Psychiatric Interviewing - Shawn Christopher Shea

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CHAPTER 1
The Delicate Dance: Engagement
and Empathy
When a doctor tells me that he adheres strictly to this or that method, I have my doubts
about his therapeutic effect. … I treat every patient as individually as possible, because the
solution of the problem is always an individual one …
Carl G. Jung
Memories, Dreams, Reflections
In the following pages, we will begin a study of the interviewing process. We will be
examining the craft in which one human attempts the formidable task of understanding
another human. By way of analogy, this task is not unlike exploring a darkened room in
an old Victorian house, holding only a candle as a source of illumination. Occasionally,
as one explores the shadows, a brisk wind may snuff the candle out and the room will
grow less defined. But with patience, the explorer begins to see more clearly. The outlines
of the family portraits and oil lamps become more distinct. In a similar fashion, the
subtle characteristics of a patient begin gradually to emerge. This quiet uncovering is a
process with which some clinicians appear to familiarize themselves more adeptly than
others. It is as if these more perceptive clinicians had somehow known the layout of the
room before entering it – and indeed, in some respects, they had.
Their a priori knowledge is the topic of this chapter. We will attempt to discern some
of the underlying principles that determine whether an initial interview fails or succeeds.
As Jung suggests in the epigraph to this chapter, these principles do not harden into rigid
rules. Instead they represent flexible guidelines, providing structure to what at first
appears structureless.
Perhaps a second analogy may be clarifying at this point. A book on 19th century art
by Rosenblum and Janson provides some useful insight.1 In it, the authors attempt to
describe the numerous processes that lead to the creation of a work of art, including
environmental influences, political concerns, and the goals and limitations of the artist.
With each painting, these historians appear to question themselves vigorously concern-
ing concepts such as color, composition, originality, perspective, and theme. In short,
Rosenblum and Janson utilize a specific language of art consisting of concisely defined
terms. This language provides them with the tools to conceptualize and communicate
their understanding. Since the language is one understood by most artists, the concepts
of Rosenblum and Janson can be widely discussed and debated.
4 Clinical interviewing: the principles behind the art
The work of the art historian is not at all unlike our own; as clinicians, however, we
are concerned with a living art. We can better study the characteristics of this living art
once we possess a language with which to conceptualize our interviewing styles. With
this language, the principles that seem to provide an experienced clinician with a “map
of the Victorian room” naturally evolve. From these principles we will garner a more
engaging, flexible, and penetrating style of interviewing.
IN SEARCH OF A DEFINITION
A Bit of Interviewing Examined and the Discovery of a Map
There probably exists no better method for uncovering a definition of interviewing than
by analyzing a brief piece of clinical dialogue. Even in a short excerpt, clarifying principles
may begin to emerge.
The following dialogue was taken from a videotaped initial interview. Of particular
note is the fact that the supervisee was disturbed by a not uncommon problem faced by
an interviewer, “the wandering patient.” Specifically, the supervisee commented, “I
couldn’t really even get a picture of her major problem (she had presented complaining
of being very depressed), because she took off on every subject that came to her mind.”
In this excerpt, the interviewer, who had done an excellent job engaging her, uncovering
her stresses, and allaying her initial anxieties, for she had never worked with a mental
health professional before, was, at this point in the interview, attempting to discover
whether she was suffering from the symptoms of a major depressive disorder. He wanted
to understand better what symptoms were present and their severity – information that
he could subsequently use to collaboratively develop an initial treatment plan with her.
The patient, a middle-aged woman, had been describing some problems with her son,
who was suffering from an attention-deficit disorder.
Pt.: … He’s a behavior problem; maybe a phase he’s going through. (Interviewer writes
note.) He’s exhibiting crying spells, which don’t necessarily have a reason. The
teacher is trying to interview him to see what exactly is wrong with the child
because he’s tense and crying, which isn’t like him; he’s been a happy-go-lucky kid.
Clin.: Is he still kind of hyperactive?
Pt.: Oh yeah … now that we’ve lowered the medication he’s a little bit better, but I was
just mad at the doctor; you know, one of them should have explained it to me.
Clin.: I would think that must be very frustrating to you.
Pt.: It was.
Clin.: And how has this affected your mood?
Pt.: Ah … I have a husband who works shifts (interviewer takes note), and he wants
to be in charge of everything. I had a job until last February, when I got laid off.
I was working more than full time. My husband does not pitch in at all. I was
working about 60 hours a week. He wouldn’t lift a dish, which really gets
to you.
Clin.: Uh-huh; I’m sure.
The delicate dance: engagement and empathy 5
Pt.: Especially when you’re working Saturdays and Sundays and you start at 6:30 in the
morning and don’t get home ‘til 8:00 at night.
Clin.: What kind of work?
Pt.: I was working in electronic assembly. I was an X-ray technician for 10 years and
then we decided to settle down and have a family. I was working at the hospital up
in Terryhill. And, uh, he said, and I can see his point …
At first glance, one can quickly empathize with the interviewer’s frustration, for indeed
this patient is in no hurry to describe her mood or her depressive symptoms. Instead,
when asked directly about her mood, she immediately darts down a side alley into a
series of complaints about her husband. She appears to wander from topic to topic. But
with a second glance, an interesting observation is apparent concerning the communica-
tion pattern between these two co-participants. It is unclear who is wandering more, the
patient or the interviewer. It is as if the two had decided to take an evening stroll together,
hand in hand.
Specifically, the interviewer had intended to explore for information concerning
depression. But when the interviewer asked about mood, the patient chose to move
tangentially. At this crucial point, where the patient left the desired topic, the interviewer
left with her. Unintentionally the clinician may have immediately rewarded the patient
for leaving the desired topic by taking notes. His scribbling may have inadvertently told
the patient to continue by suggesting that what the patient was saying was important
enough for the clinician to jot down. The interviewer further rewarded the tangentiality
of the patient by proffering an empathic statement, “Uh-huh; I’m sure.” As if this were
not enough, the clinician followed the patient down the alley by asking a question about
the new topic (e.g., “What kind of work?”).
Thus, both the patient and the clinician had an impact upon each other, their
interface defining a dyadic system unconsciously committed to the perpetuation of a
tangential interview. If we examined the next 10 minutes of this interview, we would see
a continuation of this joint rambling, an unproductive process that resulted in almost
no further information regarding the patient’s depression and the pain beneath it, mat-
erial much needed in order to begin collaborative treatment planning and subsequent
healing.
This example illustrates the point that interviews define interactional processes, some
of which facilitate communication and others of which inhibit communication. These
processes are so distinctive that one can name them. For instance, the above process
could be named “feeding the wanderer.” If one is trying to uncover specific information
within a set topic, then the process of feeding the wanderer represents a maladaptive
technique. Curiously, if one were attempting to foster an atmosphere conducive to free
association, the same technique might be beneficial. In either case, the interviewer can
and should be consciously aware of this technique, implementing it when desirable and
avoiding it when it would not be efficacious. For example, in Chapter 3 we will discover
that the interviewer may have been able, in the above dialogue, to lead this patient effec-
tively into a less digressive mode of speech through the use of sensitively well-timed
focusing statements.
As we search for a definition of the interview process, we have already stumbled upon
a cornerstone characteristic of all good clinical interviewing. It is not done solely by habit.
Good clinical interviewing is the art of choice. The gifted interviewer always tries to match
his or her interviewing techniques and strategies to the uniqueness of the patient, the
demands of the clinical situation, and the vibrancies of the patient’s culture. Allen Ivey,
whose books I highly recommend, captured this cornerstone brilliantly with his concept
of “intentionality,” which is a characteristic both of clinicians, as they engage patients,
and patients, as they engage life:
Intentionality, along with cultural intentionality, is acting with a sense of capability and
deciding from among a range of alternative actions. The intentional individual has more
than one action, thought, or behavior to choose from in responding to changing life situ-
ations. The culturally intentional individual can generate alternatives in a given situation
and approach a problem from multiple vantage points, using a variety of skills and personal
qualities, adapting styles to suit different individuals and cultures.2
In this book our task will be, both for beginning and experienced clinicians, to explore
a variety of interviewing techniques and strategies that will allow us to creatively choose
which of these are most effective for which patients, enabling us to become more and
more adept at creating intentional interviews while nurturing intentional interviewees.
With this goal in mind, we can now turn our attention to defining exactly what an inter-
view is. This definition would be equally true for an assessment interview by a social
worker or a television interview by a talk show host. The general definition reads as
follows:
An interview represents a verbal and nonverbal dialogue between two participants, whose
behaviors affect each other’s style of communication, resulting in specific patterns of inter-
action. In the interview, one participant, who labels himself or herself as the “interviewer,”
tends to ask questions in attempts to achieve specific goals, while the other participant
generally assumes the role of “answering the questions” but undoubtedly has his or her
own goals.
This definition emphasizes the interactional process of the interview. It also allows one
to refine the definition depending on the desired goals and the context of the interview.
To make this definition more specific to the clinical assessment, one has only to look for
the goals particular to the clinical situation.
In a broad sense, these assessment goals are as follows:
1. To establish a sound engagement of the patient in a therapeutic alliance

2. To collect a thorough and valid database
3. To develop an evolving and compassionate understanding of the person being
interviewed
4. To develop an assessment from which a tentative diagnosis can be made
5. To collaboratively delineate a set of practical problems to be addressed and therapeu-
tic goals to be set
6. To collaboratively develop an appropriate disposition and tentative treatment plan

for achieving these goals
7. To begin the healing process by effecting some decrease of anxiety and pain in the
patient
8. To instill hope and ensure that the patient will return for the next appointment
Furthermore, the goals of the initial interview will vary depending on the demands of
the assessment situation, including issues such as time constraints and the interviewer’s
determination of what type of data seems clinically necessary in order to make an appro-
priate disposition. For instance, a crisis clinician called into an extremely busy emergency
department to interview a victim of domestic violence will clearly sculpt a different
interview than a therapist performing an initial intake at a community mental health
center who, in turn, will create a different initial interview than one undertaken by an
analyst asked to spend an hour or two with a well-educated patient requesting psycho-
therapy for chronic depression. In short, the needs of the clinical situation should deter-
mine the style of the interview but can do so only if the clinician remains willing to
intentionally and flexibly alter his or her approach.
In any case, the above considerations emphasize one of the frequent challenges facing
the initial interviewer, namely to gain a thorough and valid database in a limited amount
of time while sensitively engaging the patient. The shorter the time period provided, the
more complex the task appears. To return to our Victorian room, it is as if a clinician
were being asked to make an inventory of a darkened room in a restricted amount of
time while being careful not to disturb the decor too much. No easy task, even for a
master of parlor games.
Perhaps this challenge reaches its most formidable peak when an interviewer or con-
sultant is placed in the unenviable role of performing an intake assessment. From his or
her assessment, frequently limited to the “50-minute hour” or less time by the numerous
time pressures present in a busy clinic, the interviewer must determine the treatment
disposition of the patient. We shall now turn our attention to the difficulties inherent in
such intake interviews.
The discussion so far has indirectly provided an operational definition of such an
assessment interview. From this definition, a map of sorts can be formulated as shown
in Figure 1.1. This map, delineating the various goals of the assessment interview, begins
with the engagement process, which, in many respects, determines whether the other
goals will be successfully achieved. As engagement proceeds, the data-gathering process
unfolds, leading to a progressive understanding of the patient. This understanding of the
patient as a unique person depends upon the clinician’s ability to see the patient’s view
of the world and recognize the patient’s fears, pains, and hopes. As the interview pro-
gresses, the clinician begins to formulate a clinical assessment, including a tentative dif-
ferential diagnosis and a practical list of the patient’s concerns and desired goals. From
both the assessment of the patient’s situation and an understanding of the patient as a
person, the clinician and patient can co-formulate a treatment plan suited to the indi-
vidual needs of the interviewee, while acknowledging the constraints placed on treatment
by the limitations of the mental health system itself.
Figure 1.1 Map of the interviewing process.
These processes of engagement, data gathering, understanding, assessment, and treat-

ment planning are, in actuality, longitudinally intertwining processes. The reverse arrows
in the center of the map emphasize this fact, highlighting the clinician’s need to attend
to engagement activities throughout the initial interview.
Person-Centered Interviewing
As we use our map to explore our Victorian room, especially as the shadows darken and
we meet areas where the patient is hesitant to share, our efforts must be guided by a
compass that can provide a sense of direction in the darkness. What is this compass? It
is the realization that our major goal for being in this room is simple, concrete, and
unwavering – we are there to help the person who has sought our care.
At first glance this axiom may seem so self-evident as to not need to be stated. But any
experienced clinician can relate to the intense time pressures of the work, the weariness
engendered by the work, the mountains of paper work attached to the work, the admin-
istrative hassles hindering the work, and their own unconscious needs sometimes
undermining the work that can make it surprisingly easy to lose this sense of direction.
For decades talented innovators, such as Carl Rogers, have felt this point to be so impor-
tant that terms have been coined such as “client-centered counseling” (and in the fields of
medicine and nursing: “patient-centered medicine”) to highlight it. The newest term that
has evolved for this concept – “person-centered” – beautifully captures the essence of our
mission. It is a term more commonly encountered in European literature.
From the person-centered perspective the clinician views the interviewee as a cascad-
ing series of unique moments in time, in which the biology, psychology, intimate rela-
tionships, family dynamics, culture, and spirituality of our patient intersect to create the
unique person before us. It is an ever-shifting matrix of which we are a part as soon as
the patient enters our office. Our goal as clinicians is to understand this uniqueness, help
our patients to better understand their strengths and weaknesses, and to learn how to
navigate this complex human matrix more effectively.
Throughout the pages of this book we will use a person-centered perspective as our
compass. Our interviewing principles, techniques, and strategies will be enriched by our
efforts to see the world through the patient’s eyes as well as our own, to make sure that
we have a collaborative understanding of what the patient views as his or her problems
and his or her goals first before sharing some of our own suggestions. It is a perspective
that gently reminds us to understand what the person seeking our help wants us to
provide before trying to provide it.
In person-centered interviewing the patient is not viewed as the problem but as a
unique individual filled with solutions to the many problems that life invariably brings
to all of us. There is a humbleness to a person-centered interviewer. It is the wisdom that,
even at our best, we do not know all the answers, for we do not even know all the ques-
tions. Thus it is intensely important to listen to what our patients have to teach us and
the questions that they bring us.
The Next Step

In this book we will focus upon the particularly challenging type of interview described
above – the initial assessment – for the principles needed to perform it gracefully can be
generalized to most other types of interviews, including emergency department inter-
views or crisis lines, where a great deal less time may be available. In short, the difficulties
presented by the initial assessment interview provide tremendous opportunities for learn-
ing skills critical to understanding the core issue of most interviews, the delicate interplay
between engagement, data gathering, and time. Many of these same skills will ultimately
also be of use in psychotherapy itself.
In Part I of this book we will sequentially explore each of the processes defined by
our map with a separate chapter (sometimes multiple chapters). In this chapter we will
look at the first way-station on our map, engagement and its relationship to empathy.
Now is an appropriate time to introduce our integrated video program and to view
our first video. As described in the Preface, more than 7.5 hours of video instruction are
integrated throughout the text. These video modules provide didactic material that con-
solidates what has been read, adds new material and nuance, and provides video illustra-
tions of the interviewing techniques. Video boxes within the text (as appears immediately
below) will alert the reader to the video opportunities as they arise. Note that video
modules are accessed via the e-book, for which directions for easy access appear on the
inside of the front cover of the book.
VIDEO MODULE 1.1

Title: Introduction to Integrated Video Package
Contents: This short, yet important, video module describes the goals and use of the integrated
video package. To utilize the video material most effectively it should be viewed before proceeding
with subsequent video modules.
CREATING THE THERAPEUTIC ALLIANCE

First Things First: The Difference Between Engagement and Blending
From the first moment in which they see, hear, smell, and touch each other, the clinician
and the patient begin the engagement process. In this complex interplay they reflect
their sensory information onto the slippery screen of their memories. From these com-
parisons, both the clinician and the patient attempt to determine where each will fit into
the other’s life. Even as simple a gesture as a handshake can lead to lasting impressions.
The experienced clinician may note whether he or she encounters the iron fingers of a
Hercules bent upon establishing control or the dampened palm of a Charlie Brown
expecting imminent rejection.
Ironically, at this same moment, the patient will have begun his or her own “mental
status” on the clinician. This process can be seen clearly in the patient who greets the
clinician’s outstretched hand not with a handshake but with a look of disdain. As the
clinician responds to the patient’s rejection of a simple social amenity, who can doubt
that the patient will be gaining some hints about the psychological workings of the clini-
cian. For example, one interviewer, perhaps with an obsessive need to “do things my
way,” may further extend his or her hand, testily adding, “Don’t you want to shake?”
Another clinician, perhaps jaded from overwork, may dryly comment, “Not in the mood
for shaking today, are we?”
In either case, the patient has struck a rich vein from which to mine answers to ques-
tions such as the following: (1) Will this interviewer get angry with me?, (2) Will this
interviewer make me do things I don’t want to do?, and (3) Am I safe here? This example
hints at the complex and mutual activities affecting the engagement process, during
which territorial issues are initially addressed.
Before proceeding, it is important to define two terms, engagement and blending.
Engagement refers to the ongoing development of a sense of safety and respect from
which patients feel increasingly free to share their problems, while gaining an increased
confidence in the clinician’s potential to understand them. Blending represents the
behavioral and emotional clues from the interview that suggest that this engagement
process is proceeding effectively. Stated differently, engagement defines a set of goals, and
the concept of blending provides a method of monitoring the effectiveness of the strate-
gies utilized to achieve those goals.
Not all writers emphasize the distinction between engagement and blending, but I
feel it is an important one. Its significance lies in the fact that it does one little good to
study engagement techniques if one does not develop a reliable method of measuring
the effectiveness of these techniques in the interview itself. The concept of blending
provides an avenue for active self-monitoring by the clinician. Problems in blending can
alert the interviewer to the need to change interview strategies before serious damage to
the clinician–patient alliance has developed.
Using Blending to Gauge the Degree of Engagement

One can assess blending by utilizing three complementary approaches: a subjective
method, an objective method, and a patient’s self-report. With regard to the subjective
technique, an interviewer can learn what sensations he or she experiences when engage-
ment is optimal – in essence, what a good interview feels like. Educators have suggested
that once this internal and idiosyncratic feeling stage has been identified, the clinician
can use it as a type of thermometer, to determine the intensity of blending at any given
moment.3
Naturally, this subjective feeling will vary from one interviewer to another. Conse-
quently it may help to examine some of the descriptions clinicians have related concern-
ing this feeling state.
a. “To me good blending feels more like a conversation and a lot less like an interview
or interrogation.”
b. “I know blending has occurred when suddenly I realize during the interview
that I’m actually talking with a person with real pain, not a case with imagined
defenses.”
c. “When the blending is good, I notice that I feel more relaxed, sometimes even giving
off a sigh. Curiously I also feel more interested.”
These descriptions suggest the personal uniqueness of the blending process. It is this
personal uniqueness that allows the concept of blending to function as such a reliable
and sensitive tool for monitoring the degree of engagement. If clinicians can train them-
selves to intermittently check the progress of blending, they will have discovered a
window from which to study the unfolding engagement process. To this extent, the
interview becomes less nebulous and more tangible. It evolves into something that can
be modified.
This increased tangibility can be furthered by utilizing the second major avenue for
monitoring the blending process, an objective look at the behavioral characteristics of
the interview itself. The behavioral clues suggested by body language will be discussed
in Chapter 8. In this chapter, an examination of the timing and structural characteristics
of the verbal exchange will be highlighted.
The issue facing the interviewer involves finding concrete behavioral cues from the
verbal exchange that indicate the presence of good blending. Wiens4 and colleagues have
provided some simple but fascinating methods of analyzing the temporal characteristics
of speech by studying three major speech variables: duration of utterance (DOU), reac-
tion time latency (RTL), and the percentage of interruptions. The DOU can be roughly
equated with the length of time taken up by the interviewee’s response following a ques-
tion. The RTL represents the length of time it takes an interviewee to respond to a ques-
tion. The percentage of interruptions represents the tendency for the interviewee to cut
the clinician off before a question has been finished. One can look at all of these variables
in relation to the clinician’s speech patterns as well.
With regard to blending, these variables offer a potentially more objective measure of
effectiveness, because certain patterns of exchange may suggest weak blending. For
instance, a guarded or suspicious patient often produces curt responses to questions (a
short DOU), long pauses before answering (long RTL), and occasional cut-offs as the
patient corrects the interviewer for inaccuracies in his or her statements. If an interviewer
spots such a pattern emerging, it may be a clue to ineffective engagement.
Another example at the opposite end of a continuum concerns the hypomanic, his-
trionic, or anxious patient who tends to wander. These wandering patients frequently
present with a long DOU and a very brief RTL and may also actually cut the interviewer
off frequently, a process triggered by the patient’s over-eagerness to make their points.
Interestingly, the interviewer may find himself or herself reciprocating with cut-offs in a
vain effort to get a word in edgewise.
Moreover, with histrionic, hypomanic, or manic patients, the blending is frequently
marked by a peculiar superficial quality. With regard to spontaneity of speech, these
patients often open-up inappropriately quickly, as opposed to the gradual increase in
blending seen with most patients. Consequently, the observed blending possesses a one-
sided and shallow quality, aptly called by one student “unipolar blending.”
In the above two examples, we have seen that variations in basic patterns of verbal
output, such as a DOU and RTL, can provide objective indications of the adequacy of
the blending process. One might ask whether this objective technique offers any advan-
tage over the subjective approach described previously. I believe that it does. But one
method does not appear more valuable than another; rather each method complements
the other. For instance, occasionally clinicians are duped by their subjective sense of
blending into missing the psychopathology of patients with histrionic defenses or those
experiencing hypomania.
One of the reasons this problem occurs is that the clinician feels at a subjective level
that the blending is unusually good. Indeed, the clinician is fascinated by the patient’s
story. In actuality, the blending is artificially good, representing the unipolar blending
just described. In fact, unipolar blending, if recognized by the clinician, could provide
the clue that “something is wrong here.” The patient’s engaging style and subtle dramatics
are misleading the clinician. If in this instance the clinician could step back to look at
the DOU and RTL, the clinician might recognize the hallmarks of a unipolar blending
and consequently evaluate the possible psychopathologic causes of it. In this case, the
objective technique sidesteps the confusion created by judging the blending process
solely by the subjective method.
The other advantage of paying attention to more concrete parameters such as DOU
and RTL is the ability to use these criteria to judge the effectiveness of a specific technique
employed by the clinician. If, for example, the clinician attempts to actively engage a
patient who seems hesitant to talk, one of the earliest and most easily recognized markers
of success will be an increase in DOU. Corresponding changes in the subjective feeling
of increased blending may appear only later and may be less easily recognized.
A third method of determining the degree of blending consists of the patient’s self-
report. Occasionally, a patient will spontaneously tell an interviewer to what degree the
interaction is enjoyable. More commonly, the interviewer may inquire, as the interview
winds down, “What was it like talking with me today?”
To this question, some patients may pointedly discuss specific concerns, sometimes
providing appropriate and constructive criticism. Often, due to a reluctance to appear
unappreciative or rude, patients will reply that everything was fine, even if it was not, but
their nonverbals may betray their true feelings. A hesitant “yes” surely indicates some
discomfort upon the part of the patient, providing us with a rich opportunity to
non-defensively uncover their concerns and address them. At such moments of hesitation,
the clinician can comment, “You know you look a little hesitant there, is there anything I
may have done or said that might have made you uncomfortable?” The answers are some-
times surprising. By non-defensively exploring the patient’s concerns, we will have greatly
increased the likelihood that there is going to be a second interview.
Other surprises may appear when the self-report contradicts the subjective and objec-
tive methods of evaluating blending. For instance, I am reminded of a young man who
appeared somewhat disinterested as we spoke. He talked softly and with little animation.
As we proceeded, I felt awkward, as if this were going to be a bad mix of personalities.
Although both the objective and subjective signs of blending suggested poor engagement,
to my surprise, at the end of the interview he reported feeling very at home with me. He
stated that he had enjoyed the interview, and he appeared sincere.
His diagnosis was paranoid schizophrenia in remission. It was either a residual blunt-
ing of affect from his schizophrenia or perhaps a side effect from an antipsychotic that
was creating both an outward and an inward suggestion of poor blending; the engage-
ment was not, in truth, weak. This disparity highlighted the type of miscommunication
that this patient could easily convey to other people, an aloofness that was both disarm-
ing and misleading. Attention to blending by self-report greatly enhanced my under-
standing of the manner in which this patient embraces the world and is embraced by
the world. It also suggested the possible utility of social skills training or perhaps a
medication adjustment.
Thus, the clinician can benefit from learning to judge blending by combining the
subjective, objective, and self-report approaches. With these three techniques in mind,
the interview becomes at once less mystifying and more gratifying. The gratification arises
from the realization that the interviewer can learn to creatively alter the interview process
itself.
Once blending has been analyzed, the clinician possesses a concrete idea of the
strength of the engagement process with any particular patient at any given moment.
Weak engagement may indicate that invalid data is more likely. It may also be a harbinger
that the patient may be less interested in the clinician’s treatment recommendations or
recommendations for follow-up. Moreover, a weak engagement process suggests one of
the following three conditions:
1. The interviewer’s actions are actively disengaging the patient
2. The interviewee’s psychopathologic processes or defenses are interfering with
engagement
3. A combination of the above
If the clinician feels that the damaged blending can be attributed to the first condition,
then the clinician can attempt to consciously alter his or her style of interaction. For
instance, a paranoid patient may be put off by an extroverted style of interviewing. In
such an instance, the clinician may decide to tone down their extroversion in an effort
to ease the patient’s fears.
If the weak blending can be ascribed to the second condition, then the clinician may
be alerted to the types of psychopathology that could be blocking the blending, such as
with the histrionic process described earlier. Naturally, if the third condition is the issue,
increased attention to both style of interaction and psychopathology can be brought into
play.
At this point we have reviewed three methods of directly assessing blending that allow
us to indirectly assess the engagement process itself. It is valuable to reflect on the map
of the interviewing process delineated earlier. On this map, the interviewer begins with
the engagement process for a good reason. The engagement process affects all subsequent
goals of the interview.
More specifically, poor engagement raises significant doubts about the validity of the
database because patients generally do not freely share with people they do not like.
Moreover, without effective engagement, one will seldom gain knowledge of the intimate
corners of the patient’s “room” alluded to in our comparison of an interview with an
exploration of a dark Victorian room. Hence, the clinician leaves with only a superficial
understanding of the patient’s pain. Furthermore, without valid data falling into place,
the clinician’s assessment and diagnosis are frequently in significant jeopardy. Finally, if
the engagement process proceeds poorly, the patient may never return for a second
appointment, casting the shadow of irrelevance over the work of the first interview.
Thus one is left with the realization that this somewhat nebulous concept of engage-
ment appears to be the pivotal process on which much of clinical practice turns. Fortu-
nately, this process is not as mercurial as it first appears. The dance of engagement begins
with empathy.
CONVEYING EMPATHY: TRAPS, STRATEGIES, AND SOLUTIONS

The Empathy Cycle
Many clinicians assume that empathy is a simple concept. It is not. The large number of
research papers devoted to its capture testifies to its elusiveness. Fortunately, over the
years insights have been achieved that help to demystify empathy, a quality that all people
feel they naturally possess but that in reality may be less ubiquitous than imagined. It
seems only appropriate to begin our story with Carl Rogers, who developed the field of
client-centered counseling. He conceptualized empathy as the clinician’s ability “to per-
ceive the internal frame of reference of another with accuracy, and with the emotional
components and meanings which pertain thereto, as if one were the other person, but
without ever losing the ‘as if’ condition.”4 Stated more simply, empathy is the ability to
accurately recognize the immediate emotional perspective of another person while main-
taining one’s own perspective.
As Rogers pointed out, there is an important distinction between empathy and iden-
tification, although they can overlap. With empathy, the interviewer quickly recognizes
the patient’s feelings. Indeed, the interviewer may even begin to automatically “feel” the
patient’s feelings himself or herself (sadness, anger, etc.) but only briefly. The empathic
interviewer has the ability to quickly step back from the process with regard to their own
emotional state. The empathic interviewer has no invested acceptance of the patient’s
feelings as being “correct” or “just like my own would be in such a situation.”
In contrast, with identification, the clinician not only recognizes – and briefly shares –
the patient’s feeling state, the interviewer continues to experience the patient’s anger or
sadness. Such a misguided clinician fully embraces the patient’s feelings as his or her
own unconsciously. A clinician who is experiencing identification, in essence, agrees with
the patient’s feelings and is personally invested in accepting these feelings as being both
accurate and reasonable.
The importance of this distinction lies in the fact that identification often marks the
pathway toward such unrecognized therapeutic gremlins as burnout and unidentified
countertransference. The persistent appearance of strong feelings of identification may
alert clinicians to the need to begin or return to their own therapy, because such identi-
fication can quickly destroy the therapeutic process.
One feels compelled to say a silent prayer for the poor patient with borderline features
who meets a clinician that boldly proclaims, “I can feel your pain.” Borderline patients
have enough problems with identity diffusion without finding “silly putty” coating the
edges of their clinician. Thus a simple but important lesson to be learned from the study
of empathy is that most patients are not searching for a person who feels as they do;
they are searching for someone who is trying to understand what they feel.
G. T. Barrett-Lennard sheds further light on the concept of empathy by recognizing
the fact that empathy is effective only if it involves both the interviewee and the inter-
viewer.5 Thus empathic skill is not limited to the clinician’s ability merely to perceive
the internal reference of the patient, but also includes the clinician’s ability to convey
this perception to the patient with an empathic statement or gesture. He calls this
shared response the “empathy cycle,” a concept providing an excellent framework with
which to study the practical application of empathy. Consequently, we will look at each
phase of Barrett-Lennard’s cycle in detail, using it as our framework for the rest of the
chapter.
The empathy cycle consists of the following phases: (1) the patient expresses a feeling,
(2) the clinician recognizes this feeling, (3) the clinician conveys recognition of the
feeling to the patient, (4) the patient receives this conveyance of recognition, and (5) the
patient provides feedback to the clinician that the recognition has been received.6 With
this cycle in mind, the empathic process begins to make significantly more sense. In fact,
one can see that a breakdown in empathy can arise at each of these five stages.
First Phase of the Empathy Cycle: Patient Expresses a Feeling

In the first phase of the empathy cycle, in which the patient expresses a specific feeling,
a variety of processes can disrupt empathy. For instance, both conscious and unconscious
defenses may block the patient from expressing his or her actual emotions. A poignant
example of this process is illustrated by the following dialogue, in which a mother of a
7-year-old with marked and permanent developmental problems discusses her son:
Clin.: Tell me a little about John’s behavior with other children.

Pt.: Oh there is really little wrong there, he’s really quite normal, just like the other
kids. He doesn’t like to play games very much or sports, but then he has a mind of
his own, maybe someday he’ll be a star golfer or skier.
Clin.: You had mentioned something about his speech earlier.

