even covered with such a client.
Even if a client admits to some suicidal ideation (perhaps mentioning fleeting
thoughts of overdosing or hanging), when exploring Region #1 (presenting suicidal ideation), unless the client has been extensively planning the attempt, has
taken some actions on it, or presents with an unusual array of risk factors, the
CASE Approach will once again be markedly shortened. Suppose, when such
a client is asked as the clinician enters Region #2, Have you been having any
thoughts of killing yourself over the past couple of months? he or she
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comments in a convincing and genuine fashion, No, not at all. Its just not an
option for me. Then validity techniques such as gentle assumption, denial of
the specific, and symptom amplification are once again not used.
The importance of such flexibility may seem like a no-brainer to the reader,
but we have found that it is very important to emphasize this point with examples
at the end of the macrotraining session, for some conscientious students with
a strong desire to do the CASE Approach well may come away mistakenly using it in a cookbook fashion. This potential problem can be easily prevented by
the actions described above. Indeed, if time permits, after discussing the need
for creativity and flexibility in detail, we like to role-play a client in which the
CASE Approach is greatly reduced in extent, to make sure the student gets it.
Tip #5: Communicating the Importance of TimingWhen to Ask About
Suicidal Ideation
Suicide remains one of the most taboo of all subjects, and people can have significant feelings of shame and guilt attached even to having ideas of killing oneself. Consequently, it becomes critical that clinicians time the inquiry in such
a way as to maximize the likelihood of uncovering the intimate thoughts of
the patient regarding their suicidal intent or planning in a sensitive fashion.
Many a clinician has lost the truth through the poor timing of the inquiry,
sometimes also resulting in the permanent loss of engagement.
Perhaps the single most common timing problem is asking about suicide too
early in the interview, an action sometimes generated by the interviewers
need to know or the desire to get the tough questions out of the way.
Such premature inquiry into such a critically sensitive topic can be off putting,
disengaging, and artificial sounding; it may lead to significant breakdowns in
the alliance, with a potentially dangerous loss of valid information and willingness to collaborate with recommendations for safety and follow-up. Consequently, as the macrotraining session draws to a close, we recommend
addressing this common problem. At what point in the interview should you
use the CASE Approach?
The optimum time for raising the topic of suicide may be conceptualized as
the intersection of three factors [24], which can help guide the interviewer:
(1) sound engagement, (2) presence of affective discharge in the client, and
(3) the client hints at the topic (a factor that is not always present). Lets
look at each of these in more detail.
(1) Engagement, engagement, engagement. Because people are much more
likely to share sensitive material with someone with whom they feel comfortable talking and have already established a safe environment, if the interviewer
happens to be the first to raise the issue of suicide, it is generally best to wait
until engagement is maximized. Such patience can significantly enhance the
likelihood that the client will share openly. Naturally, such maximization frequently occurs fairly deep into the interview, after the client has had the chance
to interface in an engaging fashion with the clinician on a variety of other
topics, such as the presenting crisis, stressors, painful symptoms, etc.
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Sometimes in phone intervention, the inquiry occurs even later than in face-toface interventions, for communication of factors such as empathy, as the noted
social scientist Edward Hall has commented, are often tied in to nonverbal
communications and cultural rhythms as opposed to the words we speak
[26]. The lack of many nonverbal communicators puts telephone interviewers
at a distinct disadvantage in creating rapid alliances compared with face-to-face
interviewers (a single warm smile may communicate more empathy than
a dozen empathic statements).
(2) In addition to waiting until engagement has been maximized, it is useful to
time the raising of suicidal ideation to a moment in the conversation when the
client is experiencing and expressing significant emotional pain. At such moments
of intense affective discharge, the defense mechanisms and prohibitions regarding stigmatization are often overwhelmed by the pain, once again resulting in
a more open sharing of the extent of ideation and suicidal intent.
(3) Although not always present, a third indicator of an excellent time to
raise the topic is when the patient not only is engaged and affectively charged,
but also hints at the possibility of suicide with comments such as Im not even
sure whether it is worth going on or Maybe my kids would be better off
without me. Obviously, the timing of raising the topic is unique to each client
and should never be approached in a cookbook fashion at a predesignated time
in the interview.
Another common problem in eliciting suicidal ideation is the misconception by
students that all elements of the suicide assessment occur at one time in the interview or in a direct linear fashion. A suicide assessment seldom unfolds in such
a neat fashion. Statistical risk factors (such as age, sex, presence of medical illness,
or alcohol abuse) and external risk factors (presence of an interpersonal crisis, domestic violence, poor social network, and social isolation) may appear spontaneously throughout the interview. Such statistical and external risk factors may
even appear in the early minutes of the interview, a time when clients often
give information regarding immediate stressors and interpersonal problems. Indeed, as an interview proceeds, it is the careful weighing of these risk factors (as
well as buffers) that can help the clinician make a decision about how detailed an
elicitation of suicidal ideation will be required later in the interview once rapport is
well-established.
By contrast, the internal (eg, phenomenological) risk factors, such as suicidal
ideation, intent, desire, past actions, current planning, feelings of isolation,
hopelessness, and despair (the exact factors on which the CASE Approach focuses and which it was specifically designed to uncover) are generally explored
in a naturalistic and flowing fashion during the optimal moment of the interview for such inquiry, as described earlier.
SUMMARY
It is our hope that with this article, the reader can begin his or her own forays
into macrotraining. Whether you are a psychiatric residency director, a director
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of any other type of mental health graduate program (including counseling,

clinical psychology, psychiatric social work, and psychiatric nursing), or a faculty mentor responsible for the training of clinical interviewing skills at your
program, we believe you will find that macrotraining can be effectively used
to train a variety of different types of interview.
Outside academic centers, macrotraining can be used by supervisors in myriad arenas, including emergency rooms, inpatient units, community mental
health centers, and crisis call centers (staffed by either professionals or volunteers), to teach a variety of interviewing skills, including crisis transformation
strategies, engagement strategies, and uncovering specific databasessuch as
differential diagnosis and eliciting suicidal ideation and histories of physical
and sexual abusein creative, flexible, and engaging fashions.
With this paper, and by reading the paper suggested earlier in the description
of the CASE Approach, supervisors can begin to use macrotraining to achieve
a vibrant and enjoyable training of students and staff in eliciting suicidal ideation, planning, intent, and behaviors more effectively. Although there is not
time in this monograph to describe the variants of macrotraining, it has also
been applied to larger groups of trainees, in which pods of four participants
break out of the larger group to use variations of macrotraining to teach the
CASE Approach.
It is hoped that the CASE Approach may prove to be a valuable addition to
the ongoing attempts to improve the quality of suicide assessments and the
training of all the clinicians from various disciplines who perform them. Since
its appearance in the literature in 1998, the Approach has been well received
among mental health professionals, substance abuse counselors, crisis clinicians, school counselors, and primary care clinicians. Perhaps someday all
graduates of training programs in mental health will be taught to a level of competence to elicit suicidal ideation using the CASE Approachor an even better
method, if one emerges from future research. The ramifications for suicide prevention may even encompass disciplines outside the training of mental health
professionals, such as volunteer crisis line workers, primary care clinicians
(including physicians, nurses, and case managers), and clergy.
A practical example highlights the promise of the CASE Approach in this regard. It is well documented that at least 50% of patients who kill themselves
have seen a primary care clinician within 1 month of their death [27]. A typical
primary care clinician is seeing patients who warrant a suicide assessment on
a daily basis. To prepare medical students for this future taskas part of the
numerous behavioral skills they are currently required to demonstrate in front
of faculty before graduatingevery student could be asked to learn and effectively demonstrate the use of an interview strategy for eliciting suicidal ideation, such as the CASE Approach.
It is likely that such medical students would be more reliably competent in
eliciting suicidal ideation than the typical medical graduate of today. Perhaps
even more importantly, because the students would both understand the importance of asking for suicidal ideation and feel comfortable and skilled in
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SHEA & BARNEY
doing it, they might be considerably more active in seeking it out in their future
primary care settings. The result could be a tangible decrease in the death rate
related to suicide.
Moreover, the behavioral specificity of the CASE Approach makes it ideal
for rigorous empiric study, which could confirm the validity of the strategy
or demonstrate the superiority of other strategies. Such research could provide
the foundation for an evidence-based model for effectively eliciting suicidal ideation, much in the same fashion that CPR was developed. As with CPR, such
an evidence-based interviewing strategy could be used as the basis for certifying
clinicians across disciplines throughout the country. The resultant effects on the
rate of suicide are unknownbut the possibilities are exciting.
Whether macrotraining is used to teach clinicians effective ways sensitively
to uncover thoughts of suicide or the unsettling memories related to ongoing
sexual abuse or to teach them how better to talk collaboratively with patients
about their medications, it holds much promise. Its strength lies in its clarity
and in the doing so dear to Rousseau, for a macrotrained clinician is one
who has shown not just theoretic knowledge but demonstrable behavioral competence in performing a complex clinical interviewing task.
As educators we come from a hallowed tradition. I am reminded of three
well-known admonitions that seem to resonate directly with macrotraining.
From the more distant pastthe 1600sJohn Clarke comments, Learn one
thing first well. More recently, Glenn Doman wisely commented, A primary
method of learning is to go from the familiar to the unfamiliar. And finally,
from Mark Van Doren of more contemporary fame, comes one of our favorite
quotes: The art of teaching is the art of discovery. So it is with
macrotraining.
In macrotraining, applying the principles of Allan Iveys microcounseling,
the student learns each small step well. Many of these small steps become
bridges to the next, more complicated sequence of interviewing questions,
allowing trainees to move from the familiar to the unfamiliar with more confidence because of their ever-growing sense of mastery. Finally, as the student
and the macrotrainer delve into more and more complicated role-plays and
clinical situations, the student has the excitement of discovering, for himself
or herself, through his or her own experiences, the power of language to
help clients both to share difficult material and to begin the healing process.
References
[1] Ivey AE, Normington C, Miller C, et al. Microcounselling and attending behavior: an
approach to prepracticum counselor training. J Couns Psychol Monograph 1968;(Suppl
15 (5 Pt.2)).
[2] Ivey A. Microcounseling: innovations in interviewer training. Springfield (MO): Charles C.
Thomas; 1971.
[3] Phillips JS. An evaluation of microcounseling as an interviewer training tool. J Couns Clin
Psychol 1973;41(2):294300.
[4] Nwachuku U, Ivey AE. Teaching culture specific counseling using microtraining technology.
Int J Adv Couns 1992;15:15161.
e29
[5] Scisson EH. Counseling for results: principles and practice of helping professions. Pacific
Grove (CA): Brooks/Cole; 1993.
[6] Daniels T. Microcounselling research: what over 450 data-based studies reveal. In: A Ivey,
M Ivey, Editors. Intentional interviewing and counselling. Belmont (CA): Wadsworth
Publishing. 2003. Interactive CD-Rom.
[7] Russell-Chapin LA, Ivey AE. Microcounselling supervision: an innovative integrated supervision model. Can J Couns 2004;38(3):16577.
[8] Ramsey M. The clinical supervision process. Handbook excerpt from the Department of
Counseling and Personnel Services, Trenton State College, Trenton, New Jersey; 1990;
ED 365 928. Reproductions supplied by EDRS.
[9] Training Institute for Suicide Assessment and Clinical Interviewing (TISA), Shawn Christopher
Shea, Director, Stoddard, New Hampshire. Available at: www.suicideassessment.com.
[10] Shea SC. Psychiatric interviewing: the art of understandinga practical guide for psychiatrists, psychologists, counselors, social workers, nurses, and other mental health professionals, 2nd edition. Philadelphia: W.B. Saunders Company; 1998.
[11] Shea SC. The chronological assessment of suicide events: a practical interviewing strategy
for the elicitation of suicidal ideation. J Clin Psychiatry 1998;59(Suppl 20):5872.
[12] Shea SC. The chronological assessment of suicide events (the CASE approach): an introduction for the front-line clinician. NewsLink (the Newsletter of the American Association of
Suicidology) 2003;28(3):123.
[13] A centralized suicide prevention education site funded by the National Institute of Mental
Health, contract #N44MH22045, provides details on the use of the CASE Approach.
Available at: www.EndingSuicide.com.
[14] Magellan Behavioral Health Care Guidelines. CASE Approach recommended to participating clinicians. In: Clinical Practice Guidelines for Assessing and Managing the Suicidal Patient. Developed by the 2002 Task Force. Columbia (MD): Magellan Behavioral Health Inc.;
2002. p. 6.
Counselor, the Magazine for Addiction Professionals 2001;2(6):1424.
[16] Shea SC. Tips for uncovering suicidal ideation in the primary care setting. Part of the fourpart CD-ROM Series entitled Hidden Diagnosis: Uncovering Anxiety and Depressive Disorders (version 2.0); 1999. Produced by GlaxoSmithKline.
[17] Innovations in the elicitation of suicidal ideation: the Chronological Assessment of Suicide
Events (CASE Approach). Presented at the Federal Bureau of Prisons Annual Meeting of
Chief Psychologists. Tucson, Arizona, 2001.
[18] Innovations in the elicitation of suicidal ideation: the Chronological Assessment of Suicide
Events (CASE Approach). Presented at the Federal Bureau of Prisons Annual Meeting of
Psychiatrists. Atlanta, Georgia, 2003.
[19] American Association of Suicidology (AAS). Available at: www.suicidology.org.
[20] Suicide Prevention Resource Center (SPRC). Available at: www.sprc.org.
[21] National Suicide Prevention LifeLine. Available at: www.suicidepreventionlifeline.org.
[22] Pascal GR. The practical art of diagnostic interviewing. Homewood (IL): Dow-Jones-Irwin;
1983.
[23] Shea SC. The delicate art of eliciting suicidal ideation. Psychiatr Ann 2004;34(#5):
385400.
[24] Shea SC. The practical art of suicide assessment: a guide for mental health professionals
and substance abuse counselors. Paperback edition with new appendices. New York:
John Wiley & Sons, Inc.; 2002.
[26] Hall ET. Excerpts from an interview conducted by Carol Travis. GEO 1983;25(3):12.
[27] Luoma JB, Martin CE, Pearson JL. Contact with mental health and primary care providers
before suicide: a review of the evidence. Am J Psychiatry 2002;159(6):90916.
PSYCHIATRIC CLINICS
OF NORTH AMERICA
The Art of Effectively Teaching

Clinical Interviewing Skills Using
Role-Playing: A Primer
Christine Barney, MDa,b,*, Shawn Christopher Shea, MDa,b
a
Dartmouth Medical School, 1 Rope Ferry Road, Hanover, NH 03755, USA

ime pressure on busy trainees who work within capped hours of service
and on busy supervisors who need to maintain clinical hours to generate
their salaries places a premium on efficiency in training students to master
clinical skills. Just as surgical trainees sometimes practice surgical skills in laboratory settings to master basic techniques before performing them on patients
[1], graduate students from all disciplines can benefit from less stressful training
situations that focus on specific skill sets through the use of individualized roleplaying by skilled coaches. In addition, it now is commonplace for clinical
institutions such as community mental health centers, inpatient units, and crisis
call centers to provide ongoing training for both new and experienced staff
using role-playing to ensure quality assurance.
Role-playing has a major advantage over the use of mere didactics, because it
requires a level of understanding that must be translated into actual behavioral
practice and subsequent demonstration of the interviewing skills. With the
advent of sophisticated applications of role-playing (such as microtraining
and macrotraining), core engagement techniques as well as complex interviewing taskssuch as transforming crises, eliciting symptoms for accurate diagnosis, and uncovering suicidal ideationcan be taught to a level of competence.
Such quality assurance of performance standards is outranked only by direct
observation of the student with an actual patient. The freedom from actual clinical demand may reduce the stress level in the learning phase, so that mistakes
can be corrected without fear of dire consequences.
Through role-playing, a supervisor can create multiple iterations of the
desired skill until competence is obtained. The skill training then can advance
in intensity and complexity, including chances to practice using the skill with
the supervisor playing the role of resistant clients. Practice continues until
*Corresponding author. E-mail address: tbarneyvt@mac.com (C. Barney).

doi:10.1016/j.psc.2007.03.001

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BARNEY & SHEA
the trainer and trainee are confident that the skill is understood and is accessible on demand and that the trainee is beginning to feel comfortable with its use.
Arising from the sound foundation created by role-playing, further skill
enhancement can occur if the supervisor has the opportunity to observe the
trainee using the techniques with an actual patient, showing that the acquired
skill has been generalized to clinical practice. Once again, this type of rigorous
training has similarities to the sophisticated development of surgeons who
achieve proficiency through the intense repetition of skills with patients while
being monitored by skilled senior staff.
Using role-playing effectively is not an easy task. If not done well, its results
can be disappointing. Moreover, employing role-playing is not every instructors cup of tea; for some teachers it is simply not going to be a good fit. Nevertheless, we believe that many supervisors, even some who initially may feel
uncomfortable with it, can be taught to use role-playing successfully and with
great enjoyment.
Indeed, we have found role-playing to be one of our most enjoyable of teaching formats. I personally have used role-playing for nearly 20 years as part of
the Dartmouth Interviewing Mentorship Program, described elsewhere in this
issue. My co-author, the creator of macrotraining, has been studying roleplaying and serial role-playing intensively for almost 30 years. Together we
hope to provide a user-friendly primer that introduces a variety of practical
considerations for using role-playing fruitfully.
Another online article in this issue described the details of a sophisticated application of serial role-playing called macrotraining. (Please see Macrotraining:
A How-To Primer for Using Serial Role-Playing to Train Complex Clinical
Interviewing Tasks Such as Suicide Assessment at www.psych.theclinics.com,
June 2007 issue). We do not intend to repeat this information here. Instead, this
article focuses on the much narrower topic of how to perform one, generic roleplaying well, whether it is used in a simple application, such as offering a student
a chance to practice interviewing skills, or in more sophisticated applications,
such as microtraining and macrotraining, in which the goal is to teach interviewing techniques and/or complex interviewing strategies to levels of verifiable competence. Our focus is on practical methods of creating believable role-plays and
how to use them to teach specific interviewing skills strategically (while always
carefully trying to decrease any anxieties the trainee may have about role-playing
itself).
This informal article is neither a research paper nor an academic review: it is
a sharing of practical knowledge from teacher to teacher, a hands-on manual of
sorts, drawn from our own experience. We do not pretend to have all the
answers, and we would love to hear from you any new ideas you have. We
hope you enjoy the article and share it to pass on clinical wisdom and technique
with all those who love the power of role-playing.
Our approach in this primer is sixfold:
1. To provide a brief history of the varied uses of role-playing
2. To describe the unique training advantages that role-playing offers
CLINICAL INTERVIEWING SKILLS USING ROLE-PLAYING
e33
3. To delineate some specific tips for role-playing more effectively and for transforming potential problems
4. To address some unexpected consequences of role-playing
5. To provide tips for creating realistic role-playing characters
6. To suggest a list of specific interviewing skills that we have found to be particularly well addressed by role-playing
A BRIEF HISTORY OF ROLE-PLAYING