Pt.: Oh, hmm, you must be thinking of his lisp. Well I think we all went through that
phase as children. In a few years it’ll all work out. You know, I have trouble
understanding most little kids when they talk, it’s part of being a little person.
One feels the pathos of this situation, in which the mother’s defenses of denial and ration-
alization prevent the expression of core feelings of pain. If the interviewer should attempt
to make an empathic statement such as, “It sounds like you’re really going through a lot
with John,” I doubt the response would be positive. In this case the patient’s own uncon-
scious defenses have prevented the empathy cycle from spontaneously unfolding.
Second Phase of the Empathy Cycle: Clinician Recognizes the Patient’s Feelings
But phase 1 does not have a monopoly on the common breakdowns that prevent the
establishment of an empathic contact. In phase 2, the recognition of the patient’s feel-
ings, problems may arise if the clinician’s perceptual or intuitive skills fall short, perhaps
related to his or her own defenses or psychopathologic undertow. In particular, interview-
ers need to be aware of the impact of their immediate emotional status on their ability
to empathize accurately. For example, a clinician who has recently experienced an unset-
tling session in supervision may have significant trouble attending to a patient’s subtle
clues of inner pain. At the other extreme, a recently divorced clinician could easily project
his own feelings of betrayal onto a patient undergoing a trial separation, when, in fact,
the patient is not experiencing such feelings at all. In both situations, the clinician’s
emotional state prevents an accurate perception of the interviewee’s feelings.
In this light, it can be stated that interviewers have only themselves to serve as mea-
suring instruments. The clinician has no microscope or magnetic resonance imaging
(MRI) to provide insight. However, like a sophisticated machine, interviewers can unin-
tentionally bias their data. Before beginning an interview, it is often useful to check the
bias of the instrument by pausing for a moment of reflection, asking what feelings are
present, before proceeding to meet the patient. Such a simple process may alert the clini-
cian to potentially distorting factors such as feeling rushed, angry, sad, or simply weary.
Once alerted to their biases, interviewers may hope to stand one step further away from
invalid data.
The second phase of the empathy cycle also raises several interesting questions con-
cerning the actual nature of intuition. Margulies and Havens7,8 have emphasized two
frames of mind that appear to be integral aspects of the empathic process. In the first
place, the clinician must possess the ability to listen with an attitude of disciplined
naiveté, literally attempting to feel the world of the patient without seeking cause and
effect, classification, or moral judgment. This receptive listening perspective was master-
fully developed by the psychological school of phenomenology, which we shall discuss
at greater length later in this book. But the bottom line can be simply stated: The clini-
cian must learn to suspend analytic thought when such thought may be destructive to
the engagement process.
The second frame of mind that Margulies discusses concerns the ability of the clini-
cian to imagine the inner experiences of the patient by creatively projecting himself or
herself into the patient’s world. He likens this ability to the poetic imagination of artists,
emphasizing the ability to move actively into the patient’s world, or “inscape,” as this
phenomenon has been called.9 When the clinician does this well, he or she not only
paints a picture of the patient’s world, but also enters it.
The ability to listen while suspending analysis and the ability to sensitively project
into what another person may be experiencing can be viewed as two skills from which
intuition is born. They remain pivotal to effective clinical practice, typically reaching
powerful proportions when clinicians achieve a high degree of blending.
Here we stumble upon a fascinating irony, because one of the characteristics of a gifted
interviewer is the ability to know not only when to use these intuitive skills but also
when not to use them. Phrased slightly differently, a skilled clinician draws from both
intuition and analysis. In a matter of a few minutes the skilled interviewer may juxtapose
periods of intuitive listening with moments of analytic thought. Indeed, the two pro-
cesses, in the hands of a seasoned clinician, tend to guide each other. For example, a
clinician may intuitively sense a patient’s extreme fear of a disintegration of the self.
Besides immediately helping the clinician to blend with the patient, this intuitive feeling
might prompt the clinician to later explore, in a diagnostic sense, whether the patient
may have defenses and behaviors consistent with having a borderline personality or a
narcissistic personality.
Similarly, an analytic process can lead a clinician to a higher level of empathy. For
instance, a clinician may observe that as the interview proceeds, the patient avoids eye
contact and becomes increasingly anxious. This analytic observation may prompt the
clinician to be more empathically aware of the patient’s feeling of being ill-at-ease. At
such moments the clinician may gently ask, “I’m wondering what it has been like for
you coming to see a therapist?” Subsequently, an empathic mode of listening may sig-
nificantly help the patient to relieve his or her sense of guilt or embarrassment. The
important point remains that intuition and analysis are complements, not antagonists.
Both skills are utilized frequently during the first encounter.
Third Phase of the Empathy Cycle: Clinician Conveys Recognition

of the Patient’s Feelings
In the third phase of the cycle – the clinician’s actual phrasing of the empathic statement
– the complexities of human interaction further manifest themselves. It is an arena of
considerable complexity in which we will examine some simplifying concepts that can
help us to effectively communicate our empathy while navigating the numerous twists
and traps in the process.
Strategic Empathy
One such unexpected twist arises from the fact that not all empathic statements work
equally effectively with all patients. With many patients appearing for their first appoint-
ment, some empathic statements appear to be appropriately engaging, but “nothing
special,” while other empathic statements appear to be compellingly powerful “grand
slams” enhancing the therapeutic alliance. Another perhaps even more puzzling aspect
of empathic statements remains their uncanny ability to promptly disengage a small

subset of patients, in short, to achieve the exact opposite of their intended use. One is
reminded of the varying fashions in which people accept compliments in everyday situ-
ations. Some people take compliments well, whereas others take them poorly. Members
of the latter group often become decidedly ill-at-ease following a sincere compliment,
shrugging it off with “Thank you, but it’s really nothing.”
One manner of interpreting this peculiar phenomenon consists of viewing the com-
pliment as pushing the recipient towards one of two uncomfortable states: (1) accepting
a view of himself or herself that seems inaccurate, or (2) feeling an emotional state (e.g.,
a pleasant sense of self-worth) that he or she is not currently capable of comfortably
experiencing, as may be seen in a person burdened by a chronically punitive superego.
So it is with empathic statements, which can backfire when they push people into inter-
personal niches they do not wish to occupy. The question is whether or not this situation
can be avoided. To a large extent I think it can be.
To understand how to more effectively utilize empathic statements, to more frequently
utilize powerfully engaging empathic statements, and to avoid empathic statements that
are disengaging, it is critical to return to our compass. From the perspective of person-
centered interviewing, it all makes sense, for it is assumed that each patient is unique
and each interviewing dyad is also unique. One size does not fit all with regard to
empathy. The defenses of the patient will have an immediate impact on how empathic
statements are received.
With this acknowledgement, the clinician views empathy as a skill set that is not used
in a habitual sense in the same way with every patient who enters the office, but is stra-
tegically utilized in a conscious fashion depending upon the needs and defenses of the
unique patient. Strategic empathy is a classic practical application of Ivey’s concept of
intentional interviewing. It weds the naturally intuitive skills of the clinician with a sound
understanding of the nuances of language, human defenses, cultural proclivities, and
dyadic interaction. Two terms are useful for developing a skilled use of strategic empathy:
(1) the patient’s “interpersonal stance” and (2) “empathic valence.”
Interpersonal Stance
One can categorize patients, with some degree of caution, into two types: those who are
trusting and those who feel guarded. Most of our patients are reasonably trusting and
we will find that the interviewer can effectively use a wide variety of empathic interview-
ing techniques with such patients with little likelihood of empathic backfiring. It is with
the latter patient, the so-called guarded patient, that empathic statements most frequently
display the nasty habit of disrupting the engagement process. The guarded quality of
these patients may arise from a variety of sources, including high anxiety or fear (perhaps
in a patient particularly uneasy about therapy or involuntarily forced to be assessed), an
idiosyncratic or situational fear of the clinician (for example, in a patient who has an
immediate negative transference to a clinician who physically resembles an abusive
parent), a long-standing character trait of suspiciousness (as seen with a paranoid per-
sonality), or frankly pre-psychotic or psychotic paranoia.
Empathic statements made to guarded patients, from whatever etiology, frequently

decrease the interpersonal distance between these patients and the clinician. This inter-
personal intimacy is exactly what guarded patients do not want. At an extreme end, the
last thing a truly paranoid patient wants is to be in the room “with someone who can
get inside my head.” Stripped of their “buffer zones” through the habitual or reflexive
use of empathic statements by a well-intentioned clinician, these patients have only one
option: to escape through retreat or attack. In short, guarded patients need psychological
“distance,” a fact too frequently overlooked by interviewers.
So far we have delineated the concept that patients may respond to empathic overtures
in different manners secondary to their degree of guardedness. Our understanding can
be developed even more fully if we now look at a characteristic of the empathic statement
itself – empathic valence – for the valence of the empathic statement often determines
what its impact will be in both trusting and guarded patients.
Empathic Valence
Valence refers to the potential “intensity” of an empathic statement, by which we mean
the degree to which an empathic statement’s impact will tend to be gently or powerfully
engaging or gently or powerfully disengaging. Empathic statements with a low valence
tend to be only mildly engaging with trusting patients but are much less likely to backfire
with guarded patients. Empathic statements with a high valence will tend to be more
powerfully engaging (quite powerfully engaging with trusting patients) yet more likely
to backfire (often quite disengaging with patients who are guarded or actively paranoid).
By recognizing the interpersonal stance of the patient (trusting versus guarded), the clini-
cian can then consciously choose to use empathic statements that have a gentle or pow-
erful valence, hence the concept of strategic empathy. At first glance, this distinction may
seem a bit confusing, but with an exploration of its practical application it will clarify
quickly.
In this regard, the valence of empathic statements appears to vary along the following
two axes: (1) the valence of implied certainty of the interviewee’s feelings by the inter-
viewer and (2) the valence of intuited attribution made by the interviewer from state-
ments offered by the interviewee. As one would expect, these axes overlap. However, for
purposes of acquiring a more sophisticated understanding, it will be worthwhile to look
at them separately, their unique qualities offering the structural foundation from which
we can build an ability to effectively use strategic empathy.
Valence of Implied Certainty
To begin our inquiry, let us speculate on the first axis – the valence of implied certainty.
Put simply, one considers to what degree the clinician implies that he or she knows
exactly what the patient is experiencing. In empathic statements with a low valence of
implied certainty, the interviewer expresses considerable uncertainty. In contrast, a clini-
cian using an empathic statement with a high valence regarding certainty will imply a
great deal more certitude that what he or she is saying is “on the mark.” In the following
dialogue, a poetic young man has just suffered the cruelties of an unwanted divorce. This
same man had lost his mother to leukemia when he was 13 years old. Following the
patient’s statement, an example of an empathic statement with a low valence of certainty

and one with a high valence will be given.
Pt.: After my wife abruptly left me, it was like a star exploded inward, everything
seemed so empty … she seemed like a memory and my life began to fall apart. Very
shortly afterwards I began feeling very depressed and very tearful.
Clin.: [low valence of certainty] It sounds like everything seemed to be collapsing around
you.
Clin.: [high valence of certainty, said with a gentle tone of voice] Your world had
collapsed in so many ways, all of them so very painful. (the patient nods his head
in agreement and begins to cry)
As a general rule, empathic statements with a low degree of certainty, which tend to
employ words like “It sounds like …” generally can be used effectively to enhance blend-
ing with both a trusting and a guarded patient.
In the case of a trusting patient, a skilled clinician may strategically choose to use an
empathic statement with a higher valence with regard to certainty as shown above. Such
a statement may suggest to the patient that he or she is in the presence of a clinician
who “really gets it” and is seeing things through their eyes in a phenomenological sense.
The well-timed use of an empathic statement with a high degree of valence regarding
certainty can be compellingly engaging with a trusting patient.
Sometimes empathic statements with a high valence regarding certainty begin with
phrases such as “It is” or “There is.” With the above patient, the clinician might have
said, “There is so much pain in a divorce of this nature, it’s essentially beyond words.”
These phrases can sometimes be unusually effective for engagement purposes.9 Such
third-person singular impersonal phrases tend to suggest a shared experience to the
patient, in the sense that the clinician acknowledges the validity of the patient’s experi-
ence while simultaneously suggesting one would (or even has) experienced similar emo-
tions. When well timed, these phrases can shore up a faltering alliance.
On the other hand, empathic statements with a high valence of certainty may disen-
gage a guarded patient, as shown in the following:
Pt.: I can’t believe how cruel people can be. My ex-boss won’t even talk with me, won’t
even give me a minute of his damn time. It hurts, yes it does. But at this point I’ve
got a million problems and nobody to help me.
Clin.: It is very overwhelming to have so many problems. [high valence of implied
certainty]
Pt.: How would you know what it feels like, have you ever been fired?
Clin.: No, I can’t say I have, but it surely must be a devastating process. [yet another
empathic statement with a high valence of certainty]
Pt.: To some people perhaps (slight glare from patient).
In this passage, the clinician’s attempt at an empathic statement with a high valence of
certainty seems to have unsettled the patient, a verbal boomerang of sorts. Perhaps this
backfire has its origins in the patient’s desire for a private and hence safe world. More
explicitly, this patient appears to dislike the process of being told what he is feeling or
should be doing, for this world is his world, and trespassers are not encouraged.
This trespass has led to a rather awkward moment, in which the patient challenges
the clinician’s ability to understand him, which is not exactly the response desired by
the interviewer, who suddenly finds himself dodging the cutting edge of an almost para-
noid accusation.
One can speculate that if the clinician had used an empathic phrase with a lesser
valence of implied certainty such as, “It sounds like it could be very overwhelming to have
so many problems,” instead of the phrase, “It is very overwhelming to have so many prob-
lems,” perhaps the interaction may have been less antagonistic. Perhaps … Nevertheless,
as we will see later in this section, even empathic statements with a gentle degree of
certainty are often ill advised when the patient is frankly paranoid.
Valence of Intuited Attribution

Now let us turn our attention to the second axis of valence regarding empathy – the
degree of intuited attribution. Along this axis, how much the clinician reads into the
patient is compared with how much the clinician repeats back exactly what he or she
has heard. In empathic statements with a low degree of intuited attribution, the clinician
often reflects back the patient’s feelings matter-of-factly without much change, trying to
communicate that the interviewer understands and is following closely. In contrast, when
employing an empathic statement that displays a high valence regarding intuited attribu-
tion, the clinician displays the ability to truly enter the patient’s inscape as Margulies and
Havens described earlier, in order to accurately intuit hidden pain that has not been yet
shared. When done with a trusting patient, such statements can be very powerful indeed.
In the following example, the opposing ends of this spectrum will be illustrated. Note
that concerning the valence of certainty, both empathic statements show a low degree of
certainty (both begin with the words “It sounds like …”). On the other hand, concerning
the valence of intuited attribution, they are radically different. This is the poetic patient
we saw earlier, who had also lost his mother to leukemia when he was 13 years old:
Clin.: [low valence of intuited attribution] It sounds as if your whole life truly began
falling apart.
or
Clin.: [high valence of intuited attribution] It sounds like it was terribly frightening to
lose her so suddenly, almost like the loss of your mother so many years ago (the
patient pauses for a moment, reflecting on the clinician’s intuited association and
promptly begins to weep).
In the empathic statement with a low valence of intuited attribution, the clinician essen-
tially employs the same wording as the patient “life began falling apart,” but might give
a sensitive emphasis by adding a word such as “truly.” In this respect, the interviewer
has, in an accurate fashion, mirrored back the patient’s thoughts. Minimal intuition is
displayed here. Consequently, there exists little chance that the statement will be per-
ceived as inaccurate or too invasive by either a trusting or a guarded patient. Moreover,
if said in a caring tone, this gentle response can convey concern while demonstrating an
attentive listening style. It may represent a rudimentary level of empathy. It does convey
caring when done well. Empathic statements that essentially mirror back the exact words
of the patient, such as this example, are sometimes simply called “reflecting statements.”
Reflecting statements are useful but have significant limitations, because they do not
particularly demonstrate great sensitivity or understanding by the clinician.
In contrast, the second example illustrated above – a nice illustration of an empathic
statement with a high valence of intuited attribution – when used with a patient with a
trusting interpersonal stance may suggest to the patient that he or she is in the presence of
a keenly perceptive therapist. For instance, in our example, this sensitivity was suggested
by the clinician’s use of the term “frightening,” a feeling never mentioned by the patient
but nevertheless felt to be present by the clinician. When accurate, such empathic con-
nections can be powerful indeed. Moreover, the second part of the clinician’s response,
suggesting a relationship of the current grief to an earlier mourning for the patient’s
mother, also represents an intuition made by the clinician. To the trusting patient, such
a powerful empathic statement may suggest that he has found a particularly understand-
ing and insightful listener. The use of empathic statements with a high valence regarding
intuited attribution often characterize the dialogue of a gifted clinician.
Once again, however, one must ask whether or not an empathic statement with a high
valence of intuited attribution can get a clinician into trouble. Not surprisingly, the
answer is “yes,” especially with guarded patients. By way of example, guardedness is often
associated with an inordinate attention to details, demonstrated by an unexpected value
on accuracy. This need for accurate understanding at all costs is bolstered by the fear that
“no one understands what I’m really feeling.” With these two processes in mind, one
can easily imagine the potential traps awaiting the clinician who unwittingly uses an
empathic response with a high valence of intuited attribution with a guarded patient. In
this case the patient is veering towards an almost paranoid stance:
Clin.: It sounds terribly frightening to lose her so suddenly, so similar to the pain you felt
when your mother died.
Pt.: No … no, that’s not right at all. My mother did not purposely abandon me. That’s
simply not true.
Clin.: I did not mean that your mother purposely abandoned you, but rather that both
people were unexpected losses.
Pt.: I suppose … but they were very different. I never was afraid of my mother …
they’re really very different.
Needless to say, this attempt at empathic connection leaves something to be desired. The
patient’s attention to detail and fear of misunderstanding have obliterated the intended
empathic message, leaving the clinician with a frustrating need to mollify a patient who
has successfully twisted an empathic statement into an insult of sorts.
Basic Guideposts for Effectively Using Strategic Empathy

At this point, with our understanding of the concepts of interpersonal stance and empathic
valence some relatively simple patterns are emerging, which can act as practical guide-
lines to strategic and effective use of empathy:
1. In general, empathic statements represent extremely valuable methods for strengthen-

ing engagement. Consequently, the clinician will usually employ such statements
intermittently throughout an interview.
2. The statements themselves vary in their valence from low to high on two axes: their
valence regarding implied certainty and their valence regarding intuited attribution.
3. The effectiveness of the empathic statement, as regards its valence, depends upon the
interpersonal stance of the patients ranging from trusting to guarded.
4. Low-valence (gentle) empathic statements are generally useful with both trusting and
guarded patients. Their weakness lies in the fact that they do not convey a particularly
sensitive understanding to the patient, although they do demonstrate concern. Their
strength lies in the fact that they seldom backfire.
5. With guarded patients it is frequently best to utilize low-valence (gentle) empathic
statements. With guarded patients, if one attempts to use a higher valence (powerful)
empathic statement, the clinician might find that the patient begins to disengage
(often shown by a disavowal of the clinician’s empathic comment). At such a point,
further high-valence empathic statements are probably best avoided. Indeed, in some
instances, all empathic statements may be liable to backfire.
6. On the other hand, with trusting patients, interviewers frequently begin with low-
valence empathic statements and progress to high-valenced empathic statements, for
such high-valence empathic statements may prove strikingly effective in producing a
deepening sense of trust.
VIDEO MODULE 1.2

Title: Effectively Using Empathic Statements
Contents: Contains both expanded didactics and annotated interviewing excerpts.
Three Examples of Using Strategic Empathy to Transform Difficult Moments

1: The Paranoid Spiral
The most extreme form of interpersonal guardedness appears with patients who are
actively paranoid and psychotic. There exist few interactions that are more daunting and
confusing to the beginning clinician. Unless one has had the misfortune of having a
loved one with paranoia, as seen in schizophrenia or some forms of bipolar process,
many trainees will have had little or no experience navigating in this interpersonal mael-
strom. And the waters are tricky indeed. Fortunately, because of our understanding of
strategic empathy, we have some tools for helping both ourselves and our patients to feel
more comfortable when paranoid process is active.
Years ago when I was the medical director of a psychiatric emergency room, I would
sometimes observe a most striking phenomenon – “the paranoid spiral” – that was
common, especially with naturally empathic trainees (who had had little experience with
paranoid process up to that date). As mentioned earlier when describing patients with
extreme guardedness, paranoid patients have an even more intense need for accuracy in
how clinicians describe them and an almost overwhelming need for psychological dis-
tance. Even empathic statements with a low valence are often rejected, and empathic
statements with a high valence, regarding implied certainty or intuited attribution, are
downright anathema to many paranoid patients, because to the patient it feels like the
interviewer is trying to “get inside my head.” Watch what happens in the following dia-
logue, which illustrates a paranoid spiral:
Pt.: Things have gotten a little dicey with my husband. I’m not certain what the
problem is. He just doesn’t communicate the way he used to. He’s not warm. We
used to show a lot of affection. It’s just not good.
Clin.: Sounds like it’s gotten pretty tough. [an empathic statement with a low valence of
certitude but a relatively high valence of intuition]
Pt.: (said testily) I didn’t say “it’s gotten tough,” I said “It’s just not good.” (note that
the patient has disavowed the clinician’s empathic statement, a real red light that
paranoia is out and about)
Clin.: Oh (pause) I’m sorry … I think I see what you mean (patient glares). What else have
you noticed? (to a naturally engaging clinician, who throughout his or her life has
normally engaged very well with people using such empathic statements, this
unexpected tenseness with the patient is psychologically jarring – sometimes
representing the first time anyone has responded to his or her empathic
communications in such an odd way. This psychological jarring was probably the
cause of the clinician’s somewhat awkward response, “I think I see what you mean.”)
Pt.: It’s just too weird. It’s like he’s not the same person. Sort of unpredictable. It’s not
that I think he is having an affair or anything. But he sure seems to be interested in
our pretty next-door neighbor, if you know what I mean. It’s pretty upsetting. And I
think he might be spying on me.
Clin.: I can see where that would be unsettling to lose trust in someone you have always
trusted. [an empathic statement with a high valence of intuition and certitude,
which would be quite effective with most people – but this patient is not “most
people”]
Pt.: It’s not unsettling, it’s upsetting. (patient glares again) And it has nothing to do
with trust.
Clin.: Oh. (pauses) Well, how do you put it all together?
Pt.: Well, finally, we have a good question (pauses). Let’s be blunt here, I think my
husband has become a strange man. You might call him evil. It’s the “divorce
game,” him trying to drive me nuts so that he can divorce me.
Clin.: How do you mean?
Pt.: For about 3 months he’s had them on me. I know they’re watching, every night at 6
o’clock. I feel their presence. I think they use telescopes and maybe mind probes to
see me, a terrible position to be in.
Clin.: That must be frightening to be constantly watched by others. [high valence of

implied certainty]
Pt.: Just what do you mean by that? How would you know what I’m feeling? (said
testily)
Clin.: Well, in the situation you’re describing I think it would be frightening.
Pt.: Frightening enough to make one lose one’s mind?
Clin.: Well … that’s difficult to say, it’s not …
Pt.: It’s what Dr. Jones? Frightening enough to make one crazy, well I’m not crazy Dr.
Jones, no matter what you think, and trust me I’m not defenseless.
In the paranoid spiral, as we are seeing above, the patient may even disavow empathic
statements with low valence. The interviewer immediately registers the disengagement,
but because they feel less engaged, the interviewer uses, by habit, what they often have
used to improve engagement in everyday life and with previous patients – more empathic
statements. Naturally, this further disengages the paranoid patient, who wants more
distance, not more intimacy, from the interviewer. Because the interviewer acutely feels
the progressive uneasiness of the encounter, they often try empathic statements with an
even higher valence, for with trusting patients these statements have often been power-
fully engaging in the past. Well … “it ain’t gonna work here.”
I have actually seen such interviews spiral downwards, plummeting into a stony
silence, hence the name “paranoid spiral.” (This misstep is an easily understandable
strategic error for an inexperienced interviewer; in my first year of residency I fell into
this trap so many times my supervisors needed a rope to get me out!) In some patients,
this reflexive use of empathic statements by the interviewer can stoke considerable hostil-
ity, perhaps placing the patient near the edge of violence. In fact, the comment from the
above patient, “trust me I’m not defenseless,” could be a veiled threat to the clinician,
well worth heeding.
Returning to our original definition of an interview, we can see that the paranoid spiral
is a beautiful example of the fact that “an interview represents a verbal and nonverbal dialogue
between two participants, whose behaviors affect each other’s style of communication, resulting
in specific patterns of interaction.” It is also a beautiful example of the value of one form
of intentional interviewing, strategic empathy, for a clinician armed with knowledge
regarding strategic empathy does not need to move reflexively. We have choice. Not every
patient wants to be on the receiving end of empathy.
Once paranoid process has been spotted, as with the first disavowal of the mixed
valence empathic statement seen above (“Sounds like it’s gotten pretty tough”), the
experienced interviewer can shift gears. Generally speaking, at this point all empathic
statements should be avoided, until there is evidence of sound engagement. Once good
engagement has been secured, if any empathic statements are going to be employed, one
should start with low-valence statements and see the impact on the patient. Any further
disengagement suggests empathic statements should probably be avoided for the rest of
the interview. For clinicians who routinely use empathic statements throughout their
interviews, this process requires true discipline and intentionality. Such discipline will
be amply rewarded, for this use of strategic empathy often works remarkably well. The
patient experiencing the pangs of paranoia can begin to feel a bit safer because of the
intentional shifting away from the use of traditional empathic statements.
Thus far we have seen what not to do with paranoid patients. Now let us turn our
attention to what interviewing strategies an intentional interviewer might choose to use
to avoid the paranoid spiral. If we look closely at the above exchange, we will see that
the interviewer is already (albeit, without intentionality) using an interviewing strategy
that is often effective with patients coping with the pain of paranoid process. Notice that
when the clinician simply showed a genuine interest in how the patient perceived what
was happening to him with questions such as, “… how do you put it all together?” and
“How do you mean?” the engagement flowed smoothly.
It is critical with a paranoid patient to help them to share as openly as possible, for
inside their paranoid delusions the seeds of dangerousness, to both self and others, may
be present. The use of an interested, yet non-empathic, conversational manner with para-
noid patients may help the clinician to uncover such critical material, while simultane-
ously helping the patient to feel more comfortable. This interviewing strategy, designed
to bring forth the sometimes dangerous secrets hidden within paranoid process, has been
called “greasing the wheels” of delusional conversation by David Robinson.10
Curiously (yet logically, if one employs what we now know regarding empathic
valence), there is one type of empathic statement that might be useful when coupled
with Robinson’s conversational strategy of greasing the wheels – reflecting statements. As
we saw earlier, reflecting statements are empathic statements with extremely low valence
regarding intuited attribution, for they simply mirror back what the patient has said.
With paranoid patients, the clinician might find that the use of absolutely pure reflecting
statements (employing only the exact words of the patient) works very well. Coupling their
use with Robinson’s strategy of greasing the wheels, the highly antagonistic exchange
seen above might have gone very differently:
Pt.: Things have gotten a little dicey with my husband. I’m not certain what the
problem is. He just doesn’t communicate the way he used to. He’s not warm. We
used to show a lot of affection. It’s just not good.
Clin.: What has changed the most in your opinion? (greasing the wheels)
Pt.: It’s just too weird. It’s like he’s not the same person. Sort of unpredictable. It’s not
that I think he is having an affair or anything. But he sure seems to be interested in
our pretty next-door neighbor, if you know what I mean. It’s pretty upsetting. And I
think he might be spying on me.
Clin.: What have you noticed about him as far as spying behavior? (greasing the wheels)
Pt.: For about 3 months he’s had them on me. I know they’re watching, every night at 6
o’clock. I feel their presence. I think they use telescopes and maybe mind probes to
see me, a terrible position to be in.
Clin.: Sounds like a terrible position to be in (pure reflecting statement). Have you
thought what you might need to do about it? (greasing the wheels)
Pt.: Yeah, I just might have to pay a visit to my “pretty next-door neighbor,” the little
bitch. She’s the one who is pushing the spying.
Clin.: When you say pushing the spying (pure reflecting statement), what do you feel
needs to be done? (greasing the wheels)
Pt.: (patient pauses, looks intensely at the interviewer and with a knowing smile says)
Maybe a little 22-caliber bullet might catch her attention, if you know what I mean.
What a difference intentional interviewing makes. Language counts. As opposed to our

first interviewer, who used empathic statements out of habit, resulting in a striking dis-
engagement, this interviewer has not only skillfully avoided the paranoid spiral, but has
uncovered material that might save the life of the neighbor who just happens to be living
next door.
On a final unexpected note regarding the paranoid spiral, our understanding of the
psychodynamics of the paranoid spiral can help us not only in the engagement process,
but also in the diagnostic process. Early in an initial interview, the disavowal of an
empathic statement may be the first hint, to an astute clinician, that the patient may be
experiencing paranoia. The clinician can then proceed to sensitively search for psychotic
process, the discovery of which could have tremendous benefits for the patient, perhaps
even saving his or her life (preventing a psychosis-induced suicide or homicide), if appro-
priate interventions result.
2: Transforming Anger with Defusing Statements

No matter how talented we may become, there are always going to be encounters in
which a patient is angry with us. Paradoxically, these moments of confrontation are
pregnant with potential for healing and the securing of a more powerful therapeutic
alliance. So important is this topic that we will devote an entire chapter to it in Part IV
of our book (Chapter 19). At present, though, it is the use of empathic statements as
methods for transforming these difficult moments that interests us.
We are going to look at those moments when a patient is specifically mad at us or
our institution. As with guarded patients, empathic statements can backfire with angry
patients, as we will see in the following exchange with a patient who has been waiting
for 20 minutes for a third appointment with an outpatient therapist. The patient has
more than his fair share of narcissism:
Pt.: Where have you been? I’ve been waiting here for over 20 minutes. What the hell is
going on?!
Clin.: I’m sorry you’ve been waiting, Mr. Jackson. I know it’s not fun to be kept waiting.
[empathic statement said sincerely]
Pt.: Not fun?! You gotta be kidding me. (pause) No, it’s not fun. How would you like to
be kept waiting? You know, I have a job that I had to leave early today just for this
appointment.
Clin.: Mr. Jackson I’ve already told you I’m sorry, but sometimes I might be late for a very
good reason. Today, I got hung up with a patient over at the inpatient unit who
needed some extra help and was in crisis. I would do the same thing for you. I will
almost always be on time for our appointments, but sometimes these emergencies
come up. I’m really sorry. I hope you understand.
Pt.: Well, I’m really sorry too. (pauses, then continues in a testy voice) I’m really sorry
I’ve got to pay for this type of crap.
This clinician is having another “fun” day at the office. Fortunately there is a style of
empathic statement that seldom backfires in these situations. These empathic statements
are called “defusing statements.” I often find that when a patient first makes an angry
comment towards me, I often feel flustered and caught off-guard, not entirely certain
where to proceed. At such moments, I find that any of the following three defusing state-
ments are often effective:
a. It makes sense to me that you would be upset.

b. No wonder you are so upset.
c. Who wouldn’t be upset!
Watch the use of one of these defusing statements with Mr. Jackson and how the defus-
ing statement gives a more powerful genuineness to the clinician’s apology:
Pt.: Where have you been? I’ve been waiting here for over 20 minutes. What the hell is
going on?!
Clin.: Mr. Jackson, who wouldn’t be upset! I’m almost 30 minutes late. I truly apologize.
I’m sorry you’ve been waiting.
Pt.: Yeah, well … (said with a mild, but less hostile intensity) you shouldn’t keep a
patient waiting.
Clin.: You’re absolutely right. I got hung up with a patient over at the inpatient unit who
needed some extra help. Listen, what I’d like to do is give you this session free, for
all of your inconvenience. Does that sound okay with you?
Pt.: Well (tone of voice softens) well, yeah, sure. You’re not gonna make a habit of this
are you?
Clin.: Of giving you sessions for free? (pauses, then smiles)
Pt.: (patient catches the humor) No, of course not. (laughs) Of being late.
Clin.: Absolutely not, sometimes emergencies do arise. I’d try to call ahead to my secretary
if that happens in the future. Hopefully it won’t. Thanks so much for being so
patient. (patient shakes his head in a “these things happen” kind of way)
Pt.: Don’t worry about it.
As this illustration demonstrates, it is hard to keep being angry with someone who
agrees with you. The clinician further addresses the situation by using a technique –
compensation (offering to do the session for free) – that we will examine in more detail
in our chapter on anger transformation, as well as a bit of well-timed humor. But the
patient’s anger had already been lessened significantly by the adroit use of the defusing
statement (“Who wouldn’t be upset!”) and the sincere apology given immediately upon
its use.
Notice also that the first clinician became somewhat defensive and began defending
why he was late. In contrast, the second clinician almost presented his appropriate
reason for being late as an afterthought, keeping the focus upon agreeing with the
patient’s perspective, exactly where the focus should be kept after using a defusing state-
ment. Such a stance can seldom do anything but begin to defuse anger as long as it is
sincere.
Unlike with guarded and paranoid patients, notice that these defusing statements
work well despite having a high valence with regard to implied certainty. In fact, they
work precisely because they have a high degree of valence regarding implied certainty. It
is the power of the clinician strongly agreeing with the patient that transforms the
moment. Indeed, each of these three defusing statements has a slightly different valence
regarding the degree of certainty, with “It makes sense to me that you would be upset”
having the least and “Who wouldn’t be upset!” having the most. I have found that the
angrier the patient, the higher the valence of the defusing statement that I use. With our
new knowledge, we can now use strategic empathy to match the right defusing statement
with the right patient. Intentionality, once again, the secret of the art.
3: Shoring Up a Young Empathic Bond with Paraphrasing Statements

Generic Paraphrases. By definition, as the therapeutic alliance is forming during an
initial interview, it exhibits a certain fragility. Empathic statements that are paraphrases
can be effectively used throughout an interview to help shore up this emerging alliance.
Unlike reflecting statements, paraphrases incorporate some of the key words and phrases
of the patient, but demonstrate that the clinician has processed the material in his or her
own head by the fact that the phrasing is subtly different, perhaps with a slight emphasis
or new nuance, but without adding interviewer opinion, reactions, or commentary. This
style of empathic statement has been called a “generic paraphrase.”11
Besides communicating empathy and the fact that the clinician is carefully listening,
Ivey points out that paraphrases can sometimes allow a patient, who keeps repeating a
story over and over, to move on to the next point. Indeed, sometimes in an initial inter-
view it is important for a patient who has been through a trauma to repeat his or her
story, sometimes from slightly differing angles, as a part of working-through the trauma.
To such patients, a clinician’s sensitive and patient paraphrasing metacommunicates that
it is okay to repeat their story. Moreover, the paraphrase conveys that the interviewer has
truly heard and respected its telling.12 Other patients may have deep concerns that
“nobody listens to me” or “gets what I mean,” so they keep rehashing. An effective para-
phrasing statement can let the patient know that he or she has been heard and can now
move on.
In their outstanding textbook, Sommers-Flanagan and Sommers-Flanagan give a nice
illustration of the power of well-timed paraphrasing to engage an interviewee, even when
it is what they call a “simple paraphrase”13:
Client: Yesterday was my day off. I just sat around the house doing nothing. I had
some errands to run, but I couldn’t seem to make myself get up off the couch
and do them.
Therapist: You had trouble getting going on your day off.
They follow with another example as well:
Client: I do this with every assignment. I wait until the last minute and then whip
together the paper. I end up doing all-nighters. I don’t think the final product is
as good as it could be.
Therapist: Waiting until the last minute has become a pattern for you and you think it
makes it so you don’t do as well as you could on your assignments.
Good paraphrases tend be “short and sweet.” Also note that like all empathic statements
they can vary as to their valence with regard to implied certainty. The paraphrase “You
had trouble getting going on your day off” represents a high valence of implied certainty,
as does the subsequent paraphrase, “Waiting until the last minute has become a pattern
for you and you think it makes it so you don’t do as well as you could on your assign-
ments.” The latter paraphrase could easily be given a lower valence of certainty, if perhaps
the patient seemed a bit wary, by simply rephrasing it as, “It sounds like waiting till the
last minute has become a pattern for you and you think it makes it so you don’t do as
well as you could on your assignments.”
Ivey14 talks about sometimes introducing a paraphrase with a separate phrase alerting
the patient that the clinician is trying to make sure that he or she “gets it” – a phrase he
calls a “stem.” Examples might be: “Demaris, I hear you saying” or “Looks like the situ-
ation is …” He also sometimes ends a paraphrase with an added question as to whether
the patient thinks the paraphrase was “on the mark,” a concept he calls “checking-out
accuracy.” Illustrations of such check-outs might be as follows: “Am I hearing you cor-
rectly?”, “Is that close?”, and “Have I got it right?”
In an earlier work, as a way of enhancing empathic resonance, Ivey describes the use-
fulness of matching both stems and check-out questions to the style of communication
that the patient uses to express themselves – a concept that Grinder and Bandler, in
neurolinguistic programming (NLP), call representational systems.15 Sommers-Flanagan
and Sommers-Flanagan have broadened this approach to include any paraphrase that is
based upon matching the patient’s sensorial predilection for expressing their personal
experiences, a technique they simply call “sensory-based paraphrases.”16 No matter what
you want to call it, Ivey succinctly describes this engagement technique with both stems
and check-outs below:
Visual patients tend to respond best to visual words (“Looks like you’re saying you see the
situation from this point of view …”); auditory patients respond best to tonal words (“As I
hear you, sounds like … does that ring a bell?”); and kinesthetic patients respond to feeling
words (“So the situation touches you like … and how does that grab you?). With many
patients a mixture of visual, auditory, and kinesthetic words will be even more powerful.17
The Metaphorical Paraphrase. Sommers-Flanagan and Sommers-Flanagan have

described a useful empathic statement they call the “metaphorical parphrase.”18 To
stressed patients, the world can naturally seem to be a chaotic place, so that their own
thoughts are often scattered and not focused clearly upon their problems or their solu-
tions. With a metaphorical paraphrase, the clinician tries to capture the “central message
within a patient’s communication.” When done well, metaphorical paraphrases are not
only engaging, but they also may have a therapeutic impact, as the patient’s thinking
becomes more crystallized by the insightful conciseness of the interviewer’s paraphrase.
The Sommers-Flanagans nicely capture the essence of a good metaphorical paraphrase
as follows:
For instance, often clients come for therapy because of feeling stuck and not making any
progress in terms of personal growth or problem resolution. In such a case, a therapist
might reflect, “It seems like you’re spinning your wheels” or “Dealing with this has been
a real uphill battle.”19
Watch the power of a simple empathic metaphorical paraphrase with a graduate student
in sociology who has been struggling to finish her dissertation and is being pressured to
wrap things up by her dissertation committee:
Pt.: I just don’t feel very motivated right now. And I don’t know what is up with me.
Maybe I’m just depressed. I really like my topic for my dissertation, but I’m not
even fully sure why it is important.
Clin.: That sounds frustrating. [gentle, low-valenced empathic statement]
Pt.: Very much so. (pauses) It’s really sort of confusing. I don’t really know what I want
to do anyway. I’m not really a researcher at heart, but everyone in my class seems
dead-set on being an academic and getting grants and stuff. But then what else
would I do with a doctorate in sociology?
Clin.: You know, it seems to me that, for you, it feels almost like you’re on a treadmill,
and you’re going nowhere fast. (metaphorical paraphrase)
Pt.: That’s exactly it. In fact I am on a treadmill of sorts. And I don’t have control of the
speed of the damn thing, my dissertation committee does.
Clin.: What will happen if the treadmill stops?
Pt.: I’m not sure I follow. What do you mean?
Clin.: Well, if the treadmill stops – you get your dissertation in – you will have to make a
decision, won’t you, about what you’re going to do with your life?
Pt.: Yeah, I suppose. (pauses, reflects for a moment, then sits up more animatedly) Wait
a minute, wait a minute. You don’t think (pause), you don’t think that one of the
reasons I am stalling on my dissertation is the fact that, as long as I am stalling, I
don’t have to make a decision, do you?
Clin.: I don’t know, maybe it’s one of the things we can look at in therapy.
In an initial interview, we generally use metaphorical paraphrases as a means of enrich-

ing the alliance. In this sense the interviewer’s empathic comment, “You know, it seems
to me that, for you, it feels almost like you’re on a treadmill, and you’re going nowhere
fast” would have accomplished this task very well all by itself. But in this instance,
perhaps because the patient clearly liked the metaphor and even spontaneously added
to it with “And I don’t have control of the damn thing …,” the interviewer was able to
expand the metaphor into a therapeutic insight.
Frequency, Timing, and Length of Effective Empathic Statements

At this juncture in our discussion of the third phase of the empathy cycle – the actual
conveyance of empathy – three further variables determining the effectiveness of empathic
statements warrant attention: frequency, timing, and length. With regard to frequency,
no magic number exists. I do not think anyone can authoritatively state the number of
optimal empathic comments per interview, because this number must surely vary for
each paired interviewer and interviewee. On the other hand, I would estimate that
well-received clinicians frequently seem to scatter empathic statements throughout their

interview, perhaps averaging one statement every 2 to 10 minutes. Moreover, it seems
likely that one could either potentially overuse or underuse empathic statements. In the
former case, the clinician runs the risk of sounding superficially caring or paternalistic.
In the latter case, the interviewer may be perceived to be as inscrutable as the sphinx,
hardly an effective tool for ensuring a follow-up appointment.
This discussion of frequency naturally leads into the issue of timing. One underlying
principle, perhaps the most important, remains that of using at least two or three, and
sometimes significantly more, empathic statements during the first 5 to 10 minutes. Gen-
erally speaking, I would suspect that many patients often determine whether they like or
dislike the clinician during these initial minutes, and their decision frequently rests upon
whether the clinician seems accepting or not. Specifically, patients may fear that the clini-
cian will not understand them or will think they are silly or weak. Few better tools exist
in the clinician’s repertoire for decisively allaying such fears than an empathic statement.
Although an easy maneuver, this technique can set the tone for an entire interview.
Of course, even with the best of intentions, empathic statements can miss their mark,
as illustrated below:
Pt.: Well I don’t really think it’s right for the university to be so upset with me for not
paying back the loan. I mean it was 7 years ago and I simply don’t have the money.
It really hurts me too.
Clin.: It sure sounds like a difficult spot to be in, what with all those pressures and
financial responsibilities. I bet it seems like you have no place to go, you know, sort
of stranded, probably makes you feel like everyone is against you. I bet you feel
isolated and lonely, like there is no place to go for financial advice or help, almost
like a criminal.
Pt.: Uh-huh (painful pause).
Clin.: What are you thinking of doing?
In this example, the empathic statement has all the power of a two-page descriptive
paragraph in an adventure story. It is far too long. In general, empathic comments display
their engagement best when they are concise and unambiguous.
This example also points out one method of determining the effectiveness of any given
empathic comment. Put succinctly, effective statements usually result in an increased
verbal production by the patient. A decrease in patient speech, as shown earlier, often
follows an ineffective comment. Leston Havens describes this process elegantly:
A more exacting test of successful empathy is the extent to which our responses stimulate
and deepen the other’s narrative flow. Does the speaker stop or change subjects? Are the
expressions of feeling increased or decreased? One of the moments of greatest clinician
drama occurs when a strong empathic flow encounters a memory heretofore forbidden to
consciousness or denied.20
There remains one last comment to make before leaving the discussion of the third phase
of the cycle. Empathy is probably not primarily conveyed through empathic statements.
Large amounts of empathy appear to be communicated through facial expressions, body

language, tone of voice, and other “empathic noises,” as Havens calls them.21 These non-
verbal elements will be given the attention they deserve in Chapter 8.
Fourth Phase of the Empathy Cycle: Patient Accurately Perceives the Clinician’s
Empathic Statement
In the fourth phase of the empathy cycle, in which the patient receives the conveyed
empathic statement, problems can also arise. Specifically, the patient’s psychopathology
may limit his or her ability to perceive empathy or even to understand language itself.
Such a situation can occur with delirious patients or severely psychotic patients. In
extreme cases, empathic statements can be malignantly transformed into an auditory
illusion, perhaps becoming a derogatory statement or threatening insult.
Another situation concerns manic patients who quite simply are sometimes too busy
talking to even register an empathic statement. Indeed, at times it is not clear whether
they care if the clinician is being empathic or not. With these patients, attempts to empa-
thize may actually be counterproductive, being in some respects contrary to what they
most want at that moment, an audience.
Fifth Phase of the Empathy Cycle: Patient Communicates an Appropriate

Acceptance of the Clinician’s Empathic Statement
In the fifth phase of the empathic cycle, in which the patient provides feedback to the
clinician that the empathic statement was received, difficulties may once again surface.
As before, the patient’s psychopathology may prevent acknowledgment of the clinician’s
empathic communications. This is perhaps most poignantly demonstrated by the patient
ravaged by a severe, regressive depression or a catatonic stupor. Such patients sometimes
seem almost hollow, as if our words pass through them unheard and unanswered. But
I think it is important not to be misled by this sensation, because these patients may
very well be hearing and even responding to empathic statements despite their inability
to convey their reception. Clinician statements such as, “I have no real way of knowing
what you are feeling, but if you are feeling lonely or sad or want to talk, I will be avail-
able, just let me know,” can be very important, perhaps even pivotal in providing a new
bridge for communication, the first resonation in the empathy cycle.
We should note that how empathy is communicated and how it is received in the
empathy cycle can be significantly impacted by the patient’s culture as well as the clini-
cian’s. We will be looking at the fine points of such diversity issues as they impact on
empathy in our chapter on techniques for exploring cultural diversity and spirituality
(Chapter 20).
As we wrap up our review of the empathy cycle, we have, it is hoped, moved from a
cliché-like understanding of empathy towards a more sophisticated understanding of one
of the most practical tools available to the initial interviewer. We have learned how the
clinician can use empathic statements in an intentional manner to lay the foundation
stones of the therapeutic alliance. The question that now arises is: Are there interviewing
techniques and strategies, in addition to the use of empathic statements, that can allow
us to deepen the therapeutic alliance? The answer is “yes,” and the interviewing tech-
niques that do so are the topic of our next chapter.
REFERENCES
1. Rosenblum R, Janson HW. 19th century art. New York, NY: Harry N. Abrams; 1984.
2. Ivey AE, Ivey MB, Zalaquett CP. Intentional interviewing and counseling: facilitating client development in a multicultural
society. 8th ed. Belmont, CA: Brooks/Cole, Cengage Learning; 2014. p. 8.
3. Ward NG, Stein G. Reducing emotional distance: a new method to teaching interviewing skills. J Med Educ 1975;
50(6):605–14.
4. Wiens AN. The assessment interview. In: Weiner I, editor. Clinical methods in psychology. New York, NY: John Wiley;
1976.
5. Barrett-Lennard GT. The empathy cycle: refinement of a nuclear concept. J Couns Psychol 1981;28(2):91–100.
6. Barrett-Lennard GT. 1981. p. 94.
7. Margulies A. Toward empathy: the uses of wonder. Am J Psychiatry 1984;141(9):1025–33.
8. Margulies A, Havens L. The initial encounter: what to do first. Am J Psychiatry 1981;138(4):421–8.
9. Margulies A. 1984. p. 1031.
10. Robinson DJ. My favorite tips for exploring difficult topics such as delusions and substance abuse. Psychiatr Clin
North Am 2007;30(2):239–44.
11. Sommers-Flanagan R, Sommers-Flanagan J. Clinical interviewing. 2nd ed. New York, NY: John Wiley & Sons, Inc.;
1999. p. 78–80.
12. Ivey AE, Ivey MB, Zalaquett CP. 2014. p. 148.
13. Sommers-Flanagan R, Sommers-Flanagan J. Clinical interviewing. 5th ed. Hoboken, NJ: John Wiley & Sons, Inc.;
2014. p. 72.
14. Ivey AE, Ivey MB, Zalaquett CP. 2014. p. 148.
15. Bandler R, Grinder J. The structure of magic 1: a book about language and therapy. Palo Alto, CA: Science and Behavior
Books; 1975.
16. Sommers-Flanagan R, Sommers-Flanagan J. 2014. p. 75–6.
17. Ivey A, Ivey M. Intentional interviewing and counseling: facilitating patient development in a multicultural society. 4th ed.
Belmont, CA: Wadsworth Publishing Company; 1998. p. 116.
18. Sommers-Flanagan R, Sommers-Flanagan J. 2014. p. 76.
20. Havens L. Exploration in the uses of language in psychotherapy: simple empathic statements. Psychiatry
1978;41(4):336–45.
21. Havens L. 1978. p. 338.
CHAPTER 2
Beyond Empathy: Cornerstone
Concepts and Techniques for
Enhancing Engagement
The first rule of life is to reveal nothing, to be exceptionally cautious in what you say, in
whatever company you may find yourself.
Elizabeth Aston
The Darcy Connection1
THE PERSON BEFORE THE LETTERS

Unfortunately many patients when they find themselves in the company of a clinician
may adopt the above dictum, especially when exploring sensitive and taboo topics such
as suicide, incest, domestic violence, and substance abuse. There are many reasons for
their caution. As they approach our office doors, they may notice various letters: M.D.,
Ph.D., M.S.W., R.N., M.A., but the letters are often relatively unimportant to them. What
is important to our patients is simple: Who is the person before the letters? Is the person
behind the door going to collaborate with them or patronize them? Will they be accept-
ing or critical, warm or cool, trustworthy or irresponsible, capable or incompetent? All
good questions. In addition, our task may be made a great deal more difficult because
previous encounters with mental health professionals may not have gone so well.
In short, patients want to know who we are, not so much the facts of our personal
lives, but our character, our ethics, and our humanness. They also want to know if we
know what the hell we are doing – our expertise. In our own personal lives, before we
would ever consider sharing intimate details about ourselves, we seek out answers to
these questions about the people we are considering as potential friends and confidants,
usually requiring many encounters before deciding whether we feel safe “baring our
souls.” A patient is expected to do this type of sharing within minutes of meeting a total
stranger, just because the stranger has some letters after his or her name. It is, at best, an
odd situation.
Yet it holds much promise for healing and the relief of suffering, if indeed we can
forge a resilient therapeutic alliance. How we address each of the above concerns offers
opportunities for deepening the engagement process that goes beyond empathy itself.
These patient concerns are less roadblocks than they are gateways. And the way we
address these issues, how our characters and humanness show themselves, is through the
interview itself. There are many interviewing principles, techniques, and strategies that
provide concrete methods for talented clinicians to intentionally, and surprisingly rapidly,
address these issues. This is a chapter about these principles and techniques, and how
we can become such clinicians. And it all begins in the waiting room.
INDUCEMENT OF A SAFE RELATIONSHIP

The patient’s waiting room period before meeting his or her clinician may pass with an
urgent slowness. It is frequently teeming with fears of rejection and with self-recrimination.
It is often accompanied by ruminations such as, “Well, it’s finally come to this, I’m so
weak I need a shrink.” As professionals we would like to think patients do not feel this
way about us, but we should not deceive ourselves. For most people (including many
mental health professionals), it is genuinely upsetting to admit the need for help with
psychological problems. The sensitive handling of this anxiety represents one of the
centerpiece tasks of the initial interviewer. In fact, if it is not handled well, there may not
be a second interview.
In his classic book The Psychiatric Interview, Harry Stack Sullivan describes a novel idea
he calls “the self-system.” This self-system consists of “a vast system of processes, states
of alertness, symbols, and signs of warnings, which protects us from a lowering of self-
esteem as we meet new people.”2 This self-system, consisting of both conscious and
unconscious coping mechanisms, becomes activated in an effort to decrease the anxiety
generated by fears of rejection. It is this self-system that rises to a high pitch as a patient
absent-mindedly turns the pages of a magazine in the waiting room or plays distractedly
with a cell phone.
Three ideas immediately come to mind. First, one of the primary goals of the clinician
in the initial interview consists of attempting to decrease the patient’s anxiety and hence
the need for an extremely active self-system. Second, the activation of the self-system
offers the clinician an excellent preview of the patient’s defenses against interpersonal
anxiety. Thus, the opening 10 minutes of the interview provide an unexpected window
into the workings of the patient’s mental “guard dogs,” both healthy and rabid. And
third, in most cases, the clinician’s own self-system is also aroused when the clinician
meets a new patient. The interplay of these three processes lies at the very heart of the
engagement process.
As we have seen, to some extent the conveyance of empathy can significantly decrease
the patient’s need for an active self-system, but other specific processes can also reassure
the interviewee. In the 1950s and 1960s, Carl Rogers developed the concept of “uncon-
ditional positive regard,” which he defined as follows: “The therapist communicates to
his client a deep and genuine caring for him as a person with potentialities, a caring
uncontaminated by evaluations of his thoughts, feelings, or behaviors.”3 It is a powerful
statement. It is not unlike the suspension of analytic thought seen in the process of
intuition.
Placed into the context of the initial interview, as opposed to ongoing therapy, uncon-
ditional positive regard translates as a suspension of moral opinion by the interviewer
Beyond empathy: cornerstone concepts and techniques for enhancing engagement 39
with respect to the interviewee. In short, the patient comes away with the feeling that the
clinician is not going to pass judgment on him. In many cases, this safe feeling contrasts
starkly with the patient’s recent experience (and, at times, lifelong experience) of encoun-
tering a long string of raised eyebrows on the faces of friends, family members, and
employers. It is up to the interviewer not to follow this parade of frowns.
In this regard, it becomes important for the clinician to work out the potentially dis-
turbing feelings raised by emotionally charged issues such as divorce, religion, sexual
orientation, suicide, violence, child abuse, rape, and abortion. No matter what the clini-
cian’s view of these activities, in the initial interview, the goal remains to show no judg-
ment to the patient. Instead, the interviewer attempts to convey interest in finding out
the significance of these ideas to the patient, recognizing the truth in the very wise state-
ment of Armond Nicholi, Jr., that “whether the patient is young or old, neatly groomed
or disheveled, outgoing or withdrawn, articulate, highly integrated or totally disinte-
grated, of high or low socioeconomic status, the skilled clinician realizes that the patient,
as a fellow human being, is considerably more like himself than he is different …”4
Practically, one effective method of spotting potentially disruptive topics for oneself
consists of monitoring interviews for topics that one consistently avoids. For instance,
one interviewer may discover that he or she seldom knows anything about the religious
beliefs of his or her patients, whereas another interviewer never asks about sexuality. Such
gaps in data gathering may point to precisely those topics about which the interviewer
has strong opinions. It is in these areas that conveying unconditional positive regard may
be problematic.
It is not only controversial issues that can disrupt the conveyance of unconditional
positive regard. In fact, as clinicians we may unwittingly sound like parents at the most
unlikely times. In the following dialogue with a young man suffering from paranoid
schizophrenia, this disconcerting process rears its head in a subtle form:
Clin.: Tell me more about what you’ve been doing since your last hospitalization.
Pt.: Things are going well. I’m getting along much better at home, and I haven’t needed
all those drugs the doctor told me to take.
Clin.: (pause, clinician looks up from clipboard) So you haven’t been taking your
medications like you’re supposed to.
Pt.: No, I just think they fog up my mind.
Clin.: We’ll need to talk about that a little later.
This clinician’s choice of words has created an atmosphere potentially suggestive of a

parent’s reprimand. Indeed, the interviewer’s last statement sounds suspiciously like a
threat to go to the principal’s office.
As a contrast, in the following dialogue, a different approach yields a different interac-
tion with significantly less activation of the patient’s self-system:
Clin.: Tell me more about what you’ve been doing since your last hospitalization.
Pt.: Things are going well. I’m getting along much better at home, and I haven’t needed
all those drugs the doctor told me to take.
Clin.: What were some of the medications you were using?
Pt.: I think it was called Haldol and a little pill … Cogentin or something like that.
Clin.: Tell me a little bit about what you felt like while you were on these medications.
Pt.: It was strange. I don’t know which one was doing it, but I always felt doped up, like
I was in a fog.
Clin.: That sounds like an unpleasant side effect.
Pt.: Yes, it was.
This interviewer has successfully conveyed concern without a price tag of obedience.
Ironically, later in the interview, I would suspect the latter clinician would be in a more
favorable position to persuade the patient to try an antipsychotic again.
This discussion suggests another characteristic – non-defensiveness – that contributes
to a feeling of safety for the patient. Patients are very quick to perceive defensiveness in
an interviewer. Defensive posturing by the clinician may create in the interviewee the
feeling that “I’ve got to watch what I say here.” The following example illustrates a defen-
sive position by the clinician, as a woman describes her anguish concerning her son’s
problems with schizophrenia:
Moth.: I just don’t know what to do with him. Nothing the doctors do ever helps. It’s
always the same. I don’t think they know what they are doing. They haven’t tried
megavitamin therapy, and I hear that it sometimes works miracles. I want you to try
that treatment.
Clin.: Well, let’s get something straight, these kinds of therapies are simply unproven and
maybe unsafe. So we don’t use those here.
Moth.: But some people claim they’ve been helped.
Clin.: Don’t believe everything you read Mrs. Jones.
Here we see the paternalistic tone that can so readily destroy a patient’s trust. The clini-
cian’s self-system has been activated, resulting in a defensive, “educational” posture,
which only serves to reciprocally activate the patient’s own self-system. This interaction
might have been avoided with the following approach, beginning with a gentle empathic
statement in which the clinician’s intuition about the mother’s inner world is right on
the mark:
Moth.: … They haven’t tried megavitamin therapy, and I hear that it sometimes works
miracles. I want you to try that treatment.
Clin.: It sounds like you’ve really gone through a lot of frustration, Mrs. Jones. In a little
while we’ll talk about the pros and cons of different treatments, including
megavitamin therapy, but first I want to hear more about your son so that I have a
better understanding of exactly what we are dealing with here.
Moth.: Sure. It’s long and complicated. But it all started about 3 years ago …
Our discussion of the principles behind the development of a safe alliance began with
the words of Harry Stack Sullivan. Sullivan also provides an important note upon which
to close our discussion. One of the contributing factors to the development of an
overactive self-system is the not-so-maladaptive fear that strangers may harbor ulterior
motives. In short, a patient may fear that he or she is going to be used or even abused.
It is hoped that conscious abuse of a patient is a rarity in our field, but less sinister
abuse may enter the picture unconsciously. Clinicians may have ulterior motives of which
they have little, if any, awareness. For example, a clinician may depend on a patient for
the gratification of the clinician’s need to feel liked or important. If the patient feels that
the clinician needs something from them, such as respect, caring, or fondness, the rela-
tionship is no longer a safe one. Once again, the patient is faced with watching what he
or she says, from the fear that professional help will be withdrawn if certain needs are
not satisfied.
Sullivan stated this principle elegantly:
He [the clinician] is an expert having expert knowledge of interpersonal relations, person-

ality problems, and so on; he has no traffic in the satisfactions which may come from
interpersonal relations, and he does not pursue prestige or standing in the eyes of his
patients, or at the expense of his patients. In accordance with this definition, the psychia-
trist is quite obviously uninterested in what the patient might have to offer, temporarily
or permanently, as a companion, and quite resistant to any support by the patient for his
prestige, importance, and so on. It is only if the psychiatrist is very clearly aware of this
taboo, as it were, on trafficking in the ordinary commodities of interpersonal relations,
that many suspicious people discover that they can deal with him and can actually com-
municate to him their problems with other people.5
Besides offering a safe relationship, the initial interviewer also actively engages the patient
in a positive fashion, utilizing those gestures and words that suggest to the patient that
future interaction will be enjoyable and rewarding, as seen in our next topic.
CLINICIAN GENUINENESS
The term “genuineness” has been described by a variety of researchers.6,7 As was the case
with empathy, genuineness appears to be a nebulous term at first glance. Once again, an
operative definition provides clarification. One can state that “being genuine” occurs
when the following is present:
The behavioral characteristics of the clinician suggest to the patient that the clinician is
feeling at ease both with himself and with the patient. It is frequently marked by three
characteristics in the clinician: (1) responsiveness, (2) spontaneity, and (3) consistency.
Perhaps there exists no better arena for examining these characteristics of clinician genu-
ineness than looking at the reactions of a clinician to patient humor. When faced with
humor some clinicians display a curious sense of awkwardness, as if humor should not
be allowed during an interview. In essence, these clinicians “run-over” the moment of
humor. Rather than responding with a smile or a chuckle, they maintain a somber
expression.
This rather extreme form of non-responsiveness can produce an immediate increase

in patient anxiety, not unlike the discomfort many of us have had the misfortune of
experiencing in a social setting, when one of our jokes is followed by an absence of
laughter. Ironically, such clinicians may argue that their non-responsiveness represents
professionalism, but it seems odd that professional behavior should result in increased
patient anxiety during the early stages of an interview. Moreover, this same lack of clini-
cian responsiveness may be uniformly provided in response to a variety of patient affects,
including tearfulness, anger, and fear, all in the name of professionalism.
Many patients balk at such pseudo-professionalism, preferring a clinician who inter-
acts with a gentle responsiveness. In the final analysis, the mark of a true professional
seems to be his or her lack of a need to feign professionalism. Such clinicians quickly
and easily appear at ease with both their body language and their reactivity. They are
attentively relaxed. Moreover, they bring to the interview a sense of appropriate sponta-
neity, the second characteristic of genuine interaction as described in our definition.
This spontaneity does not exist as a license for sharing whatever comes to mind. To
the contrary, a skilled clinician consistently assesses the potential impact of all state-
ments, but also possesses the ability to share some spontaneous feelings if they are
deemed appropriate for the patient. This spontaneous quality often demonstrates itself
in characteristics such as a well-timed sense of humor, a flexible method of structuring
the interview, and a non-defensive attitude towards questions voiced by the patient.
As just mentioned, one must be careful about the degree of responsiveness and spon-
taneity one displays. Both too much and too little can present problems. For instance, a
buoyant interviewer can intimidate certain patients, whereas a wooden interviewer may
frighten them. In regard to the latter, if the frightened patient feels too uncomfortable
with the clinician to share suicidal ideation, then the unresponsive interviewer may truly
regret having presented a wooden attitude. The clinician needs to nurture a flexible style.
The degree of spontaneity and responsiveness will probably vary from one patient to
another and with the clinical setting.
To this point, the myth of “professional blandness” may have evolved from a misin-
terpretation of the psychoanalytic concept of presenting a neutral screen upon which the
patient can project his or her transference. This neutral screen concept does not represent
a dictum for unresponsiveness. In the first place, an expressionless presentation hardly
represents a neutral stance, as Ryle8 has commented, for such a bland reaction typically
suggests that the non-responder dislikes the other participant. This supposed “neutral
stance” is, in actuality, potentially very disengaging. Moreover, rather than providing a
blank screen, it seems to bias the patient towards negative transference.
Even if one adhered to this neutral stance theory for therapeutic application, and few
talented analysts I have met do so in a strict sense, it does not necessarily follow that the
neutral stance is effective for assessment interviewing. Indeed, as we have seen, one of
the major goals of the initial interview remains the development of a sound therapeutic
alliance, which will, it is hoped, lead to a sincere interest in coming to a second appoint-
ment. A wooden interview hardly lends itself to the facilitation of engagement.
It seems timely to examine consistency, the third element commonly characterizing
a genuine interaction. Gerard Egan has emphasized the importance of consistency, as
demonstrated by the clinician’s willingness to explore the patient’s world in a shared

manner while respecting the patient’s present limitations and defenses. More specifi-
cally, the clinician avoids discordant actions, such as appearing warmly responsive in
part of the interview and coolly distant later; nor does the clinician suddenly become
confrontational, as demonstrated by Counselor A in the following example provided
by Egan.9
Patient: I want to know what you really think of me.

Counselor A: I think you’re lazy and that you would like things to get better if that could
happen by magic.
Counselor B: Frankly, I don’t find a great deal of value in such direct evaluation, but I
think it’s good to talk about this directly. Maybe we can take a look at what’s
happening between you and me.
The response of Counselor B demonstrates a willingness to share exploration, including

a foray into the developing interviewer–interviewee relationship.
Together, the traits of appropriate responsiveness, spontaneity, and consistency coalesce
to create an appealing milieu for the sharing of problems. When adroitly blended, these
three traits of genuineness convey a sense of emotional balance in the clinician, a balance
that suggests a possible source of help to the person in need.
In the following dialogue, these traits, as well as a sense of non-defensiveness, are
elegantly displayed in a situation in which a therapist could easily have swallowed his
or her foot. In this interaction, the clinician, a physician, had determined from the pre-
ceding conversation that the patient was pleasant and well integrated but very anxious.
Consequently, the interviewer felt that humor could be safely employed.
Clin.: What has it been like coming down to the emergency room today?
Pt.: Unsettling, to say the least. I feel very awkward here, sort of like I’m vulnerable. To
be honest, I’ve had some horrible experiences with doctors; I don’t like them.
Clin.: I see, well, they scare the hell out of me too (smiles, indicating the humor in his
comment).
Pt.: (chuckle) I thought you were a doctor.
Clin.: I am (pause, smiles), that’s what’s so scary.
Pt.: (smiles and laughs)
Clin.: Tell me a little more about some of your unpleasant experiences with doctors,
because I want to make sure I’m not doing anything that is upsetting you or
frightening you. I don’t want that to happen.
Pt.: Well, that’s very nice to hear. My last doctor didn’t give a crap about what I said,
and he only spoke in huge words.
In this example, the clinician has skillfully transformed a potentially “loaded moment”
into a shared resolution through humor. If patients realize that avenues for discussing
their needs and complaints are open, they frequently feel less frightened. The presence
of pathways for “filing complaints” paradoxically often decreases the need for their use.
This excerpt also illustrates the common finding that experienced interviewers fre-
quently appear to enjoy the process of interviewing itself. Experienced clinicians feel at
home in the interviewing process, their own self-systems purring quietly. It is this sense
of natural balance in the clinician that remains one of the most powerful of engagement
tools. This balance is complemented by the next trait to be discussed, yet another impor-
tant tool in the engagement process.
CLINICIAN EXPERTISE
In order to explain the concept of clinician expertise most effectively, it may be best
temporarily to view the interviewing process solely from the patient’s perspective. To the
patient, certain questions are of paramount importance. The answer to one of these ques-
tions in particular holds unusually powerful significance, perhaps even determining the
degree of final interest in whatever treatment recommendations may be made. It is a
logical question. It is a natural question. And it can be paraphrased simply as follows:
“Can this person help me?”
To ignore the reality that the patient is attempting to answer this question can lead
to serious problems in engagement. To begin with, the act of hanging out our shingles
as mental health professionals suggests that we have something to offer to patients for
which they will exchange money, time, and trust. On a basic level, they are generally
expecting to find a good listener, albeit a “paid ear” of sorts. But at a deeper level, they
are also expecting something else, something more. They are expecting to find an expert,
a term I find mildly threatening, because it comes pre-seasoned with more than a pinch
of pride. One feels hesitant to declare oneself an expert in so vast a field as human
behavior, feelings, and psychophysiology.
But the term becomes more palatable, and indeed appropriate, if one keeps in mind
two of the principles behind it. First, being an expert does not mean that one has all the
answers or, for that matter, can necessarily provide relief. And second, being an expert
does suggest that we have been rigorously schooled in an effort to consolidate a body of
knowledge found useful in our field. It is the presence of this body of knowledge that
may most successfully answer the patient’s pressing question, “Can this person help me?”
In this regard, it is also useful to remember that in an anthropological sense, the initial
clinician is fulfilling the role of a healer, and whether one is a shaman or a social worker,
as a healer one is expected to possess knowledge not commonly available to the patient.
From the above discussions, it should be apparent that, at both a personal and a societal
level, the clinician’s expertise as perceived by the patient is critical to the engagement
process.
The next logical question is, “How does one convey expertise effectively during an
initial interview?” The answer lies primarily not in what we tell the patient but in what
we ask the patient. It is the quality of our questions, not the quantity of our words, that
generally convinces a patient that the clinician knows something that might help.
Questions, like empathic statements, can be categorized along a number of continua,
including: (1) open-ended versus closed-ended, (2) probing versus non-probing,
(3) fact-finding versus opinion-finding, and (4) structured versus unstructured. Ques-
tions along the full range of these continua can be clinically useful, and all can be sur-
prisingly ineffective as well. Their effectiveness or ineffectiveness seems to depend upon
their timing as well as their appropriateness for the task facing the interviewer at any
specific moment.
In the next two chapters a great deal of time will be spent discussing the flexible use
of questions at different phases of the interview. But at this point, I want to focus on an
especially useful type of question, a type of question that can unobtrusively yet effectively
convey expertise to the patient: the fact-oriented question.
By the term “fact-oriented question,” I am referring to questions concerned with the
concrete realities of the patient’s situation, symptoms, and problems. Questions such as,
“Are you having any problem falling asleep?” or “Has your appetite changed?” represent
typical examples of fact-oriented questions. Frequently, fact-oriented questions concern
diagnostic issues, and they are generally closed-ended in nature.
Some initial interviewers shy away from fact-oriented questions, because they believe
that such questions are generally disengaging. In this regard, I agree that they can be
disengaging when used at the wrong moments, too frequently, or in checklist fashion.
And an interviewer should learn to avoid these pitfalls. But when asked sensitively, fact-
oriented questions are powerful engagement tools that also yield large amounts of valu-
able information for effective treatment planning and triage decisions.
To illustrate the point, let us look at the mid-phase of an initial interview with a
woman in her late 20s. Rather than just moving tangentially with the patient, the inter-
viewer begins a more structured effort to tease out the symptoms upsetting this patient
in an effort to arrive at a useful diagnosis. Keep in mind that the clinician has used many
open-ended questions and empathic statements in the earlier sections of the interview.
Indeed she will continue to intermittently utilize both as she explores for the presence
of an anxiety disorder by effectively increasing her use of fact-finding questions.
Pt.: I am terribly frightened about going back for my masters, I mean, is it worth it? …
When I think about it, I get all uptight.
Pt.: I start to fret and worry. I feel extremely tense and wound up like a crazy alarm
clock, ready to explode.
Clin.: Over the course of any given day, say over the last month, how much of your day
do you spend worrying like that?
Pt.: Oh, I’d say at least 70%, sometimes almost the whole day.
Clin.: (said gently) Sounds miserable.
Pt.: It really is, and the bad part is, I can’t stop it.
Clin.: Sounds like you find it difficult to relax.
Pt.: Oh my God, yes! Even when I come home I feel like I’ve got to do something,
something needs to be done and if I don’t do it I’m a bad person. It’s strange.
Clin.: People develop a lot of tensions during the day, especially in a job like yours. I’m
wondering if you find yourself having muscle aches, trembling sensations, or eye
twitches related to your tension.
Pt.: Funny you should ask. You may have noticed, but my left eye twitches when I’m
tense, drives me nuts.
Clin.: How long has that been going on?
Pt.: I’ve had it … let’s see … maybe 5 or 6 years, but ever since deciding on grad school
it’s been really much worse.
Pt.: I look like a “mad winker” (patient and clinician chuckle). It really can be
embarrassing.
Clin.: I’m sure it can be (warmly chuckles again). Tell me, have you noticed any other
evidence of tension in your body, other than the twitching?
Pt.: I’ve had a lot of diarrhea lately, I don’t know if that’s related or not, and I also have
been feeling flashes of feeling real hot, makes me think of my mother and
menopause, but I’ve had those kinds of flashes off and on for years.
Clin.: With these hot flashes, do you notice any change in your pulse rate or breathing
rate?
Pt.: No, I can’t say I have.
Clin.: Have you ever found yourself suddenly having an abrupt episode of being
extremely anxious, all at once?
Pt.: No … let me think, … not really.
Clin.: When you say “not really,” what have you experienced?
Pt.: About a week ago I really got upset about Bob, but I wasn’t really anxious, I was
mad.
Clin.: What about periods when you suddenly became very frightened, perhaps of dying,
without any apparent reason?
Pt.: No, that I can clearly say I’ve never had.
Clin.: Any periods when you suddenly found yourself panicing and perhaps short of
breath or noticing tingling sensations in your fingers or around your mouth?
Pt.: No, I don’t get that either.
Clin.: What about your concentration?
Pt.: Now that’s shot. I can’t concentrate at all. I’ve particularly noticed that when doing
the books at work. Math comes simple to me and usually I fly through that stuff,
but over the past 2 months I feel really frazzled. It takes forever.
Clin.: Earlier you mentioned the relationship of these feelings to your fears about grad
school. What are some of the connections you see?
Pt.: Well, in the first place, I don’t think I can do it. I mean I’m smart, at least I think
I’m reasonably intelligent, but I don’t know about the discipline I’d need. I think
that worries me most.
Clin.: What else worries you?
Pt.: What would happen to Bob and me, I mean, when would I see him? I don’t know,
maybe never …
I have used a rather lengthy example because I want to emphasize the usefulness of
sensitively utilized fact-oriented questions. In this excerpt, their gentle structuring, while
clearly providing answers to diagnostic questions concerning anxiety disorders, may have
also helped to convey a variety of important metacommunications to the patient, such
as the following:
1. This interviewer is obviously interested in finding out exactly what symptoms and
experiences I have been feeling.
2. This interviewer must have worked with similar problems before because the ques-
tions asked hit upon a lot of the feelings and symptoms I have had.
3. This interviewer seems to be thorough and is actively exploring many different
issues.
In short, all of these metacommunications serve to increase the patient’s confidence in

the clinician’s expertise and ultimately in the clinician’s potential to provide help. Good
friends can provide sensitive listening, but only good clinicians can provide both sensi-
tive listening and knowledgeable questioning.
It is also informative to see the frequent peppering of this fact-oriented dialogue with
unstructured questions and empathic comments. In fact, it looks as if the interviewer
was about to leave structured questioning in order to pursue a region of open-ended
inquiries into psychodynamic issues. Once again, the art lies in a flexible attitude – the
intentional suiting of the most effective form of questioning to the task at hand.
It is interesting to note that an interviewer who gets stuck on the idea of open-ended
questioning throughout most of the initial interview potentially robs himself or herself
of the chance to be perceived not only as a good listener but also as a skilled caregiver.
In addition, it goes without saying that the clinician limited to an open-ended approach
may also come away with an inadequate database for treatment purposes. The use of
fact-oriented questions in the previous example has provided a sound exploration of the
symptoms of a generalized anxiety disorder, which the patient appears to have. Simulta-
neously, the exploration of panic disorder symptoms has ruled out that problem. The
treatment clearly would have varied for these two disorders. If the questioning around
panic episodes had uncovered a panic disorder with an accompanying agoraphobia,
specific treatment modalities, such as cognitive behavioral therapy, are available that
might provide striking relief.
The above dialogue illustrates the increase in engagement that can be achieved by
flexibly mixing fact-finding questions with open-ended questions and empathic state-
ments when exploring diagnostic regions. It is an opportune time to further bring to life
such an effective strategy with a video illustration. In this video you will see me helping
a patient to share the symptoms of one of the most common presentations you will
encounter in everyday clinical practice – a major depressive disorder.
VIDEO MODULE 2.1