Role-playing has become a popular and ubiquitous method of training interviewing skills. It is used for training in numerous disciplines, including medical
students, nursing students, psychiatric residents, and residents from other specialties such as primary care and internal medicine, and for training graduate
students in techniques of counseling, clinical psychology, social work, and substance abuse counseling. Role-playing also is used as a method of ongoing quality assurance for staff at hospitals, mental health centers, and crisis call centers.
Its use can be broken into three broad categories.
In its simplest form, clinical instructors use role-playing to provide opportunities for students to practice interviewing skills in an experiential fashion (and
in a safe environment in which there are no clinical ramifications). In this setting, creative instructors also can use role-playing to present a variety of clients
(eg, from diverse socioeconomic and cultural backgrounds and with specific
types of psychopathologies or stressors) and differing clinical situations (eg, crisis intervention, ongoing therapy, and inpatient care).
In its more sophisticated and rigorous applications, role-playing can be used to
train a single specific interviewing technique, such as using an open-ended question, to a point of behavioral competence (microtraining) or to train complex
interviewing strategies, such as eliciting suicidal ideation or uncovering a history
of domestic violence, also to a level of behavioral competence (macrotraining).
Another sophisticated use of role-playing is the use of standardized patients
(role-played by actors, patients, or instructors) to measure behavioral skills and/
or provide feedback about the impact of the students interviewing style.
The broad utility of role-playing is reflected in the wide range and great
number of articles studying or reviewing its use in all three of the categories
described previously, including such remarkably diverse settings as nonmedical
classrooms for distance learning in Germany [2], improving the interest and
retention of students exploring careers in mental health research [3], training
primary care residents in interviewing [4], trouble-shooting the cooperative
function of medical teams [5], addressing patient safety issues and preventive
steps by simulating situations that have gone awry [6], and evaluating sophisticated urologic procedures [7]. A nursing review offers concise cautionary
notes regarding the challenges of designing effective simulations [8], and a Belgian study on teaching communication to medical students provides a candid
summary after 6 years of training with a small-group format [9].
Two advances in role-playingmicrotraining and macrotrainingwarrant
more detailed attention. In the 1960s, Ivey [10] developed a sophisticated
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BARNEY & SHEA
form of role-playing, microtraining (also called microcounseling), that revolutionized role-playing as an educational tool. Ivey focused on faithfully transmitting one interviewing technique at a time to a student. He realized that
providing didactic teaching would not be sufficient to pass on such a behavioral
skill, nor would the loose practicing of the skill using role-playing. Ivey
believed that the trainer must address the skill through the use of modeling
and serial role-playing to ensure accurate learning, consolidation of the skill,
and generalization of the skill to actual clients and to enhance the likelihood
of long-term retention of the skill at a level of mastery. Iveys focus was not
just on practice; it was on practicing until true competence had been shown.
His paradigm of microtraining achieved this goal through serial role-playings of
a single interviewing technique until it had been consolidated and generalized
by the student.
In classic microtraining, the interview question or behavior to be trained
must be well defined behaviorally and usually is described in a manual as
well as modeled on videotape. Some students may be able to test-out of
the session if they can demonstrate the skill in question. For those who do
not know or have not mastered the skill, a microtraining session is used.
The trainer focuses on one skill at a time (eg, the use of open-ended questions,
empathic statements, or reflecting statements).
After brief reading and a few minutes of didactics enhanced by modeling (often by watching a videotape), the trainee learns the specific skill through roleplaying until the trainer is comfortable that the trainee can demonstrate the skill
to a level of competence. In a brief period of time, often 6 to 7 minutes, the
trainee practices and consolidates the newly acquired skill using serial roleplaying as many times as possible. If time allows, new role-playing incidents
with different types of clients are introduced to see if the trainee can generalize
the newly acquired interviewing skill.
Ivey transformed role-playing from an educational tool that was loosely
applied by trainers, into an educational technology in which he delineated specific behaviors by instructors who used role-playing to enhance and consolidate
the learning to the point that the trainee could demonstrate actual clinical competence in the interviewing technique in question. Ivey did more than speculate: he went in search of empiric data that his training ideas withstood
scrutiny. As a result, microcounseling has a large evidence base and may
well represent the best-documented interviewing training technique at mentors
disposal. Its evidence base has been accumulating for decades [11]. A review by
Daniels [12] found more than 450 studies documenting its efficacy.
The next evolution in role-playingmacrotrainingwas developed by Shea
in the mid-1980s and is described in detail elsewhere in this issue. He noted
that although an interview is composed of individual techniques amenable to
microtraining, in the real world of clinical interviewing these techniques do
not exist in isolation but always are integrated into specific interviewing tasks.
Such tasks often revolve around the gathering of a specific database while
maintaining engagement with the client. Typical interviewing tasks (all of which
e35
can be taught via macrotraining) might include gathering a picture of symptoms

to make a differential diagnosis, eliciting information related to a drug and alcohol history, uncovering information related to interpersonal functioning and social history, and eliciting suicidal ideation. Especially with sensitive topics such as
domestic violence, incest, and suicidal ideation, it becomes critical for the clinician to be able to ask questions about difficult-to-share material while simultaneously attending to and nurturing the therapeutic alliance.
Microcounseling is effective for teaching individual interviewing techniques,
especially those techniques vital to engagementsuch as attending behavior,
communicating empathy, and using open-ended questions, reflecting statements, and summarizing statements. Shea began to wonder if one could delineate a complex interviewing task such as eliciting suicidal ideation into single
small steps that eventually flowed into a larger sequence of effective
questioning. If so, could this simplification of the complexities of a real-life
interviewing tasksuch as uncovering incestbe amenable to the serial use of
microtraining in each of the steps of the process until the trainee could perform
the entire interview flexibly and accurately?
The goal of macrotraining is to teach such complex interviewing strategies to
a level of competence in a single session, using serial role-playing of sequences
of questions. Complicated interviewing tasks such as eliciting suicidal ideation,
planning, and intent often are composed of numerous questions and strategies
rather than a single technique as taught in microtraining. Consequently, macrotraining sessions typically last 30 minutes to 4 hours.
Macrotraining was designed both to teach the wording and sequencing of
specific types of questions and to allow the trainer, by directly observing the
interviewers tone of voice and use of other nonverbal communications, to
ensure that the questions are asked in an engaging fashion.
Thus, while teaching the sequential questioning involved in a complex interviewing strategy, the macrotrainer can ensure that all of the critical basic
engagement skills classically taught in microtraining are being used effectively.
To date, the most striking use of macrotraining (see the macrotraining article in
this issue) is the teaching of the widely used interviewing strategy for eliciting
suicidal ideation, intent, and behaviors known as the Chronological Assessment of Suicide Events, the CASE approach [13]. The goal is to make sure
that all trainees can demonstrate proficiency in this key clinical task before
graduation.
Before closing our brief history of role-playing, we want to refer the reader
to the third sophisticated use of role-playing: the use of standardized patients
for the testing of behavioral skills. Perhaps the best example of this use has
been the development of the Objective Structured Clinical Examination,
a tool frequently used in medical student and allied health education [14].
THE BENEFITS OF ROLE-PLAYING AS AN EDUCATIONAL TOOL
To use role-playing effectively, the first thing a trainer needs is beliefbelief that
role-playing works and that role-playing provides some specific and unique
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BARNEY & SHEA
educational opportunities not available with more traditional methods of teaching. In this section we will share a series of benefits to the use of role-playing.
Let us begin by sharing one of our favorite techniques, reverse role-playing,
because it nicely illustrates the unique educational power of role-playing. Two
definitions are helpful. Standard role-playing occurs when the trainer portrays
a patient, and the student is asked to be the interviewer (practicing the skill in
question). Reverse role-playing occurs when the trainer and the student reverse roles. In reverse role-playing, the trainer interviews and the student portrays the client. Reverse role-playing is described here in some detail, because
it demonstrates what role-playing can accomplish that simply is not possible
through didactics, reading material, or even videotaped supervision.
We think you will find that the rotation of roles between the trainer and the
student can be beneficial in a variety of situations. In its simplest application, it
is used when a trainee is unfamiliar with the skill in question. Reverse roleplaying lets the trainer model the skill for the trainee at the outset, so the
expected target behavior is clear.
Another advantage of reverse role-playing, especially when used early in
a session of role-playing, is that it demonstrates that the trainer is willing to
be put on the spot, too. In fact, if you do not perform the interviewing technique as well as you wanted, a comment such as, Boy, I wish I had done that
a little differently. Maybe this would have been better. What do you think?
can go a long way toward establishing rapport with the trainee.
We often encourage students to critique our techniques. This openness to
feedback conveys a genuine desire for ongoing learning and also models for
trainees the importance of asking for feedback when teaching or when doing
therapy itself. In essence, reverse role-playing provides a potent metacommunication of nonhierarchical learning that we believe is communicated most
convincingly through reverse role-playing.
There is an even more powerful use of reverse role-playing. Sometimes
a trainer encounters a student who does not really believe in the efficacy of
an interviewing technique that is being taught. Ultimately, perhaps, the trainer
and the student will have to agree to disagree. There is no cookbook way to
interview, and we all select interview techniques we enjoy using. On the other
hand, the students hesitancy sometimes is based on inaccurate information or
on an erroneous assumption. In such instances, reverse role-playing may provide a valuable tool for transforming the resistance.
Supervisees often are more willing to use new skills once they have felt their
impact by playing the patients role. By being on the receiving end of the technique, they have direct experience with which to reassess their projected fears
or misgivings. For example, they might be afraid that the interviewing technique will not work or will be disengaging. If their personal experience in
the reverse role-playing is to the contrary, the misgivings dissolve. The following is a more specific example.
As experienced clinicians we all know that sometimes overly loquacious clients or markedly tangential clients must be redirected and that doing so
e37
sometimes requires interrupting the client. Some students are reluctant to use
such appropriate interruptions, because they fear that such an intervention is
rude and risks disengagement.
This situation is ideal for the use of reverse role-playing in which the student is asked to portray a wandering client while the trainer uses skilled interruptions effectively to structure the trainees client without causing
disengagement. At the end of the reverse role-playing, the student will
have learned from direct experience that the structuring by the interviewer
felt fine. There can be no more convincing argument than uncovering the
truth for oneself.
We often introduce this exercise by saying, Lets do a role-play in which
you play the wandering patient, and I use the structuring techniques; you can
see how it actually feels. We also point out to the resident that patients
generally want to provide the information that the clinician needs to help
them, but patients do not necessarily know what that information is. The
structuring helps, and many patients feel more comfortable if the clinician
deftly provides cues for when to move to different aspects of a particular
topic or even into a brand new topic. The patient actually might feel at sea
if the interviewer simply remains nondirective during the main body of the
interview.
The following example from my own experience shows the striking power of
reverse role-playing to transform a learning disagreement by allowing the
trainee to experience the interview strategy from the receiving end. One of
my psychiatric residents imagined that a victim of domestic violence would
find an exploration of some of the details of the violent incident intrusive in
an initial interview, especially if there was an effort to delineate the details of
the extent of the partners violence to date. After I used reverse role-playing
(in which the trainee assumed the role of the victim) to demonstrate how to
uncover such information sensitively, the trainee found it more credible that
a person could reasonably tolerate such questioning. The resident even
understood, from her own personal feelings during the reverse role-playing,
that a patient actually might feel relief that someone finally understood enough
to realize how bad things had gotten. I tacitly demonstrated this knowledge by
asking questions that could come only from a knowledge of how abuse
progresses.
At this point some fine-tuning information was given to the resident on what
type of information needed to be uncovered in such situations and how to do
so in a sensitive fashion. Then standard role-playing was used in which the
resident could practice the techniques. Fortuitously, in a follow-up session
of supervision in which I observed the resident doing a scheduled intake interview, the patient had a significant history of domestic violence. To her credit,
the resident managed to sculpt the region well, uncovering pertinent bits of
information and doing so in a competent and engaging fashion. After the
patient left the interview room, I commented on the residents success, hoping
to reinforce it so it became part of her ongoing repertoire of skills.
BARNEY & SHEA
e38
The benefits of role-playing are extensive and fall into the following
categories:
1.
2.
3.
4.
5.
6.
7.
8.
Assessing the students skills accurately

Building confidence and consolidating skills
Broadening case material
Learning to transform angry and awkward moments
Strengthening clinical reasoning
Modeling new interviewing techniques
Gaining comfort with new interviewing skills
Enhancing videotape supervision
Assessing Skills Accurately

One of the most important advantages of role-playing is the direct observation
of a students skills to assure that competence is present. No student can be
fully aware of what he or she is doing while doing it, and therefore a students
report that a technique is being done well may or may not be accurate. Indeed,
a student may be saying the correct words but may accompany the technique
with nonverbal behaviors that are disengaging or have a poor sense of timing.
In another spectrumcognitive knowledge baserole-playing can help establish the limits of the supervisees knowledge and experience. To explore a given
region of datasuch as the DSM-IV-TR criteria of a specific diagnosis or the information required in a sound social historythe trainee must be familiar with
the body of information to be elicited and must be able to consider which questions to ask to gather that data most efficiently. Role-playing uncovers any
weaknesses in this knowledge base quickly and clearly.
Paradoxically, in a small number of instances role-playing can give a more
accurate representation of skill competency than a videotape of a students
interview with an actual patient, a point seldom addressed in the literature.
Videotapes can create artifacts. These artifacts may result from the trainees
anxiety about being taped, with a resulting loss of spontaneity or natural employment of interpersonal skills, a problem we refer to as videotape freeze.
In other instances, specific singular issues that may have been prompted by
the particular patient in the tape may detract from the students overall display
of skill. For instance, a clinician who normally is adept at gathering information
regarding diagnosis in a sensitive fashion may appear quite stilted if this particular videotaped patient was hostile early in the interview and had thrown the
student off balance. Naturally, this situation on the tape will focus the trainers
attention immediately on helping the student deal with hostility, but it also may
give an inaccurate portrayal of the students typical diagnostic skills. It may
help to role-play the part of a nonhostile interview in which the students diagnostic skills would be needed, to see whether the skill is truly lacking or was
merely compromised with the particular videotaped subject.
Videotapes also may lead to inaccurate overestimation of a trainees knowledge base; for example, if a frequently hospitalized patient were taped and
spontaneously gave information so readily that little skill was required by
e39
the interviewer, the interviewer might appear artificially talented at obtaining

a robust database.
Building Confidence and Consolidating Skills
One of the most powerful advantages of role-playing is the consolidation of
skill through repetition. Repetition (with slight variation to avoid boredom)
is the cornerstone of both the microtraining of single skills and the macrotraining of complex interviewing sequences. Such consolidation can play a pivotal
role in enhancing the likelihood that the student will generalize the interviewing
skill and maintain it over time.
Similarly, it may be worthwhile to role-play some of the trainees strengths
and reinforce them. Such role-playing of safe skills may convince a student
who is wary of role-playing that role-playing is a reasonably comfortable experience with minimal attached stress. Practicing strengths also can protect
against the specific supervisory misstep of focusing too much on the acquisition
of new skills while a recently acquired skill fades through lack of positive reenforcement from the trainer.
Broadening Case Material
No matter what the inherent quality of the program in which a student is
trained, there will be some sampling bias among the patient types the student
encounters. For instance, programs may vary in how often the student works
with people suffering from acute psychotic episodes, war-related posttraumatic
stress disorder, or eating disorders or encounters with clients from minority
cultures. Role-playing of different situations with which students are less familiar or unacquainted will help them feel more prepared when they encounter
a novel patient complaint or type of presentation. Although attempting to prepare a student for all rarely encountered situations is impractical, there is utility
in screening the trainees experience to see if there are common clinical problems that the trainee is underprepared to handle effectively.
Learning to Transform Angry and Awkward Moments
Even a supervisor who is sitting in on interviews, watching through a one-way
mirror, or routinely reviewing videotaped sessions may never see the student
handling certain difficult situations. Two key difficult situations are angry
exchanges and awkward questions from clients directed to the interviewer,
such as, Do you believe it is ever okay to kill yourself? or Do you believe
in God? or What is your sexual orientation? or Do you believe me?
(asked by a patient regarding his or her own delusional belief).
Learning to handle anger gracefully and nondefensively or to respond appropriately to awkward questions highlights two other uses of role-playing.
Role-playing may well be the most effective method for training the student
in this particular set of clinical skills. Role-playing allows the student to address
a specific awkward moment repeatedly while experimenting with different
types of responses in a totally safe environment. It gives ample time for the student to share personal feelings generated by the awkward moment that may
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BARNEY & SHEA
need to be discussed before effective training can continue. Once the student
becomes comfortable with various ways of handling the awkward moment,
the skill can be consolidated through an iteration of targeted role-plays.
Strengthening Clinical Reasoning
As the alliance of the supervisor/supervisee pair develops over time, the trainer
can present the trainee with increasing levels of challenge in their role-playing.
This graduated challenge offers the trainer a better chance to assess and to
improve the students ability to evaluate clinical situations more astutely and
to problem solve more effectively in various hypothetical situations.
Role plays can provide a forum for inquiry and gaining mastery, and motivated trainees often bring clinical material from their on-call or clinic experiences to interviewing supervision. In such instances, the trainer can discuss
the trainees concerns and then collaborate to develop strategies for the trainee
to try, subsequently using role-playing created on the spot to match the
trainees concerns. Reverse role-playing can offer the trainee a chance to see
exactly what the proposed interviewing technique feels like.
Supervisors can draw from their own experience to provide training in related but less commonly encountered issues, so that trainees can be better prepared to handle the unexpected. With increasing comfort in the technique,
trainees can minimize the time spent discussing, What should I do if. . .? Instead, they are more eager to jump into role-playing to see what the suggested
intervention might offer.
Modeling New Interviewing Techniques
A picture is worth a thousand words is eminently applicable to learning interviewing and psychotherapy skills. As mentioned earlier, reverse role-playing
is invaluable in this regard when videotaped illustrations of technique are not
available. Reverse role-playing also has the advantage of immediately modeling
a technique with the exact type of client with whom the trainee encountered
difficulties, a technique not available from a premade videotape.
Gaining Comfort with New Interviewing Skills
Many of the factors that make role-playing ideal for teaching new interviewing
skills have been touched on in the discussion of the uses of role-playing. An
advantage that has not yet been noted is that the ability to practice a focused
technique in multiple iterations can reduce the trainees experience of stage
fright or of the mind going blank when trying something new, and can
push the trainee to address specific fears or weaknesses. Role-playing provides
a safe arena in which the student realizes that techniques are being practiced
and errors are expected and acceptable, and in which the training dyad can address issues requested by the student and at the students own pace. To use
role-playing to teach complex new interviewing skills and strategies to a level
of competence, we once again direct you to the educational technologies of
microtraining [10] and macrotraining (described in detail elsewhere in this
issue).
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Enhancing Videotape Supervision