Title: Conveying Empathy with Fact-Finding Questions
Contents: Contains both expanded didactics and an annotated interview excerpt illustrating an
exploration of depressive symptoms.
When reflecting upon the power of fact-oriented questions to enhance engagement, I am

reminded of several of my patients over the years who proved to be suffering from the
highly stigmatizing diagnosis of obsessive–compulsive disorder (OCD). OCD
has a surprisingly high lifetime prevalence rate of about 2.5%, yet very few outpatient
therapists report treating the high number of patients suffering from this disorder that
this high prevalence rate would suggest.
The reason is simple. People with OCD are often terribly embarrassed by their symp-
toms and guilt ridden by the dramatic fall-off in their functioning resulting from their
symptoms. I have treated very few people with OCD who have not said things like the
following to themselves over the years: “I must be one of the craziest people in the world.
There is really something very wrong with me.” As a result, the vast majority of people
suffering with OCD do not present to us complaining about their OCD symptoms; they
present complaining of being depressed or anxious, or having marital problems or prob-
lems at work. To uncover OCD symptoms, a clinician often must directly ask about them
or forever be unaware of them. Few people feel comfortable meeting a total stranger and
saying things like, “It takes me 2 hours to shower each morning because I have to keep
repeating my washing because of germs,” or “I am plagued by repeated images of knifing
my baby even though I know I would never do it. It frightens me so much that I am
hesitant to go into the nursery without my husband along.”
So strong is the self-recrimination and stigmatization of many people with OCD that
studies have shown that they suffer, on average, for about 11 to 14 years before seeking
help.10,11 Sadly, OCD is often a hidden disorder for which many people who could receive
help never do.12,13
Obviously, all people presenting with depression or anxiety should be screened for
OCD, but it is not the importance of screening that interests us here. It is the power of
a closed-ended, fact-finding question to enhance engagement that is of interest, as seen
in the following illustration, where I have just finished uncovering the depressive symp-
toms of a patient who had presented complaining, “I’ve got a really bad depression, and
I really need help for it.” We are about 20 minutes into the interview:
Pt.: … Yeah, the sleep problems really are rough. Like I told you, I wake up every
morning exhausted. I hate getting out of bed. Sometimes I start to sit up to get out
of bed and then just lie back down.
Clin.: Sounds really very tough, very painful (said softly).
Pt.: Yeah, it really is. I’ve been depressed off and on for over 10 years. My marriage has
basically been ruined.
Clin.: Hmmm (empathic tone). You know, Mary, some of my patients who are as
depressed as you are, tell me that they worry a lot. Now some people worry about
stuff that people often worry about, like money or relationships. But I have a fair
number of people who worry about stuff that they feel it is very odd to be worrying
about. Like some of my depressed patients tell me they are constantly worried they
have germs on their hands and wash their hands repeatedly. Others tell me they are
worried they have left the stove or an iron on and must repeatedly check it, perhaps
spending 10 minutes saying words like “it’s off” over and over while looking at the
stove or iron. Have you had anything sort of like this happening to you? (closed-
ended, fact-finding question)
Pt.: (patient sits up and looks cautiously surprised) Sort of, yeah,
sort of.
Clin.: What have you experienced?
Pt.: I’m afraid of germs a lot. (pauses) I mean a real lot. I wash my hands all over the place.
Clin.: Oh, that’s very common. I’ve had patients sitting in that very chair who tell me they
wash their hands over 200 times a day (patient looks truly shocked). I’ve even had
patients wash their hands so often they start to damage the skin on the back of
their hands.
Pt.: You have? (said with genuine surprise)
Clin.: Oh yeah (nodding head in agreement).
Pt.: I don’t wash my hands that much, but I wash my hands a lot, maybe 100 times a
day. Sometimes I can’t get to work, because I have to keep washing, so I call in sick.
It’s horrible. It’s so weird, and I let everybody down at work.
Clin.: You know what, Mary?
Pt.: What?
Clin.: I think I know what might be going on with you. I think you may have obsessive–
compulsive disorder – what we call OCD. I know it feels weird to you, but it’s
surprisingly common.
Pt.: Other people do these things? I’m not crazy?
Clin.: At this very instant, I would guess several million other people have OCD, and no,
you are not crazy. (warmly smiles) In addition they all do exactly what you have
done. They are so embarrassed that they tell no one, not even their spouses about
their symptoms.
Pt.: Oh my God! (patient bursts into tears) Oh, my God. Can you help me with this?
Clin.: Yeah, I think we can help you. (patient sits back, still crying from relief, wiping
away the tears) It is actually a disorder that we have lots of different treatments for.
In 30 years of practice, I am hard pressed to recall any empathic statements that I have
made that can match the power of such closed-ended, fact-finding questions to enhance
the engagement process as evidenced by the simple, yet sensitive, inquiry into the pres-
ence of OCD illustrated above. Their power emanates from their metacommunication of
clinician expertise, reassuring the patient that the interviewer has seen “this nightmarish
thing” before. In this case, it allowed Mary to share a hugely guilt-producing secret for
the very first time, after silently carrying its weight for over 10 years. Simultaneously, such
questions also metacommunicate the greatly reassuring fact that many other people have
had similar symptoms. Pretty powerful stuff for a single well-timed question.
In a last note concerning clinician expertise, we can see the complementary functions
of all the factors discussed so far under the rubric of engagement in both Chapters 1 and
2. Indeed, the ability to blend effectively with a patient is mirrored by the clinician’s
ability to blend a variety of techniques, such as: (1) the strategic use of empathic state-
ments; (2) the creation of a safe environment; (3) the ability to convey genuineness
through spontaneity, responsiveness, and consistency; and (4) the conveyance of a reas-
suring knowledge base. These four attributes lay the groundwork for quickly establishing
an effective therapeutic alliance.
At this point we have nearly completed our exploration of the engagement process,
the first way-station in our map of the interview. Yet there remains one more concept
that can provide us with a surprisingly robust platform for enhancing engagement – the
concept of collaborative interviewing.
COLLABORATIVE INTERVIEWING MODELS: NEW TOOLS FOR

ENHANCING ENGAGEMENT
From the very first pages of our book, we have consistently been looking at the interview-
ing process from a person-centered perspective. In this respect, all of our interviewing
techniques can be considered as being “collaborative” in nature, for collaboration is at
the heart of effective interviewing, as Carl Rogers demonstrated in his pioneering client-
centered approach. In addition though, there has been an exciting development in recent
decades of specific therapeutic and interviewing models that emphasize techniques for
creating the sensation of “moving with” patients as opposed to “moving against” them.
These approaches can collectively be called “collaborative interviewing models.” Promi-
nent examples of collaborative approaches include solution-focused therapy,14–18 moti-
vational interviewing,19,20 and the medication interest model.21–23 Jobes has developed
innovative collaborative interviewing approaches for helping patients who are being fol-
lowed for active suicidal ideation to find reasons for living, as well as providing a means
for determining patients’ ongoing risk.24
Collaborative models intentionally enhance engagement by helping patients discover,
for themselves, what goals they want to achieve in therapy. In addition, these models
further enhance engagement by helping patients choose which methods they want to
use to achieve these goals, while finding personally chosen motivators for sticking to
these methods until the goals have been achieved. The emphasis is clearly upon collab-
orative goal setting as a major, if not the major, gateway to enhancing engagement. From
this perspective, it is believed that collaborative goal setting may be used to forge power-
ful and sustainable therapeutic alliances, even in situations where empathy does not work
particularly well or might even backfire if used.
Cheng points out in an insightful and provocative article that, even in a historical
sense, very powerful bonds have occurred among countries based not so much upon
empathy, or even respect, but upon common goal setting.25 He points out that one of
the greatest alliances of modern times, the alliance between the Allies in the Second
World War, included countries like the United States, Britain, and Russia. It is doubtful
that the alliance between the United States and Russia was primarily based upon mutual
empathy, trust, and respect; but it most certainly proved to be a powerful alliance, an
alliance strong enough to topple the Third Reich. It was an alliance based upon the
agreement to have a common goal.
Thus, interpersonal processes, such as jointly arriving upon a set of common goals,
working together to achieve these common goals, and sharing in the enjoyment of
obtaining them can be powerful tools for nurturing the engagement process. Sometimes,
in clinical situations where there may not be strong immediate empathy and respect (as
with the first meeting with an actively paranoid patient or an angry teenager forced into
therapy by his parents), the successful navigation of these collaborative processes may
not only forge the core of the initial alliance, but eventually, over time, lead to the devel-
opment of genuine empathy and respect.
As prototypic person-centered models, collaborative approaches emphasize that the
success of many therapeutic alliances is dependent on how well the clinician comes to
understand the goals that the patient views as important and the methods the patient
wants to use to arrive at these goals. The clinician can then attempt to forge a collabora-
tive and shared understanding both of these goals and the methods for reaching them.
It is important to remember that in collaborative interviewing, we do not necessarily do
whatever patients wants us to do, rather we make a sincere effort to help our patients to discover
for themselves what it might be best for them to do.
Cheng points out that decades ago, Borden,26 with the delineation of his transtheoreti-
cal model, helped to lay the foundation for these collaborative approaches when he
described a sound therapeutic alliance as having the following three components (note
that two of Borden’s three “pillars of engagement” are related to collaborative goal setting
and treatment planning):
1. Agreement on goals, which are the desired outcomes of the therapeutic process
2. Agreement on tasks, which are the steps that will be undertaken to achieve the
goals
3. Bond between patient and therapist, which encompasses Rogerian aspects such as
trust, respect, genuineness, unconditional regard, and empathy
It can be seen from Borden’s definition that collaborative models fully embrace all
of the engagement techniques we have already explored. What they add is merely an
emphasis point, but it is an important point – the power of intentionally focusing upon
seeing the world first through the patient’s eyes, then helping the patient to discover for
himself or herself his or her own goals, methods, and motivations for effective change
and healing. When done well, such a focus has powerful ramifications for enhancing
engagement.
Collaborative approaches, such as motivational interviewing (MI) and the medication
interest model (MIM), are so valuable in establishing a powerful alliance in the initial
interview that we will devote an entire chapter to each of them in Part IV of our book
on advanced interviewing techniques. In the meantime, let us look at two techniques
from the psychotherapeutic model known as solution-focused therapy that can be imme-
diately adapted to the initial interview itself.
Solution-Focused Goal Setting

We will begin by looking at an interview that did not go well with a disgruntled teenager
who would like to be anywhere but in this clinician’s office on this particular day:
Clin.: What’s the problem that brings you here today?

Pt.: I don’t have a problem. I don’t need to be here. My parents need help, not me.
Clin.: Your parents told me that your mood is irritable, you’ve 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.
Pt.: I knew this was gonna be a waste of my time. I’m getting out of here!27
Things aren’t going too well here at the ranch, are they? Part of the communication
breakdown is that this interview is not person-centered. It is parent-centered. Moreover,
the clinician is not waiting to hear directly from the patient what the patient sees as the
problem.
In contrast, solution-focused interviewing is goal-directed and attempts to uncover,
from the patient himself or herself, exactly what goals they seek. It is important not to
assume what the patient wants, but to hear it in the patient’s own words. Sometimes
there are surprises. Cheng28 suggests two nice questions for this purpose:
1. “What would make this a helpful visit?”

2. “What would you like to see different from coming here?”
He then offers the following excellent illustration of these techniques at work with the
same disgruntled teenager:
Clin.: What’s the problem that brings you here today?

Pt.: I don’t have a problem. I don’t need to be here. My parents need help, not me.
Clin.: Okay – so what would make this a helpful visit?
Pt.: Tell my parents that I don’t need to be here; they’re the ones who have the
problem.
Clin.: Things sound stressful with your parents. What do you wish could be different with
your parents?
Pt.: For one, tell them to stop nagging me all the time, they just don’t understand how
hard it is for me these days.
Clin.: 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)
Pt.: Sure, that would make things better.
Clin.: Any other things you wish could be different? (clinician continues to ask about
more goals)
When employing solution-focused interviewing techniques for uncovering the patient’s

goals, notice how the interviewer allows the patient to complain openly, for one can
often reframe a complaint as “a goal.” This is a process akin to a concept called “rolling
with the client’s concerns,” which we will explore in detail in Chapter 22 on motivational
interviewing. The art of engagement here rests in the clinician’s gentle, yet persistent,
attempt to hear directly from the patient what the patient sees as wrong.
The Miracle Question

Arguably, de Shazer29 has created one of the most popular of all solution-focused inter-
viewing techniques – the miracle question. Patients often get stuck in the past, convincing
themselves that the future cannot be different, a position that undermines problem
solving and hope. Such patients often don’t see achievable goals, blinded by their own
cognitive traps. The initial interviewer can sometimes open these traps, by gently pulling
the patient into the “possibilities” of the future with the following question:
“If you woke up in the morning, and a miracle had happened, so that your life was the
way you wanted it to be, what are some of the things that would be different?”
There are many ways to phrase the miracle question; I happen to like the one above – for
it is direct. Notice that it also asks “what are some of the things that would be different”
(gently opening the door to multiple goals) as opposed to “how would it be different”
(sometimes closes the door to all but one goal).
Cheng30 provides a beautiful illustration of the miracle question at work:
Clin.: Imagine that tonight you go to bed, like you normally do. Then, imagine that while
you’re asleep … [pause] … a miracle happens. Imagine that because of this miracle,
your depression [or whatever the patient’s problem is] goes away. What will your
day be like tomorrow?
Pt.: Well, I guess I would wake up, and rather than sleep in, I’d wake up on time and
get ready instead of procrastinating. Then I’d eat breakfast rather than skipping it,
and at breakfast, we’d all get along better without fighting. Then I’d go to work, and
I’d have more confidence, so I would say “no” to people if they ask me to do too
much …
The miracle question has opened up a veritable cornucopia of potential goals for therapy
including (1) waking up earlier, (2) decreasing procrastination, (3) eating breakfast on
a regular basis, (4) improving discourse at the breakfast table, (5) being more confident,
and (6) being able to appropriately set limits on expectations at work.
Now imagine that this was a patient who had been pressured by his wife to enter
therapy. Now further imagine that earlier in the interview he had belatedly admitted that
he might have “a little bit” of a drinking problem (one of the reasons for not waking up
on time) and also had a “tiny” temper problem (breakfast conversation issues). If instead
of using the miracle question, the clinician, at the end of the interview, spontaneously
suggested that they address both of these obviously important problems, things might
not move successfully towards a second interview.
If instead, the clinician, after employing the miracle question, said something like,
“Well there are all sorts of things we will be able to focus on in therapy if you’d like, for
instance you noted earlier you wished you were drinking less, but let’s focus first on some
of the things you most want to change like the waking up early and eating breakfast on
time. Let’s say we could start by working on two of the things you mentioned if a miracle
had happened, which two would you be interested in starting with in the therapy?”, a
second session is much more likely to be in the works.
Ultimately, the number one goal from the clinician’s viewpoint in an initial interview
is to ensure that there is a second one, for we can’t help someone who is not in our
office. Paradoxically, as the sessions proceed and the alliance strengthens, this particular
patient may discover for himself that it is difficult to get up on time and have civil
conversations at breakfast if one drinks heavily. At that point, the patient himself may
recognize that the focus needs to shift to recovery issues, and he will be much more self-
motivated to do so. The seeds for this subsequent therapeutic breakthrough were directly
planted in the initial interview by the clinician’s intentional decision to use the miracle
question as a means of enhancing engagement.
CONCLUDING STATEMENTS
In our first two chapters we have attempted to develop a practical language through which
we can study the engagement process. We began with an operative definition of the
interview itself and uncovered a useful map for exploring its nuances. We have subse-
quently covered a lot of ground, examining key concepts and techniques for securing
and enhancing engagement, the first way-station on our map, including blending, stra-
tegic empathy, the creation of safety, genuineness, clinician expertise, and collaborative
interviewing techniques.
It is hoped our new language offers us a chance to explore effectively our own styles
of interviewing, while greatly increasing the opportunity to learn from observing others.
This language of the interview has revealed the fact that interviewing is an art and, like
the art historians mentioned in Chapter 1, one can discuss this craft precisely and con-
cretely. Indeed, the language we have uncovered, utilizing words such as interpersonal
stance, empathic valence, the paranoid spiral, responsiveness, spontaneity and consis-
tency provide us with the details of the map regarding interviewing process. The interior
of our Victorian room now appears considerably less foreboding.
We have developed a language with which to begin our study of the interviewing
process. But this language is incomplete, for an examination of the complex interplay
between clinician and patient, as critical data and history are uncovered, represents a
pressing matter as yet unexplored. Other factors have yet to be considered such as the
sometimes-daunting tensions existing between the engagement process, time constraints,
and the gathering of a useful and thorough database. It is this volatile interaction that
creates the dynamic structure of the interview. And it is to an understanding of how to
shape this structure that we will now turn our attention.
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Publishing Company; 1975. p. 97.
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Cambridge, CA: Belknap Press of Harvard University Press; 1978.
5. Sullivan HS. 1970. p. 12.
6. Rogers CR, Traux CB. The therapeutic conditions antecedent to change: a theoretical view. In: Rogers CR, editor. The
therapeutic relationship and its impact. Madison, WI: University of Wisconsin Press; 1967. p. 97–108.
7. Egan G. 1975. p. 90.
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1979;16:252–60.
27. Cheng M. 2007. p. 160.
28. Cheng M. 2007. p. 160.
29. de Shazer S. 1998.
30. Cheng M. 2007. p. 161.
CHAPTER 3
The Dynamic Structure of the
Interview: Core Tasks, Strategies, and
the Continuum of Open-Endedness
Unceasingly contemplate the generation of all things through change, and accustom thyself
to the thought that the nature of the universe delights above all in changing the things
that exist and making new ones of the same pattern.
Marcus Aurelius1
The clinical interview manifests as a relationship. As with all relationships, it undergoes

a continuous process of change. It takes two things that exist, the clinician and the
patient, and creates something that did not exist – a therapeutic dyad. This therapeutic
dyad, and its accompanying alliance, will change as the needs, agenda, perspectives, and
fears of the two participants evolve. This metamorphosis occurs whether either partici-
pant wants it to occur or not. The clinician must choose whether to move with these
changes gracefully or to struggle against them.
At first glance, these changes can appear almost overwhelming in their complexity, for
as noted earlier, daunting tensions exist between the engagement process, time con-
straints, and the gathering of a useful and thorough database. It is this volatile interaction
that creates the dynamic structure of the interview. The complexity becomes significantly
more understandable by moving to the next way-station on our map – a study of the art
of data gathering (Figure 3.1). By better understanding how the disparate forces of
engagement and data gathering shape each other, we will discover that there are prin-
ciples and “rules” that determine this process. From this understanding we will develop
specific strategies and techniques for shaping this unfolding as it occurs, for there is no
need for us to be at the mere whim of the universe as it creates this new pattern. Indeed,
it is the skilled shaping of this process by the clinician that can maximize the likelihood
that the patient’s suffering can be most rapidly and effectively relieved.
An interview can be described as having five phases in its macrostructure: (1) the
introduction, (2) the opening, (3) the body, (4) the closing, and (5) the termination.
Categorizing the stages of the interview in this fashion is somewhat artificial, but this
separation temporarily provides an avenue for a more sophisticated study. In reality, these
phases merge with one another, a process at least partially determined by the pathways
chosen by the clinician. Appreciating that the clinician has a choice in the process creates
both a more efficient interview and a more exciting one. As we shall see, the ability to
intentionally sculpt the structure of the interview is one of the differences between a
good clinician and an outstanding one.
INTRODUCTION: PHASE 1
The introduction begins when the clinician and the patient first see one another. It ends
when the clinician feels comfortable enough to begin an inquiry into the reasons why
the patient has sought help. When done well, it lasts a minute or two. When done poorly,
it hardly occurs at all, or worse yet, the clinician and/or the patient regrets having been
a part of it. The introduction represents one of the most important phases of the inter-
view, because patients will frequently have formed their initial impression of the clinician
by its end. This initial impression, whether justified or not, may help to determine the
remaining course of the interview and perhaps even of therapy itself.
Creating a Safe Environment

The goal of the interviewer during the introduction remains relatively simple: engage the
patient by decreasing the patient’s anxiety. Employing one of Sullivan’s terms mentioned
earlier, we can state the goal as follows: the clinician attempts to decrease the patient’s
need for an overactive self-system. In a similar vein, the goal of the patient is also rela-
tively easy: “to find out what is going on here,” because many patients are encountering
a mental health professional for the first time.
The patient’s need to understand the immediate interview process itself tends to be
rather intense, for it is stoked by some of the fears described in Chapter 2. It is worth
The dynamic structure of the interview 59
reviewing these concerns in more detail here, for it is in the introduction phase that we
have our first opportunity to address them, before they can create a lasting problem with
engagement:
1. Who is this clinician?

2. Is he or she competent?
3. Is this person understanding?
4. What does he or she already know about me?
5. Whose side is this clinician on?
6. How long will this assessment take?
7. Am I going to be hurt?
8. Do I have any control in this matter? (Am I going to be “mind-raped”? as one patient
described her initial fear.)
Not all patients are dealing with all these fears, but most patients are probably coping
with a good number of them, either consciously or unconsciously. The goal of the clini-
cian and the goal of the patient are really the same at this moment in the interview: in
short, to help the patient to feel more at ease. To achieve this more comfortable state of
affairs, after some friendly chit-chat the clinician can address some of these questions in
the introduction either directly or indirectly. If done sensitively, the patient’s initial
anxiety should begin to decrease and the interview should begin to gracefully move
forward.
There exists no correct method for handling these fears. Consequently, each clinician
needs to determine a comfortable style of addressing these issues in his or her own
fashion. I shall give two examples. The first example is the work of an inexperienced
clinician. The second dialogue demonstrates one method that addresses the issues more
smoothly.
[The clinician enters brusquely, shaking the patient’s hand very firmly. The clinician does not
smile.]
Clin.: Well John, my name is Dr. James, I’ll be conducting the interview. I understand you
have some problems. Tell me about them.
Pt.: Let me see, I’m not really sure where to begin.
Clin.: Why don’t you start at the beginning. I understand you’ve been acting a
little odd.
Pt.: Who told you that?
Clin.: Your wife, but that’s neither here nor there, I need to know when it all began.
It is hard not to chuckle at this exchange, for the interviewer has successfully aroused
almost all of the anxieties mentioned earlier. Even such word choices as “I’ll be conduct-
ing the interview” suggest that the patient should expect no control here, although the
clinician’s overpowering handshake may have already served as a premonition of this
fact.
The following dialogue represents a more satisfying solution to the demands of the
situation.
[The patient enters the room (or if there is a waiting room the clinician will have greeted the
patient there). The clinician smiles warmly and spontaneously. He walks over to the patient
at a normal pace and shakes the patient’s hand with a gentle firmness.]
Clin.: Hello, my name is Dr. James. I’m one of the senior psychiatrists at the clinic. Why
don’t we sit over here. By the way, if you like, I can hang your coat up (gestures
toward wall).
Pt.: Thank you (patient passes coat and sits down).
Clin.: Did you have any trouble finding a parking space?
Pt.: No, not really. It’s not that bad at this time of the day.
Clin.: Good. Sometimes people have some problems with it. … You ought to see it here
when the college kids are coming back – it’s a zoo. (clinician pauses, smiles) Don’t
worry; I’d never schedule us on that day.
Pt.: Good to hear. (patient smiles)
Clin.: Oh, before we get started, would you like some coffee or tea?
Pt.: I don’t think so.
Clin.: We got some good chai tea.
Pt.: No, really. Thanks though.
Clin.: Well, why don’t we begin by my giving you some idea of what to expect today.
Pt.: That sounds good to me.
Clin.: By the way have you ever seen a therapist before or any type of mental health
professional?
Pt.: No. I can’t say that I have.
Clin.: Oh, I better be nicer than usual (smiles, patient laughs).
Clin.: First of all, do you like to be called Mr. Fenner or William or Bill?
Pt.: I don’t like the name William. “Bill” would be just fine.
Clin.: Good. (pauses) When your wife called to set up your appointment, she passed on
some of her concerns. She said you had wanted her to do that.
Pt.: Well, sort of. She said she would, and I told her to go ahead. I didn’t know if she
had or not.
Clin.: She didn’t say a lot, but she did say a few things. And shortly we’ll talk about how
much you want me to share or not to share with her about our work together as
well as how much input you want her to have. I want to make sure that I know
directly from you what you’re comfortable with, but, for now, let me just
summarize my impression from her call. She certainly seems concerned and a little
confused about what you’ve been thinking and feeling recently. She seems to feel
that you may be somewhat depressed. What I’d like to do is begin by hearing from
you and getting your perspectives on what, if anything, has been going on. We’ll
talk for about 40, or so, minutes, and then we’ll spend about 10 minutes chatting
about what might be of value to you and the types of options for work together we
might have. How’s that sound?
Pt.: That sounds good.
Clin.: Good, But before we get started, though, this might be a good time to explain more
about confidentiality. I know you haven’t been in therapy before, but have you ever
heard the term confidentiality before as far as therapy goes?
Pt.: Sort of, I think. It’s what you were talking about before, about what can or can’t be
shared with Sally.
Clin.: Exactly. Let me fill you in on the details … (interviewer discusses confidentiality, a
process we will address in detail shortly)
[After confidentiality is explained and discussed, the interview might proceed as follows:]
Clin.: Perhaps we could start with your telling me a little about how you see things at this
point. I know from Sally that she feels you’re depressed, but what is more
important is what you think.
Pt.: It will take me a second to get in gear here … well … let’s see … In the first place, I
must admit I’ve been feeling sort of down, not depressed mind you, but down.
She’s right about that.
Clin.: Uh-huh.
Pt.: Things have been going poorly at work. My boss left and he was replaced by a, let
me just say, someone more difficult to get along with. The end result has been that
I’m not enjoying my work like I used to.
Clin.: And where is it you work?
Pt.: Down at the lumber company.
Clin.: Go on (said gently).
Pt.: Well, about 3 weeks ago I did something I’ve never done in all my 20 years of work
… (pause, clinician waits) I called in sick without actually being sick.
Clin.: Uh-huh.
Pt.: It’s really unusual for me to do that.
Clin.: Okay.
In this introduction, which has imperceptibly moved into the opening phase, the clini-
cian has smoothly addressed many of the potential concerns mentioned earlier. In par-
ticular, a large element of respect has been conveyed to the patient by the simple gesture
of offering to hang up his coat and by addressing the information his wife communicated
during the appointment call. The clinician also clearly appears to be on no one’s side,
emphasizing the desire to hear the patient’s opinions, and even stating that the issue of
a problem with the patient has not been determined yet by the comment “and getting
your perspectives on what, if anything, has been going on.”
Storr2 points out that the situation may be slightly different if the patient has been
referred by a fellow mental health professional or from an inpatient unit. In these cases,
Storr adds a nice touch, as follows:
Clin.: I’ve read your notes and I have some idea of your background and your present
trouble, but I would be grateful if you would go over some of it again. I know that
you have told it all before to various people and that it must be very tedious for
you to repeat it, but I find it difficult to remember details from notes made by other
people. I understand that your present trouble is depression. … Could we start

there? What is your kind of depression really like?2
In this example, Storr conveys respect and concern, essentially acknowledging that the
patient might find repeating the story again somewhat irksome. The last statement also
indicates, from the perspective of person-centered interviewing, the clinician’s desire to
understand the patient as a unique individual, not just a case. Some clinicians also prefer
to end the introduction by asking, “Before we go on, do you have any questions?” Such
a question once again conveys a sense of respect, while checking for possible patient
concerns.
Going back to our own example of an effective introduction, we find that the clinician
has also managed to give a sense of control to the patient with phrases such as, “Perhaps
we could start with your telling me a little about how you see things at this point. I
know from Sally that she feels you’re depressed, but what is more important is what
you think.”
The clinician also asked the patient how he would like to be addressed. One will
encounter many vehemently held opinions both for and against using a patient’s first
name. I shall not add many pages to this debate, because I think the intensity of the
debate has led to overstated arguments on both sides. I, personally, feel that one should
not assume a first name basis without asking first. Some patients may find a first name
threatening or a “put down,” especially if the patient is a young adult or is much older
than the clinician. Consequently, when first greeting a patient, I always use his or her
last name.
On the other hand, the ability to use the patient’s first name can be a powerful asset
in engagement. When used sparingly, and with good timing, it can effectively help
patients to share difficult material. In a cultural sense, first names are generally used by
people who care about us and are privy to our private thoughts. Consequently, I have
found it both satisfying and rewarding to simply ask the patient how he or she would
like to be addressed. This question accomplishes several tasks:
1. It conveys respect.
2. It gives the patient direct control over an important ego issue. (Some patients
do not like to be called by last names and others do not like to be called by first
names.)
3. One may learn a significant amount concerning the dynamics of the patient as
revealed by the patient’s preference.
For instance, very strong opinions voiced by the patient may represent the presence of
personality pathology or defensive posturing, thus offering the clinician immediate grist
for the mill. A patient developing grandiose thinking as part of a manic episode may
adamantly insist on being called “Dr. Jones.” At the other extreme, patients with regres-
sive tendencies may sheepishly smile while stating, “Please just call me Jim.” With experi-
ence one can begin to discern the sense of self-identity implied by the patient’s response
to this simple question. Indeed, one wonders what psychodynamic issues, if any, may
lie beneath ambivalent responses such as, “It doesn’t really matter, you can call me Jim,
Jack, or Jimmy.” One can see that even in the introduction phase, the data-gathering
process has begun.
There are some exceptions to the above guidelines. If the clinician knows beforehand
that the patient has a history of paranoia, it may be advisable to use the last name
throughout the interview, because such “distance” may be more comfortable for a patient
with a paranoid interpersonal stance, as we saw in our exploration of empathic valence.
Patients who are much older than the clinician may prefer to be addressed by last name.
In the opposite direction, children and adolescents generally should be addressed on a
first name basis from the start. In these cases, though, it is often useful to ask the patient
which first name to use. For instance, the family may call an adolescent “Sue,” yet the
adolescent would prefer being called “Susan.” Such a simple show of respect can go a
long way towards ensuring a powerful engagement.
I should add that with regard to addressing the patient, I have yet to find any problem
arising in either the initial interview or subsequent psychotherapy using the above
approach. In the end, the reader must decide, from his or her own experience, what feels
most comfortable.
In familiarizing the patient with the ensuing interview process, some clinicians go one
step further than illustrated above. They specifically describe for the patient what to
expect, depending on the goals of the interview, an approach that directly addresses the
patient’s underlying question of “What is going on here?” After the clinician and patient
have introduced themselves, the dialogue may proceed as follows:
Clin.: Perhaps it would be of value to describe what we’ll be doing today.

Pt.: Sounds good to me.
Clin.: Well, first, we’ll start by getting a better idea of what some of your concerns are and
what types of stresses you’re coping with, and also what you’re hoping to achieve
from today. As we go along I’m sure I’ll get a better idea of what you feel the major
problems are and what you’ve already been doing about them. Later in the
interview, I’ll try to get a little better idea of where you’re from and your
background by asking some questions about your family, your health, your
schooling, and any previous symptoms you might have had. I find that getting an
understanding of your background can really help me understand your current
problem better. And then, at the end we can brainstorm on ways we might have
that could help you to get some relief. The whole appointment will take roughly
about 50 minutes. Do you have any questions?
Pt.: Not really, no … not really.
Clin.: Then let’s begin by looking at what brought you here today.
Pt.: (sigh) I’ll tell you, it’s a long story.
Clin.: I have big ears (smiles).
Pt.: (chuckles) Well, it has to do with some problems with my wife and me. It began
about 2 months after our first child, Jenny …
The purpose of a more extended description of the process is twofold. First, it is hoped
that the patient’s fear of the unknown will be decreased. Second, the description of the
process serves as an educational strategy, subtly alerting the patient to the fact that large
amounts of data will be covered in 50 minutes. This may allow the clinician to
collaboratively structure the ensuing interview more effectively. It also provides one
method for smoothly switching gears later with transitions such as, “As I mentioned
earlier, I’d like to learn a little more about your family. How many children do you have
besides Jenny?” At the end of this interaction, the clinician also demonstrated the use of
well-timed humor to break the anxiety of the first meeting.
Before moving on, one final point may be of value. As with all the other aspects of
interviewing we have discussed so far, the format of the introduction varies from one
patient to another. In some instances in which the patient is extremely psychotic, the
patient may quickly cut short the introduction. In such cases, it is wise to follow
the patient’s lead, because clearly such patients have a need to tell their story quickly. It
would be inappropriate to adhere rigidly to the typical format of the introduction with
such patients. The format is a guide, not a rule.
Addressing Confidentiality
At some point near the end of the introduction, or as one is transitioning to the opening
phase of the interview, it is typical to address confidentiality. It is important to be clear
about confidentiality, for it has critical ramifications for building trust. A dialogue might
evolve as follows:
Clin.: One thing we should talk about before we get going is the topic of confidentiality.
Is that a term you are familiar with?
Pt.: Yeah, sort of.
Clin.: Let me fill you in on what I mean by the term. For the most part, everything you
say in here with me never leaves this room. There is total privacy between us, so
that you feel comfortable sharing whatever you feel you need to share. Does that
make sense?
Pt.: Oh, yeah, I figured that was the case.
Clin.: As with just about anything, there are exceptions to the rule, but these exceptions
make good sense. (Note that these exceptions may very a bit from state to state and
country to country.) If you share something that indicates to me that you might kill
yourself or hurt somebody else, then I might need to talk with somebody else to
get more information or to make sure everybody is safe. Naturally, I’d ask your
permission to do so, but if you refused – in this rare situation – I would need to
break the confidentiality to make sure you or others are truly safe. And, obviously,
if there was child abuse or abuse of an elderly person you are taking care of, I
actually, by law, have to report that activity to the proper authorities to get you the
help you need and to protect any children or elders.
Pt.: Yeah, that makes good sense.
Clin.: Also, other than potentially dangerous situations, if you and I agree that it would
be useful for us to talk with somebody else, I would need to get your written
approval to do so. So if you wanted me to talk with a family member or friend, you
could give me written permission to contact them. I can’t just call them up without
asking you. If we felt another clinician or a physician, or even a lawyer, would be
useful to talk with, I could do so only after you gave me written permission. I take
confidentiality very seriously and the bottom line is that, other than exceptions like
the above, what you say here is totally private between you and me.
The Sommers-Flanagans make several excellent points about confidentiality.3 If patients

ask further questions about it, then they often are metacommunicating that they might
be especially conscious of trust issues, indicating that further open discussion about
confidentiality is probably warranted. They also remind us that the confidentiality issues
related to written records is important to address with statements such as, “I’ll be keeping
records of our meetings, but only my office manager and I have access to these files. And
the office manager will also keep your records confidential.”3 I also add, “And, of course,
in order for you and I to get your insurance company to reimburse us, they may request
information about your diagnoses and care.”
As electronic health record (EHR) implementation evolves, confidentiality issues will
also evolve. Various institutes may handle accessibility to the patient’s EHR differently.
In a private practice, the confidentiality may be exactly as stated above. In contrast, some
hospitals and clinics may allow wider access to records from various clinicians and per-
sonnel (for instance every clinician on a given team or all nursing staff may have imme-
diate access to a patient’s EHR as well as administrative personnel). Moreover, as
confidentiality evolves, we may see some patients allowing records to be proactively
transferable to other institutes and clinics. Whatever evolves, it is important for the inter-
viewer to know the exact confidentiality rules within his or her employ, and these rules
must be conveyed to the patient explicitly when discussing confidentiality.
If you are in training and will be discussing the case either in individual or group
supervision, the Sommers-Flanagans handle this gracefully as follows, “Because I’m a
graduate student I have a supervisor who checks my work. Sometimes we discuss my
work with a small group of other graduate students. However, in each of these situations,
the purpose is to enable me to provide you with the best services possible. Other than
the exceptions I mentioned, no information about you will leave this clinic without your
permission.”3
Confidentiality discussions are critical. I seldom encounter problems with them and
part of the art is discussing them in a matter of fact tone of voice. But it should be noted
that, even when done well, this early introduction of complex and potentially unnerving
information, sometimes may disrupt the naturalistic flow of the interview just as it is
getting started. Some clinics, hospitals, and emergency rooms alleviate this problem, in
a creative fashion, by having a different staff member than the interviewer, such as a
well-trained receptionist, review confidentiality issues in detail before the patient sees
the clinician. In these situations, the patient has ample time to ask questions and will
also sign a written statement of understanding regarding confidentiality.
This process allows the actual interview to unfold very naturally without the need for
the discussion of a delicate topic right off the bat. In these instances, I will ask the patient
in the introduction if he or she has any questions about confidentiality. And I still review
the key points and exceptions of confidentiality with the patient personally, but can now
wait to do so during the closing of the interview, where it fits very nicely. Re-addressing
confidentiality in the closing phase of the interview also functions to consolidate the
patient’s understanding of confidentiality for our future sessions. Moreover, for a new
patient who has never experienced therapy before, the experience of the therapy hour
may have raised new questions about confidentiality by the end of the hour.
OPENING: PHASE 2
With the clinician’s first inquiry into the patient’s immediate state of affairs, the opening
phase heralds a more active phase of data gathering. It ends when the clinician begins
to focus his or her questions on specific topics deemed important by the clinician after
listening to the patient nondirectively. Whether a 30-minute emergency room interview
or a 60-minute initial intake, the opening phase should last about 5 to 7 minutes, because
it is the cornerstone of engagement.
Combined with the introductory phase, the opening phase probably represents the
most critical time for establishing rapport with the patient. If the end of the introduction
marked the formation of the patient’s initial impression of the clinician, the end of the
opening phase represents the solidification or rejection of that impression. For the most
part, patients have determined by the end of the opening whether they basically like or
dislike the interviewer. These patient opinions are not irrevocably etched in stone, but it
would take a rather large chisel to change them. In many instances when patients
abandon therapy after two or three sessions, their disapproval may have been seeded in
the opening 7 minutes of the first interview.
The patient has two primary goals during the opening phase: (1) to determine whether
it is “okay” to share personal matters with this particular clinician, and (2) to determine
which personal matters to share. A third major goal of the patient also surfaces, namely
“to tell my story right, so that the clinician understands me.” Despite a well-handled
introduction, the patient’s self-system will usually be activated during this phase, because
it is here that conscious self-exposure begins.
With these ideas in mind, one of the complementary goals of the interviewer becomes
apparent: The engagement process begun in the introduction must be secured during the
opening. The durability and elasticity of this engagement bonding, to a large degree, will
determine the depth of probing and the degree of structuring that the patient will toler-
ate in the subsequent phases of the interview. It is at this time that many of the engage-
ment skills discussed in our first two chapters meet their greatest challenge and yield
their highest reward.
The approach to the opening phase generally proceeds along the following lines: Once
the clinician has ended his or her introduction, an open-ended technique is used to turn
the interview over to the patient on a verbal level. Frequently used openings include the
following:
a. “Tell me a little about what brought you here today.”

b. “Perhaps you can begin by letting me know what some of your concerns have been
recently.”
c. “To start with, tell me a little about what has been happening, from your perspective,
over the past several weeks or so.”
d. “What are some of the stresses you have been coping with recently?”
Such open-ended questions or statements provide the patient with a chance to choose
to begin sharing by talking about something with which the patient feels reasonably
comfortable. Broadly speaking, the goals are to decrease the patient’s self-system while
beginning to uncover the patient’s viewpoint. Both of these goals are generally met by
giving the patient plenty of room to wander during the opening phase.
During this facilitating opening phase, one hopes to begin to see outward signs of
good blending, such as the patient’s assumption of a more relaxed body posture and a
reasonably long duration of utterance (DOU) by the patient following the clinician’s
questions. This facilitation can be nurtured by the use of phrases such as “Go on,” “And
then what happened,” and frequent short conveyances of the clinician’s interest such as
“Uh-huh.” Generally it appears useful to employ at least several gentle (low valence)
empathic statements during the opening phase, because such phrases frequently circum-
vent the patient’s fear of imminent rejection.
The opening phase bears a characteristic that distinguishes it from other phases of the
interview. In sharp contrast to the introduction, in the opening phase the clinician speaks
very little. Furthermore, there exists a strong emphasis on open-ended questions or open-
ended statements in an effort to get the patient talking. Generally speaking, in an uncom-
plicated opening phase, approximately 60 to 90% or more of the clinician’s questions
or statements will be open-ended. During an assessment interview, the opening phase
will probably represent the least verbally active phase for the clinician, because in the
subsequent body of the interview, clinicians tend to increase the frequency of their ques-
tions as they attempt to clarify psychological and situational nuances, diagnostic con-
cerns, and triage issues.
With regard to this open-ended emphasis, two frequent problems are encountered:
(1) premature structuring of the interview before the patient has begun to relax, and (2)
the too frequent use of closed-ended questions. Both of these tendencies remove control
of the interview from the patient, a policy that may serve only to heighten the patient’s
interpersonal anxiety. Perhaps equally important, these activities represent an increased
amount of clinician speech, and, at this early stage of the interview, a direct correlation
can be drawn between clinician confusion and the amount of time that the clinician
spends with his or her mouth open. In short, the opening phase is a time for reflection,
not action, unless a specific patient hesitancy needs to be transformed.
Before proceeding, it is worth noting that some clinicians like to employ a bridge
between the introduction and the opening. This bridge consists of a brief series of demo-
graphic questions that function to provide a cursory background while not intimidating
the patient. The clinician may state, “As we get started I’d like to ask a few background
questions that can help give me some perspective. For instance, how old are you, Mr.
Jones?” Further questions may concern the place of residence, occupation, or a descrip-
tion of the patient’s family. Following these questions, the clinician may proceed with
the opening as described above. Once again, the emphasis is on effective and rapid
engagement. Whether or not to use this approach is an option that becomes a clinician
preference. I, myself, tend not to use this approach, for in my experience it ever-so-slightly
hinders the natural flow of initiating the conversation.
Active engagement techniques are not the only activities of the clinician during the
opening phase. Much of the activity cannot be seen, because it is mental in nature. More
specifically, the opening phase represents an intensely productive assessment period for
the clinician. During these initial minutes, the clinician scours the interpersonal coun-
tryside in search of clues that may lead to the most effective engagement techniques for
this particular patient. Simultaneously, the clinician determines the best manner in which
to structure the body of the interview itself. In short, the clinician develops a tentative
game plan, in the sense that a strategy for the interview will be developed, hand-tailored
to the unique needs of the patient.
In the opening phase, the clinician receives a rare opportunity to assess four vital areas:
(1) the patient’s conscious view of his or her problems, as well as the patient’s conscious
goals for the interview itself (e.g., What does the patient want from the interview?);
(2) the patient’s immediate mental state, which can influence the type of interview the
clinician feels would be most clinically appropriate for this particular patient; (3) the
clinician’s own conceptualization of the patient’s problems, as well as the clinician’s view
of the patient’s unconscious goals for the interview (e.g., What, in reality, does this patient
desire from this interview?); and (4) an evaluation of the interview process itself.
Through an understanding of these four variables, the clinician can begin the delicate
matter of matching the patient’s goals with his or her own goals. If common goals are
not collaboratively active, the resultant interview may prove to be relatively unproductive.
It is interesting to note, just as Lazare4 states that outpatient psychotherapy has a con-
tractual nature; in a sense, each initial interview possesses a contractual element. The
contract can be either implicit or explicit – but it always occurs.
Indeed, as we saw in our section on collaborative interviewing, interviews frequently
break down when the participants cannot agree to shared goals. Many of these commu-
nication breakdowns result when the clinician does not recognize the goals of the patient
or, worse yet, knows the goals but does not acknowledge them, resulting in a dysfunc-
tional encounter that is the antithesis of a person-centered interview.
The four analytic tasks of the opening phase are creatively coupled with the intuitive
skills of the clinician. Armed with this interplay between analysis and intuition, the clini-
cian quickly begins an initial “knowing” of the patient. In an attempt to sharpen the
analytic skills of the opening phase, the following acronym, PACE, is useful in reminding
the clinician of the tasks at hand:
Patient’s perspectives and conscious goals

Assessment of the patient’s immediate mental state
Clinician’s perspective of the patient’s problems and the patient’s unconscious goals
Evaluation of the interview itself
Patient’s Perspective and Conscious Agenda

Each patient brings a unique set of perceptions and opinions to the initial interview.
From our person-centered perspective, these views are invaluable for understanding
where to collaboratively move in the interview. Two patient perspectives appear to be
particularly crucial in determining whether contractual agreement will occur: (1) the
patient’s concept of what is wrong, and (2) the patient’s expectations of the interview
and the interviewer. To uncover these perspectives, I often use the following two ques-
tions, or a variation of them, at some point during the opening phase:
1. “In your opinion, what exactly do you think the main problem is at this time?”
2. “What are some of the things that you hope we might be able to accomplish today?”
Many roadblocks to the interview process can arise when the answers to these two ques-
tions are not known by the clinician.
On the other hand, sometimes it is the patient’s conscious goals that actually get in
the way of the interview, as might be seen in malingering or drug seeking. At such
moments, it may be even more important that the clinician be able to ferret out what
the real agenda of the patient might be. If the interviewer becomes aware of these poten-
tially problematic beliefs or agendas, some roadblocks may be diminished, worked
through, or perhaps even nipped in the bud.
To illustrate the usefulness of uncovering a patient’s conscious agenda, it may be useful
to look at a short piece of dialogue. We will picture a man in his mid-30s, who has
scheduled an appointment at the strong urging of his wife. He nervously looks about
the office, as if anticipating the appearance of a Grand Inquisitor. He has a small mus-
tache and a nervous nose. Early in the opening phase the following interaction
develops:
Clin.: Tell me a little bit about some of the reasons you came here today.
Pt.: It is very difficult to say. I don’t know what Jane thinks is happening, but I’m not
nuts. It’s all got something to do with my chemistry, of that I’m sure. Somehow or
other I’m a little speeded up.
Clin.: In what sense do you feel you’re speeded up?
Pt.: I’m feeling excitable, ready to rock and roll, very creative, but maybe a little too
juiced up. That’s why I think it’s biologic, not mental. I’ve been doing some reading
about physical fitness and its impact on emotions, and I think I’ve got some
understanding of what the hell is going on here.
The art inherent in the opening phase consists of listening not only to what the patient
says his or her goals are, but also to what the patient implies his or her goals might be.
A careful examination of this patient’s opening dialogue may yield some pertinent
information.
His opening comment, “It is very difficult to say,” suggests a genuine fear of being
misunderstood by the interviewer. This phrase is followed by the statement, “I don’t
know what Jane thinks is happening, but I’m not nuts.” Paradoxically, the patient relates
that he does not know what his wife thinks yet he implies that she has labeled him as
“nuts.” The connection with his fear of being misunderstood seems clearer: one of his
goals is to make sure the clinician “gets it” – that he is not crazy; a second goal may be
the hope that the clinician will make sure that his wife “gets it.” He probably also fears
that the clinician will not value his opinions, which he openly shares with the phrase,
“It’s all got something to do with my chemistry, of that I’m sure.”
With this last statement, he offers an explanation for his problem on one level but
also provides two more important pieces of information: (1) at some plane of awareness,
he recognizes a problem, and (2) he has a need not to view the problem as psychologi-
cal. With the subsequent phrase, “Somehow or other, I’m a little speeded up,” he further
describes his perception of the problem.
With the next question, the clinician demonstrates a desire to understand the patient’s
world by requesting a more phenomenological description of his stated symptom. The
patient’s reply, once again, confirms his immediate need to conceptualize the problem
in physical terms, betraying his fear that the “clinician-inquisitor” will not share this
perspective (a second goal has clearly emerged – the need to convince the clinician that
the problem is physical not mental). Of course, the patient’s insistence on a physical
cause may represent an example of a person who “doth protest too much.” Even the
patient may subconsciously fear a psychological problem.
From this brief dialogue we can see that, in a generic sense, the conscious goal of this
patient is to make sure the clinician hears his side of the story and believes it. This generic
goal manifests itself as two more specific goals: (1) make the point he is not crazy, and
(2) make the point that the problem is physical not mental.
The next question arises: What can be done with this information? First, one can easily
imagine what not to do, as would be exemplified by the clinician’s proceeding with
statements such as, “Perhaps you can start by telling me about some of your stresses with
your son, since your wife seems to feel these stresses are at the root of your problem,”
or “Physiology may play a part here, but first let’s look at some of the psychological issues
that may be playing a part in your problems.” Such blundering inquiries must represent
the clinician’s hidden masochistic needs, because the clinician is adamantly refusing to
explore the patient’s world through the patient’s eyes. A reciprocal desire by the patient
not to accommodate the clinician’s goals and recommendations will most likely follow.
Two can play at this game.
In contrast, let us look at a possible line of questioning that attempts to move with
the patient’s needs while ultimately joining both the goals of the patient and of the
interviewer:
Pt.: I’m feeling excitable, ready to rock and roll, very creative, but maybe a little too
juiced up. That’s why I think it’s biologic, not mental. I’ve been doing some reading
about physical fitness and its impact on emotions, and I think I’ve got some
understanding of what the hell is going on here.
Clin.: Oh, what kinds of things have you come up with?
Pt.: Well, some people have found that running and jogging can release substances in
the brain called endorphins that help people feel good. I’m thinking that maybe
that is why I’m speeded up.
Clin.: Hmm, that’s interesting. How frequently do you run?
Pt.: About 3 miles every day, sometimes up to 5 miles.
Clin.: It sounds like you must be in pretty good shape. How did you get interested in
physical fitness to begin with?
Pt.: I guess you could say it runs in the family, no pun intended (patient and clinician
smile). My father was a jock, and my two brothers both went to college on football
scholarships.
Clin.: Tell me a little bit about them.
Pt.: Oh, they’re both high-powered people, both very successful … (pause), more
successful than me, but I do okay. John is a corporate lawyer in Dallas, and Jack is a
physician.
As opposed to a denial of the patient’s overt goals, this interviewer has implicitly acknowl-
edged them. For example, the clinician picks up on the patient’s hint, “… and I think
I’ve got some understanding of what the hell is going on here,” by asking, “Oh, what
kinds of things have you come up with?” – essentially a variation of our question, “In
your opinion, what exactly do you think the main problem is at this time?” The patient
is being expressly asked to tell his side of the story.
This particular choice of topics by the interviewer has also reinforced the issue of
physiology, which symbolizes an area in which this patient feels safe, a topic in which his
self-system is less likely to be activated by discussion. By moving with this patient’s needs,
the conversation transforms itself gracefully into an exploration of family relations.
This example stands merely as an illustration. Patient needs and perspectives change
with each individual. But certain conscious – although not always stated – patient agenda
items are fairly common, and the interviewer may want to listen attentively for their
presence. The following list includes some of the more common appropriate conscious
needs:
1. Somebody to sensitively listen to their story.

2. Somebody to confirm specific beliefs.
3. Somebody to provide, in a generic fashion, relief from their pain.
4. Somebody to provide, in a specific sense, some intervention such as psychotherapy
and/or medications.
5. Somebody to “discover secrets,” such as suicidal intent or a history of incest, which
the patient has been afraid to share previously.
6. Somebody to reassure them that they are “sane,” because they fear otherwise.
7. Somebody to uncover that they are “insane,” because they are worried that they
might be.
8. Somebody to simply “tell me what’s happening to me.”
As mentioned earlier, there are some goals that may or may not be compatible with the
goals of the clinician. In particular, problems arise when the patient’s agenda may not
originate from a sincere motivation for help, as with the following more manipulative
needs:
1. A desire for addictive drugs.

2. A desire to be hospitalized secondary to a need for shelter.
3. A desire to have the clinician help him or her in a legal hassle by proving the patient
is “seeing a therapist.”
4. A desire to appear mentally ill for legal purposes.
5. A desire to have the clinician confirm that the patient’s regular therapist is “all wrong.”
6. A desire simply to get a relative “off their back” by “seeing a specialist.”
7. A desire for the clinician to tell relatives and friends that there is “nothing wrong.”
These latter goals can significantly disrupt the development of a sound therapeutic alli-
ance. If a clinician intuitively becomes suspicious that conscious problematic goals might
be present, they can be intentionally sought. If the clinician has not already asked, “What
are some of the things that you hope we might be able to accomplish today?” such
hidden-agenda items may surprisingly surface with a simple variation of this question
said in a gentle and non-accusatory way: “At this point in our talk, it might help both of
us to clarify what we want to accomplish in this interview. What specifically would you
like me to do for you today?”
Assessment of the Patient’s Immediate Mental State

Much can be learned from a single glance if the glance has years of experience behind
it. Although the details of the mental status examination will unfold in the body of the
interview, during both the introduction and opening phases a simple passive noting of
the patient’s immediate mental state can provide invaluable information. In this “scout-
ing period” of the interview, the clinician searches for mental state clues that may suggest
a need for changing the strategy of the interview itself.
These clues are of three major types: (1) clues suggesting possible diagnoses and,
hence, suggesting future areas for more extensive diagnostic exploration; (2) clues sug-
gesting significant patient concerns about the interview process itself that need to be
addressed; and (3) clues indicating that rather radical changes in the interview format
may be needed because severe psychopathology may be present. In Chapter 16 we will
look at the mental status in more detail, but for now we will briefly survey these three
topics as they pertain to the opening phase.
With regard to diagnostic clues, one of the more interesting findings revolves about
the issue of psychosis. If a patient presents with a smoldering psychotic process, it is not
unusual for subtle signs to be present during the opening phase. Such subtle signs may
include processes such as an infrequent loosening of associations, a slightly inappropriate
affect, or an overriding intensity to the patient’s feelings and affects. The presence of such
clues may suggest that questions dealing with psychosis may yield a rich harvest later in
the interview.
In relation to the second area, evidence of patient concerns about the interview
process itself, the opening phase is of vital importance. If patient concerns are present
and the patient is feeling uncomfortable or angry, it generally becomes necessary to work
through these concerns, if possible, before proceeding to the main body of data gather-
ing. Unresolved hesitancies or anger may leave the clinician with an incomplete or erro-
neous database because invalid data often lie in their wake.
To this end, the clinician keeps an attentive eye out for behavioral evidence suggesting
unspoken roadblocks to the development of a therapeutic alliance. As discussed earlier,
interpersonal anxiety is to be expected, but unusually high anxiety states may indicate
intense fears of rejection, embarrassment, or ridicule. If the clinician suspects the pres-
ence of these fears, the following, said gently, may bring them to the surface where they
can be dealt with more effectively: “It can be somewhat anxiety provoking to talk with
a therapist like myself, especially the first time we are meeting. I’m wondering what, if
any, types of things might be concerning you as we are talking here today?” Some inter-
viewers prefer a slightly different wording, which is less assumptive of a problem: “It can
be somewhat anxiety provoking to talk with a therapist like myself, especially the first
time we are meeting. I’m wondering what you are feeling as we are talking today?”
James Morrison, in his informative book, The First Interview: A Guide for Clinicians,
takes this one step further in a technique that he refers to as “naming emotions.” If a
patient appears to be stalled, secondary to such hesitancies, Morrison suggests addressing
this process by naming several emotions that could be behind the patient’s concerns. His
gentle, yet direct, approach is as follows:
“I can see that you are having a real problem with that question. Sometimes people have
trouble with questions when they feel ashamed. Or sometimes it’s anxiety or fear. Are you
having any of those feelings now?”5
This technique can open the gate to transform a potentially damaging communication
impasse. It should also be kept in mind that patient concerns may be quite direct, as
evidenced by purposefully vague answers, an irritated or hostile affect, or no answer at all.
With regard to the third area, the discovery of a need to significantly change the struc-
ture of the interview, the issue of disruptive psychopathology rears its head. The question
becomes whether a given patient can tolerate a standard initial interview. This question,
frequently relevant to the emergency room setting, focuses directly upon the patient’s
immediate impulse control. A good clinician becomes facile at recognizing the situation
in which the best interview may be a short one.
For instance, the clinician may happen upon a patient whose thinking has become
laced with delusional ideation. The patient may be furiously pacing about the waiting
room, shaking a fist at voices heard only in the private world of a psychotic nightmare.
When questioning begins, this type of patient may rapidly escalate towards violence. As
such a rapid escalation begins to unfold, the clinician may decide to alter the strategy of
the interview drastically, including its length. This type of agitated behavior may also
suggest the wisdom of interrupting the interview briefly in order to alert the charge nurse
to the possibility of impending violence.
Clinician’s Perspective of the Patient’s Problems and the Patient’s

Unconscious Goals
A significant chasm may separate the patient’s perspective from the clinician’s perspective.
For example, a patient may feel that the central problem consists of a vicious harassment
devised by the FBI. The clinician may view this patient’s problem as the development
of a paranoid delusion. In other instances, the clinician and the patient may share
similar views concerning the nature of the problem but differ on the issue of its etiology.
Fortunately, much of the time, both the clinician and the patient share similar
conceptualizations.
It is useful for a clinician to be aware of possible diagnostic issues early in the inter-
view, because this tentative formulation may help determine the basic strategy of the
interview itself. By way of illustration, the clinician may be interviewing an elderly man
brought by his family because “he can’t take care of himself anymore.” During the
opening phase, the clinician may notice thought disorganization, thought blocking, and
a striking memory deficit. Normally, the cognitive mental status examination is brief and
generally appears late in the body of the interview. But in this instance, the clinician may
decide that a determination should be made of the severity of this patient’s cognitive
deficit earlier in the interviewing process. Moreover, with this type of patient, the cogni-
tive examination may be lengthened in an effort to explore the degree of cognitive deficit
while uncovering the possible presence of a delirium or dementia.
If severe memory deficits are recognized, then little can be gained by a lengthy inter-
view, which would be both tiring and frustrating for the patient suffering with a moderate
or severe dementia. Instead, this time may be more profitably spent with members of
the patient’s family, because they may provide a more reliable history. Once again, the
clinician moves flexibly, adjusting to the unique needs of the patient and the clinical
situation.
Of equal importance is the determination made by the clinician of the patient’s
unconscious goals. It is worth emphasizing repeatedly that much of the art of interview-
ing consists not of analyzing what the patient says but of speculating on what is not said
and why it is not said. In a similar vein, patients often “half mention” issues, and the
clinician needs to uncover what has been left partially clad. In particular, the issue of
unconscious goals remains one of the major tasks of the opening phase.
The unconscious goals include those psychodynamic drives of which the patient may
be partially or totally unaware. These needs, frequently arising from core psychological
pains, may represent the most telling reasons why the patient has come for help or may
also present significant roadblocks to the task of the initial assessment. An example will
help to clarify this concept.
In this illustration the patient is a man about 30 years of age. His speech has a pres-
sured quality, as if his words need to escape his mouth. He has been brought by his
father, who threatened to commit him after the patient squirted his father with tear gas
during a family squabble.
Clin.: Tell me some more about what brought you here today.
Pt.: (patient looks away disdainfully) I’ll tell you what brought me here today … No!
Before I tell you that, let me reassure you that I’m not crazy! My father’s crazy, yeah,
crazy, a real nut. … I’m an important person with important business, I don’t have
time to waste and I don’t belong here, my father belongs here, you should see him,
let’s wrap this thing up here quickly.
Clin.: Perhaps we could (patient interrupts).

Pt.: I need a glass of water, you got any?
Clin.: Yes, I do (clinician brings the patient a cup of water).
Pt.: Thanks (takes a couple of sips). Look, I need to be out of here by 4 o’clock … the
bottom line, the goal line is that there is nothing wrong with me that a little peace
and quiet won’t help, too many people do all the talking and no one listens. I’m a
man whose time is worth big bucks. Here, look at this (patient shows clinician
business card).
Clin.: Let me take a closer look at that (inspects card). I see you are a vice president, no
wonder your time is valuable. Perhaps we should start to get to the point.
Pt.: No kidding, that’s a good idea. I think you and I could work this thing out
logically. We’re both professionals, so professional to professional is the way to
work this out. There is a big misunderstanding here. He’s got it all wrong, I didn’t
want to squirt him in the face but he attacked me, he needed a lesson, a whopper,
something to put him in his place, always talking, always telling me what to do.
That’s the way he’s always been and I’m sick of it.
Clin.: Tell me more about the misunderstanding, the way you see it, and take as much
time as you need.
Pt.: The way I see it, no one appreciates me. I just started a mail order business with my
fiancée; she is wonderful, she understands. It’s a dog-eat-dog world out there and
the old man doesn’t give a damn, he lives in the age of horse-hoofs, the Stone Age.
He thinks the web is something a spider spins.
Clin.: What are some of the specific stresses you are handling right now?
Pt.: Financial strain, paying the rent, getting ready for the wedding, this, that, and the
other.
Clin.: Sounds like a lot of bills to pay.
Pt.: You’re darn right. The trouble is my landlord is a jerk. All he thinks about is money
and payments. I’ve been a good tenant, and he has no right to throw me out.
Clin.: When is he threatening to throw you out?
Pt.: Two weeks from now, the man’s got a lot of nerve. To think I used to say nice
things about him.
Clin.: How have all these pressures affected your sleep?
Pt.: I don’t need much sleep, I get along with very little sleep because I’m energized.
Clin.: What time do you go to sleep roughly?
Pt.: Well, that varies. Usually around 12 or 1 o’clock, but recently I’ve been staying up
later to do my work.
Clin.: And what kinds of things do you do when you stay up?
In this vignette, one can see the subtle maneuverings of the opening phase. The art lies
in the interviewer’s ability to recognize the unstated needs of the patient, while subse-
quently attending to some of these same needs. The passage warrants a closer look.
At a conscious level, the patient’s agenda includes items such as convincing the clini-
cian that nothing is wrong, convincing the clinician that the patient’s father is wrong,
and making a quick exit subsequent to an equally quick interview. But it is the uncon-
scious goals that yield the most fertile engagement secrets.
Two of these unstated needs could be described as follows:
1. The need to appear important, possibly related to an underlying fear of inferiority.

2. The need to be in control, perhaps generated by the impending threat of an invol-
untary commitment, which would represent a total loss of control.
The first unconscious goal, the need for praise, manifests itself early in the dialogue. For
instance, the patient immediately raises himself by putting down his father, “the nut,”
and the interviewer with a disdainful look. These defiant steps, indicative of a frightened
ego, are quickly followed by a blunt request for praise, “I’m an important person with
important business.” Later we hear, “I’m a man whose time is worth big bucks,” at which
point he proceeds to display his business card.
It is at this moment that the clinician plays a gentle gambit. Specifically, she goes out
of her way to provide the much needed praise. The clinician does not merely glance at
the offered business card – she calmly admires it. Indeed, it is this quiet admiration that
represents the real and immediate business of this interview, for with its presence the
engagement process can begin to unfold. This quiet praise is furthered by a simple but
elegantly effective acknowledgement of the patient’s importance, “I see you are a vice
president, no wonder your time is valuable.” At last, the patient’s self-system receives a
chance to relax. Someone has seen his worth. Defenses, such as narcissistic put-downs
and accusations, may become less necessary.
Further acknowledgment of the patient’s importance resides in the clinician’s recogni-
tion of the patient’s stated time needs, “Perhaps we should start to get to the point.” With
this apparently appeasing statement, the clinician, in reality, is beginning to structure the
interview. In a relatively short time this patient will be providing diagnostic information
related to mania instead of demanding a shorter interaction.
The second hidden need, the need for control, begins with a subtle redirecting of the
clinician’s attention by the patient, “… my father belongs here, you should see him …”
and ends with a not so subtle directive, “… let’s wrap this thing up here quickly.”
The patient continues to control the interview by interrupting the clinician’s question
by stating a demand, “I need a glass of water …” It is not so hard to imagine that
someone close to involuntary commitment would feel threatened, because he is in reality
threatened with an imprisonment of sorts. Fortunately, the interviewer recognizes this
need and she focuses attention on helping this patient regain some semblance of
self-determination.
First, she procures the requested water. Her strategy of releasing control in the service
of gaining control is further engendered by the phrase, “Tell me more about the misun-
derstanding, the way you see it, and take as much time as you need.” This conveyance of
control is gently bolstered by suggesting that the patient has been appropriately manag-
ing at least some aspects of his life as implied by the wording, “What are some of the
specific stresses you are handling right now?” How different this phrase must sound
compared with a similar content message, “What problems are unsettling you right
now?”, a phrase that would have ignored the patient’s need to feel confident.
This dialogue represents only one of numberless interactions. It is not merely the
specific words that are important here. It is the underlying principle of listening for the
psychodynamic needs of the patient, even when a major psychiatric illness such as
bipolar disorder is active, that warrants emphasis. Uncovering the patient’s unconscious
goals may yield a more compassionate understanding of his or her pain, an understand-
ing that opens the door to engagement. Because this interviewer has deftly attended to
this patient’s unconscious needs in the opening phase, she has distinctly decreased the
possibility of this patient becoming severely agitated. In the hands of a less skilled inter-
viewer, the mania of this patient could easily be triggered into a violent emergency room
incident.
Having completed our examination of the first three tasks of the PACE, it is time to
explore the last task of the PACE – the Evaluation of the interview itself. Before doing
so, in order to consolidate what we have covered, let’s watch an actual interview unfold.
We will sit-in during the first 8 or so minutes of an interview with one of my patients.
In fact, we will return to the patient that we first met in Chapter 1. This time we will
watch the interview consecutively unfold from the introduction through the opening
phase and even into the early minutes of the body of the interview. In this sense, it will
not only illustrate the real-life dynamics of the introduction and opening, it will give us
a preview of how we may transition into the body of the interview itself.
VIDEO MODULE 3.1

Title: Macrostructure of the Interview: The Graceful Unfolding of the Introduction, Opening, and
Body of the Interview
Contents: Contains expanded didactics and an annotated interview excerpt.
We are now ready to examine the last task of the PACE acronym – the Evaluation of the
interview itself. We will discover that this task serves as a bridge between the opening
and the body of the interview, for parts of it may occur in the opening and parts of it in
the body. As we shall see, problematic processes – such as shut-down interviews – will
generally present and be transformed in the opening phase. Other problematic processes
– such as wandering interviews – may provide hints of their presence in the opening
phase yet be subsequently transformed by the clinician in the body of the interview itself
after more fully manifesting. The successful transformation of all of these hindrances to
engagement are made possible by the various techniques I just referred to at the end of
our video module and to which we now can turn our attention.
Evaluation of the Interview Itself

Interviews, like the people creating them, tend to develop personalities of a sort. The
personality of the interview appears to be determined by the quality and quantity of the
communication evolving between the participants. Ideally, a clinician would like to
become a co-participant in an interview characterized by a patient who produces
relatively large amounts of pertinent and valid information, while easily focusing on
issues raised by the clinician. This ideal patient would become increasingly at ease as the
interview proceeded, becoming the proverbial open book. Within minutes, an adequate
level of engagement would be achieved, the patient and clinician working together
towards unified goals.
In reality, ideal interviews are hard to find. Fortunately, good interviews are not. One
of the keys to developing consistently productive interviews remains the ability to spot
bad interviews before they become painful lessons in frustration. By consciously evaluat-
ing the interview process, the clinician opens the door to control and flexibility. Phrased
more accurately, once the clinician has determined the personality of the interview, he
or she may be better positioned to effectively structure the interview by adaptively alter-
ing technique.
To this end, during the opening phase, the clinician needs to attempt a conscious
assessment of the progress of the interview. If pleased with its nascent development,
then the clinician may continue with similar strategies. If displeased, the clinician
may consider new options, yet a further expansion of our abilities to be intentional
interviewers.
The interviewer should be on the lookout for a variety of less productive patterns in
communication, three of which are the shut-down interview, the wandering interview,
and the rehearsed interview. All three of these interview types are common and can lead
to serious problems with engagement and data gathering. All three, once spotted, warrant
a change in strategy. But before a clinician can spot his or her role in the creation of these
problematic interviews, and before we can see how to circumvent them, it is necessary
to examine in detail the key component to their transformation – the words that we use
when framing our questions.
Degree of Openness Continuum (DOC): Open-Ended Questions, Gentle Commands,