Videotape supervision can be enhanced if the supervisor is skilled in the use of
role-playing, microtraining, and macrotraining. We call such supervision roleplay-enhanced videotape supervision. If a particular problem in which a specific
interviewing technique could be useful is spotted during videotape supervision,
it can be highly effective to replay the relevant tape segment, describe the skill,
and immediately follow the demonstration with role-playing to try out the new
technique. Subsequent role-playing can be used to consolidate the learning.
When facilic supervision (a method for spotting problems with how residents
structure interviews and make transitions between topics, described in detail
online in the Web Archive of this June issue at www.psych.theclinics.com)
is used in conjunction with videotaping, new avenues for the productive use
of role-playing arise. If the trainer sees on the videotape that the resident has
problems gracefully exploring a specific diagnostic region, this problem can
be highlighted, and the trainer, using reverse role-playing, can immediately
model more effective ways for naturalistically exploring the desired symptoms.
The trainee then can try out the new techniques in a standard role-playing.
At times, a students skill deficit may be related to emotionally charged material or to countertransferential feelings (eg, a student routinely does a poor
exploration of the region of substance abuse related to the students father suffering from alcoholism). In such cases, the use of interpersonal process recall
[15] can help the trainee better address the indicated clinical skills. This triadic
combination of videotape, interpersonal process recall, and role-playing can be
powerful.
SOME TIPS FOR MORE EFFECTIVE ROLE-PLAYING
Minimizing Anxiety Related to Role-playing
Students vary significantly in their attitudes toward role-playing, ranging from
obvious enthusiasm to intense dislike. The direct observation of ones skills can
generate an intense awareness of scrutiny, with a heightened sense of a trainees
vulnerability. We have found a variety of attitudes and methods that can significantly enhance a trainees sense of appreciation for and comfort with roleplaying.
With regard to the trainers attitude, two key attributes have helped guide
our actions over the years: humility and fallibility. We manifest these attributes
by emphasizing that we are teaching a wide variety of tools to broaden a clinicians options, rather than teaching the right way to do interviewing. We
emphasize that we are trying to generate enthusiasm about the power and nuances of clinical interviewing in which we eagerly invite discussion, differences
of opinion, and creative approaches to strategizing. We hope that we are providing the trainee with the tools to engage in a lifelong study and refinement of
interviewing process. To re-enforce further that we, too, are learning, and that
we, too, make mistakes, we occasionally find it useful to recount our own errors or misfires when a technique that seemed to be indicated did not work
well with an individual patient.
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BARNEY & SHEA
Flexibilityknowing what else to try when a given approach is unsuccessful

is a much more useful goal than a robotic repetition of technique. Helping interviewers allow for blunders or gaffes, and even modeling how to apologize to
a patient who finds a particular phrase or intervention offensive or disquietening, can help trainees abandon constricting ideas that reduce their humanity
and can allow the appropriate use of their personalities in interviews.
If a student believes that patients are fragile and apt to fall apart unless the interviewer displays perfect empathy, they may be reluctant to offer any empathic
statements for fear of being out of synch with the patient. Casting off the myths
that the trainer is a perfect interviewer, or that perfection is even an achievable
goal in the real world of clinical interviewing, can reduce the burdens under
which particularly anxious or high-achieving trainees may labor.
Before beginning role-playing, we recommend asking, Have you ever done
role-playing, and what was it like for you? Many students have had good experiences, but a sizeable number have not, especially if they have experienced
poorly done role-playing. Typical biases, as mentioned in our macrotraining
article in this issue, include the idea that role-playing is silly, unrealistic, artificial, useless, or makes one feel uncomfortable [16]. That is quite a list! It is better to have these concerns out on the table than constantly undermining the
role-playing experience as one proceeds. Once doubts are out on the table,
the supervisor has the opportunity to transform such biases or to reduce them.
When an occasional trainee expresses strong misgivings about role-playing,
we recommend beginning by acknowledging and accepting the resistance with
a comment such as, You know, you are absolutely right. Role-playing can really be pretty much a waste of time. I personally had some bad experiences
with it in my training, where it just didnt do anything for me. What Ive
learned over the years is that there are good ways to do it and not so good
ways, and I think Ive learned a lot of ways to make it work well. Part of
the trick is making the patients seem real, and Ive gotten pretty good at
that. Youll have to let me know if Im not believable in a given role, but
Ive got some pretty interesting patients to show you that are based directly
on my own clinical practice.
We also find it useful to describe gently (using soft sell, not hard sell) some of
the unique advantages to role-playing to the trainee:
1. Role-playing allows the role-players to study a specific type of clinical situation that may occur only sporadically with actual patients (eg, a patient describing delusions), whenever they wish, and as often as they wish.
2. Role-players can go at their own pace, and the trainee will determine what
pace is best.
3. Role-players can practice whatever they want.
4. Role-players have the luxury of focusing on only one clinical interviewing
technique at a time.
5. There are absolutely no clinical pressures on role players because they are
merely practicing. There is no real patient in the room, and any mistakes
either role-player makes have no ramifications.
e43
After the very first role-playing session, we also recommend asking, How
did that go for you? Depending upon the students answer, we might ask,
Is there anything we might do to make this even more comfortable or useful
for you?
In my own work with trainees and with clients, I am indebted to the work of
behavioral psychologist Pryor [17]. Her work in positive reinforcement training
across multiple species is instructive in basic principles for creating a safe, effective, and enjoyable environment for behavioral change. She has convincing
experience that establishes the need for
1.
2.
3.
4.
Having clear expectations

Marking the desired behavior precisely as it emerges
Recognizing initial steps that are approximations toward the desired goal
Gradually raising the bar on the skill level of the performance that is needed
to get recognition
5. Eliminating expression of the trainers frustration to the subject
6. Rewarding correct behavior
7. Attending to the subjects fatigue or frustration, and ending the training session on a positive note with a skill that is under mastery
Pryor [17] also offers an intriguing approach toward reducing performance

anxiety. She notes that training the last step in a behavioral sequence first
can be a key to successful completion of a behavioral chain, especially when
learning this last skill set to competence assures recognition and reward.
The principle in such training backward from the end is that the mostrehearsed skill set (because the trainee has role-played it to competence) and
therefore the area of greatest confidence becomes something that the trainee
is moving toward during the remainder of the role-playing sessions. Rather
than experiencing anticipatory anxiety, the trainee anticipates the relief of
approaching a comfort zone.
(Clinicians who use positive imagery and hypnosis may see a parallel to the
technique for decreasing anticipatory anxiety or phobic avoidance in which clients imagine safety from a feared task by rehearsing a successful conclusion
and then develop the sequence in reverse. For example, a patient who has airplane phobia could begin by picturing a successful landing and getting off the
plane and then work backward in small steps, eventually picturing the sequence from the beginning, with preparing to leave for the airport.)
Back to interview training, suppose you were training a resident to do an entire
initial interview, and he or she has a history of trouble getting patients to close
down at the end of an interview. You might start by role-playing the closing of
the interview first, with the trainee practicing the closing until competence is
achieved while you provide much positive feedback with each element of improvement to instill more confidence. From this point onward, as you begin training the resident, in steps, for the rest of the interview, the trainee always will know
that he or she is moving toward a task (the closing of the interview) with which
the student now feels comfortable and competent. This technique might be
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BARNEY & SHEA
helpful for students who have performance anxiety about finishing on time, gathering enough data, or being able to bring the interview to an acceptable close.
Another aspect of decreasing anxiety deals with addressing the emotional impact of the role-playing as the session goes on. For instance, sometimes it is best
to end role-playing early if the trainee seems to be exhausted or disheartened
by not getting it right. Ideally, the trainer can go back to an earlier role-playing that the trainee did well, ensuring that the supervision session ends on
a note of success. At other times, one may shift completely away from roleplaying and use didactics, as well as a sense of humor, to bring the session
to a nonthreatening and comfortable end.
Another aspect of reducing anxiety relates not to the session at hand, but to
the use of ongoing role-playing with a student whom one may be supervising
over a longer period, as when a trainer/trainee pair is sustained over the course
of a year. Here a new principle enters the picture. Within the safety of a welldeveloped longitudinal relationship with the supervisor, a trainee may be able
to tolerate and benefit from deeper scrutiny.
In short-term role-playing training, one usually focuses on the exact wording
and sequencing of behaviorally specific interview techniques and strategies. Attitudes conveyed by the interviewer, however, can have a great impact on how
well that interviewer is received by a given patient. These attitudes are transmitted through qualities such as tone of voice, timing of intervention, other
nonverbal mannerisms, and the basic attributes of the residents personality.
(Some residents can come across as self-important big shots or as poor listeners who seem as though they do not really care; others may be prone
to making narcissistic insults or have a paternalistic demeanor.) Clearly, it is
important to address these problems. We have found that the tone of the
delivery of our feedback and our ability to maintain a respectful attitude are
important in helping residents with such delicate matters that reflect back on
their personality structures.
Equally important, during longitudinal supervision, we purposefully avoid
focusing on many such nonverbal communication problems until much later
in the year, to allow more time for rapport to be established before trying to
alter behaviors that the trainee might view as too personal or potentially invasive. Once a safe supervisory relationship has become well established over
months, it sometimes is surprising how many of these more delicate matters
can be addressed successfully through direct discussion and also through
role-playing.
You may encounter a few trainees who have remarkably elevated anxiety
related to role-playing. In a rare instance, a trainee may have a true social
phobia with an intense fear of performing any task in which he or she will
be observed directly. If you encounter such a situation, role-playing may be
counterproductive, and the teaching of the interview strategy that was the
subject of the role-playing session may be approached better in less directly
observed ways while helping the trainee seek professional help for the ongoing
social phobia.
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Effectively Interrupting the Role-playing to Make a Teaching Point

In theory, one can wait to provide feedback to the trainee until the role-playing
is completed, and there are good reasons for doing so in specific settings. On
the other hand, it is much more common to want to provide immediate feedback, especially if the trainee is doing a technique poorly. One reason for such
prompt interruption is that one does not want the trainee to consolidate the error by repetition. Also, from a behavioral learning perspective, it can be more
advantageous to provide corrective feedback as soon after the problematic
behavior as possible and to reward good behavior promptly. We refer to this
interruption of role-playing as marking the role-play.
In behavior modification with nonhuman animals a clicker device often is used
to mark a behavior as soon as it happens [17]. Although such a device could be
used as a marker in role-playing, we have found it much easier to agree on a specific hand signal, which either the trainer or the trainee can use at any time, to stop
the role-playing. Such a hand signal functions like a time-out signal used to call for
a break in the action of a football game.
Unless a time-out has been called, the dyad remains in role at all times. Students who are hesitant to do role-playing are notorious for breaking out of role
often, greatly diminishing the likelihood that a realistic feeling will begin to unfold. This problem can be addressed easily by enforcing the norm that, unless
a time-out is called, both parties will remain in role. It cannot be overemphasized that, for role-playing to become real to the participants, it is critical
that they stay in role unless the role-playing has been marked by one of the
participants. Trainees benefit greatly when the simulation achieves the emotional intensity that would be generated in an actual clinical interview (eg,
the fear of someone with paranoia, the despair of a depressed patient, or the
hostile irritability of someone who is manic). If trainees have encountered
and mastered such emotionally charged situations during role-playing practice,
they are less apt to be disconcerted by them when subsequently encountered in
clinical practice.
Even if the student has done a good job, you should try not to smile or nod
encouragement, because this action breaks the role-playing: the patient you are
portraying would not make such a gesture. You can give simple, on-the-spot
positive feedback effectively by marking the session, breaking out of role
briefly, and saying something like, That was a great use of open-ended questions; keep going, and lets see what else you uncover, and then returning immediately into role. Such a consistent adherence to the rules of role-playing
keeps the sessions on track and realistic, much as sticking to group norms in
group therapy is vital to the functioning of the group.
HANDLING UNEXPECTED CONSEQUENCES OF ROLE-PLAYING
Role-playing, by its very nature, is ad lib. A trainer never knows exactly which
direction a specific role-play may take, because this direction depends on the
students responses. Spontaneity is the name of the game, sometimes for the
good and sometimes for the bad.
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BARNEY & SHEA
On the bad side, the focus of the learning may move unexpectedly to a new
topic. Thinking on the fly, with ones plan being to focus on a single teaching
point, we as trainers may believe we are training only the topic of focus; however, the trainee is responding to our dialogue and nonverbal behaviors and to
the trainees own internal associations. Although we believe we are training one
specific point or technique, and even if we clearly state that intention to the
trainee, the student may be detecting something else in the role-playing that
is notable for the trainee but may have been unintentional or incidental in
the mind of the supervisor. I sometimes ask for questions or comments at
the end of a role-playing to see if unintended points were made or if some
ambiguity arose.
Unscheduled shifts into new teaching areas are not always problematic. Indeed, as the level of comfort and familiarity between trainee and trainer increases over multiple meetings in a longitudinal supervision, it may become
both easy and advantageous to flow with the new direction the trainee takes,
addressing serendipitous teaching points that may be very useful to the trainee.
One always can return subsequently to the intended teaching point.
Another unintended consequence of role-playing is related to the emotional
intensity generated by the role-playing itself. Although many students begin by
saying that role-playing does not feel real to them, the situation can become all
too real in the hands of a gifted role-player. The evolution of a role suddenly
can become compellingly intense, and trainees may use it to put forth some
profound or distressing interaction they have had with patients in the past.
At other times, the trainers portrayal of a patient may elicit a reaction in the
student that seems excessive, and even a brief inquiry from the trainer may
result in the students revealing an important incident such as incest in the
trainees own life.
Supervisors vary in how they attend to such revelations, by briefly exploring the incident as it relates to its immediate impact on the trainee as a clinician
or by referring the trainee to a psychotherapy supervisor whose role more frequently includes dealing with countertransference. Of course, in conjunction
with the residency director, a decision sometimes is made to suggest individual therapy if there clearly is a significant area of concern for the trainees
mental health or if the trainees emotional distress hinders his or her clinical
work.
On a much lighter note, however, the most common serendipitous consequence of role-playing is laughter and the use of humor by both the trainer
and the trainee. When a role-played patient with manic disinhibition is baiting
a young trainee by picking on his or her lack of training or flies into a hysterically funny set of loose associations, sometimes you just have to laugh. If one is
at a critical point in teaching a technique, and there is just a bit of a chuckle
from the trainee, it often is best simply to stay in character, and the trainee
will follow suit. If both parties are struck by a particular spontaneously funny
circumstance, it usually is best to mark the session, pull out of role, and laugh
with abandon. Such moments can be valuable in creating a comfortable and
e47
enjoyable alliance with the student. The humanness of both parties is reassuring and delightfully refreshing.
TIPS FOR CREATING REALISTIC CHARACTERS
IN ROLE-PLAYING
The following tips are adapted from the Training Manual for Macrotrainers [16]. In
role-playing, it often is useful to picture a specific client you have encountered
in your practice and to borrow heavily from that clients presentation in your
role-playing. In visualizing the client, you should pay particular attention to
your memories of the clients hand gestures, tone of voice, rate of speech,
and posture. These details often give a stamp of reality to role-playing, because
they may be quite different from your own nonverbal mannerisms.
For instance, a patient who has a severe depression generally speaks at
a much slower rate than the typical trainer, and this difference should be quite
apparent to the trainee (but will undoubtedly require your conscious effort
while in the role).
As you begin to use role-playing regularly, it is useful to prepare a stock set
of role-plays from which you can borrow freely. For instance, you may develop
readily reproducible characters that portray excessively wandering clients,
shut-down clients, the classic client who responds with, I dont know to every question, a suicidal client with minimal intent and actions, a suicidal client
with intense intent and actions taken on his or her suicidal plan, a delusional
client, or a client with marked loosening of associations. As you use these personalities over the years, your portrayals can become more vivid and more
realistic.
As stated earlier, to help enhance the realism of the role-playing, both parties
should stay strictly in role. Always make it plain whether you are in role or out
of role, using a hand signal for time-outs as markers. Before you start role-playing, you should take a moment to visualize the role and get into character, then
picture what you are going to do, recalling the character or patient who embodies the target quality or history. Proceed with, Okay lets go, and begin
the role-playing. Be sure to think about making your attire congruent with that
of the patient being portrayed: you may want to remove items such as ties,
scarves, or suit coats.
Usually a couple of minutes are needed for the realism of the role-playing to
take hold. Consequently, you should not enter the skill you wish to teach
until the role-playing has continued long enough to give the student a feel
for the patient you are portraying. Likewise, when first learning how to use
role-playing to enhance interviewing skills (and students role-playing skills
do improve), students sometimes fall out of role, falter, or giggle in the
early moments of the role-playing. Stay in role! The student will follow suit,
greatly speeding up your ability to use role-playing as an effective educational
tool.
In teaching more complex interviewing skills, as occurs during macrotraining, you often will create new roles designed specifically to meet the training
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BARNEY & SHEA
needs of the student at that exact moment. Once again, it is helpful to try to
picture a patient you encountered in the past. A newly minted role may not
be as realistic as those you use regularly. That is fine and to be expected. It always is more important to build role-playing that allows the trainee to learn the
desired skill than to create an Oscar-winning performance.
If you are creating role-playing in which the trainee is to consolidate a skill
by practicing the exact skill again, but with a different patient, one should try to
make the new patient have a distinctly different personality. We find that recalling the memory of a real patient and focusing on showing distinctive mannerisms (nervously picking at ones nails, twirling hair, or looking down at the
floor to avoid eye contact) that differ from the previously portrayed patient
makes it much easier to separate adjacent role-playings.
Finally, while you are designing role-playings on the spot, you must keep in
mind the guiding principle, keep it simple. Trainers should aim to teach one
skill at a time; be sure you know what the skill you want this particular roleplaying to develop in the student and make sure the student is ready to learn
that skill. In essence, ensure that you are not asking too much of a particular
student: he or she must be ready to move on to the next step. Before you begin
role-playing, it is useful to restate the task and ask, Do you have any questions
about what you are trying to do in this role-play?
SPECIFIC INTERVIEWING SKILLS WELL ADDRESSED
BY ROLE-PLAYING
The number of clinical skills well addressed by role-playing is extensive, from
interviewing techniques to psychotherapeutic skills, limited only by the behavioral specificity of the techniques and the imaginations of the trainers. Over the
years we have found some interviewing techniques and strategies that can be
addressed with particular success using role-playings. These techniques and
strategies are listed here. We feel certain that you will create many more:
1. Individual interviewing techniques (optimally taught through microtraining)
a. Open-ended questions
b. Closed-ended questions
c. Empathic statements
d. Reflecting statements
e. Summarizing statements
f. Gentle commands, qualitative questions, statements of inquiry [18]
g. Validity techniques
Behavioral incident [19]
Gentle assumption [20]
Shame attenuation, symptom amplification, denial of the specific [18]
h. Facilitative nonverbal communications (eg, head-nodding, forward
leaning)
2. Interviewing sequences and strategies (optimally taught through
macrotraining)
a. Sequential use of basic engagement techniques to strengthen the alliance
e49
b. Scouting training: performing the first 7 minutes of the interview in an

engaging fashion with different types of patients, then asking the
interviewer to provide his or her plans for shaping the rest of the interview
[18]
c. Effectively handling the flow of questioning while sculpting out a specific
DSM-IV-TR diagnosis in a sensitive and comprehensive fashion
d. Focusing wandering or hypomanic patients
e. Opening up shut-down or frightened patients.
f. Interviewing psychotic and paranoid patients
g. Transforming angry moments (including verbally abusive patients)
h. Nondefensively handling awkward or intrusive questions directed at the
clinician
i. Sensitively and comprehensively eliciting potentially taboo histories:
Sexual history and sexual orientation
Domestic violence
Incest
Alcohol and substance abuse
Antisocial, criminal, and homicidal thoughts or behaviors
j. Eliciting suicidal ideation, planning, intent and behaviors using the Chronological Assessment of Suicide Events [13] (also see online macrotraining article in this issue)
k. Providing psychoeducation
l. Talking effectively with patients about their medications and addressing
their concerns about side effects [21]
SUMMARY
We hope this article provides a useful introduction to the art of role-playing.
Over the years, we and our students have found role-playing to be a valuable
tool for improving interviewing skills. In addition, it has provided us with some
of our richest encounters with our trainees and with our favorite moments of
humor. We hope it does the same for you. In the long run, it is our patients
who will benefit the most.
References
[1] The 360 degree view: a question of competence. Rochester Medicine Spring/Summer
2006;26.
[2] Becking D, Berkel T, Betermieux S, et al. Altering the roles of learners and tutors in a virtual
practical training by means of role-playing. In: Proceedings of World Conference on Educational Multimedia, Hypermedia and Telecommunications. Chesapeake (VA): AACE; 2003.
p. 227881.
[3] Phelps CL, Willcockson I. The LEARN curriculum: hands-on classroom experiments
[abstract]. Society for Neuroscience Abstract Viewer & Itinerary Planner 22.42], 2002.
[4] Smith RC, Lyles JS, Mettler J, et al. The effectiveness of intensive training for residents in
interviewing: a randomized, controlled study. Ann Intern Med 1998;128(2):11826.
[5] Baker DP, Gustafson S, Beaubien JM, et al. Medical team training programs in health care.
Advances in Patient Safety 2005;4:25367.
e50
BARNEY & SHEA
[6] Barach PR, Mohr JJ. Microsystems simulation: designing and evaluating an approach to
patient safety and systems thinking. Abstract A:1108. Presented at the Anesthesiology
Abstracts of Scientific Papers Annual Meeting, 2002.
[7] Knowles C, Kinchington F, Erwin J, et al. A randomized controlled trial of the effectiveness of
combining video role play with traditional methods of delivering undergraduate medical
education. Sex Transm Infect 2001;77:37680.
[8] Jeffries PR. A framework for designing, implementing, and evaluating simulations used as
teaching strategies in nursing. Nurs Educ Perspect 2005;26(2):96103.
[9] Deveugele M, Derese A, De Maesschalck S, et al. Teaching communication skills to medical
students, a challenge in the curriculum? Patient Educ Couns 2005;58(3):26570.
[10] Ivey A. Microcounseling: innovations in interviewer training. Springield (MO): Charles C.
Thomas; 1971.
[11] Scisson EH. Counseling for results: principles and practice of helping professions. Pacific
Grove (CA): Brooks/Cole; 1993.
[12] Daniels T. Microcounseling research: what over 450 data-based studies reveal. In: Ivey A,
Ivey M, editors. Intentional interviewing and counseling, Interactive CD-ROM, 200315.
[14] Harden RM, Stevenson M, Downie WW, et al. Assessment of clinical competence using objective structured clinical examination. British Med J 1975;1(5955):44751.
[15] Benedek EP. Interpersonal process recall: an innovative technique. J Med Education
1977;52:93941.
[16] Shea SC. Macrotraining manual. Training Institute for Suicide Assessment and Clinical Interviewing (TISA). Available at: www.suicideassessment.com, copyright 1997.
[17] Pryor K. Dont shoot the dogthe new art of teaching and training. Revised edition. Bantam
Books; 1999.
[18] Shea SC. Psychiatric interviewing: the art of understandinga practical guide for psychiatrists, psychologists, counselors, social workers, nurses, and other mental health professionals. 2nd edition. Philadelphia: W.B. Saunders Company; 1998.
[19] Pascal GR. The practical art of diagnostic interviewing. Homewood (IL): Dow-Jones-Irwin;
1983.
[20] Pomeroy WB, Flax CC, Wheeler CC. Taking a sex history. New York: The Free Press; 1982.
PSYCHIATRIC CLINICS
OF NORTH AMERICA
Facilic Supervision and Schematics:

The Art of Training Psychiatric
Residents and Other Mental Health
Professionals How to Structure
Clinical Interviews Sensitively
Shawn Christopher Shea, MDa,b,*, Christine Barney, MDb
a
b
very day, live theater unfolds as two strangers step into the roles of clinician and patient to engage in a brief but complex interactionthe initial
interview. This unscripted play may have remarkably important ramifications. As the players collaboratively create the script, the clinician is responsible for gathering a daunting amount of material that may be of use in
relieving the pain of the patient.
The interviewer must uncover the patients presenting problems, perspectives, symptoms, and diagnostic complexities. In addition, the interviewer
must be able to explore information regarding an array of social supports
and circumstances that may be hindering the patient or may prove to be of potential use in helping the patient. Unlike an actor, however, the clinicians task is
not to create a role but sensitively to help the patient drop the many social roles
that can prevent the patient from sharing the intimate details of his or her story.
To magnify the task further, all of this material must be gathered in roughly
50 minutes while establishing and maintaining a powerful therapeutic alliance.
Put succinctly, good clinicians cannot afford merely to listen empathically:
they also must learn to explore actively in a comprehensive yet sensitive fashion. Indeed, gifted clinicians have the knack for exploring this vast database in
such a fashion that patients come away feeling that they have been participating
in an engaging conversation with a caring human being rather than having
been interviewed by some shrink with a clipboard.
This critical ability to gather a useful database while simultaneously enhancing engagement is one of the most difficult clinical skills to master, but painfully
*Corresponding author. Training Institute for Suicide Assessment and Clinical Interviewing,
1502 Route 123 North, Stoddard, NH 03464. (Website: www.suicideassessment.com).
E-mail addresses: sheainte@worldpath.net (S.C. Shea).
doi:10.1016/j.psc.2007.03.003

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SHEA & BARNEY
little time is spent in many a clinicians training regarding its mastery. In the
mid-1980s, when I was developing the interviewing course at Western Psychiatric Institute and Clinic at the University of Pittsburgh [1,2] (also described in
detail elsewhere in this issue), I quickly realized that one of the problems facing
interviewing mentors was that no supervision language existed with which one
could easily discuss, model, and teach these elusive structuring skills.
Supervision languages existed for talking about a variety of interviewing
skills, such as recognizing defense mechanisms and the use of specific types
of clinician responses (eg, open-ended questions and empathic statements).
Moreover, broad fields of study had been delineated regarding important nonverbal considerations such as proxemics [3] (the study of how people use space)
and kinesics [4] (the study of how people use gestures and body motion), but
no language had been developed to understand and describe how interviewers
structure and shape interviews as they gather data.
At Western Psychiatric Institute and Clinic we developed a new field of
study and a supervision language with which to explore this field [5]. Facilics
is the study of how interviewers structure interviews while gathering data (eg,
what topics they choose to explore, how they go about exploring those topics,
how they make transitions from topic to topic) and the manner in which they
approach this task while managing time constraints. The term facilics is derived from the Latin root facilis, indicating grace in movement.
In addition to the baseline definitions and principles created for this study of
how clinicians go about the task of structuring interviews, a schematic shorthand was developed that allows a supervisor to note the flow of the students
interview quickly and unobtrusively. After the client has left the room, the
supervisor can share this map with the student, visually, in a fashion that
is easily understood and can shed light immediately on the students strengths
and weaknesses.
Facilic supervision proved to be the single most popular teaching tool that we
used with residents in their interviewing training [1]. Facilics also can be used to
study the structuring of any type of interview, from clinical interviews to newspaper interviews to an attorneys deposition to a late-night television host chatting with a celebrity. Facilics is not a way to interview; it is a way to capture and
study how ably someone structures an interview.
Absolutely all interviews have a structure. Sometimes this structure is fluid.
Sometimes it is awkward. Sometimes the interviewer is consciously aware of
creating the structure. Sometimes the interviewer does not have the foggiest
idea that a structure is being created. Nevertheless, a structure inevitably unfolds as any two peoplein this case a clinician and a patienttry to navigate
the others defenses while communicating about intimate topics that are filled
with nuance and shadows.
As supervisors we can use an understanding of facilics to give our students
a refreshing, and sometimes surprising, self-awareness of how each of them
possesses a characteristic style of structuring interviews. Through our use of
facilic principles and schematics we can show students the myriad of creative
FACILIC SUPERVISION AND SCHEMATICS
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options that they can use to facilitate communication with their patients and to
weave clinical interviews that move with the easy flow of an everyday
conversation.
Facilics provides one more valuable framework, among the many already
useful supervision languages, for our students use as they diligently work at
developing an ever-more-active observing ego. An understanding of facilic
principles enhances the residents approach to self-observation by providing
an additional lens for understanding the mysteries of the interviewing process.
This powerful new lens shows trainees methods for sculpting interviews so that
important databases are gathered in an engaging fashion, minimal information
of use in helping the client is missed, sensitive material is shared more readily,
and the client is more likely to show up for a second appointment and/or to
follow up with the recommendations of the clinician.
Facilic supervision is composed of two activities: (1) the tagging of the students style of structuring for purposes of self-awareness, and (2) the clinical
application of facilic principles and language to give the student practical suggestions on how to structure interviews more effectively.
Parts of this monograph were adapted from the chapter, The Dynamic Structure of the Interview, in the second edition of Psychiatric Interviewing: The Art of Understanding [6], which provides a thorough introduction to the use of facilics for
trainees. The chapter introduces trainees to the facilic tagging system and provides practical suggestions on how to structure interviews in a conversational
fashion that optimizes interviewers data gathering and their ability to enhance
engagement.
Even more comprehensively than the chapter in the book, this monograph
focuses on the first activity of facilic supervision: how to use the language to
tag the students style of structuring. The goal is to give the reader a solid understanding of the language of facilics, securing a more effective use of the language for use during supervision. We hope the monograph will enable the
reader to hit the road running with an approach that is faithful to the model
and simultaneously will help the mentor communicate the model quickly and
clearly to students. The monograph also looks at some topics not covered in
the book chapter, topics that focus specifically on creative methods for optimizing the use of facilics as a supervision tool and for communicating ones own
opinions on how to structure interviews in a powerful and persuasive fashion.
In short, you are holding a teachers manual.
In addition to my use of facilic supervision at the Western Psychiatric Institute
and Clinic, the Dartmouth Interviewing Mentorship Program, described elsewhere in this issue, has provided a lively clinical laboratory in which my co-author and I have had the privilege of using this tool for the past 17 years. We hope
that, with our combined experience of nearly 40 years in using facilic supervision, we can provide the interested supervisor with a matter-of-fact introduction
comprehensive enough to be applied immediately to clinical training.
The facilic supervision system described in this article has well-established
face validity and has been used extensively. During the past 25 years, facilic
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techniques have been translated into a variety of languages including Chinese,

French, and Spanish. Facilics has been used in graduate programs both nationally and internationally across numerous disciplines including psychiatry, nursing, counseling, clinical psychology, and social work. Its principles have been
presented at the annual meetings of the American Association of Directors of
Psychiatric Residency Training and the American Psychiatric Association
and in a variety of major clinical symposia including the Cape Cod Symposia,
the Santa Fe Symposia, the Door County Institute, and the Muskoka Summer
Seminar Series sponsored by McMaster University.
Despite the widespread use of facilics, a practical manual has never been
available to guide supervisors new to the system and its application. This
monograph was created to fill this gap in the clinical education literature.
Our approach in the monograph is fourfold: (1) to introduce the basic facilic
definitions and terminology, (2) to describe the facilic schematic system, (3) to
share tips and strategies for using facilic supervision more effectively, and (4) to
provide a programmed text in the Appendix that will expand and consolidate
the readers knowledge of both the principles of facilic supervision and the use
of the facilic shorthand. By the end of this article and its Appendix, we hope
that the reader will have enough familiarity with the facilic system to be able
to use it immediately as a supervision tool.
DEFINITIONS OF FACILIC SUPERVISION TERMINOLOGY
Facilics focuses on the following series of concepts: the topics being explored during an interview (called regions), the method of exploring these topics once
they are entered (a process referred to as an expansion), and the methods of
making transitions between topics (an interviewing structure called a gate). Regions are divided further into two types, content regions and process regions.
Content Regions
A content region is any area of an interview in which the primary focus of the
interviewer is on the delineation of a specific database (naturally, the interviewer is attending simultaneously to rapport). For a clinical interview the
following 10 regions are often focused on in no specific order:
History of the present illness
Diagnostic regions (areas in which symptoms are elicited relating to specific
DSM-IV-TR diagnoses)
The patients perspectives and goals (understanding the patients views on his or
her problems, the patients ideas about what might help, and his or her fears,
pains, and expectations)
Mental status examination (Many elements of the mental status are evaluated simultaneously with the exploration of the other regions. The more specialized
cognitive mental status, in which a clinician examines orientation, attention
span, memory functions, and general intellect, tends to form a more discrete
region that is easily identifiable during an interview.)
Social history
Family history
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Elicitation of suicidal/homicidal history, ideation, and intent

Past psychiatric history and treatment
Developmental and psychogenetic history
Medical history and review of systems
This brief survey shows that despite the immensity of the database culled in
an initial interview, the contents tend to fall into relatively discrete regions.
Some of these regions tend to overlap. In general, however, a given section
of an interview tends to focus on a single region, much as an everyday conversation tends to focus on a single topic at a time. In the following excerpt the
content region concerning drug and alcohol abuse is readily apparent.
Clinician: So right now you havent been using alcohol?
Patient: No.
Clinician: You talked about using drugs in the past. Im wondering what kind of
things you used then and now.
Patient: Right now Im only using pot. I dont mess around with anything else.
Clinician: Are you using it everyday?
Patient: Almost every day.
Clinician: How many joints might you have in a day?
Patient: Maybe split two; me and Jack might split two.
Clinician: Uh, huh.
Patient: Because it really does calm me down. It doesnt make you sick like alcohol can make you sick, or give you a bad head the next day. It just relaxes
you.
Clinician: Any type of pills youre taking now?
Patient: No.
Clinician: Nothing but the marijuana . . . What kinds of drugs were you using in
the past?
Patient: Well, I never got into any one drug real heavy.
Clinician: Uh, huh.
Patient: But I have taken LSD, speed, different goofballs, and stuff . . . but I never
injected any drugs like dope.
Expansion of Content Regions

Different trainees may display a broad range of skill in how skillfully and
gracefully they can expand a specific content region such as the elicitation of
the diagnostic criteria of a major depression or the exploration of a social
history.
Speaking broadly, two styles of gathering any given database can be observed, and these styles represent opposing extremes: stilted expansions
and blended expansions. (In actuality these styles represent a continuum
of skill.) In stilted expansions, the expansion lacks a feeling of conversational
flow. Instead, the client is asked a series of questions that seem somewhat
forced because the interviewer is rigidly attempting to get specific answers.
This type of expansion may cause a client to experience the unpleasant feeling
mentioned earlier that he or she is being interviewed rather than talking with
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someone. To describe stilted expansions more vividly, we sometimes call them

a Meet the Press type of interview. Rigidly structured interviews sometimes
foster this style of expansion, as illustrated here:
Patient: The pressures at home have really reached a crisis point. Im not certain
where it will all lead; I only know Im feeling the heat.
Clinician: Whats your appetite like?
Patient: I guess its okay. . ..
Clinician: Whats your sleep like?
Patient: Not too good. I have a hard time falling asleep. My days are such
a blur. I never feel balanced, even when I try to fall asleep. I cant concentrate enough to even read.
Clinician: What about your sexual drive?
Patient: What do you mean?
Clinician: Have you noticed any changes in how interested you are in sex?
Patient: Maybe a little.
Clinician: In what direction?
Patient: I guess Im not as interested in sex as I used to be.
Clinician: And what about your energy level? How has it been?
Patient: Fairly uneven. Its hard to explain; but sometimes I dont feel like doing
anything.
This particular trainee seems doggedly intent on rigidly expanding the

depression region, specifically the neurovegetative symptoms of depression.
This style of expansion exhibits a mechanical quality, as if the interviewer
has a list of questions to reel off. Such rigidity characterizes stilted expansions.
As a contrast, in a blended expansion the interviewer once again focuses on
a specific region of data. In this expansion, however, the interviewer attempts
to blend the questions into the natural flow of the conversation. Instead of the
feeling that they are being interviewed, this type of expansion creates in clients a sense of gentle flow that tends to foster the engagement process. Moreover, by decreasing the anxiety of the patient, this type of more naturalistic
interviewing may enhance both the quality and validity of the database.
In the following excerpt, a blended expansion unfolds, once again exploring
the depression region:
Patient: The pressures at home have really reached a crisis point. Im not certain
where it will all lead; I only know Im feeling the heat.
Clinician: Sounds like youve been going through a lot. How has it affected the
way you feel in general?
Patient: I always feel drained. Im simply tired. Life seems like one giant chore.
Clinician: What about your sleep? Has that been affected as well?
Patient: Absolutely. Perhaps thats the reason Im drained. I just cant rest. My
sleep is horrible.
Clinician: Tell me more about it, what it actually feels like.
Patient: I cant fall asleep. It takes several hours just to get to sleep. Im wired. Im
wired even in the day. And Im so agitated I cant concentrate, even enough
to read to put me to sleep.
Clinician: Once youre asleep, do you stay asleep?
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Patient: Never, I bet I wake up four or five times a night. And about 5:00 AM Im
awake, as if someone slapped me.
Clinician: How do you mean?
Patient: Its like an alarm went off, and no matter how hard I try, I cant get back
to sleep.
Clinician: What do you do instead?
Patient: Worry . . . Im not kidding . . .. My mind fills with all sorts of worthless
junk.
Clinician: That sounds really unpleasant.
Patient: Yea, it is.
Clinician: We might be able to help you with that.
Patient: That would be super.
Clinician: You mentioned earlier that you were also having problems with concentration. Tell me a little more about that.
Patient: Just simply cant function like I used to. Dictating letters, reading, writing
notes, all those things take much longer than usual. It really disturbs me. My
system seems out of whack.
Clinician: Do you think your appetite has been affected as well?
Patient: No question. My appetite is way down. Food tastes like paste . . . really
very little taste at all. Ive even lost weight.
Clinician: About how much and over how long a time?
Patient: Oh, about 5 pounds, maybe over a month or two . . .
This section of interviewing explores the same region as the previous interview,
but this time the questioning seemed to flow more naturally, generating an increasing flow of information, peppered with moments of empathy and requests
by the clinician to hear more about specific symptoms that suggested both interest
and caring. The trainees questions seemed to relate directly to what the patient
was saying, thus creating a sense that the trainee was with the patient.
A further point to consider concerning the expansion of regions is whether or
not, once a supervisee enters a specific content region, the supervisee finishes the
entire region before leaving it. Sometimes it is useful to leave regions before completion (a process called a split-expansion), and many times it is not. Facilics allows us, as supervisors, to monitor this particularly telling trait of the supervisee
objectively and to point out to the trainee whether it was advisable to use a splitexpansion with a particular patient at a particular point in the interview.
For instance, while expanding the diagnostic criteria for the generalized anxiety disorder region, the patient may mention the use of diazepam (Valium). At
this point, the clinician may choose to expand the medication history, after
which he or she can return to the anxiety disorder region to complete its expansion. Sometimes a clinician may choose to split even a single expansion multiple times before finishing it. Although they sometimes are indicated, splitexpansions often can lead to serious omissions if the clinician does not keep
track of what information has been gathered and subsequently fails to return
to seek the needed information.
On occasion, a clinician may expand simultaneously two regions whose contents are similar in nature. For instance, one could expand the anxiety disorder
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region and the affective disorder region in a parallel fashion (called a parallel
expansion), because the symptoms in these disorders frequently overlap. Such
parallel expansions are a bit tricky: it is easy to miss important data, because
the clinician must keep track of two sets of diagnostic criteria simultaneously.
This task is not always easy and almost never is easy for a novice interviewer.
The overriding point remains the clinicians need to develop an active and
conscious awareness of the data flow while simultaneously creating the sensation of a natural flow of conversation. An understanding of facilics allows
a trainee to do just that. As supervisors we find it useful to remind trainees
in an ongoing fashion of the following points regarding expansion of content
regions (an example of the second aspect of facilic supervision: applying facilics
to communicate tips for improved structuring):
1. Generally speaking, an effort should be made to achieve blended expansions as opposed to stilted expansions; such blended expansions move
with the patient.
2. Techniques such as split-expansions and brief excursions can be useful as
long as one remembers to monitor the completeness of his or her database,
but they need to be used judiciously. Otherwise, significant errors of omission can occur if the interviewer gets lost in the wanderings of the patient
and does not return to finish compiling important material in prematurely
exited content regions.
3. The interviewer always should attend to engagement on both a verbal and
a nonverbal level during the expansion of content regions.
Process Regions
In addition to focusing on content, thereby gathering a prespecified database,
interviewers often need to shift focus to the actual process of the interview
on a meta-level. For instance, while uncovering a drug and alcohol history,
an interviewer may inadvertently offend the client. At that point the interviewer must attend directly to the engagement process by addressing the potential anger of the client. In a broad sense, in facilic language, all expansions that
are not content expansions (eg, focused primarily on the gathering of a specific
database) are called process expansions.
Thus classic situations in which one is focusing on the process of the interview (eg, specifically enhancing engagement, addressing resistance and anger,
and exploring psychodynamic processes or defense mechanisms) are depicted
as process regions. In addition, other regions that do not focus primarily on
data gathering but are not directly related to the meta-process of the interview
are also still called process regions. Examples of this type of process region are
periods of crisis intervention or sections of time devoted to providing psychoeducation. For purposes of illustration, three of the classic process regions are
discussed in more detail.
Free facilitation process regions
The free facilitation process region remains one of the foundations of all interviewing. It is the traditional method of nondirective listening. In it, the
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interviewer invests effort in creating an atmosphere that is optimally conducive