Swing Questions, and the Power of Language
In Search of an Answer: What Is an Open-Ended Question?
The concept of an open-ended question appears at first glance to be so self-explanatory
that it warrants little discussion. But one could not be more mistaken. In actual practice,
the open-ended question is frequently not utilized effectively. Moreover, numerous refer-
ences to the technique in both research literature (an extensive literature called “response-
mode” research exists in which pioneering researchers, such as Clara Hill, have carefully
studied how clinicians phrase questions and statements) and interviewing texts tend to
disagree with each other about the definition of open-endedness and about which ques-
tions are open and which are closed.6–21
For instance, how should we classify the following question, “Can you tell me a little
bit about your past?” Is it best viewed as open-ended because it certainly opens up an
enormous range of possible answers for the patient with minimal limitation by the
interviewer. Or should it be viewed as closed-ended, for it can easily be answered with
a curt “yes,” “no,” or “not really,” especially by an angry prison inmate forced to see a
corrections psychologist by a warden. I could show you outstanding interviewing
textbooks that call this question closed-ended and some that view it as a prototypic
open-ended question. Puzzling. What exactly is an open-ended question?
Our search for this answer will lead us into one of the most fascinating aspects of
clinical interviewing – the realization that every question, as well as every statement that
we use, possesses a degree of openness, thus impacting on how easy it is for a patient to
talk with us. Moreover, as we saw in Chapter 2, both open and closed questions can be
both engaging and useful depending upon the clinical task at that moment of the inter-
view. As we examine this continuum of openness, paradoxes will also appear. For instance,
some statements may be more open-ended than some questions. In addition, some questions
are simultaneously open-ended and closed-ended. Understanding these paradoxes is criti-
cal for understanding how open or closed our own interviewing style is by habit. With
this self-knowledge, we can move away from interviewing by habit to our goal of inten-
tional interviewing.
To make sense of these paradoxes, we will look at a simplifying, yet sophisticated,
“supervision language” – the Degree of Openness Continuum (DOC) – for categorizing
our own questions and statements. Once mastered, our understanding will allow us to
intentionally pick and choose the type of questions or statements that are most likely to
transform shut-down, wandering, or rehearsed interviews. From paradox, practicality will
be born.
Using the DOC (Table 3.1) we can classify any verbalization we make (whether a
question or a statement) into one of nine mutually exclusive types. By definition these
nine types of questions and statements fall into one of three broad categories with regard
to their degree of open-endedness. These three broad categorizations are: (1) open-ended
verbalizations, (2) variable verbalizations, and (3) closed-ended verbalizations. Where
specific types of verbalizations fall on the DOC depends upon three characteristics:
(1) the degree to which the verbalization tends to produce spontaneous and lengthy
responses, (2) the degree to which the verbalization does not limit the patient’s answer
set, and (3) the degree to which the verbalization, in a generic sense, possesses a tendency
to open up moderately shut-down interviewees.
The nine types of clinician verbalizations are as follows. Open-ended verbalizations
include open-ended questions and gentle commands. Variable verbalizations include
five types: (1) swing questions, (2) qualitative questions, (3) statements of inquiry,
(4) empathic statements, and (5) facilitating statements. Finally, closed-ended verbaliza-
tions include closed-ended questions and closed-ended statements. Let us take a look at
how the system works.
Open-Ended Verbalizations
Keeping in mind that both questions and statements can be classified as open-ended or
closed, we immediately encounter our first paradox: some statements are more open-
ended than some questions. For example, the statement, “Tell me something about your
old high-school girlfriend” is significantly more open-ended than the question, “Did you
have a high-school girlfriend?”
By definition, open-ended verbalizations are difficult to answer with one word or a
short phrase, even if the interviewee is moderately guarded or resistant, as in a shut-down
Table 3.1 Degree of Openness Continuum (DOC)
VERBALIZATION EXAMPLE
Open-Ended
1. Open-ended questions 1. What are your plans for the future?
2. How will you approach your father?
3. What are some of your thoughts about the marriage?
2. Gentle commands 1. Tell me something about your brother.
2. Describe your initial reaction to me.
3. Share with me some of your hopes about the marriage.
Variable
1. Swing questions 1. Can you describe your feelings?
2. Can you tell me a little about your boss?
3. Can you say anything about the marriage?
2. Qualitative questions 1. How’s your appetite?
2. How’s your job going?
3. How’s your mood been?
3. Statements of inquiry 1. You have never smoked marijuana?
2. You say you were fifth in your class?
3. So you left the marriage after 3 years?
4. Empathic statements 1. It sounds like a troubling time for you.
2. It’s difficult to end a marriage after 10 years.
3. It looks like you’re feeling very sad.
5. Facilitating statements 1. Uh-huh
2. Go on
3. I see
Closed-Ended
1. Closed-ended questions 1. Do you think your son will pass?
2. Are you feeling happy, sad, or angry?
3. What medication is he taking?
2. Closed-ended statements 1. Please sit over there.
2. I read the letter Dr. Smith wrote.
3. Anxiety can be helped with behavioral therapies.
interview. It is extremely difficult to respond to open-ended verbalizations with a simple

“yes” or “no.” Moreover, questions that provide or imply possible answers, or ask for
specific facts, items, places, dates, numbers, or names are closed-ended, for they limit the
patient’s freedom of choice. In contrast, both types of open-ended verbalizations leave
the patient significant latitude as to where he or she may want to go with an answer.
Broadly speaking, in patients with whom the engagement is high, open-ended verbaliza-
tions tend to produce relatively large quantities of speech.
Open-ended verbalizations appear in one of two forms: (1) open-ended questions
and (2) what I like to call to call “gentle commands.”22 A classic example of an
open-ended question would be as follows, “What would you do if your wife decided to
leave you?” (see Table 3.1 for further examples). This question does not guide the patient
towards any specific answer, nor can it easily be answered tersely. It invites the patient
to share personal experience. Questions that begin with “How” or “What” and do not
limit the potential answer set by asking for a specific short answer, name, number, time,
place, or fact are usually open-ended. Thus the question, “How would you handle your
college days differently if you could go back?” is an open-ended question, whereas “How
many credits did you take last semester?” is not an open-ended question (even though
they both begin with the word “how”).
We have already seen one example of a gentle command. They consist of statements
such as “Tell me something about your old high-school girlfriend,” which direct the
patient to speak but do not markedly limit the potential answer. Gentle commands begin
with words such as “Tell me …” or “Describe for me. …” They are stated with a gentle
tone of voice while expressing a genuine interest. Such statements, in order to be viewed
as a gentle command, as was the case with open-ended questions, cannot limit the poten-
tial answer set by asking for a specific short answer, name, number, time, place, or fact.
Thus, “Tell me what you are finding unpleasant about your new job” is a gentle command.
“Tell me who your favorite colleague is at work” is not. A series of gentle commands or
a mixture of these statements with open-ended questions frequently increases the blend-
ing and spontaneity of even the most shut-down interaction. Generally speaking, gentle
commands represent one of the most powerful tools available for helping hesitant
patients to share more freely.
Closed-Ended Verbalizations
At the other end of the DOC one encounters closed-ended verbalizations. With closed-
ended techniques, it is extremely easy for a moderately shut-down patient to answer with
one word, a short phrase, or a simple “yes” or “no.” Even in instances in which the
engagement is high, these techniques may tend to decrease interviewee response length.
Indeed, as we shall see shortly, closed-ended inquiries are frequently useful in focusing
wandering patients.
Closed-ended verbalizations come in two types: (1) closed-ended questions and
(2) closed-ended statements (see Table 3.1). Closed-ended questions frequently are of a
yes/no format such as, “Did you seek therapy at the time of the accident?” or ask for
specific details such as, “Which hospital were you at in 1982?” Although frequently
hunting for facts, they may also seek out opinions and emotions as seen with, “Do you
think your husband is hard working?”
Closed-ended statements do not suggest that any response is expected from the patient
and frequently are of an explanatory or educational slant as with, “We will begin by
looking at some of your symptoms,” or “I spoke with your previous therapist as you
suggested.”
Variable Verbalizations
Variable verbalizations represent a middle ground with regard to openness, because they
tend to vary in the responses they create depending upon the degree of engagement.
When engagement is high, these types of questions often result in the production of large
amounts of spontaneous speech. But when engagement is low and the patient is defen-
sive, angry, or embarrassed, the very same questions can be easily answered tersely. And
therein lies their danger for the clinician, for these questions and statements are tickets
towards monologue when used in a shut-down interview. Consequently, we will examine
the five variable verbalizations: swing questions, qualitative questions, statements of
inquiry, empathic statements, and facilitating statements, in detail.
Swing questions23 are characterized by the distinctive fact that the interviewer literally
asks the patient whether he or she will answer the question. They often begin with
phrases such as, “Can you tell me …”, “Can you describe …”, and “Would you say some-
thing about …” We can now address our earlier question as to how to classify the
question, “Can you tell me a little bit about your past?” Here is our second paradox: it
seems to be both open and closed simultaneously. But, in actuality, it may be best viewed
as laying somewhere in between the two. The impact of such questions literally swings
from open to closed depending upon the degree of engagement with the patient. When
engagement is high, a patient may merrily chatter away following such a question. But
when a patient is hesitant, for whatever reason, these questions can be curtly answered
with responses such as, “not really,” “don’t feel like it,” or simply “no.” Consequently,
as mentioned above, it is generally wise to avoid their use in shut-down interviews.
A second type of variable verbalization is the qualitative question,24 with which the
clinician inquires about the quality of the state of the patient, his symptoms, his rela-
tions, or activities. They frequently begin with the words, “How is your …?” Qualitative
questions such as, “How’s your relationship with your son?” have the potential to
produce a significant elaboration if the engagement is high. But, as was the case with
swing questions, a shut-down patient could easily answer tersely with a phrase such as,
“Just fine.” Operationally speaking, if a question begins with the word “how,” has a form
of the verb “to be” within it, and theoretically could be answered by the single word “fine,”
then it is, by definition, a qualitative question.
The third type of variable verbalization, the statement of inquiry,25 is represented by
a complete sentence followed by a question mark. Unlike closed-ended statements, they
are intended to stimulate a response from the patient as seen with, “You were working
at the factory right after college?” or “You’re viewed as the black sheep in the family?”
The tone of voice of the clinician has a lot to do with the transformation of these state-
ments into questions. The clinician’s tone of voice can move these statements from a
reassuring reflection to a gentle probing to a blunt confrontation. Statements of inquiry
tend to perform one of several functions: clarification, summarization, confrontation, or
interpretation. As with the two previous variable verbalizations, statements of inquiry
can be easily answered tersely or with a “yes” or “no” by shut-down patients, whereas in
situations of high engagement these statements may function as springboards for further
patient elaboration.
It should also be noted that because statements of inquiry lead with a supposed “state-
ment of fact” by the clinician, they all represent a form of leading question. When it is
used to merely reflect back what the patient has said in an engaging fashion, this
“leading” quality is minimal. In contrast, when a statement of inquiry raises a new issue
and/or communicates a clinician judgment, the leading quality can be striking. State-
ments of inquiry that are strongly leading in nature often begin with the word “so,” as
seen with “So, you were an alcoholic even back in junior high?” If a clinician or supervi-
sor wants to find out whether a clinician has a leading style of interviewing, the frequency
of statements of inquiry can often provide insight.
Also note that a particularly problematic statement of inquiry, with regard to poor
validity, is the “negative statement of inquiry.” It includes a negative, such as the word
“not,” as with, “So, you’re not feeling suicidal?” Such statements clearly can lead patients
to feel that the interviewer expects (or wants) them to answer with a “no.” The result is
often invalid data – in this case, potentially dangerously invalid data. I see no redeeming
value in negative statements of inquiry – with one exception. Some clinicians find that
if said with a doubting tone of voice and facial expression on the word “not,” they can
be utilized to challenge malingering or antisocial patients immediately after they make
a patently false statement. But, generally speaking, I suggest eliminating them entirely if
you find them as a part of your interviewing style.
The final two types of variable verbalizations, empathic statements and facilitating
statements, can be usefully discussed together, because they generally tend to open
patients up, although with patients who have a guarded or paranoid interpersonal stance
they may backfire, as discussed in Chapter 1. By definition, as described in detail in
Chapter 1, empathic statements are attempts to convey to patients that one is gaining
an understanding of their feelings and perceptions of the world (see Table 3.1).
Facilitating statements include the wide range of single utterances or short phrases
used to signal that the clinician is carefully listening, such as, “Uh-huh” and, “Go on.”
Although these facilitating phrases tend to urge the patient towards more speech, looked
at on an individual basis they are not as powerfully open as a gentle command or an
open-ended question. With hostile patients they may even backfire. I recall one instance
in the emergency room, when an intoxicated patient began angrily aping both my facili-
tating statements and my head nodding, saying, “Yeah, yeah, yeah, you’re a shrink all
right, yeah, you’re a shrink.” Several minutes later he attacked a safety officer.
Transforming Shut-Down Interviews

Characteristics of Shut-Down Interviews
Now that we have surveyed the types of questions and statements along the DOC, it is
time to see how we can use this knowledge to both recognize and transform common
communication gremlins, such as the shut-down interview (Table 3.2). In the shut-down
interview, the patient displays a short duration of utterance, a long response time latency,
and usually a variety of body language clues indicating that things are not going well. In
particular, eye contact is often poor.
I am reminded of a patient that I observed during supervision who sat morosely, her
legs propped up on a stool, her own crossed arms representing the main objects of inter-
est to her eyes. As if to place appropriate exclamation points in her nonverbal commu-
nication, she yawned with impeccable timing. She represented the ideal persona of a
shut-down in communication.
Table 3.2 Interview Typologies
INTERVIEW TYPE CHARACTERISTICS OF PATIENT CHARACTERISTICS OF INTERVIEWER
Ratio of
Open-Ended
Natural Body Questions to
Duration of Response Time Language such Closed-Ended Focusing Facilitating Maneuvers,
Utterance (DOU) Latency (RTL) as Eye Contact Questions Statements Empathic Statements
Shut-down interview ↓ ↑ ↓ ↓ ↑ ↓
Wandering interview ↑ ↓ ↑ ↑ ↓ ↑
Rehearsed interview ↑ ↓ ↕ ↕ ↓ ↑
KEY: ↑ = increased; ↓ = decreased; ↕ = either increased or decreased.
However, shut-down interviews are not the creation of the patient alone. As emphasized
earlier, all interviews represent interaction. In this respect, the action of the patient just
described suggests the possibility that the interview will become a shut-down interview.
But for this process to unfold fully, the interviewer often must feed it.
This feeding occurs when the interviewer fosters the shut-down pattern by utilizing a
low ratio of open-ended to variable/closed-ended verbalizations. In shut-down inter-
views, both variable and closed-ended techniques generally tend to decrease patient
spontaneity and, hence, hinder the engagement process. This tendency becomes further
entrenched when the interviewer uses a high proportion of focusing statements and other
structuring techniques. It may be even further entrenched if the clinician fails to utilize
facilitating nonverbal maneuvers such as head nodding and an encouraging tone of voice.
During shut-down interviews, especially if there is a negative attitude emerging from
the patient, it is not uncommon for clinicians to feel frustration, which often manifests
itself in a sharpness to their tone of voice and a distinct lack of nonverbal empathic
communication. Ironically, such action fosters the further development of the shut-down
process itself. Thus, the dyadic nature of the interview surfaces once again.
Unlocking Shut-Down Interviews

Over the course of years of clinical work, variable verbalizations – swing questions, state-
ments of inquiry, and empathic statements – can tend to become habits for interviewers.
As an interview becomes more shut-down, habits have a tendency to return, just when
they are least useful. As the patient provides short answers and begins to appear more
withdrawn, hesitant, or testy, the natural tendency is to ask questions even faster, for the
awkwardness of the silence is unnerving. At such points, interviewers tend to rely more
upon swing questions, in which the words “Can you say more about …” have an almost
apologetic tone or pleading quality. Both low-valence and high-valence empathic state-
ments appear by habit, because the interviewer becomes acutely aware of the poor blend-
ing of the interview, and naturally turns towards a technique – empathic statements – that
usually improves blending; but not today. Closed-ended questions also seem to appear
more frequently, probably because they are easier to formulate than open-ended ques-
tions. The unpleasant result may be as follows:
Clin.: How long had you been in prison? (closed question)

Pt.: (looking somewhat disgusted) Two years.
Clin.: Was it a bad experience? (closed question)
Pt.: What do you think? (said sarcastically)
Clin.: Were the guards tough? (closed question)
Pt.: Yeah.
Clin.: Did they get on your nerves? (closed question)
Pt.: Yeah.
Clin.: Did you get time for exercise? (closed question)
Pt.: Sometimes.
Clin.: Pretty bad food, I bet. (empathic statement)
Pt.: Yeah.
Clin.: Did you get very lonely there? (closed question)
Pt.: Yeah. (patient rolls his eyes)
Clin.: Could you tell me a little about what that felt like? (swing question)
Pt.: Not much to tell you.
Clin.: Well, I, uh, was it tough being away from your wife? (closed question)
Pt.: Sort of.
Clin.: Would you be able to tell me how she felt about it? (swing question)
Pt.: Don’t really know.
Clin.: Can you tell me if she still loves you? (swing question)
Pt.: Don’t really know that either.
Clin.: What do you think? (open-ended question)
Pt.: I think she might.
Clin.: How’s the communication between you two? (qualitative question)
Pt.: Just dandy.
Clin.: How do you mean? (open-ended question)
Pt.: I mean she still visits, she’s got the kids. We’re divorced.
Clin.: Ah, how often does she visit? (closed question)
Pt.: About twice a year.
Clin.: When is that? (closed question)
Pt.: Take a guess … around Christmas and on my birthday.
The only person probably less comfortable than the patient in this room is the inter-
viewer. Indeed, here is a classic shut-down interview moving into a spiral of silence. It
illustrates several errors described earlier, including an initial barrage of closed-ended
questions. In the latter half, one sees the use of swing questions and an empathic state-
ment, under the mistaken thought that they are open-ended. The result proves otherwise,
for they are variable verbalizations that function as closed-ended with reticent or angry patients.
Then one sees the use of two true open-ended questions, “What do you think?” and
“How do you mean?” But two open-ended questions are too few.
The secret to unlocking shut-down interviews lies in using a series of open-ended
verbalizations as with a combination of open-ended questions/gentle commands, not
just a couple. In addition, the interviewer tries to pick topics that, at a conscious or
unconscious level, the patient wants to talk about. These are usually topics that have a
strong affective charge for the patient or about which the patient has a strong opinion.
Following the first couple of open-ended techniques, the patient’s responses will prob-
ably still be brief. But after six or seven open-ended verbalizations in a row, especially if
an appealing topic has been broached, many patients will start to yield to the awkward-
ness of not responding appropriately.
The above exchange also illustrates how easily other variable verbalizations, such
as qualitative questions, can be shut down by shut-down patients. In the following
example, we will see the course the previous dialogue might have taken if handled
differently:
Clin.: How long were you in prison? (closed question)

Pt.: (looking somewhat disgusted) Two years.
Clin.: Huh … Obviously, most people hate being in prison but some deal with it better
than others. What did you do to keep yourself busy? (open-ended question)
Pt.: Workout in my cell and play cards, workout in my cell and play cards, but it grows
old real fast.
Clin.: I really don’t know much about what a prison is like; tell me something about it.
(gentle command)
Pt.: Let me put it this way. You wouldn’t last a day (patient smiles with a mild disdain,
shaking his head from side to side). Yeah, they’d get you real fast.
Clin.: Tell me what it’s really like in there. (gentle command)
Pt.: Well, it’s boring, day after day of the same old shit. You’re only out of that damn
cell for an hour a day. And time goes damn slow. Everything, everything changes for
you, man. Eating dinner is something to do; a fucking movie is the highlight of the
week. And you become a “con,” not a jerk-off.
Clin.: How do you mean, a “con”? (open-ended question)
Pt.: A “con” is no one’s fool. We don’t come on to the guards or anyone. You can’t
survive unless you watch your back. (pauses) There wasn’t a minute of the day that
I wasn’t aware of who was near me. You never know when some asshole is gonna
pull a shank on you or something.
Clin.: You know, I gotta plead a little dumb here. I don’t exactly know what you mean by
a shank. What exactly is it? (open-ended question)
Pt.: Man (smiling, almost warmly out of pity), you wouldn’t last an hour, forget a day.
(pauses) A shank’s a sharp, a knife. Not a real knife. You make them out of stuff.
You know, like you can file down a toothbrush if you have to. It’s pretty amazing
how creative you can be if you have nothing to do hour after hour for months or
years. I’ve seen some pretty amazing shit made into a shank. One time I saw a guy
who …
This clinician is cleverly engaging the patient by utilizing open-ended questions and
gentle commands. Notice the rather remarkable increase in spontaneous speech (longer
DOU) of the former inmate compared to the first interview. In particular, the clinician
has avoided the pitfall of utilizing swing questions and other variable verbalizations,
which could function in a closed role, as evidenced in the earlier example. This clinician
also wisely went into an area in which the patient felt comfortable and, indeed, could
“instruct” the clinician.
The following list reviews the techniques we have discussed for transforming a shut-
down interview and also suggests a few more tips:
1. Employ large numbers of combinations of open-ended questions, peppered with

some gentle commands, in a series. Too frequently interviewers ask one or two open-
ended verbalizations, followed by a close-ended question or a variable verbalization,
which can immediately defeat the gains made by the open-ended approach. Often
a combination of six or seven open-ended questions or gentle commands in a row
will be necessary to switch the gears of the interview process towards more open
conversation.
2. Even an empathic statement (one of the variable verbalizations) can break up the
momentum towards more open patient sharing. Avoid stand-alone empathic state-
ments when trying to unlock a shut-down interview. Instead, if you feel an empathic
statement may be of use, couple the empathic statement with an open-ended tech-
nique by using it as the lead, a technique known as a “piggy-back” empathic state-
ment (e.g., “That sounds like a really tough divorce, tell me more about what your
husband has been doing that is so upsetting.”).
3. Follow up any topic that the patient gives the slightest hint that he or she wants to
discuss (i.e., any topic on which the patient shows an increasing DOU, even for a
brief period of time).
4. Avoid, in general, difficult or sensitive topics such as lethality, drugs and alcohol
abuse, and sexual history.
5. Pick topics that gather general background information such as, “Tell me a little bit
about the neighborhood you live in?” or “What are the people like where you work?”
Or choose topics about which the patient has strong opinions as with, “What are
some of the things your boss does that seem unfair?”
6. Avoid the use of swing questions such as, “Can you tell me …?” or “Would you tell
me. …?” Such swing questions are easily answered with silence or frowns. Instead, it
is frequently best to use gentle commands that often prompt more open sharing.
Curiously, if one has a habit of using swing questions, one can easily break the habit.
In a shut-down interview, when you find yourself about to use a swing question (e.g.,
“Can you tell me a little about problems at work?”), drop off the words “Can you”
and then proceed with whatever you were about to ask. Notice that you will have
immediately transformed your potentially disengaging swing question into an engag-
ing gentle command that begins with the words, “Tell me …”
7. Increase attempts at eye contact, while increasing the reinforcement of verbal output
with head nodding, engaging tone of voice and empathic sounds, except with hostile
or paranoid patients, with whom a less frequent use of such techniques may be
advisable.
8. In initial interviews, avoid long pauses before asking the next question. Long pauses
can be effective techniques for eliciting information from reasonably well-engaged
patients who stop their flow because of their desire to avoid a topic (as might be
encountered in ongoing psychotherapy). On the other hand, long pauses in shut-
down patients frequently create further defensiveness and resentment in a first
encounter. Effective use of long pauses depends on effective timing and good common
sense.
It should also be kept in mind that the above techniques are generally applicable not
only in shut-down interviews but also during the opening phase of any interview. In
contrast, in interviews with good engagement, patients may spontaneously talk about a
variety of painful or sensitive areas fairly early. In even sharper contrast, the first principle
outlined above is specific to shut-down interviews. In naturally evolving interviews, open-
ended techniques are interwoven with statements of empathy and closed-ended ques-
tions, both of which serve to clarify issues and demonstrate the clinician’s interest. Thus
it is uncommon in naturally unfolding interviews with good initial blending to employ

overly long strings of purely open-ended techniques (without using variable verbaliza-
tions such as empathic statements), remembering that about 60 to 90% of verbalizations
in the opening phase are open-ended.
This list offers some of the guiding principles with which to approach shut-down
interviews. Most importantly, a concerted effort should be made to increase patient
output before proceeding with information gathering. If these techniques do not
work, then a more deep-rooted communication roadblock may have formed. Approaches
to resolving such deep-rooted stalemates will be discussed in Chapter 19. Another
method of approaching shut-down interviews is to address suspected patient concerns
about the interview process or situation itself. This technique is also discussed in
Chapter 19.
The most telling point remains that the presence of an evolving shut-down interview,
spotted during the opening phase of an initial assessment, indicates a need for an active
change in interviewing style before proceeding to the body of the interview, a transfor-
mation that we can now accomplish because of our understanding of the DOC. These
intentional changes frequently and rapidly result in a more fruitful dialogue, as we saw
with the former inmate above.
As with any interview, one must work flexibly and creatively with the individual
patient. In some instances of a shut-down interview, the above techniques may actu-
ally hinder progress. In particular, some patients whose thinking is grossly disorganized,
secondary to either interpersonal anxiety or psychotic process, may respond poorly
to open-ended questions or gentle commands. These techniques force these patients
to conceptualize at a level at which they may not be capable, further increasing
anxiety.
In these instances, very structured and concrete questions may help the patient with
organization. In support of this goal, the clinician may employ a higher number of
closed-ended questions and statements of inquiry. With experience, one quickly learns
which technique works best with which type of patient.
In a similar vein, some adolescents and adults need to “warm up” with a higher ratio
of closed-ended questions, because these tend to be less probing and can be more quickly
answered. Two other types of questions merit attention. At first glance they seem like
classic open-ended techniques – and they are open-ended – but they tend to perplex
patients and should, in my opinion, be avoided in shut-down interviews.
The first problematic questions are those that begin with the word “why” such as,
“Why did you drop out of school?” As Alfred Benjamin has cogently discussed, questions
beginning with “why” frequently sound judgmental and break the feeling of uncondi-
tional positive regard, especially if the tone of voice is even mildly harsh.26 For some
patients, hearing the word “why” immediately conjures images of Mom or Dad in “criti-
cal mode.” Such questions also seem to suggest that there exists one answer to the ques-
tion, and it may be difficult for the patient to sort through all the confounding factors
to produce the single right answer. The fix to phrasing these questions is simple – replace
the word “Why” with the words “What were …” Various wordings can be used such as,
“What were some of the things going through your mind when you decided that it would
be best to leave school?” or “What were the pros and cons of leaving school when you
made your decision?”
The second troublesome question that tends to hinder dialogue in a shut-down
interview may represent the all-time stereotypical “shrink question,” and it reads some-
thing like this: “What are you feeling as we talk?” In actuality, it is both uncommon
and difficult for most people to be aware of their inner feelings. Thus, in shut-down
interviews, this type of question is particularly good at producing looks of consterna-
tion on patients’ faces. Avoid it. It may be of use in certain communication breakdowns,
which we will discuss in a later chapter, or be quite useful later in therapy, or with
patients with whom the blending is high. But in shut-down interviews I find little
use for it. By the way, children and adolescents, in particular, may find this question
puzzling.
Transforming Wandering Interviews

Characteristics of Wandering Interviews
At this point we have spent a large amount of time discussing methods of working
through a shut-down interview, because this type of interaction is both common and
frustrating. At the other end of the continuum, one may be unfortunate enough to
become a participant in a wandering interview, one of the most feared gremlins in a
managed care setting or a busy clinic.
We met a mild variant of this entity at the very beginning of the book. As we saw
then, in the wandering interview (see Table 3.2) the patient displays a tendency toward
tangential thought that can de-rail the interviewer’s train of questioning into a frustrating
series of unnecessary and unproductive stops. The patient’s loquaciousness is often char-
acterized by a mild pressure to speech, resulting in a long DOU, almost tempting the
interviewer not to ask questions, because each question creates a new verbal leak. The
response time latency (RTL) is short, and eye contact is often good.
A variant of the wandering interview, “the loquacious interview,” occurs when the
patient demonstrates large amounts of speech but does not stray off the topic. In such
interviews, both the patient and the clinician become bogged down in a mass of irrele-
vant details about the requested topic.
The characteristics described above represent the attributes of a patient that predispose
the patient towards the development of a wandering interview. But once again, a true
wandering interview remains the joint creation of both the patient and the clinician.
Clinicians foster the wandering by using open-ended verbalizations (open-ended
questions or gentle commands) and by not utilizing focusing statements. In short, as
the patient extends his or her hand, the clinician accepts it. And the rambling walk
begins.
Frequently clinicians unwittingly further their own demise by employing many facili-
tating gestures and sounds, which only serve to reward the patient’s abundant flow of
speech. Note taking can also serve to reward this process, functioning as a metacommu-
nication to the effect of “What you just said is important, keep going.” Interviewers can
learn to quiet all of these facilitating activities in the service of closing off a runaway
interview, but to do so the clinician must first be aware of them.
The patient’s contribution to the wandering interview has many etiologies. Such an
interpersonal style may accompany histrionic personality structure or indicate the earliest
stages of a mania; or this style may represent something much less serious, as seen with
a patient who is simply anxious, a very common cause of wandering.
In any case, several principles may be of value in transforming such an interview into
a more productive exchange. Generally speaking, one does the opposite of what is used
to open-up a shut-down interview. While moving out of the opening phase, begin to
help the patient structure his or her answers as follows:
a. Decrease the ratio of open-ended verbalizations and variable verbalizations to closed-

ended verbalizations, with only a rare use of open-ended questions or gentle com-
mands and minimal use of any of the variable verbalizations. Remember that variable
verbalizations, especially swing questions and empathic statements, will function as open-
ended questions with wandering patients.
b. Avoid reinforcing the wandering pattern by excessive head nodding or paralanguage
cues to “go on.” This process was referred to earlier as nonverbally “feeding the
wanderer.”
c. Begin with a gentle structuring by immediately returning to the topic of the question
that led to the tangential sidetrack.
d. If the wandering continues, become progressively more structured with focusing
statements such as, “For a moment, let’s focus on what your mood was like back
then.”
e. If the wandering continues, one can further increase the effectiveness of focusing by
using statements such as, “This is such an important area I would like us to just focus
on it for a few minutes.”
f. If the above techniques fail (relatively rare, most patients will have responded nicely
to the above techniques), one can more explicitly tell the patient what is needed: “We
have a limited amount of time. Consequently, I’m going to focus on some of the very
important areas you mentioned in an effort to understand more clearly. It’s important
for us to focus on one topic at a time so I can get the best possible understanding of
what you think is going on.”
g. Finally, if all of the techniques above do not work (rare in my experience), one can
become very strongly structured: “Because of time, we need to focus directly on the
last 2 weeks of your mood. It will be important not to wander on to other topics,
because learning specifically about your mood is so important for our understanding.
In fact, if we wander off, you’ll notice that I’ll bring us back to the last 2 weeks. Is that
all right with you? … Let’s start with your sleep. Over the past 2 weeks how long has
it been taking you to fall asleep?”
h. Another alternative approach if the early and mid-level focusing techniques (“a”
through “e” from the above list) fail consists of addressing the interview process itself:
“I have noticed that when I ask questions we somehow seem to wander off the
subject. What do you think may be going on?”
Generally speaking, unless the patient has some serious underlying psychopathology,
such as a manic process, the first several techniques will decrease the wandering process.
In some instances when employing the above techniques, it may also be necessary to
literally cut a patient off in mid-sentence. This technique is fairly forceful and conse-
quently should be utilized after less aggressive focusing techniques have failed, although
clinicians frequently don’t use it early enough. One way to maintain engagement,
even when cutting a patient off, is to use a technique we used earlier with shut-down
patients – the “piggy-back” empathic statement. Only this time, after leading with the
empathic statement, we will follow-up not with an open-ended verbalization but with a
closed-ended question that focuses the patient:
Clin.: Exactly how depressed have you been feeling?