for the client to feel safe enough to begin sharing his or her problems. The client is able to wander freely to whatever topics he or she chooses, while the interviewer maintains a nondirective attitude. The major interventions of the
interviewer are usually facilitating head nods, uh-huhs, and simple facilitative
statements.
These free facilitation regions can occur at any point in an interview and often are a useful method of enhancing engagement. For instance, during the
opening phase of the interview, clinicians frequently use a series of free facilitation regions. Naturally, most content regions have many attributes in common with free facilitation regions; but a free facilitation region differs in the
goal of its use, which remains the strengthening of the engagement process.
The patient may reveal surprising amounts of useful information during these
unstructured facilitation regions, but it is without specific direction by the
interviewer.
A brief example may help to clarify when a section of an interview can be
labeled as a free facilitation region.
Patient: I dont know whats coming over me. . .I just feel sort of crazy.
Clinician: What do you mean?
Patient: All my thoughts seem to be mixing like a wet rainbow; distinctions are
blurred, people distorted . . .[pause] I feel this way when Im with my mother.
She . . ..[pause]
Clinician: Go on.
Patient: She always seems so oppressive, so large, like a giant machine always
pushing, always pulling. Honestly, I dont know where to go with her.
Clinician: In what sense?
Patient: She wants me to be a success, Lord knows what that means. I think she
wants me to be a college professor or some dean of this or that. But shes not
interested in what I need, never was. A baby without a bottle, thats what
I am . . ..
This type of nondirective interviewing frequently helps enhance engagement. It also sometimes brings out responses from patients that may hint at
an underlying psychotic process as this excerpt illustrates.
Transforming resistance process regions
In a resistance transformation region the interviewer actively attempts to
decrease a specific resistance to the engagement process. Such resistance may
arise from any number of factors, including the interviewees fears, expectations, or unconscious processes. The resistance may show itself as an angry
comment or perhaps an awkward and personally intrusive question from the
client. Without a resolution of these resistances, the validity of the subsequent
data and the power of the therapeutic alliance may be jeopardized. In any case,
the defining characteristic in a resistance region is the interviewers conscious
attempt to resolve a resistance shown by the patient.
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In the following selection we see an interviewer in the midst of a resistance

region:
Patient: My boss was really into my work and thinks I may be a little. . . you
know. . . I dont really think I ought to go on. Do you have a supervisor
around?
Clinician: You seem concerned about something.
Patient: Well, Id just feel a little better if I were talking to someone a little older.
Clinician: What do you think an older clinician would be able to do to help
you?
Patient: Hed understand what Im going through better, thats for damn sure.
Clinician: You know, its true Im younger than you and consequently, I havent
experienced the same things, but I can try to gain some understanding of
what youre experiencing. You could help by telling me a little more about
how people have been pressuring you about your age.
Patient: Well if you must know, it all started with my wife. She left me about
3 years ago for a younger man.
Psychodynamic process regions

In a psychodynamic process region the interviewer asks questions in which the
clinician is more interested in how and why the patient responds to the clinician
than in the content of the patients answers. In general, the clinician attempts to
answer questions such as the following:
How reflective is the patient?
Does the patient have much insight?
How does the patient respond to interpretive questions?
How good is the patients observing ego?
Answers to these questions may help determine the suitability of the patient
for specific types of time-limited psychotherapy, as well as provide insight into
the patients intellectual development, ego strength, defense mechanisms, selfconcept, or genuine readiness to engage in treatments such as substance-abuse
counseling. To answer questions in a psychodynamic region, the patient must
reflect and offer an opinion.
The following excerpt may clarify when a psychodynamic region is occurring:
Patient: My father always kept a strangle hold on me. He wanted to know my
every move. God pity the boy who wanted to take me out. It was like a Gestapo interview for the guy.
Clinician: What kind of impact do you think your fathers behavior has had on
you?
Patient: Hes made me scared. Im afraid of him, and who knows, maybe I keep
my distance from him because of it . . . Sort of strange, because when I was
a kid I always wanted to be around him. I even would wait for him when he
was at work.
Clinician: Go on.
Patient: Oh, its sort of silly, but I wondered if he had a toy or something for
me . . . I remember a small doll he brought home once, with big black
eyes. Just a little doll, but important to me.
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Clinician: Go on.
Patient: Not too much more to say, except that its sort of sad the way things
have turned out between us.
Clinician: What are you feeling as you talk about your father right now?
Here, content is clearly taking a second place to process. The clients responses suggest a willingness and a certain degree of proficiency at self-exploration. This type of region can occur anywhere in an interview, often appearing
between content regions.
The Scouting Region: A Unique Combination of Content and Process
Now that we have a good understanding of the differences between content
regions and process regions, it is a good time to look at an outlierthe scouting
phase. It is a stage of a clinical interview ripe with potential for both problems
and opportunities. The facilic term scouting phase is used to describe the
opening 7 minutes or so of an interview, in which the interviewer introduces
himself or herself and proceeds with the opening phase of the interview. There
is a premium on free facilitation regions and the engagement process itself.
Open-ended questions and an empathic statement or two are classic foundation
blocks of the scouting phase. On the other hand, as much as the scouting phase
emphasizes the use of process regions, invariably much valuable data will be
forthcoming from the client. The clinician does little to structure this data;
nevertheless, clients often spontaneously share critical aspects of the database
early in the interview. Thus the scouting phase is a unique type of region: it
is both a process region and a content region at once, with a relatively equal
emphasis on process and data gathering.
Gates: The Pathways of Transition
As a conversation or an interview passes from one topic to another, different
types of transitions occur. In facilic supervision, we refer to the actual statements joining two regions as gates. Although numerous types of gates exist,
five major forms are the most common: (1) the spontaneous gate, (2) the natural gate, (3) the referred gate, (4) the implied gate, and (5) the phantom gate.
An understanding of the use of these gates gives trainees a simple but elegant
method of gracefully maneuvering an interview.
The trainees habitual use of gatesand they generally are used out of habitmay well be the single most powerful indication of how conversational or
awkward a trainees interviews will feel to patients. Helping trainees identify
their own gating and subsequently helping them master ways of using the other
types of gates flexibly (because all types of gates have their advantages and disadvantages) is, in our opinion, one of the greatest gifts we can give a trainee.
Such self-knowledge and the resulting flexibility in style it provides are frequently the difference between a trainee who would have gone on to a career
of Meet-the-Press interviews and one who has a career of powerfully engaging clinical interactions. Lets take a look at each of the gates and how they
manifest in actual interviews.
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Spontaneous gates
The spontaneous gate, as its name suggests, unfolds without any effort by the
interviewer. Instead, the gate results from a change in topic unilaterally taken
by the patient. These gates occur when the patient spontaneously moves into
a new region (called a pivot point), and the clinician proceeds to ask
a follow-up question in this new region. The patient does the shifting here.
The clinician merely follows, sometimes with phrases as simple as Tell me
more about that, or How do you mean? In the following example,
a spontaneous gate provides an essentially imperceptible movement out of
an expansion of depressive symptoms and into a new content region. See if
you can spot it.
Patient: The past 2 months have been so horrible. I think its the worst time of my
life. I just cant get away from the feeling.
Clinician: What feeling are you referring to?
Patient: The sadness; the heaviness.
Clinician: What else have you noticed when youre feeling sad and heavy?
Patient: Nothing seems worth doing. Its late November and my yard is covered
with leaves. Usually theyd all be gone into neat little piles, like a little farm,
but not now . . .
Clinician: Besides not having energy for chores, do you find you can still enjoy
your bridge club or other hobbies?
Patient: Not really. Things seem so bland. I havent even gone to bridge club for
several months. It is all so different from before. In fact, there were times in
the past when I could barely keep still, I was so active. I was a super dynamo.
Patient: Oh, I used to be incredibly active, into bridge, tennis, golf, and everything. It was hard to find people who could keep up with me.
Clinician: Did you ever move too fast?
Patient: In what sense?
Clinician: Oh, sometimes one can get so energized that it gets difficult to get
things done.
Patient: Actually, there were a couple of odd times when people kept telling me
to slow down, slow down.
Clinician: Tell me a little more about one of those times.
Patient: About a year ago I got so wound up I hardly slept for almost a week. Id
stay up most of the night cleaning the house, washing the car, and writing
furiously. I didnt seem to need sleep.
Clinician: Did you notice if your thoughts seemed to be speeded up then?
Patient: Speeded up. I was flying. Everything seemed crystal clear and moved
like lightening. It was strange . . .
In this example, two content regions are discussed sequentially. In the first
region, the interviewees DSM-IV-TR symptoms of depression are being
explored. In the course of this exploration, the interviewee brings up a statement
that enters a different diagnostic region dealing with mania. The transition
statement was, In fact, there were times in the past when I could barely
keep still, I was so active. I was a super dynamo.
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The interviewer then followed this movement into a region exploring manic
symptoms by simply asking, How do you mean? Once within the diagnostic
region of a mania, a blended expansion was begun. This movement into a new
topic was practically imperceptible.
Spontaneous gates create movement that seems unblemished by effort or resistance. In this sense, a clever interviewer frequently will make use of such
gates whenever transitions into new regions are desirable. But herein lies a
potential pitfall, mentioned earlier when discussing split-expansions: frequently
it is not desirable to leave a region before it is fully expanded.
In this light, pivot points represent critical areas in which the interviewer
should decide consciously whether to redirect the patient gently back into
the current expansion and complete it or move with the patient into the new
region the patient just entered. If the clinician can become aware of such pivot
points, he or she will gain considerable control over the flow of questioning.
One does not and should not follow every pivot point with a follow-up question into a new region. Once within the body of the interview, if a patient needlessly wanders out of a content region, it is often best to gently bring them back
to finish gathering any missing important information from the region. Such
gentle structuring can significantly decrease errors of omission.
Indeed, the concepts of spontaneous gates and pivot points provides
us with a way of conceptualizing wandering interviews in which little information of importance is uncovered. These interviews occur when the
clinician follows pivot points whenever they appear, resulting in a consistent pattern of incomplete split-expansions with a subsequently weak
database.
At times a clinician may decide wisely to follow a pivot point into a spontaneous
gate even in the middle of an incomplete expansion. Such situations include the
following: (1) the patient may have unexpectedly related emotionally charged
material that needs to be ventilated; (2) the patient may have spontaneously mentioned sensitive material that may best be approached immediately, such as suicidal ideation or incest; and (3) specific memories, such as screen memories,
dreams, or traumatic events, may warrant immediate follow-up.
With the use of facilics, supervisors can point out the appropriate and inappropriate instances of following pivot points into new regions through spontaneous gates. Indeed, helping trainees become routinely aware of pivot points as
they arise in interviewsproviding them a chance to decide consciously
whether to leave a region or gently refocus a wandering patient back into a
regioncan be the key in helping trainees to structure interviews effectively
and sensitively.
It can be a revelation to trainees to learn experientially that clinicians can
exercise significant choice as to the structural pattern any given interview will
take as long as the clinician recognizes the pivot points and purposefully
decides whether or not to follow them into new topics through the use of
a follow-up question (a spontaneous gate). By understanding facilics, a trainee
can learn first-hand that interviewers are not merely at the whim of a clients
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wanderings. Sensitively structured interviews do not just happenthey are

created.
Natural gates
The natural gate consists of two parts: the cue statements and the transitional question. The cue statements represent the last one or two sentences
(usually the last one) made by the interviewee that may contain content
material that the interviewer can relate creatively to a new region. If the interviewer takes cues from these statements to enter a new region, the interviewee will feel that the conversation is flowing from his or her own speech,
as indeed it is. Such a transition seems both natural and caring to the
interviewee.
The transitional question represents the actual question asked by the interviewer that creates a bridge from the cue statement into the new region. As distinguished from the spontaneous gate, the clinician, not the patient, is moving
the conversation into a new region.
In the following excerpt we see a transition from the region covering depressive symptoms into the drug and alcohol region. This smooth transformation is
made through a natural gate.
Clinician: Have you been able to enjoy your poker games or your shop work?
Patient: No, I just dont feel like doing anything since Ive been feeling depressed. Its a really ugly feeling.
Clinician: Tell me more about what it feels like.
Patient: Really pretty miserable. Life doesnt seem the same. Im tired all the time;
no sleep.
Patient: Over the past several months sleep has almost become a chore. Im always having trouble getting to sleep, and then I wake up all night. I must
wake up five times and it took me 2 hours to fall asleep in the first place.
*Clinician: Have you ever used anything like a nightcap to sort of knock yourself out?
Patient: Yeah, sometimes a drink or two really relaxes me.
Clinician: How much do you need to drink to make yourself sleepy?
Patient: Oh, not too terribly much. Maybe a couple of beers. Sometimes more
than a couple of beers.
Clinician: Just, in general, how many drinks do you have in a given day?
Patient: Probably. . .Now, Im just guessing, but probably a six-pack or two,
maybe three. I hold liquor pretty well. I dont get plastered or nothing.
Clinician: What other kinds of drugs do you like to take to relax?
Patient: Well, I might smoke a joint here or there.
In this excerpt, the cue statement was, I must wake up five times and it took
me 2 hours to fall asleep in the first place. Note that the patients cue statement
is still within the region of depression. But the clinician, wanting to change content regions, sensed that this statement could be used as a springboard into
a new topic. The succeeding transition question (indicated by an asterisk)
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smoothly achieved this desired transition into the drug and alcohol region with
the phrase, Have you ever used anything like a nightcap to sort of knock yourself out?
From the perspective of the second aspect of facilic supervisionapplying facilics to communicate tips for improved structuringtransitions of this sort are
seldom perceived as focusing mechanisms, because the patient generally feels
as if he or she brought up the new topic. This type of smooth transition can
greatly enhance a conversational feeling in the interview, slowly bringing the
patient into a more powerful sense of safety and spontaneity. The interview begins to take on a self-perpetuating momentum, unique to its own nature.
Fig. 1 demonstrates the immense power of the natural gate. We shall assume
that the expansion of the stressor region has been winding down. The patient
then provides a cue statement that the clinician can use to enter one of any
number of new content regions as illustrated. The flexibility of the natural
gate is limited only by the awareness and creativity of the clinician.
Pt.]
Stressor Region
My arguments with my
husband are so bad that
I just dont know whats
happening anymore.
d
Borderline Personality
Region
a
Lethality Region
b
c
Depression Region
Alcohol & Drug