Pt.: Well, let’s see, in the past several months a lot has been happening to me, you
know, what with the move and everything. I was very upset by my mother’s nagging
and the bills are really mounting, much as they did when I was living with Aunt
Louise. Fortunately, I’m not quite as bad off as with Aunt Louise because …
Clin.: (clinician cuts off patient) It really sounds like you’ve been through a lot. Have you
been feeling depressed over the past 2 weeks? (piggy-back empathic state followed
by a closed-ended question)
Pt.: Oh, I’ve been feeling very depressed.
Clin.: Have you cried or felt like crying? (closed-ended question)
Another method of effectively using a cut-off is to include a comment acknowledging

the importance of what the patient is saying such as, “So much of what you are saying
is important that we need to focus a bit on it to ensure we get the most important points.
Has your mood been depressed over the past 2 weeks?” Once again the patient was cut
off in mid-stream, but the opening line acknowledges the importance of what the patient
is saying while focusing the conversation. If one has appropriately engaged a patient in
the introduction and opening phase, I am frequently pleasantly surprised how rarely he
or she is disengaged by the effective use of cut-offs deeper into the interview. Patients
want us to get the information we need to help them.
To this point, I would like to emphasize that the recognition of a wandering interview
occurs during the opening phase, but the attempt to transform this process actually occurs
somewhere in the body of the interview. This point warrants emphasis because one of
the major deterrents to focusing a patient effectively is the attempt to focus too early.
Ironically, such premature focusing can leave the patient and the clinician in a duel for
control. In such a duel, both participants may go home wounded, because the patient
responds by talking even more profusely in an effort to gain control. Or worse, the patient
becomes disgruntled and shuts down. The main point remains: engage first, structure
second.
A second major factor in successfully focusing a wandering patient is to conscien-
tiously apply the principles regarding the DOC. As stated earlier, the interviewer should
be aiming to decrease the ratio of open-ended verbalizations and variable verbalizations
to closed-ended verbalizations, with only a rare use (perhaps as the first question when
entering a new topic) of open-ended questions or gentle commands, and minimal use
of variable verbalizations. It’s pretty simple. When directly trying to reverse the wandering
style of communication, the interviewer uses essentially only closed-ended questions.
Remember that with a wanderer, all five variable verbalizations essentially function like
open-ended questions. Pay particular attention to avoiding swing questions, for their use,
in a wandering interview, is opening the gate to a potentially wild gallop into tangential
information.
A third major factor in gracefully reining in a wandering interview lies in the effective
use of paralanguage and body language during the structuring process. The art is not so
much in the choice of words but in the method of presentation. For instance, if said with
a concerned tone of voice, a phrase such as, “Let’s look again at what your mood was
like over the past 2 weeks,” will seldom be interpreted as a structuring ploy. On the other
hand, the same phrase said harshly, or in frustration, may quickly disengage a timid
patient.
Let’s examine an interviewer skillfully working with a persistent wanderer. The inter-
viewer recognized the wandering pattern during the opening phase and, consequently,
began to structure as the opening phase ended and the body of the interview began. The
patient presented saying, “I’m really depressed.” We shall pick up the interview at a point
where the interviewer is trying to determine both the presence and severity of the patient’s
depressed symptoms.
Clin.: Tell me what your sleep has been like (gentle command).
Pt.: My sleep, now that’s a good question. Nobody in my family has ever been a sound
sleeper. I remember my father always talking about his restless nights. Same way
with Uncle Harry, although, personally, I think Uncle Harry was a drunk. They say
drunks, I shouldn’t call him that (patient giggles), have really bad sleep.
Clin.: How has your sleep been over the past 2 weeks? (qualitative question, gently
re-focusing the patient back onto the patient’s sleep pattern)
Pt.: Pretty bad, more wound up, what with all the worries on my mind. I’m really upset
about my decrease in pay. I don’t think my boss should have cut my salary. Now
there is a guy who needs to see a shrink. I can’t believe what he does sometimes.
You really ought to see him, a real winner! (note that the patient has “taken off”
with this qualitative question, which one would expect to happen if one uses a
variable verbalization with a wanderer)
Clin.: It sounds like you’ve had a lot of worries related to your boss; I’m wondering if it’s
keeping you up at night. How many hours do you think it takes you to fall asleep?
(closed-ended question)
Pt.: Oh, maybe 2 or 3.
Clin.: Once you’re asleep, do you stay asleep the whole night or do you tend to wake up
occasionally? (closed-ended question)
Pt.: No, no, once I’m out, I’m really out, just like the night after my chem final. I was
so tired I literally slept like a log; but fortunately I was alert enough to pack up for
home, although I don’t know why I should want to go home, why …
Clin.: (cuts off patient) Before we talk about some of the important issues at home, help
me to get an even clearer picture of how your sleep has been affected. For instance,
over the past 2 weeks have you been awakening earlier than usual for yourself?
(closed question)
Pt.: No, I can’t say that I have.
Clin.: Do you sleep at all during the day? (closed question)
Pt.: No, once I’m up, I’m really up.
Clin.: How has your energy been recently? (qualitative question)
Pt.: Up and down, mostly down. I guess I’m not as interested in things as I used
to be.
Clin.: How do you mean? (open-ended question)
Pt.: Well, I used to be into jazz dance and ballet. On Wednesday nights I did aerobics.
My sister, Jane, had gotten me into aerobics, she was always a super athlete. Now
there’s another example of a big shot. She has been one pain in the ass for years,
for instance she …
Clin.: (the open-ended question seemed a reasonable way to clarify the patient’s
anhedonia, but, sure enough, the patient is “taking off” again – time for another
cut-off, but deftly tied into a topic of interest for the patient) What about your own
interest in things like dance now – has it increased or decreased? (closed-ended
question)
Pt.: Definitely decreased. I’m finding it harder and harder to enjoy all my hobbies. I’m
even having a hard time reading.
Clin.: Is your depression making it hard to concentrate when you read? (closed-ended
question)
Pt.: Absolutely, it makes it really really hard to read.
In this illustration of some very nice interviewing, the clinician has begun structuring
this interview without disengaging the patient. This toning down of a wound-up wan-
derer was accomplished using a variety of techniques, including focusing statements,
closed-ended questions, and even interrupting the patient with cut-off statements when
appropriate.
Even when using the initial patient cut-off, the clinician maintained both engagement
and blending by conveying the importance of gaining a clear picture of exactly what the
patient had been experiencing. Moreover, the clinician also emphasized the importance
of what the patient was discussing by implying that the topic would be examined later
in the interview. Both of these goals were accomplished with a single elegant phrase,
“Before we talk about some of the important issues at home, help me to get an even
clearer picture of how your sleep has been affected.” Even the use of the words “help
me” were part of the process, for they metacommunicated a shared goal and a clinician
who was genuinely interested in achieving this goal.
Not surprisingly, working with a wandering patient is one of the most frequent prob-
lems for which clinicians request supervision, probably because we are often hesitant to
structure, anticipating a rebuff from the patient. This hesitancy prevents us from learning
how to structure effectively. In a sense, a wandering interview reminds one of an unchecked
nuclear reaction; its ultimate result is a chaotic and sparse understanding of the patient.
On the other hand, the ability to effectively, yet sensitively, structure the flow of the
interview offers the clinician a method of controlling the reaction, so as to garner the
information that can most help the patient and lead to healing.
Later, in the body of the interview, the clinician may find good reasons to
unleash the reaction again while exploring the patient’s dynamics or feelings. The
important point remains that the clinician can intentionally modify the interview
process in either direction, depending on what the goals of the interview are at
that moment.
To end this discussion of the wandering interview, it is of value to list some of the
most common errors that clinicians commit while handling a wandering patient:
1. Continuing to “feed the wanderer” instead of beginning to structure gently as one

enters the main body of the interview.
2. Being afraid to focus or interrupt the patient. When done effectively, focusing state-
ments are generally well tolerated by patients.
3. Structuring too early. During the opening phase, one generally lets the patient go
wherever the patient wants to go. The interview, at this stage, is highly unstructured.
This facilitation period allows one to increase engagement, while letting the clinician
assess the various areas of PACE, as mentioned earlier.
4. Focusing too bluntly before trying more subtle approaches. It is best to begin
with subtle focusing techniques, increasing the firmness as needed in a graduated
fashion.
Transforming Rehearsed Interviews

Characteristics of Rehearsed Interviews
The third type of problematic interview commonly encountered in clinical practice is the
“rehearsed interview.” It frequently manifests when working with a person coping with
a severe and persistent chronic mental illness who “knows the system all too well” or
any circumstance in which the patient has been required to tell his or her story many
times. In this situation, the patient can relate a story that may even bore the patient
himself or herself because it has been told so often. The history seems pat and simple,
and therein lies the problem.
Both the patient and the clinician can be lulled into a joint acceptance of half-truths.
No person’s life history or history of their presenting problems or illness is simple. To
get at the appropriate facts, both the patient and the clinician need motivation and
involvement. Without these features, the validity and thoroughness of the database may
be jeopardized.
A rehearsed interview does not always arise from indifference. Quite the opposite,
rehearsed interviews not infrequently grow from a patient’s attempt to control the inter-
view. This process may rear its head with patients who are not upfront about their
agendas, as seen with malingering, drug seeking, or perhaps during a disability interview
for a feigned mental illness. It can also manifest when a patient wants to avoid a given
topic, as with a patient trying to hide his or her alcohol dependence from the clinician
by focusing on a spouse’s personality “issues” instead.
To transform a rehearsed interview, one must first recognize it (see Table 3.2). Such
interviews frequently announce themselves with early diagnostic statements by the
patient (as with, “I’m a schizophrenic”) and/or a quick and unsolicited review of the
history of the present illness by the patient (a veteran who rambles off the symptoms of
post-traumatic stress disorder as if reading them from the DSM-5). When patients are
reeling off lists of malingered symptoms, their monologues frequently result in quite
long DOUs and short RTLs. Eye contact varies depending upon the situation. It is gener-
ally good, but if the patient is feeling guilt or is uncomfortable with deceit, eye contact
may be poor.
Whatever the root causes of a rehearsed interview, a clinician can inadvertently
collude with the maladaptive process by focusing poorly or by providing an abun-
dance of facilitating nonverbal activities as seen in the wandering interview. Unfortu-
nately, unlike the process of transforming shut-down or wandering interviews, our
knowledge of the DOC provides little advantage, for a rehearsed interview can be fed
by the use of open-ended, variable, or closed-ended verbalizations. Any question or
statement on the DOC that tracks with the patient can reinforce the direction of the
interview.
The following brief vignette conveys a feeling for such an interview:
Clin.: Tell me what brings you here today?

Pt.: Well, I got out of St. Joseph’s hospital 2 months ago. After I got out, I moved to a
new catchment area, so I need new doctors. I’ve been feeling a little edgy and need
to be on lithium. You see I’m bipolar.
Clin.: I see.
Pt.: Now, I’m not having racing thoughts or problems sleeping, and my energy is just
fine. You’ll probably be hearing from my sister and don’t listen to a word she says.
She over-reacts and she doesn’t understand this disease. Other than my edginess
everything is fine. I’m sleeping just great, no speeded up speech, none of that manic
stuff. Oh yeah, don’t worry, I’m not spending too much money and I’m not over-
sexed or any of that stuff.
The problem here is the validity of this data. All angles are being covered so quickly that
one can feel hedged in by the patient’s story, almost as if one should not ask any more
questions. To break this mechanical storytelling, a variety of methods can be used.
Breaking Through a Rehearsed Interview

One of the methods of transforming a rehearsed interview consists of disrupting the flow
of the patient’s scripted story by asking for behaviorally specific facts. This type of behav-
ioral questioning serves the dual purpose of forcing the patient to reflect, while also
helping the clinician to gain a more effective database.
A second method consists of interrupting the twice-told tale by getting the patient to
discuss areas that require new conceptualizations by the patient or bring the patient face
to face with affectively charged topics that, at some level, he or she wants to talk about
– a strategy I like to call “affective interjection.” These affectively charged topics can lure
the patient away from the rehearsed storyline.
For instance, let’s return to the above interview. This time we will see the interviewer
deftly break the flow of the rehearsed interview by using affective interjection to move
the patient into new territory, thus dismantling the patient’s attempt to minimize any
manic symptoms:
Clin.: Tell me what brings you here today?
Pt.: Well, I got out of St. Joseph’s hospital 2 months ago. After I got out, I moved to a
new catchment area, so I need new doctors. I’ve been feeling a little edgy and need
to be on lithium. You see I’m bipolar.
Clin.: I see.
Pt.: Now, I’m not having racing thoughts or problems sleeping, and my energy is just
fine. You’ll probably be hearing from my sister and don’t listen to a word she says.
She over-reacts and she doesn’t understand this disease. Other than my edginess
everything is fine. I’m sleeping just great, no speeded up speech, none of that manic
stuff. Oh yeah, don’t worry, I’m not spending too much money and I’m not over-
sexed or any of that stuff.
Clin.: You mentioned your sister several times, tell me a little bit about her.
Pt.: She’s sort of a jerk and I’ll tell you one thing, I want her to keep her nose out of my
affairs.
Clin.: What has she been doing recently that has been so upsetting?
Pt.: She’s been mouthing off, getting me in trouble.
Clin.: What sort of ways?
Pt.: She got me into the hospital a month ago, when I didn’t want to go. I didn’t need
to be in there, but she called the cops and the next thing I know, I’m committed.
She claims I’m a danger to her children. I would say the greatest danger to her
children is their mother.
In this instance, the patient has been led away from his rehearsed story through the gate
of affect. With this side trip, important information that may not have been intended for
clinician ears has surfaced, namely that the patient was recently committed involuntarily.
Perhaps things are not as cut and dried as the patient wanted the clinician to believe.
It is hoped that the above information explains why a large amount of time has been
devoted to the opening phase, during which the clinician explores the elements of the
acronym PACE. Its importance would be hard to exaggerate, because in it the first hints
of understanding are born in the clinician, the alliance with the patient is solidified, and
numerous steps will have been taken to set a platform for a productive first encounter
and a flowing communication. The clinician is now prepared to enter the patient’s world
more fully.
If both the introduction and the opening phases have been done effectively, the clini-
cian will generally be asked to enter the patient’s world as an invited guest, and there
will be no need for a “break in.” The question now becomes an issue of finding the most
effective method to gather the necessary clinical information efficiently while further
enhancing the therapeutic alliance.
BODY OF THE INTERVIEW: PHASE 3

The Gathering of the Database
In this section we will carefully delineate the challenges that we will encounter in this
phase of the interview (the nuances of gathering a large database in a sensitive fashion
and in a short time period). But we will not yet address the solutions to these challenges,
for the interviewing strategies and techniques that provide these solutions are of such
critical importance that we will devote the entire next chapter to their study. Our imme-
diate task in this chapter is to better understand both the magnitude of the task and why
it tends to create more than its fair share of anxiety in clinicians.
We opened this chapter with the words of Marcus Aurelius, who invited us to accept
the simple fact that all is change in the universe, even in a universe as circumscribed
as an interviewing dyad. In the first two phases of the interview, the introduction and
opening, we saw that, indeed, these phases are less “structures” than they are “constantly
changing processes.” We have learned a variety of practical strategies and techniques
that allow us to intentionally shape these processes to ensure the interview is off to a
powerfully reassuring start for the patient. In the body of the interview, we will see
that change and flexibility are even more dramatic in nature and that, correspondingly,
the skills required to intentionally sculpt these dynamic processes are even more
critical.
Let us look at another quotation that will provide us with a guiding principle for
understanding the challenges facing us, this one from the T’ai Chi Master Al Chung-liang
Huang:
Insecurity and uncertainty are everywhere. If you don’t let it become part of your flow, you
will always be resisting and fighting. If the ground here suddenly shakes and trembles,
can you give with it and still maintain your center? … If you can become fluid and open
even when you are standing still, then this fluidness and openness makes you able to
respond to changes.27
Of course Huang is addressing the insecurity and anxieties encountered in martial art
combat and, by extension, into navigating life’s everyday hurdles. I have noticed over
several decades of training interviewers that such psychological tensions also often arise
when exploring the body of the interview. Why is there so much insecurity and uncer-
tainty encountered in this phase of the interview, especially for clinicians in their first
several years of training? The answer is simple: Because it is like nothing they have ever done
before in their lives.
Let me explain. Those of us who have chosen to become mental health professionals,
almost by definition, come to the field because we like people and we have generally
enjoyed talking and listening to people throughout our lives. Indeed, we naturally come
to the field somewhat gifted in listening skills and empathy, or we probably wouldn’t be
coming to the field in the first place. Thus, the skills we discussed in our first two chapters
and were subsequently applied in the introduction and opening phases – empathy and
collaborative listening – are not new to us. We use them every time we talk with a friend
or a family member. As we saw in these chapters, we can certainly hone these skills and
take them to whole new levels of sophistication and competence, but we have already
had years of utilizing them in our daily lives.
In contrast, it would be a rare day indeed, when listening to a friend over a steaming
café latte in a local café, that we would enter the conversation with an intentional goal
of covering, literally, hundreds of pre-determined data points. Moreover, it would be very
odd if we entered this conversation having decided in a pre-ordained fashion that this
massive database would need to be culled in under the time it would take to finish, let
us say, two café lattes apiece. Furthermore, it would be strange indeed if we had decided
that we would deliberately “rein our friend in” to topics we deemed to be appropriate if
Tommy happened to be a bit too loquacious on this particular evening. Such encounters
are the stuff of Monty Python skits. In real life, they would result in a painfully long
evening as well as a painfully short list of friends.
The ability to sensitively and intentionally structure a conversation in order to cover
a massive pre-determined database is simply not a skill set we bring to our psychiatric
residencies and graduate programs from our everyday experiences. Yet this is the exact
skill set required to effectively continue the healing process in the body of the interview.
And it is complicated. I truly believe it is as complicated as performing surgery, for it is
one thing to be empathic when allowing a patient to wander aimlessly. It is entirely a
different matter to communicate empathy while gathering the large factual background
that one needs in order to most effectively help a patient in pain, as we will be asked to
do routinely in a busy community mental health center, hectic private practice, or psy-
chiatric inpatient unit. People are complicated and there is an enormous amount of
invaluable information that we can use to collaboratively create the most effective treat-
ment plan for each unique individual from a person-centered perspective.
Just how complex is the task? Let’s look at what information we need to gather during
the body of the interview in a standard initial intake, as it would be done in a typical
community mental health center or inpatient unit. In roughly a 30- to 40-minute time
frame (the time available for the body of the interview in a 50-minute intake) the clini-
cian will try to sensitively uncover the following databases:
1. History of the presenting problem and primary DSM-5 diagnosis: This database will begin
in the opening but will be refined in the body of the interview and there are fre-
quently multiple presenting situational problems and diagnoses.
2. Interviewee’s perspective: Most of this will be uncovered in the opening, but nuances
will usually appear in the body as well.
3. Screening for other DSM-5 diagnoses: This includes screening for mood disorders,
anxiety disorders, schizophrenia spectrum disorders, eating disorders, substance
abuse disorders, personality disorder, etc.
4. Social history: This includes educational history, employment history, current living
circumstances, and sensitive areas such as incest and domestic violence.
5. Framework for meaning and spirituality: This needs to be explored in a fashion that is
sensitive to issues of cultural diversity.
6. Family history.
7. Uncovering of suicidal/homicidal ideation, planning, behaviors, and intent.
8. Past psychiatric history and treatment.
9. Developmental and psychogenetic history.
10. Medical history.
11. Informal mental status.
12. Formal cognitive mental status examination (sometimes optional): This region is reserved
for the more specialized cognitive mental status, in which a clinician examines ori-
entation, attention span, memory functions, and general intellect.
Hmm. This doesn’t look easy to do in 30 to 40 minutes. It isn’t.

From the above, it is obvious that before we can address the strategies for accomplish-
ing this difficult task in the next chapter, we must first acknowledge that one of the major
challenges confronting the intake clinician is that daunting volumes of data often need
to be gathered in short periods of time. Stated differently, good clinicians do not merely
empathically listen, they actively explore. Patients do not necessarily know which infor-
mation is relevant for their treatment planning. It is the clinician who must provide the
gentle structuring and guidance that will establish a valid foundation for action. 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 (which indeed they have) rather than having been interviewed by “some
shrink with a clipboard.”
The apparent “magic” with which a skilled interviewer accomplishes this task is not
really magic. It is a skill. It is a skill based on the knowledge of which questions to ask
and when to ask them during the body of the interview, and a quiet acceptance that one
cannot gain all the pertinent information in a single interview. This craft emerges, as it did
with the introduction and opening phases, directly from a study of the dynamic interac-
tions creating the informational flow of the interview.
Conveying Expertise, the Generation of Hope, and the Return Visit

Thus far we have focused upon the immense importance of data gathering in the body
of the interview, for it is the resulting information that allows us to develop an effec-
tive treatment plan that suits the unique needs of the patient. But something else is
happening, something special, in the body of the interview. As an interviewer skillfully
weaves together the disparate threads of the patient’s story, a second visit is being
secured.
As stated in our first chapter, it can be argued that the single most important
goal of the initial interview is the securing of a second interview (a return visit).
No matter how good the clinical formulation and treatment plan of an initial inter-
view may be, we cannot help a patient who does not return for a second interview.
Interestingly, as the body of the interview winds down, it has been my experience
that many, if not most, patients have already decided whether or not they are
returning.
Let us see why. Naturally, much of the patient’s interest in returning has to do with
the continued use of our cornerstone engagement skills (such as strategic empathy and
genuineness) during the body of the interview. But these engagement skills are far from
the whole story, for patients don’t come back to see a therapist solely because they feel
the therapist is a compassionate and caring person (they may have friends that amply
provide them with both of these traits). They come back because they think we can help
them. They come back because we have convinced them that we have an expertise that
their friends do not have. It is our expertise coupled with our caring that creates the all-
important sensation of hope. It is hope that leads to a return visit.
How is expertise communicated? As discussed in Chapter 2, one of the strongest com-
municators of expertise is the power of our fact-finding questions, for they communicate
that we have been there, done that; that we have seen this problem before and we are
comfortable helping people with it. Thus, the questions we ask during the body of the
interview not only uncover invaluable information, but they also metacommunicate to
patients that they are in the presence of someone “who knows what they are doing.” It
does not matter whether we are a shaman or a therapist, the key to healing is inherently
entwined with our ability to create hope through the patient’s perception that we possess
expertise. A shaman may use the casting of magical stones to communicate their secret
knowledge; we do so by the fashion in which we cast our questions.
Fortunately, this magic can be taught, and we will see exactly how to gracefully, and
easily, accomplish this task in our next chapter. It is there that we will further develop
the fluidness and openness that our T’ai Chi Master Huang described as being critical for
success. But before we can do so effectively, it is valuable to view the body of the inter-
view within the context of the entire interview process, for, if handled well, it will grace-
fully telescope into the closing and termination phases, which also require skilled
handling.
CLOSING OF THE INTERVIEW: PHASE 4

As the interview steadily moves towards its closure, certain tensions may arise in the
interviewee. From the patient’s perspective, the question becomes one of “What have we
accomplished here?” or “Was this worth my time and/or money?” A variety of questions
may be arising in the patient’s mind, either consciously or unconsciously. Not every
patient will have all of these concerns, but many patients will be seeking answers to a
significant number of them. These include:
1. What is wrong with me?

2. Am I crazy?
3. Did I tell the interviewer what he or she needed to know?
4. Does this interviewer understand my problems?
5. Did this interviewer like me as a person?
6. Do I have a diagnosis?
7. Will I get better?
8. Can I be helped?
9. What are my treatment options?
10. What will happen to me next, and will I see this clinician again?
All of these questions are appropriate and natural. Indeed, the patient, in a sense, has a
right to a discussion of these issues with the clinician. The clinician will possess only
tentative answers to many of them, and the patient should be made aware of this fact.
But even tentative answers may provide a powerfully reassuring experience for the patient.
If answered sensitively, the clinician can help decrease the patient’s fear of the unknown,
including the plaguing question of “What’s happening to me?”
Addressing this point, Sullivan has stated that a patient should gain something from
the assessment process itself.28 He emphasizes that patients frequently gain a consider-
able sense of relief merely by exploring their problems in an orderly fashion with a
concerned listener. An orderly inquiry frequently begets a more orderly and calming
perspective.
One of the main tasks in the closing is to consolidate the positive feelings and stir-
rings of hope that have been generated in the first three phases of the interview, while
helping the patient to come away with tentative answers to some of the disturbing ques-
tions raised above. The types of experiences that, as Sullivan would suggest, a patient can
“take away” from an initial intake can be summarized as follows:
a. The patient feels better after the interview.

b. The patient feels comfortable with the interviewer.
c. The patient feels that the interviewer also feels comfortable with the interaction.
d. The patient trusts the clinician.
e. The patient feels that the clinician appears balanced and calm.
f. The patient feels that the clinician appears to be down to earth and accessible.
g. The patient feels that the clinician may be able to help in the future (expertise has
been conveyed).
To a significant extent, the presence of such favorable feelings reflects that the interview
has achieved one of its greatest goals – the generation of hope. This generation of hope
will, at least partially, be determined by the manner in which the clinician has handled
the introduction, the opening, and, especially, the body of the interview, as we have
already discussed. But it remains the closing phase in which many of these positive feel-
ings can be significantly consolidated and enhanced. Moreover, if the closing is handled
poorly, then these positive feelings can be rapidly destroyed.
One of the major methods of enhancing these favorable feelings consists of taking
the time to carefully address the questions mentioned earlier. The very fact that the clini-
cian addresses these issues may convey that the clinician can be trusted and seems to
understand the patient’s needs. Indeed, the clinician’s actions represent a direct acknowl-
edgement of the patient’s needs at that moment.
One could discuss the issues concerning the closing phase in great detail, but I think
it may be of more value to look at a closing phase as it unfolds. This dialogue will
represent only one approach to the closing, but it illustrates many of the principles dis-
cussed earlier.
In the following illustration, the clinician has been interviewing a middle-aged
woman at a local mental health center. The clinician is functioning as an assessment
clinician and has decided that the patient is most likely suffering from a major depres-
sion. We will pick up the dialogue near the end of the body of the interview. In order
to highlight the various aspects of this interview phase, the entire closing phase is
included.
Pt.: I don’t think any other members of my family … let me see … no, I don’t think
anyone else besides my sister and my uncle have been depressed like this. My
mother certainly never went through anything like this, perhaps that’s why she
doesn’t seem to understand.
Clin.: Well, it doesn’t seem like too many people in your family have been depressed,
but at least two people have. We’ve covered a lot of ground so far. At this point,
we are coming to the close of our interview today. I’d like to spend some time
summarizing what we’ve talked about and discussing some ways of possibly
helping you to help yourself. But first, you mentioned that your mother doesn’t
seem to understand. I’m wondering how you put together what is happening
to you?
Pt.: Hmmm … it all seems so complicated. I think I may have reached a time of life
when my bad qualities are catching up with me. Certainly I’m becoming a burden
for my husband and I’m not really doing my share.
Clin.: What are some of the reasons that you think it’s happening now?
Pt.: Maybe because I deserve it, I don’t know. Or maybe because the kids are starting to
leave the nest, as they say.
Clin.: Do you think there is anything you might want to add as we close that we haven’t
covered, that might help us to understand what is going on?
Pt.: No, not really, we’ve covered an awful lot … well, one thing though, I didn’t
mention this because it was so long ago, but in college I had one semester in which
I did very poorly in school. Now that I think about it, maybe I was suffering from
the same type of thing.
Clin.: What were you feeling back then that makes you feel these experiences were
similar?
Pt.: Many of the same things. I couldn’t sleep well and I was constantly worried, I was
so worried about flunking out I almost did.
Clin.: Did you seek help back then?
Pt.: Are you kidding! My parents didn’t think anything was wrong except I was lazy. It
never even crossed my mind to get help.
Clin.: Fortunately, you’ve come for help today and I’m wondering what kinds of ways you
thought we might be able to help you?
Pt.: I’m not really certain. Maybe I thought you might have some magic pill that would
take all this away (patient smiles and begins a subdued chuckle). I’ll tell you one
thing though, it was hard to come here.
Clin.: I’ll bet it was … tell me a little about what it was like actually coming here
today.
Pt.: Oh, I felt very self-conscious walking in off the street. In fact, I looked around first
to see if anybody I knew was around. When the coast was clear, I shot in like a
dive-bomber … While I was waiting to see you, I felt very awkward. I didn’t know
what I was getting into. I almost left.
Clin.: What made you stay?
Pt.: I think I realized I needed help of some sort. I really am at a loss. What do you
actually think is happening?
Clin.: First, let me reassure you, most everyone who comes for a first appointment feels
much as you have. That’s totally normal. It’s difficult to share with a stranger. You’ve
done an excellent job of helping me to get a good picture of what you’ve been
experiencing. From what you said I have some ideas of what might be going on. I
agree with you that you seem to be dealing with a lot of stresses within your home,
including a changing relationship with your children as they leave and a fair
amount of tension with your husband.
Pt.: Yes, I really didn’t emphasize the problems with Jack but they are there and have
been for years. It’s not just the kids.
Clin.: I think these issues will be very important for you to try to understand better, so
that you can cope with them more effectively. They are complicated. And
sometimes some of the pains we feel from the past, like your leaving home at an
early age, may also be contributing to the present. Because of this, I think it would
benefit you to talk with one of our therapists, perhaps on a weekly basis for a
while, to try to sort things out. In addition, I think there is more to the picture as
well. You described a variety of symptoms such as an inability to sleep, a loss of
energy, decreased enthusiasm, and a loss of sexual drive. All these symptoms
suggest that you may be suffering from a depression that has some biological
component to it.
Pt.: How do you mean?
Clin.: Over the past 40 or so years, we have made tremendous advances in understanding
various forms of depression. It used to be thought that depression was only caused
by psychological problems, but now we have discovered that some forms of
depression are caused, or in some instances made worse, by chemical imbalances in
the brain. No one thinks about how incredibly complicated the brain is. When one
realizes how incredibly complicated the brain is, with over one hundred billion
brain cells, it is no wonder that sometimes chemical imbalances arise. In any case,
the symptoms you have so nicely described today are commonly seen in these forms
of depression. Another item pointing that way is the fact that two members of your
family seem to have also suffered from a very similar depression, and we have found
that the biological forms of depression are frequently seen among family members.
Pt.: What does all this mean?
Clin.: Well, some of these depressive symptoms, perhaps caused, or at least made worse,
by your biology, may make it more difficult for you to effectively work on your
psychological concerns and interpersonal stresses. They may even be making it
harder to cope with your daily chores. Fortunately, we have found a variety of
medications that frequently help to get rid of these depressive symptoms. There are
no magic pills though, nor are there promises for success, but these antidepressant
medications can be very effective with some people. Because your symptoms do
suggest that you may also have a biological depression, I’m going to make a referral
to our Mood Disorders Clinic. If you are interested in going there, you’ll find the
therapists are very skilled in both talking therapies and medications. After they get
to know you better, they will let you know exactly which psychotherapies, or
perhaps medications as well, may help you the most. I am convinced that
psychotherapy would be helpful and I think there is a good chance that a
medication may help too. Oftentimes we try psychotherapy first and if that doesn’t
provide enough relief, we add an antidepressant. (pause) I’ve given you a lot of
information, I’m wondering if this is making any sense?
Pt.: Yes, yeah, I think so at least.
Clin.: Try to tell me in your own words what I’ve been explaining to make sure that I’m
being clear.
Pt.: Let me see, you think that I need to talk with somebody about what is going on
with my husband and also with my kids taking off for school. You also think there
may be something wrong with the chemistry in my brain and that may also be
making me feel depressed. And you think some medications may help.
Clin.: That’s right. This means that there may be more than one way to help you feel
better. Do you think you’d be interested in seeing our therapist, I think it could
really help.
Pt.: Yes, I think I would like to give it a try, at least. I’ve read about depression being
caused by chemical problems too, I just really never recognized myself as being
depressed. And I know I need to talk some of this stuff out, I really do.
Clin.: I really think you will benefit from therapy, and medications may help too. Depression
is complicated. Sometimes depression is hard to recognize. Perhaps back in college
your parents didn’t recognize it in you, just as you didn’t recognize it yourself today.
Pt.: I never thought of it that way, but I guess it’s actually possible.
Clin.: In any case, as we wrap up here, I’m wondering what this interview has been like
for you, was it what you were expecting?
Pt.: For the most part, yes. I really didn’t know exactly what to expect. I really felt we
covered a lot of important ground. It seemed very thorough.
Clin.: Is there anything I could have done differently that might have made you feel more
comfortable?
Pt.: No, no … I felt, I feel very comfortable with you. I do think you could use more
magazines out in the lobby though. It really gets uncomfortable sitting out there.
Clin.: Hmmm … that might be a good idea.
Pt.: Will I be working with you again at all?
Clin.: No, as I mentioned earlier, I only work over here in the Assessment Clinic, but I
think you’ll find the therapists in the Mood Disorders Clinic very knowledgeable
and also very nice. Like myself, they will try to gain a broad knowledge of how
things have been going for you over the years, in an effort to understand you better.
Pt.: Good, do I call them or what?
Clin.: I’ll give you a card here (hands card to patient). This has their number on it, and
you can call later today for an appointment. This card also has our number on it, if
there are any other unexpected problems before your appointment. I think you
made a very good decision coming here today. I think they’ll be able to help you to
help yourself.
Pt.: Well, thank you. I actually feel a little better.
Clin.: Good, I have a feeling things are going to go well for you, and I really enjoyed
getting to talk with you today. Give us a call if there’s a problem.
Pt.: Thank you very much, I enjoyed talking with you too. (patient exits)
This is a nice example of a straightforward closing phase. The first thing to note is that
the closing phase takes time. To have this time available, the clinician must leave appro-
priate time for the closing to occur. One of the most frequent problems I see in supervi-
sion remains the over-extension of the main body of the interview, thus forcing the
clinician to rush through the closing phase.
A rushed closing can leave the patient feeling disjointed and uncertain as to what just
happened. To the contrary, during this phase, where engagement looms so critical for
securing a return visit or following up on our recommendations for referral, the clinician
should appear unhurried, concerned, and calm. There is a give-and-take element to the
closing phase. The clinician is truly interested in the patient’s opinions, and this respect
helps the patient to feel a sense of trust and control.
If one looks through this dialogue, most of the questions listed earlier as being per-
tinent to the closing phase were addressed. The clinician added a nice touch by asking
for comments about her own performance. I frequently ask this type of question for
several reasons. Sometimes patients provide very good constructive criticism. Second, the
metacommunication of the clinician to the patient is reassuring, for the clinician is
stating, “I care about how I come across to you and am aware that I sometimes make
mistakes and can improve as well.” This type of metacommunication can help the patient
to feel that he or she will be listened to and not just ordered about.
Before leaving the topic of the closing phase, two areas that are optional components
of the closing phase are worthy of note. The first area is of concern for psychiatrists, nurse
clinicians, and other potential prescribers who are frequently expected to recommend a
medication, if appropriate, at the end of the first session. Introducing a medication is a
fine art and it requires time, probably at least 5 to 7 minutes. Not infrequently, in order
to do it well, it will take longer. Consequently, the clinician must cut back on the body
of the interview by an appropriate amount of time or simply run overtime. I have cer-
tainly done both. Sometimes one has the option of introducing the medication at the
next session, which can provide a more leisurely approach that also may prove to be
more effective.
In any case, it is critical that the discussion of the possible use of medications be done
in a sensitive and engaging fashion, optimizing the patient’s knowledge, comfort, and
interest in the medication. It is unlikely that in the initial interview you will have time
to address all of the following topics. But, from following list you can pick and choose
several tips that will maximize your ability to collaboratively discuss the possible use of
medications and, if applicable, to help the patient match the best medication to his or
her unique needs:
a. Ask what his or her previous experiences with medications have been like.
b. Ask if he or she feels particularly sensitive to meds. If the patient states that this is a
concern, it is important to listen and convey that this concerns you too. Often such
a patient feels better if the physician, nurse clinician, or physician assistant subse-
quently starts off with a lower than normal dose. This is a powerful metacommunica-
tion that the clinician is listening to the patient carefully.
c. Ask if he or she has heard anything about the medication or knows someone who is
taking it. If a close friend has had horrible experiences, this might not be the smart
medication to choose. Consider using an equivalent medication. If none are available,

addressing the patient’s fears directly may alleviate the patient’s reluctance to take the
med. Not eliciting this information is a way of almost guaranteeing that the med will
soon be stopped.
d. Be very open about side effects, and explain common side effects clearly. Any more
serious dangers regarding the med should be discussed in a calm and reassuring
manner, which accurately reflects any risks.
e. Alert the patient that side effects sometimes occur before benefits, and that if the
patient knows what the side effects are, he or she will not be frightened by them. This
is one more reason why it is important to explain side effects in detail.
f. Emphasize to the patient that you need his or her help regarding side effects. Only
the patient knows what he or she is feeling. Ensure that the patient knows that your
goal is not to keep him or her on a medication but to help the patient to find a
medication that he or she genuinely wants to be on because it helps.
g. Emphasize that you are the patient’s consultant. Ultimately, the patient makes the
final decision regarding whether to take a medication or not (this might not be the
case in an involuntary commitment), and you are there to help by providing the best
possible medical advice.
h. Carefully delineate the benefits of the medication and point out specific areas of relief
that you are expecting to see.
i. Emphasize the effectiveness of the medication and describe successes you’ve had with
it and how much better people felt when using it.
There are many other considerations in this area, bridging into the topic of ongoing
efforts to increase patient understanding and interest in medications, which are beyond
the scope of this chapter but will be highlighted in Chapter 23 on the medication inter-
est model (MIM). However, the above principles provide a starting point.
The second area that sometimes becomes a component of the closing phase of the
initial interview is asking permission to contact corroborative informants such as signifi-
cant others and friends. This is one reason that the topic of confidentiality not infre-
quently re-emerges for discussion at this time of the interview. In most instances, I find
that this is not a problem. If the patient does have concerns about contacting significant
others, the wisest course is to explore these concerns in detail. By the way, sometimes
the concerns are good ones, and the patient is correct that the person should not be
contacted (e.g., the patient is stuck in an abusive relationship and the spouse/partner
may be abusive if he or she hears about therapy). Many times the patient’s main concerns
deal with future confidentiality. Once reassurances are made on this point, most patients
will feel comfortable with the contact.
If the patient still seems a little edgy, Morrison has a nice way of phrasing the reasons
for contacting a corroborative source:
What you’ve told me is confidential, and I’ll respect that confidence. You have that right.
But you also have a right to the best help I can give. For that I need to know more about
you. That’s why I’d like to talk with your wife. Of course, she’ll want to know what’s wrong
and what we plan to do about it. I think I should tell her, but I’ll only tell what you and
I have already agreed upon. I won’t tell her anything else we’ve discussed, unless you give
me permission in advance.29
Such a reassuring approach often transforms the patient’s apprehensions.