Region
Fig. 1. Natural gates utilized as smooth transitions. Transition questions: (a) With all these tensions mounting, have you had any thoughts of wanting to kill yourself? (b) How have all these
stresses affected your mood? (c) With all these stresses, have you been drinking at all in an
effort to calm yourself? (d) Some people hold all their anger in and others really let it out,
maybe even throwing things like glasses or plates. How do you handle your anger? (From
Shea SC. Psychiatric Interviewing: The Art of Understanding, 2nd edition. Philadelphia: WB
Saunders Co., 1998; with permission.)
Referred gates
A referred gate occurs when the interviewer enters a new region by referring
back to an earlier statement made by the interviewee. Typical referred gates
begin with phrases such as, Earlier you had said . . . or I want to hear
more about something you mentioned before . . . To the interviewee, a referred gate metacommunicates, I have been listening very carefully to you;
moreover I want to learn more about something you said to see if I can
help. It is a wonderful example of a structuring tool that is also an engagement
technique. It allows the interviewer to enter a fresh region smoothly at almost
any place in an interview. It also is extremely useful for re-entering a region
that was not completely expanded earlier. Structurally, a referred gate lacks
an adjacent cue statement, because the cue has been taken from an earlier segment of the interview.
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In the following illustration we enter the interview at the end of a psychodynamic process region in which the patients feelings about his siblings have
been explored. As this process region winds down, the interviewer, by referring
to something said earlier in the interview (but not shown in this transcript) enters the content region dealing with psychotic phenomena by using a referred
gate.
Clinician: What was it like for you when your brother would come home from
college?
Patient: Sort of odd; a little bit like a trespass. You see, when he was gone I had
the room all to myself, even the phone was mine alone. As soon as he came
back, boom, the room was his again.
Clinician: What other feelings did you have?
Patient: Some excitement. I really did look up to him, and when hed come
home hed tell me all about college, frat parties, smoking grass; and it
was exciting.
*Clinician: Earlier you had told me that sometimes when you were alone youd
have scary thoughts. Tell me a little more about those moments.
Patient: Okay. Its sort of like this. I might be sitting late at night listening to some
music and things seem sort of weird, almost like something bad is going to
happen. And then I have thoughts that keep coming at me and they tell
me to do things.
Clinician: Do the thoughts ever get so intense they sound almost like a voice?
Patient: They are voices. They seem very real. In fact, sometimes I try to cover
my ears. I just dont know. I dont know. . .
Referred gates, such as the one indicated by the asterisk in this dialogue, are
unobtrusively powerful. They can be used to enter new regions essentially at
will and to re-enter incompletely expanded regions. Clinicians can use referred
gates to enter potentially disengaging regions (eg, the cognitive mental status)
gracefully.
While asking questions about orientation and checking digit spans or serial
sevens, novice clinicians frequently worry that patients will feel insulted by the
simplistic nature of the questions. To this end, they may use phrases such as,
Im going to ask you some silly questions now, I hope you dont mind, or
Now I have to ask you some routine questions that I have to ask everybody.
These phrases usually are accompanied by an apologetic tone of voice or an
insecure rustling of the clinician in his or her chair.
The irony of such introductions lies in the fact that, rather than dispelling
anxiety in the patient, they sometimes create it. The patient senses that the clinician feels insecure with the subsequent questioning. All that remains for the
patient to wonder is why the clinician needs to apologize. What do these routine questions mean, and why does a professional ask questions if they are
silly? In short, the clinicians sudden obsequiousness signals to the patient
that something odd is afoot.
Here one of the many uses of the referred gate becomes apparent. By
referring to earlier statements by the patient concerning problems with
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concentration or thinking, the interviewer can enter the cognitive examination

smoothly and without a need to apologize. Quite to the contrary, the interviewers interest indicates a sincere concern to the patient as well as a display
of professional expertise. The use of the referred gate metacommunicates to the
patient that these questions are being asked for a specific reasonto clarify collaboratively the degree of cognitive impairment, a point of interest to both the
clinician and the patient. Let us take a look at such an approach in action. The
patient is suffering from an agitated depression and had complained earlier in
the interview of problems concentrating:
Patient: Overall, I know its all my fault. I should never have retired, its ruined
everything. But life goes on. I only hope I feel better some day.
Clinician: What do you see for yourself in the future?
Patient: Hopefully, some pretty good stuff. Ive always wanted to travel and my
wife is interested in doing so as well, so, I think we will probably do a little
traveling. And, I also used to paint a little bit, maybe Ill do a little of that too.
Clinician: That sounds pretty neat. I hope it works out for you.
Patient: Yeah, me too.
Clinician: You know, a little earlier, you had mentioned that one thing that was
bothering you was your lack of concentration and some problems with
memory. I have some questions that would give us both a clearer idea exactly
how much your concentration and thinking have been affected by your
depression. Some of the questions will be very simple, while some of them
may get fairly challenging. Why dont we start with some of the simple
ones first?
Patient: Sure.
Clinician: What day of the week is this?
Patient: I think its Wednesday.
Clinician: Thats correct. What city is this?
Patient: Pittsburgh.
This interview dyad has gracefully moved into the cognitive mental status
examination with a sense of purpose and no hint of uneasiness on the part
of the clinician.
Phantom gates
A phantom gate seems to come from nowhere. It lacks a cue statement and also
lacks previous referential points, unlike referred or natural gates. In short, it
jolts the spontaneous flow, as the following example shows:
Patient: I havent felt the same for months. Im always down and Im sick of it.
Clinician: What does it feel like to be down?
Patient: Very unsettling. Im like a slab. I dont want to do anything. I miss doing
things with my best friend, silly as that may sound. I really havent been the
same since she died.
*Clinician: Was your father an alcoholic?
Patient: No . . . [pause] I dont think he was. He drank every once in a while.
Clinician: What about your brothers, sisters or blood relatives? Have any of
them had drinking problems?
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Patient: Not that I know of.

Clinician: What about depression? Have any of your relatives been depressed?
This interviewers sudden leap into the family history region certainly
seemed abrupt and ill timed. Obviously, if such phantom gates (indicated by
the asterisk) occur frequently throughout an interview, engagement can be seriously hampered. Even in milder forms, they can quickly produce the Meet
the Press feeling discussed earlier, especially if accompanied by stilted expansions. They often pop up toward the end of interviews, when interviewers suddenly realize there are several things they forgot to ask, and they are running
out of time. If indeed important regions have been incompletely expanded, a
supervisor can point out that a referred gate, rather than a phantom gate, usually can be used without substantially interrupting the flow of the interview.
In the meantime, a phantom gate placed here and there probably will not
cause much of a problem, especially if the engagement seems to be high, and
the content of the question is not sensitive in nature. In general, however,
one should avoid phantom gates, because it seems senseless to risk damaging
the flow of the interview.
Implied gates
To complete our summary of transitions used during the body of the interview,
we turn our attention to implied gates. Implied gates are structurally similar to
phantom gates: they do not cue off the patients immediately preceding statements; they do not refer back to earlier statements; and the clinician, not the
client, initiates the movement into the new topic. There is one important difference between an implied gate and a phantom gate: the implied gate enters a
region that is topically similar to the previous region.
Put slightly differently, in an implied gate, the movement into a new region is
characterized by asking a question that seems to be generally related to the region
already under expansion. Thus, it is somewhat implied that the interviewer is
simply expanding a topic already germane to the interviewee. Consequently,
implied gates tend to be much less disruptive to flow than phantom gates.
In the following example, movement is made from the region dealing with
immediate stressors into past social history. The transition (indicated by an asterisk) seems relatively smooth, an effect that is secondary to the similarity in
content between these two regions.
Patient: Were living in a fairly nice house now. It has three bedrooms and a couple of acres. Believe me, we need the space with our four kids.
Clinician: How are the kids getting along?
Patient: The two oldest, Sharon and Jim, get along pretty well, on different
tracks. They stay out of each others way. But the two little onesoh my!
They live to torture each other . . . Pulling each others hair, yelling, screaming. Its a zoo.
Clinician: Im wondering if, with all those mouths to feed, money is a problem?
Patient: In some respects, yes; but my husband is a lawyer and is doing well. In
fact, if anything, our income has increased recently.
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*Clinician: Tell me a little bit about what it was like for you when you grew up
back in Arkansas.
Patient: First of all, I came from a large family of eight children. So we sometimes, many times, had to do without. I remember all the hand-me-downs,
and, believe me, I appreciated them. My mother was a loving woman, but
beaten down by life. She was tough, but her pain showed through.
Clinician: Do you remember a specific time when her pain showed through?
Patient: Oh, yes. I was about 5, I think, and . . .
For purposes of review, keep in mind that, unlike a natural gate, an implied
gate does not cue directly off the preceding statement. Furthermore, unlike a referred gate, the interviewer does not directly refer back to earlier statements.
And, in contrast to the phantom gate, the implied gate seems to fit in fairly naturally with the current flow of the dialog. Indeed, when the newly entered region appears very similar to the preceding one, an implied gate is practically
imperceptible and rivals a natural gate for smoothness of transition.
As the regions connected by the gate increase in disparity, the implied gate
becomes progressively more abrupt. Thus, with regard to smoothness, implied
gates range on a continuum between natural gates and phantom gates. When
the two regions are closely related, implied gates approach the gracefulness of
natural gates. On the other hand, if the topics are poorly related, an implied
gate may approach the awkwardness of a phantom gate.
At this junction, we have completed our introduction to the core terminology
of facilics. Facilics provides a simple language with which to follow the complex
structuring techniques of both interviewers and those they supervise. Once a clinician understands the principles of facilics, the interview can be developed and
altered almost at the whim of the interviewer. These tricks of the trade can increase the engagement with the patient, the effectiveness of the data gathering,
and ultimately the validity of the database itself.
Initiated by the conscious decisions of the interviewer, the clinical dialogue
can unfold in a more graceful and effective manner. With each unfolding,
the initial resistance of the interviewee gradually recedes, because the interviewer, instead of opposing this resistance, moves with it. Using natural gates
and blended expansions, the trainee can create interviews that move with the
gentle dynamics of a collaborative conversation. The patient feels more
relaxed, defenses drop, and the interviewer discovers a rich field of pertinent
information opening before him.
Once familiar with the basic facilic terminology, a supervisor can map out an
entire interview from front to back. We have not found any structural situations that cannot be mapped using this system. (There are a few facilic anomalies, such as introduced gates, in which the clinician literally states, Id like
to spend some time asking about . . .,and observed gates, in which the clinician makes note of a clients nonverbal communication, as with, It looks
like you are starting to well up, for which there is not space for a thorough
discussion in this article). Armed with this introduction, you are ready to use
the system. There is only one more critical aspect of facilics that you need to
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SHEA & BARNEY
know before beginning: the facilic shorthand. Lets take a look at it. It is delightfully straightforward.
AN INTRODUCTION TO THE FACILIC SCHEMATIC SYSTEM:
A SHORTHAND FOR SUPERVISORS
Facilic schematics allow a supervisor to make a permanent record of the supervisees interview quickly and provide a concrete, visual springboard for immediate feedback. The flow of the trainees interview can be captured graphically
in a way that brings the interview to life for the trainee while presenting an easily understood map of the trainees explorations of major topics and the transitions used to connect them. This system of shorthand can be used in direct
supervision, class discussion, and videotape supervision.
The idea for the system originated from a most unlikely source. One hot
summer day I was perusing a book on modern dance. To my surprise,
when I came upon the Appendix, I found several dance notation systems created by various choreographers to capture on paper the flows of their dances.
Thus, a dance created at a summer festival, once notated, could be resurrected
by an entirely new group of dancers a decade later.
If the complicated movements of a modern dance could be encoded simply,
surely the structural movements of an interview could be represented as well.
Facilic schematics were born.
Subsequently, these facilic schematics have become one of the most popular
aspects of the facilic system, and some would say they are key to its practical application in supervision. We certainly have found them to be invaluable in training.
Two complementary systems are available. In a longitudinal facilic map,
the interview and its transitions are followed from start to finish chronologically. This technique is the backbone of the system, providing a detailed but
easily followed description of the trainees expansions, gates, and flow. We
make a longitudinal map for our trainees whenever we have an opportunity
to view their interviews directly, whether within the interview room, behind
a one-way mirror, or by videotape.
The second system is called a cross-sectional map, a fancy name for a simple pie diagram, which depicts the interview as being divided into four quarters
of time. These cross-sectional maps do not track the specific structural techniques of the trainee but do allow a graphic look at how the trainee managed
time, providing a powerful complementary tool to the fundamental longitudinal facilic map.
Making a Longitudinal Facilic Map: Tricks of the Trade
Before beginning our description of facilic schematics, we should mention that,
on rare occasions, a student may misconstrue the purpose of the system, thinking that the schematics are a graphic system drawn by the interviewer during
the interview to track the information he or she has gathered. Remind your student that facilic symbols are not intended to be made by the interviewer: they
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are a shorthand for the supervisor, who later will share the map with the student after the interview.
The first convention is that a content region is shown as a rectangle, with the
abbreviated name for the region within it. Thus, as you follow the flow of the
interview, if the trainee is exploring the DSM-IV-TR diagnosis of major depression, you simply jot down a rectangle with Maj. Dep. written inside it.
The degree of thoroughness in expanding any given content region is depicted by slash marks at the corners of the rectangle. One slashed corner represents that the trainee explored 25% of the needed information, two slashed
corners represent 50%, three slashed corners represent 75%, and four slashed
corners represent a completely expanded region. Thus, if the trainee leaves the
region of major depression prematurely with 50% of the criteria not explored,
this split-expansion is noted simply by making a single slash mark at any two
corners of the rectangle as soon as the dyad leaves the area. This notation immediately tells the supervisor that the resident needs to return to this region at
some point later in the interview to finish the expansion to avoid errors of
omission.
You always makes these slashes depending on the database you, as a supervisor, think should be covered within the specific region. The completeness is
determined by the task at hand. Keep in mind that the requisite data for the
task at hand can vary depending on the setting and type of interview being
done by your trainee, even though the content region is the same.
For example, in a classic initial 50-minute interview, when expanding the region related to major depression, it would be expected that most of the criteria
for a major depression would be covered. If the interviewer touches on all these
criteria, the supervisor would mark the rectangle with four slashes representing
100% completion of the task at hand.
In a busy emergency room, in which the entire interview might only be 20
minutes, it would be inappropriate for the clinician to cover all these criteria.
Instead, criteria for several major depressive symptoms (with a close look at
suicidal ideation) would be covered, with a special emphasis upon the severity
of the symptoms, because it is the symptoms severity that may best help the
emergency room clinician make a safe triage for the patient (outpatient versus
inpatient).
When supervising an emergency room interview, if the trainee covered only
a handful of the symptoms of a major depression but carefully explored their
severity and the clients extent of suicidal ideation, once the trainee left the region of major depression the supervisor would make four slashes, indicating
that all the appropriate data points had been covered for the task at hand
(an emergency room assessment) . Indeed, if in that hectic emergency room,
the clinician carefully covered all the criteria for major depression (thus losing
precious time on data that will not help with the triage of the patient), the supervisor would make a fifth and possibly sixth slash on the rectangle indicating
that too much information was gathered for the task at hand. The resident
must learn to be more flexible in making data-gathering decisions.
SHEA & BARNEY
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As you follow split-expansions, when the dyad re-enters the expansion you
simply draw a rectangle again, with the appropriate topic abbreviated inside,
and immediately mark the same number of slashes as it already had, because,
obviously, that amount of data has already been covered. Once the dyad leaves
the region, the supervisor adds slashes as deemed appropriate for any new
information that has been covered.
You can see that if a trainee has a tendency to expand regions incompletely,
resulting in numerous errors of omission at the end of his or her interviews,
this problematic tendency will be displayed clearly in the facilic maps by
a bevy of incomplete expansions. The power of the facilic map to highlight
the problem visually helps residents see the extent of the problem more readily
and, ideally, be motivated to change it.
Process areas (such as psychodynamic inquiries and areas in which resistance
is transformed) are represented by circles. Once again the correct title of the
process region is abbreviated within the circle as with Dynam. or Resist.
The scouting phase is indicated by the combination of a rectangle and a circle
(eg, a rectangle with a half circle on each end as shown in the illustrative facilic
map) (Fig. 3).
All gates are depicted as shown below in Fig. 2 and are placed between two
successive content or process regions to form a continuous map of linked figures that accurately represent the flow of the interview:
Spontaneous Gates
Phantom Gates
Natural Gates
Introduced Gates
Referred Gates
Observed Gates
Implied Gates
Fig. 2. Transitional gates. (From Shea SC. Psychiatric Interviewing: The Art of Understanding,
2nd edition. Philadelphia: WB Saunders Co., 1998; with permission.)
The entire interview and its flow can be captured permanently using this
small set of symbols. In contrast to writing several sentences to capture the
complexities of a single transition by a trainee, the facilic shorthand allows
the supervisor to minimize the amount of time spent making supervision notes
and focus more attention on the interview itself.
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We think that, with some practice, you will be pleasantly impressed with the
degree of complex information about the trainees structuring style that can be
captured quickly.
With videotape facilic supervision, the supervisor first watches the tape
alone and subsequently reviews it with the trainee. When first watching
the tape, the supervisor uses the facilic schematic system to note the flow
of the interview while adding comments about any other technical aspects
of the interview, such as engagement techniques and psychodynamic concerns. The duration of the interview in minutes and the videotape counter
number (if available) are noted periodically. This ability to identify sections
of the videotape that represent particularly important teaching points allows
the supervisor to turn to them quickly during the supervision itself, maximizing the quality of the supervision hour. The system also provides a permanent
outline of the trainees interview that can be referenced in future sessions
of supervision by both the supervisor and the trainee. An example of part
of a longitudinal analysis of an actual trainees interview is shown in
Fig. 3.
The asterisks represent areas of videotape that it may be useful to view with
the trainee. This clinician tends to overuse abrupt transitions (as evidenced by
many phantom gates) and to leave content regions prematurely (as evidenced
by many split- and never-completed expansions). These errors may weaken the
thoroughness of the database needed in this particular style of intake assessment, in which a complex triage was to be determined and a full diagnostic
evaluation was requested. Numerous positive comments highlighting the skills
of the clinician also were made in the actual supervision.
The facilic map merely provides a framework for discussion. In fact, as illustrated in Fig. 3, another advantage of the system is that it provides an easily
accessible visual record that helps the supervisor remember points of interest
related to all aspects of the interview (not just points related to structuring), including nonverbal communication, psychodynamic considerations, and
methods of handling resistance.
To annotate points in the interview that the supervisor intends to comment on later or to describe the exact wording of the interviewers gates,
a circled letter of the alphabet is placed on the facilic map with the accompanying supervision point listed below the map as shown in Fig. 3. The supervision itself is characterized by spontaneity, humor, and discussions of both
dynamic and personal feelings related to the interview. The trainee also may
request that certain areas of the tape be viewed in case the trainee had questions about areas of the interview the supervisor did not highlight.
The second type of facilic map, a cross-sectional schematic, provides an illuminating view of the actual use of time in the interview. Thirty minutes of
a cross-sectional analysis are shown in Fig. 4.
Facilic maps, whether longitudinal or cross-sectional, help make interviewing
skills that at first glance often appear nebulous and confusing to a young trainee
more real and manageable. We have found that the behavioral specificity of the
SHEA & BARNEY
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9:33
11 mins
0:00 tape
0 mins.
Somatic comp.
Anxiety Symp.
Referral
Process
a
Dynamic
b
12:96
16 mins
10:41
Past Psych.
Hx.
Drug
& Alc.
e
Dynamic
d
Meds.
c
17:60
23 mins
15:30
Medical
History
Fam. Hx.
Social Hx.
Premature
Closing
30 mins
34 mins
Depression
Dynamic
Fig. 3. Counter settings.

I. Transitions (gates)
a. What made you come to our clinic today?
b. What were some of your feelings about coming here today?
c. What role do you think your actions play in some of these problems?
d. Have you ever seen a psychiatrist before?
e. Are you a problem drinker?
II. Teaching points
1. Scouting phase is appropriately unstructured and free-floating but is too long
2. Too much detail and time spent in the referral process region
3. Good psychodynamic questioning.
4. Decrease use of phantom gates (ask clinician what he was feeling at this point of the
interview)
5. Explore use of chronology as a reference framework
6. Good use of empathy: Sounds like the world was caving in on you back then
7. Use behavioral incidents when delineating the drug and alcohol history. I think this
patient was providing invalid information. (Also comment on note takingtoo
much.)
8. Heres a series of type A validity errors including multiple questions and negative
questions
(From Shea SC. Psychiatric Interviewing: The Art of Understanding, 2nd edition. Philadelphia:
WB Saunders Co., 1998; with permission.)
system enhances the likelihood that tangible and enduring changes in interviewing technique will result from supervision. These tangible changes, once
perceived by the trainee, often trigger a renewed fascination and respect for
the art of interviewing itself.
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Scouting Phase
Referral Process
60 min
Dynamic Exploration
45 min
Medications
Dynamic Exploration
Past Psychiatric History
Drugs and Alcohol
30 min
Medical History
Family History
Social History
Premature Closing
Fig. 4. Cross-sectional schematic. (From Shea SC. Psychiatric Interviewing: The Art of Understanding, 2nd edition. Philadelphia: WB Saunders Co., 1998; with permission.)
IMPORTANT NOTE: At this point, we recommend pausing from the body

of this article and turning to the Appendix. There we have provided a programmed text that gives the reader a chance to practice using facilic schematics.
This exercise will expand and consolidate your understanding of facilic schematics in a way that we hope is both fun and efficient. After completing the programmed text in the Appendix (which requires about 40 minutes), you will
have a significantly better, hands-on understanding of the principles of facilic
supervision and the use of the facilic shorthand. PLEASE COMPLETE
THE PROGRAMMED TEXT IN THE APPENDIX OF THIS MONOGRAPH BEFORE PROCEEDING.
TIPS AND STRATEGIES FOR USING FACILIC SUPERVISION

MORE EFFECTIVELY
In closing our introduction to facilic supervision, we want to comment on a few
tricks of the trade that we have found useful over the years. These tips include:
1.
2.
3.
4.
5.
Preparing the trainee to use the system effectively

Using past facilic maps to re-enforce progress
Variations on making longitudinal facilic maps
Common structuring errors made by trainees
Combining facilic supervision with role-playing and other educational tools
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SHEA & BARNEY
6. Using the presence of phantom gates to spot emotional or countertransferential responses in trainees
7. Using facilic schematics in a classroom setting
Preparing the Trainee to Use the System Effectively

To help prepare the trainee to use the system, we begin by having the
trainee read the chapter from Psychiatric Interviewing: the Art of Understanding [6]
mentioned earlier in this article. We recommend providing a brief, informal
didactic presentation on the topic as well. After the reading of the chapter
and the didactic follow-up, we strongly recommend providing the trainee
with the self-programmed text provided in the Appendix of this article. We
have used this programmed text with residents regularly, and it is well received.
In addition to being read by a single resident, the programmed text can be
done together as a group as part of your didactic presentation on facilics. In
a group setting a selected resident draws his or her answer on a whiteboard followed by a group discussion as to its correctness. By the end of a single session,
we have been pleasantly surprised how well the residents know the system, allowing its rapid use in individual mentoring.
We also recommend that, before using facilics in supervision, you ask the
student to draw the symbols for the different gates while you watch. If the
student cannot draw the symbols, the student does not really know the system and will not get much out of the supervision (but the student probably
will pretend to follow what you are saying). By informally testing the students understanding of the system before using it, you can spot foggy areas
of understanding and provide immediate education to clarify the system.
Using Past Facilic Maps to Re-enforce Progress
We want to emphasize the usefulness of keeping a file with all of the facilic maps
generated during the course of longitudinal supervision. An occasional review
of this file by the supervisor can significantly increase the objective tracking of
progress, jar the supervisors memory of interviewing techniques that were going to be addressed but may have gotten lost in the shuffle, and suggest moments when past files can be shared productively with the trainee to show the
trainee areas of improvement in a graphically concrete fashion.
By way of illustration, let us picture a trainee who, at the beginning of the
year, frequently follows wandering patients, leaving content regions prematurely, with the result that there routinely are major gaps in the trainees database at the end of the interview. As mentioned earlier, this problem would be
strikingly apparent in the facilic maps of these interviews (incomplete split-expansions throughout the map). Now let us picture that, as the year proceeds,
the trainee makes significant progress in correcting this problem.
In such situations, by pulling out past facilic maps the supervisor can provide
immediate, visual, and compelling positive feedback with comments such as,
Mary, just look at your earlier interviews where you were often missing
important information. Split-expansions all over the place. Now take a look
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at the interview you just did. Fantastic! Every single region was explored fully.
Four slashes everywhere! You can really feel good. You have made excellent
progress in your ability to gather a comprehensive and useful database sensitively, and it is your patients who will benefit.
Variations on Making Longitudinal Facilic Maps
The facilic mapping system can be used any way you see fit. We invite flexibility. Facilic schematics are a tool to be fashioned as you choose.
For instance, when making a longitudinal facilic map, we prefer making the
map as described earlier, in which the facilic map is placed at the top of the first
page, and annotations are placed below the map.
One of our colleagues prefers a different approach. He marks out a column
on the left-hand side of his supervision notes page. As the interview proceeds,
he follows the facilics by writing schematics down the column (not across the
page). As he goes down the column, he usually has room to mark one gate and
the region into which it led per line. Directly to the right of these facilic schematics, he makes all of his notations, annotating the interview as it proceeds.
Such a system has advantages and disadvantages. You can experiment and
see which style of placement of the facilic maps works best for you or best
for your trainee.
Common Structuring Errors Made by Trainees
Certain errors in structuring that we find to be particularly common with residents are the focus of the fourth tip. Sometimes, such as when we are reviewing a videotape and tracking its facilics, we have found it useful to have a list of
these errors to be on the look-out for. We thought you might find the list
useful. Feel free to add other common errors to it.
1. Scouting phase errors
a. Scouting phase is too shorttrainee is structuring prematurely before engagement is secured.
b. Scouting phase is too longa very common error in which the
trainee lets the patient ramble on far too long before beginning
to structure effectively. We have seen scouting phases go on for
30 minutes!.
2. Expansion errors
a. Trainee uses stilted expansions.
b. Trainee uses too many split-expansions and does not return to gather
important information.
3. Gating errors
a. Trainee does not recognize pivot points and therefore does not take
an active part in structuring the interview.
b. Trainee uses too many phantom gates (the Meet the Press interview) when natural and referred gates could be used much more effectively to create a conversational flow.
c. Trainee does not use enough natural and referred gates on a routine
basis.
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Combining Facilic Supervision With Role-Playing and Other Educational

Tools
The power of facilics to enhance videotape supervision has already been
discussed.
In addition, facilics provides a particularly useful method for annotating an
interview while you are watching it live (either in the room with the interviewing dyad or behind a one-way mirror). During such supervision, we sometimes
take a break from the interview (patients always are forewarned that such
breaks may occur for supervision purposes), share with the trainee (outside
the room) the graphics of his or her facilic flow, make suggestions for change,
and then have the trainee return to the room to practice implementing the suggested changes. Similarly, facilic maps can be used with the bug in the ear
method commonly employed in family and group supervision from behind
one-way mirrors.
Another advantage of actually being in the room with the resident is that the
supervisor has the chance to demonstrate more effective facilic structuring
techniques directly by interacting with the patient. Such modeling can be a powerful learning experience for a trainee. Thus, after pointing out (in a break
taken outside the interview room) with the facilic diagrams that a patient is
wandering, the mentor can offer to go back in and act briefly as the interviewer
modeling directly how to structure an overly loquacious patient effectively.
Facilics also can be coupled effectively with role-playing techniques. If a resident persistently uses stilted expansions when exploring diagnostic criteria, the
trainer can use reverse role-playing (in which the student plays the client, and
the trainer conducts the interview) to model the technique of using a blended
expansion. (See the article by Barney and Shea in this issue for a guide to
effective role-playing techniques such as reverse role-playing.) Sometimes before
modeling the correct method, we actually use a series of phantom gates (stilted
expansion) to let the trainee see how unpleasant such an expansion feels. This
demonstration highlights, by contrast, the subsequent modeling of the blended
expansion. After effective modeling, the student can practice being the interviewer, using blended expansions with various patients that we present with
diagnoses ranging from major depression to posttraumatic stress disorder.
Let us wrap up with an example of one of our favorite uses of facilics in combination with both videotape and role-playing: helping residents who rely excessively on phantom gates discover experientially alternative and more
conversational ways of making transitions. If you spot a phantom gate on
the videotape, you ask the trainee if he or she can think of a gate that would
provide a smoother transition, usually a natural gate or a referred gate. If
the trainee can create a more conversational gate, you provide positive feedback on the suggestion and immediately have the trainee try out the more engaging gate by directly role-playing the interview segment with the patient just
seen on the videotape.
If initially the resident cannot generate alternative gates, you can provide
concrete examples of smoother gates and demonstrate them by a reverse
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role-play (you play the clinician, and the trainee plays the patient). After you
model the alternative type of gate, you have the trainee practice the technique
using standard role-playing in which you play the patient. In this fashion, facilic
supervision, videotape, and role-playing often can be used together quite
powerfully.
Using the Presence of Phantom Gates to Spot Emotional
or Countertransferential Responses in Trainees
If a trainee who seldom used phantom gates during previous observation
suddenly uses one for no apparent reason, it sometimes indicates that the
trainee, at an unconscious level, did not want to continue exploring the topic.
For example, when a trainee who usually creates nicely flowing interviews using natural and referred gates starts exploring substance abuse, he or she might
tend to short-circuit the expansion abruptly with a premature exit using a phantom gate. In such situations, you can show the trainee the segment of the videotape where the phantom gate was used and ask what the trainee was
experiencing, a technique known as interpersonal process recall [7]. The resulting discussion may reveal important information (eg, that the trainee was
abused by an alcoholic father) that is useful for the trainee to understand
and ultimately bring to resolution (in work with one of the trainees psychotherapy supervisors, where this type of information is more typically processed,
or perhaps in personal therapy).
Using Facilic Schematics in a Classroom Setting
Facilic shorthand can be a popular tool with groups of students in a classroom
setting in which videotapes or live interviews are being watched and discussed.
The class can map out the facilics of the interviewer while the interview is done
or the video is watched.
During subsequent discussion, different students can be asked to draw the
facilics of certain parts of the interview on a whiteboard. The class then can
use this visual as a springboard for discussion: How do you guys think this
gate worked here? Does anybody have any other ways of maybe making
this transition? Could you draw that alternative way up on the board here?
What do people think of Marys idea of using a referred gate here instead of
an implied one? Which gate feels more conversational to you? I have found
such use of facilics to be excellent in generating animated classroom discussion
and interaction.
SUMMARY
We hope you find facilic supervision to be as enjoyable and effective to use as
we have over the years. It provides a lens for studying and understanding one
of the most complex of interviewing tasks, gathering large databases in
a timely and sensitive fashion. As stated in the introduction, every clinical interview is as complex as a play, vastly more unpredictable, and potentially life
changing. The skilled use of facilic supervision and facilic schematics can
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optimize the likelihood that trainees understand the dynamics of these plays
and that they can create stages on which compassion and healing can emerge
more easily.
APPENDIX
EXERCISES FOR CONSOLIDATING THE UNDERSTANDING AND
USE OF FACILIC SHORTHAND
The following 12 exercises, adapted from a manual created at the Training Institute for Suicide Assessment and Clinical Interviewing [8], present excerpts
from different interviews, exactly as you might encounter them while observing a supervisee interviewing live or watching a previously videotaped
interview.
Below each exercise (or on a separate piece of paper if viewing this article
from our Web archives), draw in the appropriate schematics for the first region
being explored, the gate used by the student as the region is left, followed by
the correct schematic for the subsequent region being entered.
Remember that the regions can be either of the content type (signified by
a rectangle) or the process type (signified by a circle). No matter which type
of region you draw, be sure to abbreviate within it the type of content or process region that it happens to be.
Use the appropriate symbols for the gates, as shown earlier. This process is
exactly the one you will follow when using the shorthand during actual supervision sessions. As an aid to get you started, an asterisk appears before the
interviewer statement that is a gate. In the following exercises, the only thing
that you cannot indicate is the completeness of the expansions of the content
regions (normally done by placing slashes at each corner of the rectangle),
because you are not shown enough of the dialogue in each region to make
such a determination.
This section is designed as a programmed text to maximize the learning experience for the reader. Each exercise is followed immediately by the correct answers and a brief explanation as to why they are correct. We hope you will
enjoy the exercises and that they are as much fun to do as they were to create.
Exercise #1
Patient: Ive been feeling very sad. . . what with my wifes illness and all the rushing back and forth to the hospital for radiation therapy, its tough; no real
rest.
Clinician: Yea, it sounds tough, and it sounds like youve been a great support
for your wife. Im wondering how its impacting on your energy.
Patient: What energy? [patient smiles]
Clinician: And how about your concentration?
Patient: As you can imagine thats pretty bad too. You know, I try to avoid crying, because I want to be strong for her, but its tough.
Clinician: I bet you cant sleep either. Is it rough to fall asleep?
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Patient: Oh yeah; Id say it takes a couple of hours, unless I take some of my

clonazepam.
*Clinician: Roughly how much clonazepam are you taking a day?
Patient: I think its one tab three times a day.
Clinician: Do you know how many milligrams each tab is?
Patient: Yea, I think its 5.0 mg, no, no, its 0.5 mg
Clinician: What other medications are you on?
Patient: Oh, I got a bunch. Ive been taking Cymbalta for a couple of months.
Directions
Draw the first and second region connected by the appropriate gate below.
Answer to exercise #1
Depression content region followed by a spontaneous gate into the content
region of the medication history as mapped below (Fig. 5).
DEP.
MED. HX.
Fig. 5.
Discussion
In this exercise we see a nice example of an interviewer recognizing an opportune time to enter the medication history, because the patient introduced the
topic by mentioning his clonazepam. Notice that it is the patient who brought
up a new region spontaneously by mentioning the medication. The interviewer
then simply used a follow-up question, Roughly how much clonazepam are
you taking a day? that functioned as a spontaneous gate. Most likely, once
within the topic of the patients medication history, the interviewer will finish
it fully using a blended expansion. If the diagnostic region of depression has
not been completed (a split-expansion for that topic), the interviewer could
use a referred gate back into the depression region to complete the diagnostic
exploration of depression after having explored the patients medication history
thoroughly.
Exercise #2
Patient: Its been a long haul. Besides all those short hospitalizations, I also
wound up in the State Hospital in 2006.
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Clinician: How long were you there?

Patient: Oh, about 3 months.
Clinician: Any other times youve been in a hospital specifically for your
depressions?
Patient: No, that about does it. When I was at the State Hospital, I seemed to get
a little better; Im not really certain why. Maybe it was something they did.
*Clinician: Have you felt like people are out to kill you?
Patient: No, not really.
Clinician: What about hearing voices?
Patient: I dont think so, except maybe a time or two.
Clinician: Tell me more about that.
Patient: A couple of times back home, maybe late at night Id be watching TV,
and Id think Id hear my son call my name.
Clinician: What would he say?
Patient: Oh, hed just call out my name.
Clinician: Have you ever felt like people were poisoning your food?
Directions
Past psychiatric history followed by a phantom gate moving into the content
region of psychosis (Fig. 6).
PAST PSYCH.
H X.
PSYCHOSIS
Fig. 6.
Discussion
In the first section of this excerpt, the patient was describing his previous history of treatment related to his depressions. He was relating some past relief
that occurred while being at the State Hospital whenout of nowherethe
student asked about paranoia. As with all phantom gates, no cue statement
suggesting the presence of a new region to explore was present. The student
unwittingly compounded the awkwardness of this transition by proceeding to
explore the psychotic region in a stilted fashion, asking questions in a rigid
sequence. To the patient, this exchange could hardly have been reassuring.
Lets see a different interviewer working with the same patient.
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Exercise #3
Patient: Its been a long haul. Besides all those short hospitalizations, I also
wound up in the State Hospital in 2006.
Clinician: How long were you there?
Patient: Oh, about 3 months.
Clinician: Any other times youve been in a hospital specifically for your
depressions?
Patient: No, that about does it. When I was at the State Hospital, I seemed to get
a little better; Im not really certain why.
*Clinician: Do you think any of the medications they used might have helped?
Patient: I think that one might have. . . I think, I think its called Paxil.
Clinician: Do you remember how much you were taking?
Patient: I think it was about 20 mg in the morning.
Clinician: How do you think it helped?
Patient: I didnt feel as overburdened. I really felt brighter, more energized,
more alive [pause]. I just felt better.
Clinician: Have you ever tried any other antidepressants?
Patient: A slew of them,
Clinician: Do you remember some of their names?
Directions
Past psychiatric history followed by a natural gate moving into the content
region of the medication history (Fig. 7).
PAST PSYCH
HX.
MED. HX.
Fig. 7.
Discussion
In contrast to the trainee in the previous exercise, this trainee is moving with
the patient nicely. The patient had mentioned that he had gotten better (notice
that he did not say anything about medications or treatment, as would have
been the case with a spontaneous gate). The trainee cued directly off this last
statement by the patient, building a naturalistic bridge into the content region
of medication history. Nothing fancy here; just a smooth transition created by
the effective use of a natural gate.
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Exercise #4
Patient: I just dont feel like doing anything since Ive been feeling depressed.
Clinician: Tell me more about what that feels like.
Patient: Really pretty miserable. Life doesnt seem the same. Im tired all the time;
no sleep.
Patient: Over the past several months sleep has almost become a chore. Im always having trouble getting to sleep, and then I wake up all night. Its
miserable.
*Clinician: Have you ever used anything like a nightcap to sort of knock yourself out?
Patient: Yea, sometimes a good belt really relaxes you.
Clinician: How much do you need to drink to make yourself feel sleepy?
Patient: Oh, not too terribly much. Maybe a couple of beers. Sometimes maybe
more than a couple of beers.
Clinician: Just, in general, how many cans do you drink in a given day?
Patient: Probably . . . Now, Im just guessing here, but probably a six-pack or
two. I hold liquor pretty well. I dont get drunk or nothing.
Clinician: Whats your favorite size can of beer, 12 ounces, 16 ounces, 24
ounces?
Patient: Usually the bigger ones, theyre a better deal for your money, Doc [patient smiles].
Clinician: What other kinds of drugs do you like to take to relax.
Patient: Well, I might smoke a joint of two here or there [smiles again].
Directions
Depression content region followed by a natural gate moving into the drug and
alcohol history (Fig. 8).
DEP.
Fig. 8.
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Discussion
We enter this interview when the dyad had been discussing the patients depressive symptoms for a while (depression had been the patients chief complaint). In this excerpt the trainee had finished the depression region. When
the patient started to complain of severe sleep difficulties, the interviewer
smoothly slipped into the drug and alcohol region. By bridging directly off
of the clients last statement, Im always having trouble getting to sleep, and
then I wake up all night. Its miserable, the trainee used a natural gate to
move the conversation into a new topic. Notice that with a natural gate it is
the interviewer, not the patient, who introduces a new topic. This particular
use of a natural gate was both smooth and clever, because it allowed the interviewer to enter a somewhat sensitive topic (eg, drinking habits) unobtrusively.
This trainee displays some very good interviewing skills. Note how she astutely asked the patient for the size of beer cantheres quite a difference between a six-pack composed of 12-ounce cans and one composed of 24-ounce
cans. No wonder the patient was smiling! Without this question, this important
bit of information probably would never have surfaced.
Exercise #5
Patient: Even though my sister was much older, she still had an impact on me.
Clinician: In what kind of way?
Patient: She was always an extrovert, and Im pretty quiet. Consequently, she was
always popular, and I was . . . well . . . just not with the in crowd, if you know
what I mean. Good grades, class presidentyou name it, she was it.
Clinician: What kind of impact did this have on you?
Patient: Not good . . . I sort of hung out . . . Thats all I really did. I was afraid to
be compared, so I kept out of the limelight.
Clinician: If you had to do it again, how would you handle those years?
Patient: Id like to think Id tell her to shove off, in my mind. Id like to think Id
be more aggressive in doing what I like doing. Im not my sister. Im me. But
Im not so sure I would; Id guess thats one of the reasons Im here . . .
*Clinician: Earlier you had mentioned that you were afraid that drugs were
holding you back. What did you mean?
Patient: Since dropping out of school, Ive picked up some bad habits. One of
them is popping a couple of tabs of speed every day.
Clinician: Do you use anything to bring yourself down?
Patient: Sure, sure. Ludes and Valium, if I can get a hold of them.
Clinician: How long have you been using speed?
Directions
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Psychodynamic process region followed by a referred gate moving into the
content region of the drug and alcohol history (Fig. 9).
DYNAM.
D&A
Fig. 9.
Discussion
In the first section, the interviewer was probing in a psychodynamic sense,
asking questions that require a significant amount of reflection and self-observation on the patients part. Indeed, the patient shows a fairly facile ability to
look at herself with some degree of insight, a good sign for the potential to refer
her to psychotherapy. Because we see only a segment of this interview, it is possible that this dynamic process region, indicated by a circle, may have been
going on for quite some time. It may have originally evolved out of specific
content regions, such as the social history or the family history. In any case,
at this point our interviewer has decided to move on.
Instead of using a potentially disengaging phantom gate, the trainee wisely
opts to enter the new region by referring back to an earlier statement made
by the patient; hence the gate is correctly identified as a referred gate. Notice
that the patient quickly picked up on this referred gate and animatedly joined
in a naturalistic expansion of the content region related to the elicitation of
a drug and alcohol history.
Exercise #6
Patient: Then my damn aunt came . . . What a turkey! . . . Shes always coming
over. Shes got this disease and that disease. One day shes got cancer and
the next day shes sure I have it. Then shes telling me about what I should
eat. Honestly . . . it drives me nuts.
Clinician: Sounds frustrating.
Patient: Frustrating! You better believe it. Shes Gods gift to busybodies.
Clinician: Is she like anybody else in your family?
Patient: A little bit. My mother doesnt always mind her own business . . . but I
live with her. She supports me, so I dont think I should complain.
*Clinician: Do you have any medical problems?
Patient: No, not exactly.
Clinician: What do you mean?
Patient: Well, Ive had my tonsils out.
Clinician: When was that?
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Patient: Back in 1960.

Clinician: Any other hospitalizations?
Patient: No.
Clinician: Have you had to see your doctor about your heart or lungs?
Directions
Content region of the social history followed by a phantom gate moving into
the content region of the medical history (Fig. 10)
SOC. HX.
MEDICAL
HX.
Fig. 10.
Discussion
Needless to say, the transition by this trainee was not the smoothest one on
record. The client had been discussing various aspects of family relations,
whenout of nowherethe trainee switched topics. The reason for the subsequent questions, and their apparent urgency, was certainly unclear to the client,
especially because she had been discussing a bit of her social history that was
emotionally important to her. Lets see an alternative approach.
Exercise #7
eat. Honestly . . . it drive s me nuts.
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*Clinician: You know, you had mentioned that your aunt almost drives you nuts
worrying about your health as well. Have there been any things in your
health that might have prompted any of her fears?
Patient: No, not really. I have had some problems, but all minor league. Although even minor league problems can get her going.
Clinician: What kinds of problems have you had?
Patient: Well, I had my tonsils out, when I was 6.
Clinician: How did that go?
Patient: Oh, no problem; just a good way to get some ice cream.
Clinician: Any other hospitalizations?
Patient: I had my wisdom teeth pulled out; andoh yeaI was in a car accident
and broke my leg. . ..
Directions
Content region of the social history followed by a referred gate moving into the
content region of the medical history (Fig. 11).
SOC. HX.
MEDICAL
HX.
Fig. 11.
Discussion
What a difference it can make to replace a phantom gate with a more flowing
gate such as the referred gate used here. Unlike the trainee in exercise #6, this
trainee wanted to move into the same new regionmedical historybut strategically used a referred gate that gently moved the conversation into the medical
history region. Sometimes referred gates refer back to patient comments made
long ago in the conversation, and sometimes, as in this example, the referred
gate points back to a relatively recent patient comment. More distant comments
can be referred to just as easily and seem just as natural and conversational to
the patient, once again metacommunicating that the clinician has been listening
carefully. Lets see yet another direction the interview with the above patient
could have taken.
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Exercise #8
eat. Honestly . . . it drives me nuts.
*Clinician: What makes you say that you dont think you should complain?
Patient: Its sort of complicated, you know, but if I depend on my mother for food
and shelter, well, who the hell am I to complain? But I hate this feeling . . . this
feeling of being dependent, owing her something. Im almost 26; I ought to
be on my own.
Clinician: Any ideas about why you havent left?
Patient: Maybe Im scared . . . I used to get scared when I was away at college,
you know, homesick. Theres still a lot of little girl in me.
Clinician: What role does this little girl play in you?
Directions
Content region of the social history followed by a natural gate moving into
a psychodynamic process region (Fig. 12).
SOC. HX.
DYNAM.
Fig. 12.
Discussion
Notice that the trainee felt she was done with the social history and cued directly off of the patients last statement (ie, . . .but I live with her. She supports
me, so I dont think I should complain) by using the natural gate, What
makes you say you dont think you should complain? With this skillful use
of a natural gate the trainee almost imperceptibly guided the interview into
a psychodynamic region. Note that, as opposed to a free facilitation region,
in a psychodynamic region the interviewer peppers the region with interpretive
questions rather than just letting the interviewee go.
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Naturally there can be some overlap between free facilitation regions and
psychodynamic regions. Sometimes while free facilitation regions are being
used, important dynamic considerations pop up spontaneously as the patient
talks freely. But the difference in the two regions can be found by looking at
the primary intent of the interviewer. In a free facilitation region the main intent is purely engagement. In a psychodynamic region the main intent is to use
interpretive questions to see how the patient responds, what defense mechanisms appear, and the extent of the patients own observing ego.
Exercise #9
Patient: The situation at work is not good. My boss is short staffed and is pushing
the work on me. And I cant do it all. He wants to bring in 150 new clients for
the program, simply impossible.
Clinician: How does he put the pressure on you exactly?
Patient: Basically, by asking me to do his work. Thats what really bothers me. He
might sit in the recreation room shooting pool, while Im supposed to miss lunch.
*Clinician: Earlier you said that you were feeling constantly wired at work.
Im wondering if you ever get the chance to relax?
Patient: Occasionally. But even at home I feel pretty uptight.
Patient: Even when Im watching TV, I feel restless and worried about work, or
maybe the kids.
Clinician: Do you view yourself as a worrier?
Patient: Oh, God, yes! Im the original worrywart. I spend a lot of time each day
just pacing around.
Clinician: Do you ever have times when you feel your heart racing?
Patient: Oh yea; thats common, especially if Im upset. The other day, when I
was mad at Johnny about his grades, I thought my heart would explode.
Clinician: Besides things like your heart racing, how often do you get backaches, headaches, or other tension-related pains?
Directions
Content region of the social history followed by a referred gate moving into an
exploration of generalized anxiety disorder (Fig. 13).
SOC. HX.
Fig. 13.
G.A.D.
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Discussion
In this example, two content regions are bridged nicely by a referred gate. This
time the statement made by the patient, and subsequently referred to by the
trainee, apparently appeared much earlier in the interview and does not
show up in this brief excerpt. This trainee also has increased the effectiveness
of the transition by using a referred gate that demonstrates his active concern
(ie, Earlier you said that you were feeling constantly wired at work. Im wondering if you ever get the chance to relax?) All in all, this transition was
engaging and conversational.
Exercise #10
Patient: The depression just seems to get worse and worse.
Clinician: How long has it been going on?
Patient Ever since I got back from Christmas vacation. This semester is a lot
harder than I was expecting. Im finding calculus much more difficult than
algebra.
Clinician: It sounds real tough. Are your symptoms with you all the time?
Patient: Yea, I cant shake them . . .
Clinician: Has it impacted on your sleep?
Patient: You bet! Cant fall asleep, cant stay asleep, and I wake up early and all
gunked up. Of course, it doesnt help that my suitemates are big party guys.
*Clinician: Are you worrying a lot?
Patient: Almost constantly. Ive always been a worrier. My Mom used to tell me,
Just go in the corner and worry for 5 minutes and be done with it. Dont
waste the day fretting, it wont help anything.
Clinician: [smiles] Sounds like your Mom had some good advice?
Patient: [smiling] Yea, she still does.
Clinician: What about relaxing, can you ever relax, you know, say on
a Saturday?
Patient: Not really. Im always wound up tighter than a kite, and Ive been that
way even before I got depressed.
Clinician: When did that begin?
Patient: Probably since around September.
Clinician: Hmm . . . so your anxiety has been around for a while. Does it cause
you to have aches and pains, like backaches and headaches?
Patient: Oh yea. I get tension headaches all the time. Those started almost as
soon as I started my Freshman year here.
Directions
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Content region of major depression followed by an implied gate moving into
an exploration of generalized anxiety disorder (Fig. 14).
DEP.
G. A. D.
Fig. 14.
Discussion
This is the first example of an implied gate in these exercises. The early conversation focused on an exploration of depressed symptoms, which had been
going on some time before the excerpt begins. After feeling that she had completed expanding the major depression region, the trainee decided to enter the
expansion of generalized anxiety disorders merely by asking, Are you worrying a lot? There is significant overlap between depressive symptoms and anxiety symptoms, so clinicians often use implied gates to move from one to the
other with barely a noticeable change in pace. Implied gates can be used any
time two adjacent regions are so congruent in topic that the transition seems
appropriate.
In contrast to a spontaneous gate, in an implied gate the clinician initiates the
change of topic, not the patient. Unlike a natural gate, the implied gate does not
cue directly off the preceding one or two statements by the patient. Unlike a referred gate, the interviewer does not refer directly back to a previous statement
by the patient. Finally, in contrast to a phantom gate, the implied gate seems to
fit naturally.
When the new region is extremely similar to the preceding region, as in this
example, an implied gate can be almost imperceptible and rivals a natural gate
for smoothness of transition. If the connected content regions are less similar,
an implied gate becomes less smooth and eventually approaches the abruptness
of a phantom gate.
For instance, the clinician could have said, Tell me more about your
stressors, instead of, Are you worrying a lot? This inquiry would have represented an implied gate into the content region of the patients current
stressors, although it would not have flowed quite as well as the previous
example of an implied gate, because the topics are not as similar in nature.
In summary, implied gates range in smoothness on a continuum between
natural gates and phantom gates. When the two regions are closely related, implied gates approach the gracefulness of natural gates. On the other hand, if the
topics are poorly related, an implied gate can approach the awkwardness of
a phantom gate.
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Before leaving this example, it is worth noting that, after entering the generalized anxiety disorder region, the trainee did a nice job of exploring the region
using a blended expansion by conveying reassuring nonverbal communication
(such as smiling) and using engaging comments (Sounds like your Mom had
some good advice).
Exercise #11
In the following example, the reader should be on the lookout for three regions
connected by two gates.
Patient: I keep getting the same thoughts over and over. I really dont understand
it.
Clinician: What types of thoughts have been bothering you?
Patient: I cant get it out of my head that I have germs on my hands.
Patient: I hate shaking peoples hands. If I shake somebodys hands I will absolutely have to go the bathroom to wash them. I wont be able to stand being
in the room, until I do.
Clinician: How many times might you wash your hands in a day?
Patient: At least 100 times. Im not kidding.
Clinician: Are there other actions that you find you have to keep doing over and
over?
Patient: This is sort of embarrassing to talk about, but I have a hard time
dressing.
Patient: Sometimes, when Im dressing, I have to take my pants off and on 20
times. I count it out. Sometimes it might take me 30 minutes to dress, I get
so anxious.
*Clinician: Do you want to kill yourself?
Patient: No, not really. I just want to stop worrying and doing these crazy things.
Clinician: But have you had any thoughts of hurting yourself?
Patient: Uh [pause] No.
*Clinician: Does anyone in your family have a serious mental illness?
Patient: How do you mean?
Clinician: Has anyone in your family been depressed?
Directions
Draw all three regions and their connecting gates below.

Content region of obsessive-compulsive disorder followed by a phantom gate
moving into an exploration of suicidal ideation followed by a phantom gate
into the content region dealing with family history (Fig. 15).
SHEA & BARNEY
e94
OCD
SUICIDE
FAM. HX.
Fig. 15.
Discussion
The early phase of this excerpt illustrates the expansion of a content region
dealing with obsessive-compulsive disorder. This region is being expanded in
a reasonable fashion, when, without any warning, the trainee abruptly asks
about suicide, a clear-cut example of a phantom gate.
This trainee seemed particularly intent on disrupting the conversational flow
here, because he no sooner enters the suicide region than he exits, using yet
another phantom gate into the family history region with the question,
Does anyone in your family have a serious mental illness? Such strings of
phantom gates may leave the patient wondering if the clinician knows what
he is doing and certainly can contribute to a Meet the Press style interview.
In the next example, the interviewer tries a different approach with the same
patient.
Exercise #12
Patient: I keep getting the same thoughts over and over. I really dont understand
it.
Clinician: What types of thoughts have been bothering you?
Patient: I cant get it out of my head that I have germs on my hands.
Patient: I hate shaking peoples hands. If I shake somebodys hands I will absolutely have to go the bathroom to wash them. I wont be able to stand being
in the room, until I do.
Clinician: How many times might you wash your hands in a day?
Patient: At least 100 times. Im not kidding.
Clinician: Are there other actions that you find you have to keep doing over and
over?
Patient: This is sort of embarrassing to talk about, but I have a hard time
dressing.
Patient: Sometimes, when Im dressing, I have to take my pants off and on 20
times. I count it out. Sometimes it might take me 30 minutes to dress, I get
so anxious.
*Clinician: That sounds very upsetting and painful. When your worries torment
you like this, do your thoughts ever get so disturbing that you think of killing
yourself to escape it all?
Patient: Sometimes I do wonder if its all worth it. I mean, why bother, when you
really get down to it? But those thoughts seem to pass quickly.
e95
Clinician: When you do get those thoughts of perhaps taking your own life,
what exactly do you think of doing?
Patient: One time, about a month ago, when I was really upset, I thought of taking some pills . . .
Directions

Content region of obsessive-compulsive disorder followed by a natural gate
moving into an exploration of suicidal ideation (Fig. 16).
OCD
SUICIDE
Fig. 16.
Discussion
This exercise is the last one in this Appendix, and it highlights the powerful
difference the choice of a single gate can make in engagement, conversational
flow, and even in the validity of the patients answers. Unlike the previous interviewer, this trainee manages to bring up the topic of suicide while simultaneously communicating empathy through the skillful use of a natural gate
cueing directly off the pain expressed in the patients immediately preceding
comments. Note the remarkably different history related to recent suicidal ideation that results secondary to the difference in engagement between the clinician and the patient in the two examples. Technique counts, and facilic
supervision effectively teaches technique combined with compassion.
You have finished the programmed text. We hope it has been of value.
Please return to the main body of the article.
References
[1] Shea SC, Mezzich JE, Bohon S, et al. A comprehensive and individualized psychiatric interviewing training program. Acad Psychiatry 1989;13(2):6172.
[2] Shea SC, Mezzich JE. Contemporary psychiatric interviewing: new directions for training.
Psychiatry, Interpersonal and Biological Processes 1988;51(4):38597.
[3] Hall ET. The hidden dimension. New York: Doubleday; 1966.
[4] Birdwhistell ML. Introduction to kinesics: an annotation system for analysis of bodymotion and
gesture. Louisville (KY): University of Louisville Press; 1952.
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SHEA & BARNEY
[5] Shea SC. Psychiatric interviewing: the art of understanding. Philadelphia: W.B.Saunders
Company; 1988.
[6] Shea SC. Psychiatric interviewing: the art of understanding. 2nd edition. Philadelphia:
W.B.Saunders Company; 1998.
[7] Benedek EP. Interpersonal process recall: an innovative technique. J Med Educ 1977;52:
93941.
[8] Training Institute for Suicide Assessment and Clinical Interviewing (TISA), Available at:
www.suicideassessment.com.

Clinical Interviewing - Practical Tips From Master Clinicians

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Psychiatr Clin N Am 30 (2007) xvxvii

Shawn Christopher Shea, MD

0193-953X/07/$ see front matter

2007 Elsevier Inc. All rights reserved.

Psychiatr Clin N Am 30 (2007) 145156

Approaching the Mind in Clinical

Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA

2007 Elsevier Inc. All rights reserved.

TECHNIQUES OF SOUNDINGS AND COUNTERPROJECTION

CLINICAL IMAGINATION IN THE INITIAL INTERVIEW

TECHNIQUES OF SOUNDINGS AND COUNTERPROJECTION

TECHNIQUES OF SOUNDINGS AND COUNTERPROJECTION

Watch the technique at use in another tricky clinical situation, determining

TECHNIQUES OF SOUNDINGS AND COUNTERPROJECTION

I believe it is the acknowledgment of this paradox that brings interpersonal

TECHNIQUES OF SOUNDINGS AND COUNTERPROJECTION

A counterprojective statement has three components. First, it must point out

world of experience. Unfortunately this imaginative attempt to understand the

Psychiatr Clin N Am 30 (2007) 157166

New Approaches for Creating the

Mood and Anxiety Clinic, Childrens Hospital of Eastern Ontario (CHEO),

2007 Elsevier Inc. All rights reserved.

WHAT IS THE MOST IMPORTANT FACTOR IN ESTABLISHING

Biologic needs such as food, shelter, safety, and physical health

NEW APPROACHES FOR CREATING THE THERAPEUTIC ALLIANCE

SOLUTION-FOCUSED INTERVIEWING: THE NEW WAVE

What would make this a helpful visit?

The following example illustrates some of the advantages of solution-focused

NEW APPROACHES FOR CREATING THE THERAPEUTIC ALLIANCE

MOTIVATIONAL INTERVIEWING: THE ART OF

NEW APPROACHES FOR CREATING THE THERAPEUTIC ALLIANCE

The following example demonstrates some of the motivational interviewing

Additional questions can be used to help the client to

Motivational interviewing, as well as Bordins [1] transtheoretical stages in

THE MEDICATION INTEREST MODEL: THE FINE ART

NEW APPROACHES FOR CREATING THE THERAPEUTIC ALLIANCE

Psychiatr Clin N Am 30 (2007) 167180

Practical Interview Strategies

*Corresponding author. VA Maryland Healthcare System, MIRECC, 6A-157, 10 North

2007 Elsevier Inc. All rights reserved.

MURRAY-SWANK, DIXON, & STEWART

INTERVIEWING FAMILIES OF MENTALLY ILL PATIENTS

MURRAY-SWANK, DIXON, & STEWART

hospitalization is to help get people through a crisis when their symptoms

INTERVIEWING FAMILIES OF MENTALLY ILL PATIENTS

MURRAY-SWANK, DIXON, & STEWART

INTERVIEWING FAMILIES OF MENTALLY ILL PATIENTS

Follow-up inquiries can include more focused questions such as:

MURRAY-SWANK, DIXON, & STEWART

With regard to medication, an example dialogue may be as follows:

Problems with establishing a sound rapport and reliable contact

INTERVIEWING FAMILIES OF MENTALLY ILL PATIENTS

In this example, the social worker is actively coaching Mrs. Jones as to

MURRAY-SWANK, DIXON, & STEWART

Potential Obstacles for Clinicians in the Outpatient Setting

INTERVIEWING FAMILIES OF MENTALLY ILL PATIENTS

2. Have they ever attended any kind of educational programs or groups?

MURRAY-SWANK, DIXON, & STEWART

Difficulties with engaging family members

INTERVIEWING FAMILIES OF MENTALLY ILL PATIENTS

been tried on numerous ineffective cocktails of medications, whose painful

MURRAY-SWANK, DIXON, & STEWART

Psychiatr Clin N Am 30 (2007) 181197

Talking with Patients About