Naturally, each closing phase will be different, but the basic principles outlined above
offer at least one practical approach. The reader may discover many others. The important
thing remains the realization that the closing phase is different from other sections of
the interview – its character being formed by the changing needs of the two co-participants.
TERMINATION OF THE INTERVIEW: PHASE 5

The termination phase consists of the actual closing words and gestures of the interviewer
and interviewee. As with the introduction, the clinician frequently shakes hands and
smiles appropriately. It is not uncommon, if the clinician is functioning as a triage agent
and will not be seeing the patient again, to wish the patient good luck with a simple
phrase such as, “I hope things go well for you.”
The only problems that tend to arise here occur when the clinician feels, for
some odd reason, the need to be overly formal and cool. Once again, such pseudo-
professionalism runs the risk of creating alienation in the patient. Instead, a quiet warm-
ness seems more appropriate, a warmness generated by two people who have worked
together in an attempt to increase understanding.
I would like to add only that if the clinician will be seeing the patient again, perhaps
as the patient’s therapist, then increased attention to the actions of the patient at termi-
nation may be valuable. Indeed, termination functions as a mini-loss to the patient. In
responding to such a loss phenomenon, the patient may betray behaviors suggesting
dependent feelings and difficulties with separation. These behaviors may offer early clues
to more far-reaching psychodynamic processes.
For instance, some patients may dawdle at the door, looking anxiously back at the
clinician for one more sign of approval or acceptance. Other patients may suddenly
become cooler, as if they resent the ending of their hour. Such a display may be an early
sign of narcissistic entitlement or borderline rage. In any case, a sensitive clinician can
gain some insight from even a small piece of patient behavior, ranging from a peculiarly
soft knock on the door to an unusually rapid series of departing footsteps.
CONCLUSION
In this chapter we have looked at the ever-changing, dynamic structure of the interview
with a sophisticated analytical approach. The use of these strategies and techniques may
seem awkward at first, but with practice they become a natural and integral part of the
clinician’s style. A new and more penetrating intuition emerges from the balance, poise,
and confidence that characterize an interviewer who understands, not only patients, but
the interview process itself. Moreover, patients sense this internal balance and are
powerfully attracted to it. As we pointed out in Chapter 1, talented interviewers are

neither solely intuitive nor solely analytic. They are both.
With interviewing, one is reminded of a fictional art form described by the writer
Herman Hesse in his novel The Glass Bead Game. This so-called game was, in reality, the
most highly evolved of all art forms. In it, an artist attempts to synthesize two totally
opposing views into a unified statement. The more graceful the metamorphosis, the more
brilliant the artist. One cannot help but see the parallel between this fictional art form
and the craft of clinical interviewing. In this context, the reward is not artistic adulation
but increased understanding of the patient and a more powerful sense of caring.
I mention Hesse’s game because the following excerpt, depicting the qualities sought
for in a glass bead player, illustrates the very essence of a talented and flexible
interviewer.
Remember this: One can be a strict logician or grammarian, and at the same time full
of imagination and music. One can be a musician or Glass Bead Player and at the same
time wholly devoted to rule and order. The kind of person we aim to produce, would at
any time be able to exchange his discipline or art for any other. He would infuse the Glass
Bead Game with crystalline logic, and grammar with creative imagination. That is how
we ought to be. We should be so constituted that we can at any time be placed in a dif-
ferent position without offering resistance or losing our heads.30
And so it is with interviewing: flexibility and creativity are born from understanding and
discipline.
REFERENCES
1. Schneider MS. A beginner’s guide to constructing the universe: the mathematical archetypes of nature and science. New
York, NY: HarperCollins Publishers; 1994. p. 288.
2. Storr A. The art of psychotherapy. New York, NY: Methuen; 1980. p. 9.
3. Sommers-Flanagan R, Sommers-Flanagan J. Clinical interviewing. 5th ed. New York, NY: John Wiley & Sons, Inc.;
2013. p. 180–2.
4. Lazare A. Outpatient psychiatry diagnosis and treatment. Baltimore, MD: Williams & Wilkins; 1979.
5. Morrison J. The first interview: a guide for clinicians. New York, NY: Guilford Press; 1993. p. 176.
6. Campbell AA. Two problems in the use of the open question. J Abnorm Soc Psychol 1945;40:340–3.
7. Converse JM. Strong arguments and weak evidence: the open/closed questioning controversy of the 1940s. Public
Opin Q 1984;48:267–82.
8. Dohrenwend BS. Some effects of open and closed questions on respondents’ answers. Hum Organ 1965;24:175–84.
9. Elliott R, Hill CE, Stiles WB, et al. Primary therapist response modes: comparison of six rating systems. J Consult
Clin Psychol 1987;55(2):212–23.
10. Friedlander ML. Counseling discourse as a speech event: revision and extension of the Hill counselor verbal
response category system. J Couns Psychol 1982;29:425–9.
11. Hill CE. Development of a counselor verbal response category system. J Couns Psychol 1978;25:461–8.
12. Lazarsfeld PF. The controversy over detailed interviews – an offer for negotiation. Public Opin Q 1944;8:38–60.
13. Marquis KH, Marshall J, Oskamp S. Testimony validity as a function of question form, atmosphere, and item
difficulty. J Appl Soc Psychol 1972;2:167–86.
14. Metzner H, Mann F. A limited comparison, of two methods of data collection: the fixed alternative questionnaire
and the open-ended interview. Am Sociol Rev 1952;17:486–91.
15. Naik RD. Responses to open and closed questions: an analysis. Indian J Soc Work 1984;44:347–351.
16. Rockers DM. The effects of open and closed inquiry modes used by counselors and physicians in an initial interview on
interviewee perceptions and self-disclosure. Ph.D. dissertation, 1976.
17. Rugg D, Cantril H. The wording of questions. J Abnorm Soc Psychol 1942;37:469–95.
18. Schuman H. The random probe: a technique for evaluating the validity of closed questions. Am Sociol Rev
1966;21:218–22.
19. Schuman H, Presser S. The open and closed question. Am Sociol Rev 1979;44:692–712.
20. Singleman CK. Evaluating alternative techniques of questioning mentally retarded persons. Am J Ment Defic
1982;86:511–18.
21. Sigelman CK, Schoenrock CJ, Spanhel CL, et al. Surveying mentally retarded persons: responsiveness and response
validity in three samples. Am J Ment Defic 1980;84:479–86.
22. Shea SC. Psychiatric interviewing: the art of understanding. 1st ed. Philadelphia, PA: W.B. Saunders; 1988. p. 77–9.
23. Shea SC. 1988. p. 80.
24. Shea SC. 1988. p. 80.
25. Shea SC. 1988. p. 80–1.
26. Benjamin A. The helping interview. 2nd ed. Boston, MA: Houghton Mifflin Company; 1974.
27. Chung-liang Huang A. Embrace tiger, return to mountain – the essence of t’ai chi. Moab, UT: Real People Press; 1973.
p. 179.
28. Sullivan HS. The psychiatric interview. New York, NY: W.W. Norton; 1970. p. 219.
29. Morrison J. 1993. p. 166.
30. Hesse H. The glass bead game. New York, NY: Holt, Rinehart and Winston; 1970. p. 68.
CHAPTER 4
Facilics: The Art of Transforming
Interviews into Conversations
It was said that Wang Hsia’s brush sometimes waves and sometimes sweeps. The color of
his ink is sometimes light and sometimes dark. Following the splotches of the ink he shapes
them into mountains, rocks, clouds, and water. His action is so swift as if it were from
Heaven. Spontaneously, his hand responds and his mind follows. All at once clouds and
mists are completed; wind and rain are painted. Yet, when one looks carefully, one cannot
find any marks of demarcation in the ink.
Chung-yuan Chang, discussing Wang Hsia, Chinese master painter
Creativity and Taoism: A Study of Chinese Philosophy, Art & Poetry1
SENSITIVELY CREATING CONVERSATIONAL INTERVIEWS

Secrets from Everyday Conversation
We have studied the fashion in which interviews develop discrete phases, which for want
of a better term we can call the macrostructure of the interview. We have also studied
what tasks are necessary for each phase, as well as a variety of specific interviewing strate-
gies and techniques for achieving these tasks. What we haven’t covered, though, is: How
does one effectively, within each of these phases, actually weave together all of these
specific tasks, strategies, and techniques?
Within each phase of an interview, every single sentence and question bears a relation-
ship to the immediately preceding and subsequent statement or question. This complex,
almost microscopic analysis of the weave of an interview represents a microstructure of
the interview. Indeed, especially in the body of the interview, how an interviewer achieves
the interlacing of this microstructure may very well determine whether the patient per-
ceives the initial encounter as a cold example of “being interviewed” by some guy with
a clipboard or a laptop, or as an engaging conversation with a warm and knowledgeable
person who genuinely cares about the other person in the room.
In Chapter 1 we observed that an interview in which the engagement and blending
is high seems to take on many of the characteristics of an everyday conversation. A natural
flow emerges. The two participants appear to move with one another. Common hall-
marks of a flowing conversation appear, such as humor and natural body posturing, as
the two become “engaged” in conversation.
The engagement process, spontaneously developed during natural conversation, holds
within itself some pertinent clues as to how we might create a similar naturalistic flow
to a clinical interview itself. Consequently, we will begin our study of the microstructure
of the clinical interview by examining the processes involved in an everyday conversation
as it might unfold in a local café teeming with people, tablets, and smart phones. It is
here, with the sounds of alternative rock and animated chatter bouncing off the walls,
that we may stumble upon some unexpected secrets.
To begin with, if one observes two café habitués chatting over some coffee and cheese-
cake, one will quickly notice – if one possesses a habit of eavesdropping – that their
conversation is not simply a potpourri of unrelated statements. Quite to the contrary,
such conversation usually possesses a gentle structure, determined, albeit unconsciously,
by its participants. In general, one friend brings up a topic, which both friends animatedly
expand. Often the second member of the conversation will ask questions in an effort to
more thoroughly understand the first, while also showing an appropriate increase in
interest.
Once the topic has been discussed, one of the friends will move the conversation to
a new topic. This transition is often prompted by something that has already been dis-
cussed. Frequently the new topic is triggered directly by a preceding statement. And so
the conversation between the friends moves, swelling and ebbing, as more or less inter-
esting topics arise. The basic structure of the conversation consists of succeeding topics
connected by transitions.
A smoothly flowing interview possesses many of these same structural elements. One
of the keys to generating a natural flow of speech during the body of the interview con-
sists of learning to move gracefully from one topic to another while taking cues from the
interviewee’s statements. The interviewer is aware of which topics are most pertinent for
the type of interview being undertaken (initial intake in a community mental health
clinic, university counseling center, private practice office, inpatient unit, emergency
room, telephone crisis center) and can gently guide the conversation to these topics.
Once within a desired topic, the interviewer takes advantage of the natural conversational
mode in order to fully expand that topic. When done well, the interviewer has structured
the interview imperceptibly. The clinician establishes a powerful engagement with the
interviewee while efficiently gathering a strategic database for collaborative treatment
planning.
This ability to structure patients naturally while uncovering a dauntingly large data-
base is one of the most, if not the most, difficult set of skills for clinicians to acquire. As
mentioned in Chapter 3, part of the difficulty is the simple fact that the skills needed to
sensitively gather a large database in a constricted time limit is simply not a skill set used
in everyday life. It is a novel skill set that must be learned.
We have already seen how a carefully delineated supervision language, such as the
DOC, can help a trainee to rapidly learn complex interviewing skill sets such as opening
up a shut-down interview or effectively structuring a wandering interview. The question
Facilics: the art of transforming interviews into conversations 115
is, can we develop a supervision language that can effectively help a trainee to learn how
to sensitively structure an initial interview? In addition, a clear and concise supervision
language could provide a gateway for self-supervision for the remainder of a clinician’s
career, for once a clinician possesses a behaviorally concrete and unambiguous language
for tagging interviewing patterns and techniques, each interview becomes a potential new
learning experience.
In this regard, I certainly hope that I will be learning something new during my very
last clinical interview. I am reminded of the wise words of the great internist Sir William
Osler, “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.”2 Our goal is to create such a
system for our ongoing self-development in the art of transforming interviews into
healing conversations.
Of course, the reason that, historically, trainees had to “wing it” through the complexi-
ties of sensitively structuring the body of the interview was that a simplifying supervision
language, as described above, did not exist for approaching this task until the first edition
of this book. 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 (e.g., open-ended questions and empathic statements), but no language had
been developed to understand and describe how interviewers structure and shape inter-
views as they gather data.
A Solution to the Dilemma

To address this dilemma, at Western Psychiatric Institute and Clinic at the University of
Pittsburgh we developed a new field of study and an accompanying supervision language
with which to train graduate students across disciplines including clinical psychology,
counseling, social work, psychiatry, and psychiatric nursing.3–5 The system was subse-
quently refined in the Dartmouth Interviewing Mentorship Program of the Psychiatry
Department at the Dartmouth Hitchcock Medical Center, with a heavy emphasis upon
direct coaching and the mentoring of trainees longitudinally.6
The resulting system, “facilics,” is the study of how interviewers structure interviews
while gathering data (e.g., what topics they choose to explore, including why and when,
how they go about exploring those topics, and how they make transitions from topic to
topic), including the manner in which they approach this task while managing tight time
constraints. The term “facilics” is derived from the Latin root facilis, indicating grace in
movement.
The practical application of facilics is composed of two activities: (1) learning how to
mindfully be aware of how we are structuring the interview as it proceeds, a process that
will form the foundation for our ability to intentionally and sensitively shape the data-
gathering process and (2) learning how to apply specific facilic interviewing strategies
and techniques that can facilitate the graceful procurement of a unique database. In the
following pages, we will learn how to apply both of these activities in a simple and
practical fashion. By the end of this chapter, the apparently daunting task of sensitively
gathering a powerful database in a short amount of time will appear a good deal less
daunting.
INTRODUCTION TO THE PRACTICAL APPLICATION OF FACILICS

Part I: Learning How to Tag the Flow of the Interview –
What Topics, When?
Descriptions and Characteristics of Facilic Regions
In the body of the interview, one of the first problems facing the novice interviewer
remains the issue of determining what information is important to gather in a full intake
assessment. In this regard, the concept of a “region” is the first facilic concept that we
need to examine.
A region is defined as any section of an interview, lasting at least several sentences,
in which there exists either: (1) a unified attempt to gather data related to a specific
topic or (2) a unified focus upon the process of interaction or upon a non-data-gathering
task. In this sense, two general categories of regions exist, content regions and process
regions.
Content Regions
As with an everyday conversation, an interview tends to revolve around discrete topics.
A “content region” is any area of an interview in which the primary focus of the
interviewer is the delineation of a specific database. As one would expect, during the
exploration of content regions the interviewer continues to carefully attend to patient
engagement.
As we saw in the last chapter, in an initial interview ten or more broad regions are
often focused upon in no set sequence. In order to explore these regions effectively, one
must become familiar with their intricacies. (Some broad regions are composed of
smaller specific content regions. Thus the broad DSM-5 region of substance use disorders
is actually composed of numerous smaller content regions such as cocaine use, opiate
use, marijuana use, etc. And the broad content region of social history is composed of
smaller content regions such as living conditions, employment history, domestic violence
history, etc.) In later sections of this book we will look at methods for sensitively explor-
ing these more specific content regions in detail. At present, it is only important to
emphasize that most topics of discussion can be categorized within one of the following
broad regions. In order to ensure a common, initial understanding of these critical
content regions, let us review them in a little more detail than we did in Chapter 3:
1. History of the presenting problem and/or stresses: This region examines the presenting
situational and psychological problems of the patient. Often this content region is
spontaneously shared by the patient during the opening phase of the interview and
is not part of the body of the interview.
2. Interviewee’s perspective: Most of this material will also be uncovered in the opening,
but nuances will usually appear in the body as well. It generally includes an attempt
to understand the interviewee’s views on his or her problems/solutions and what

type of help the interviewee is hoping to receive. It also touches upon the inter-
viewee’s fears, pains, and general expectations for the interview.
3. History of the presenting illness (HPI): The HPI delineates the chronological develop-
ment of the patient’s presenting primary DSM-5 psychiatric disorder (if one is
present), exploring the types, characteristics, and severity of the patient’s symptoms
and their duration. This database will sometimes also spontaneously begin during
the opening phase of the interview, but it will generally need to be continued and
refined in the body of the interview.
4. Comorbid DSM-5 diagnoses: Many people have multiple diagnoses, some of which
they may even initially try to hide because of stigma, guilt, and/or fear of conse-
quences. Throughout the interview, the clinician will periodically pose various
screening questions about common DSM-5 diagnoses. If the patient comments
positively to the possible presence of a disorder, then the diagnostic criteria for
that disorder will be sensitively explored, an exploration that will subsequently
constitute a discrete content region. The uncovering of any of these disorders, if
initially hidden, can be of immense importance to helping the patient. Missing
comorbid psychiatric disorders can result in significant unnecessary pain or even
suicide (for instance obsessive–compulsive disorder [OCD] and substance use dis-
orders are frequently missed disorders, both of which have significant suicide
attempt rates).
Note that the process of intermittently asking single screening questions for the
various DSM-5 diagnoses – timed to best fit the natural flow of the patient’s con-
versation – is a clinical task known as the “psychiatric review of symptoms.” The
questions themselves are not asked in sequence in a specific area of dialogue but
are gracefully integrated into the interview conversation. Thus the individual questions
of the psychiatric review of symptoms do not constitute a facilic content region. But
if the clinician follows up a screening question with an exploration of criteria for a
specific DSM-5 diagnosis, that diagnostic exploration does, indeed, constitute a
content region.
Your routine diagnostic screening will include questions covering symptoms
suggestive of mood disorders (such as major depressive disorder and bipolar dis-
order), anxiety disorders (such as panic disorder, OCD, generalized anxiety disorder,
social phobia, and post-traumatic stress disorder), the schizophrenia spectrum dis-
orders (such as schizophrenia and schizoaffective disorder), substance use disorders,
eating disorders, personality disorders, and, as indicated, miscellaneous disorders
such as developmental disorders, attention-deficit disorders, gambling and sexual
dysfunction.
5. Social history: Broadly speaking, the social history includes both interpersonal and
environmental information. With regard to interpersonal history, one is interested
in interaction with family, friends, employers, and even strangers, both in the past
and present. Concerning environmental history, a clinician is interested in factors
such as living conditions, neighborhood, economic status, and availability of food
and shelter. This region often includes current and past stressors. It is also the area in
which ultra-sensitive topics such as incest and domestic violence are often explored.
One may also uncover evidence that the patient is facing cultural biases and/or
bigotry related to any number of characteristics including race, ethnic group, reli-
gion, sexual orientation, gender identification, presence of a mental illness/physical
disability, body habitus, etc. (see Chapter 20 on culturally adaptive interviewing).
6. Framework for meaning and spirituality: The patient’s unique worldview will be
explored in this region, with a keen sensitivity to issues of cultural diversity and
spirituality (aspects of this topic will be explored as they arise spontaneously in
other content regions as well throughout the interview).
7. Family history: This region includes an exploration of psychiatric illnesses in the
patient’s blood-related family. It commonly includes a survey of entities such as
schizophrenia, mood disorders, anxiety disorders, suicide, excessive alcohol or drug
use, developmental delays, and seizure disorders.
8. Uncovering of suicidal/homicidal ideation, planning, behavior, and intent: This lethality
region requires a careful and sensitive expansion by the interviewer and should never
be omitted. It will be documented as part of the mental status, although it is actu-
ally always woven gracefully into the flow of the interview itself.
9. Past psychiatric history and treatment: This region explores previous mental health
problems, as well as previous interventions, such as forms of treatment (e.g., psy-
chotherapy, counseling, medication, hospitalizations).
10. Developmental and psychogenetic history: This region traces the development of the
individual from birth onwards, and it can selectively include a variety of topics
(depending upon the proclivities of the clinician and time constraints) such as birth
trauma, developmental milestones, toilet training, schooling, and early relation-
ships as viewed through frameworks such as psychodynamic and/or cognitive per-
spectives. If time constraints do not allow an exploration of this region in the initial
interview, clinicians often opt to explore this region in subsequent sessions.
11. Medical history: This region includes past and present illnesses as well as a medical
review of systems. Current medications and allergies are delineated here. In addition,
current physicians, nurse clinicians, physician assistants, and other health care
providers/alternative healers are also elicited in this region.
12. Cognitive mental status: This region is reserved for a specialized cognitive mental
status, in which a clinician examines processes such as orientation, attention span,
memory functions, reasoning, and general intellect. It forms a discrete facilic region
that is easily identifiable during an interview. It is not always performed in an initial
interview in a formal fashion, but it becomes a major point of focus when the clini-
cian is suspicious that the patient is suffering from a delirium, dementia, or other
impairment of cognitive and intellectual functioning such as might occur in schizo-
phrenia or adult attention-deficit disorder (see Chapter 16 where a thorough cogni-
tive examination is illustrated in Video Module 16.2).
This brief survey illustrates that, despite the immensity of an initial database, the contents
tend to fall into relatively discrete regions. Some of these regions may overlap. In general,
however, a given section of an interview tends to focus on a single region, much as a
conversation tends to focus on a single topic at a time.
It is also important to openly acknowledge that this database appears to be intimidating in

size. Truth be told, it is. It is important to remember that it is rarely possible – perhaps not
possible – to cover all of this information in a single initial interview. I’m not sure I have ever
done so in 30 years of practice! Nevertheless, it is all valuable information that can, indeed,
help the patient when utilized during treatment planning and triage. The art becomes one of
learning how to maximize the amount of useful information that can be elicited during the body
of the interview while always powerfully and gracefully engaging the patient in a conversational
fashion.
With each patient, this solution is a unique one. Clinicians must learn how to priori-
tize information effectively as the interview proceeds. Facilics provides us with the inter-
viewing approaches and strategies to do so successfully. When a well-trained clinician
applies facilic principles, it is rather amazing how much useful information can be sen-
sitively gathered in a mere 50 minutes. It is the patient who benefits greatly from the
clinician’s application of this hard-won skill set.
For the purpose of illustrating a content region, in the following excerpt, the general
region concerning drug and alcohol use is readily apparent:
Clin.: … So right now, have you been drinking at all?

Pt.: No.
Clin.: You talked about using drugs in the past. I’m wondering what kinds of things you
used then and now.
Pt.: Right now I’m only using pot. I don’t mess around with anything else.
Clin.: Are you using it every day?
Pt.: Almost every day.
Clin.: How many joints might you have in a day?
Pt.: Maybe split two; me and Jack might split two.
Clin.: Uh-huh.
Pt.: Because it really does calm me down. It doesn’t make you sick like alcohol can
make you sick, or give you a bad head the next day. It just relaxes you. And now
that it’s legal here, why not take advantage of it.
Clin.: Any type of pills you’re taking now?
Pt.: No.
Clin.: Nothing but the marijuana? (patient indicates with a head nod that nothing else is
being used currently) What kinds of drugs were you using in the past?
Pt.: Well, I never got into any one drug real heavy.
Clin.: Uh-huh.
Pt.: But I have taken LSD, speed, different goofballs, and stuff … but I never injected
any drugs like dope. And I stay away from any shit like K2. I like the real stuff not
some crap some idiot made in a laboratory.
Process Regions
In a typical process region the interviewer is less interested in focusing on content and
the gathering of a specific database than on the process of the interview itself – what is
happening between the clinician and the patient or in the patient’s head as the interview
is proceeding. (Note that there are also atypical process regions, where once again the
focus is not on data gathering per se, but on a specific interviewer task, such as providing
psychoeducation or a specific therapeutic activity such as crisis intervention.) Let us take
a look at the three most common “process” regions.
1. Free Facilitation Regions

This region remains one of the foundations of all interviewing. It is the traditional
method of nondirective listening. In it, the interviewer invests effort in creating an atmo-
sphere in which it is optimally conducive for the interviewee to feel safe enough to begin
sharing problems. The interviewee is able to wander freely to whatever topics chosen
while the interviewer maintains a nondirective attitude. The major interventions of the
interviewer are usually facilitating head nods, uh-huhs, empathic statements (both low
and high in valence), and simple facilitating statements.
These free facilitation regions can appear anywhere in an interview and are often a
very useful method of enhancing engagement. As noted in Chapter 3, during the opening
phase of the interview the clinician frequently utilizes a series of free facilitation regions.
In actuality, the opening phase is a combination of spontaneously appearing content
regions intermixed with free facilitation regions. Furthermore, a psychoanalytically
focused therapy session may consist almost entirely of free facilitation regions strung
together. Naturally, most content regions also place a premium upon engagement; but a
free facilitation process region differs in the goal of its use, which remains the uncovering
of information that the patient reveals spontaneously without direction from the inter-
viewer. In content regions, the interviewer is consciously trying to explore a specific topic.
In a free facilitation process region, the interviewer is consciously allowing the inter-
viewee to wander wherever he or she wants to wander.
A brief example may help to clarify when a section of an interview can be labeled as
a free facilitation region. Note that most of the interviewer’s responses are merely facili-
tating statements, open-ended questions, or gentle commands:
Pt.: My wife and I are really at odds.

Pt.: Oh, we see the world very differently. She is always money conscious and I tend to
see the world as, as … (pauses) I don’t know, more of a place to play.
Clin.: Now that does sound like a bit of a difference (clinician gently smiles). How does
this play out for you guys?
Pt.: Badly (patient smiles). We fight all the time, over the silliest things. And let me tell
you, these are nasty arguments, nothing physical or anything, but really hurtful.
God, they get hurtful.
Clin: In what sense?
Pt.: I’ve called her things I shouldn’t say, and that I didn’t really mean. And so does she.
And then we both miss the point of what life is all about; what’s really important.
Like we have enough food to eat, we are both healthy, and other important stuff …
(pauses).
Clin.: Go on.
Pt.: Like our kids for God’s sake. We have two really wonderful kids. They mean the
world to me.
Clin.: Tell me about them.
Pt.: They are the best. They are so special. They … (patient proceeds to talk about his
children in great detail)
A free facilitation region is generally used to improve engagement. It also often helps to
lower the defenses of the interviewee so that his or her major concerns will surface. In
some instances it can even be utilized to foster the uncovering of subtle psychotic process,
for it tends to bring to the surface whatever is lying just below the surface, as will be
described in Chapter 11.
2. Transformational Regions
In a transformational region, the interviewer actively attempts to decrease a specific
roadblock to communication stemming from unconscious defense mechanisms or con-
scious feelings of anger or defensiveness in the patient. In previous editions of this book,
these were referred to as “resistance regions,” but the term “resistance” seems to miss the
point that these regions of disagreement are invitations to transforming the relationship
in a positive fashion, if handled well.
They are areas rich in information for understanding what makes the patient tick if
approached as an area of collaborative discovery by the interviewer instead of an example
of patient opposition. Such potential points of disengagement – whether they are
expressed by overt patient anger or by aggressive questions asked of the interviewer by
the patient – may arise from any number of factors including the interviewee’s fears,
expectations, or other ramifications of the self-system. Without a resolution of these
concerns, the validity of subsequent data and the power of the therapeutic alliance may
be greatly reduced. In any case, the defining characteristic remains that in a transforma-
tional region, the interviewer consciously is attempting to resolve a communication
roadblock as opposed to gathering information as would be seen in a content region.
In the following dialogue, we see an interviewer deftly navigating a potential point of
disengagement arising around the clinician’s age, for he is 40 years younger than the
patient. Clearly the interviewer is focusing upon addressing the patient’s hesitancies, not
upon gathering a specific database:
Pt.: My boss was really into my work and thinks I may be a little … you know … I
don’t really think I ought to go on. Do you have a supervisor around?
Clin.: You seem concerned about something …
Pt.: Well, I’d just feel a little better if I were talking to someone a little older.
Clin.: What are some of the ways in which you think an older clinician might be better
able to do to help you than a younger clinician? (note the lack of defensiveness by
the clinician)
Pt.: He’d understand what I’ve gone through better, that’s for damn sure. He’d have a
lot more experiences like I have had, seen a lot more of life.
Clin.: You know, Mr. Greyson, I wouldn’t argue with that for a second. It’s true I am
younger than you, and, consequently, I haven’t experienced the same things. It’s an
undeniable fact and an important point that you make. I guess what I’m hoping to
be able to do is to help us both gain an understanding, that is as clear as possible,
of exactly what you’re experiencing and what solutions might be available. My one
advantage is that I’ve worked with many people your age, and they have taught me
a lot about the clever ways they have found for dealing with some of the problems
you are describing. In essence, they have shared their years of experience with me,
just like you’ve been doing, and they have taught me a lot, just like you’re doing.
Maybe some of their experiences, not mine, are what might be useful to you. Does
that make any sense?
Pt.: I guess so. (said a bit reluctantly, but softened in tone)
Clin.: I’m sort of hoping that you might give me a chance to share some of their ideas,
and see how they match up with your own, because you’re right, experience does
count. I think we could be a good team that way – at least I hope so. (patient nods
head in mild agreement) If, by the end of our session today, you still feel
uncomfortable, we can talk about perhaps switching to an older clinician, that’s not
a problem at all. I hope you can give me a chance first though, because I have the
feeling that together, we might be able to turn this thing around for you. Is that
okay with you? To just see how the rest of the session goes?
Pt.: Yeah, I guess so. (said with a gentle agreement)
Clin.: You could help me by telling me a little more about how people have been
pressuring you about your age.
Pt.: It all started with my wife. She left me about 3 years ago, and you guessed it, for a
younger man …
Non-defensively navigating potential points of disengagement, such as the one above, is

a complex task and not always easy to do. It is of such importance that we will devote
an entire chapter to it later in the book (Chapter 19).
3. Psychodynamic Regions
In a psychodynamic region, the interviewer asks questions but is more interested in how
and why the patient responds, as opposed to the content of what the patient says. In
general, the clinician attempts to answer questions such as: How reflective is the patient?
Does the patient have much insight? How does the patient respond to interpretive ques-
tions? How good is the patient’s observing ego?
Answers to these questions may help determine the suitability of the patient for spe-
cific types of time-limited psychotherapy, as well as provide insight into the patient’s
intellectual development, ego strength, defense mechanisms, self-concept, or genuine
readiness to engage in treatments such as substance abuse counseling. To answer ques-
tions in a psychodynamic region, the patient must reflect and offer an opinion.
The following excerpt may clarify when a psychodynamic region is occurring:
Pt.: My father always kept a stranglehold 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.
Clin.: What kind of impact do you think your father’s behavior has had on you?
Pt.: He’s made me scared. I’m afraid of him, and who knows, maybe I keep my
distance from him because of it … Sort of strange though, ‘cause when I was
a kid I always wanted to be around him. I even would wait for him when he was
at work.
Clin.: Go on.
Pt.: Oh, it’s 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.
Clin.: And?
Pt.: Not too much more to say, except that it’s sort of sad the way things have turned
out between us.
Clin.: What are you feeling as you talk about your father right now? (patient wells up
with tears)
Here, content is clearly taking a second place to process. The interviewee’s 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 frequently between content
regions.
Thus far, three types of process regions have been illustrated: (1) the free facilitation
region, (2) the transformational region, and (3) the psychodynamic region. As men-
tioned earlier, other types of process regions exist, including process regions focusing on
interviewee ventilation of emotions, psychoeducation, crisis intervention, or phenome-
nological regions of questioning. These additional process regions often provide windows
through which a better understanding of the patient gradually emerges.
Equipped with a facility to move freely among both content regions and process
regions, the clinician possesses a powerful flexibility with which to approach any given
interviewing task. It is not a matter of learning to interview only in a fairly structured
fashion (emphasizing content) or learning to interview in a nondirective style (empha-
sizing process regions). One needs to master both styles, often delicately interweaving
them into a conversational tapestry.
There does not exist a single “correct style” of interweaving these regions or of sequenc-
ing them. Instead, one finds styles of exploring such regions and creates unique
sequences for each interview of ordering them that may be more or less useful for any
given clinical situation or the needs or personality quirks of a specific patient. Too fre-
quently, students learn only one approach, while building an unfounded bias that other
styles of interviewing are inferior. No surer method of handicapping one’s clinical flex-
ibility can be found.
The Scouting Region: A Unique Combination of Content and Process

Although an understanding of facilics is particularly useful for helping us to navigate the
body of the interview, the system allows us to understand the conversational flow of all
five phases of the macrostructure of the interview described in the last chapter. In this
regard, the introduction and the opening phase of the interview are included in a unique
facilic region called “the scouting region,” which lasts roughly 7 minutes or so. We have
already explored the importance, goals, and strategies of these two phases of the inter-
view. Here, it is only necessary to emphasize the conversational flow of these two regions,
which merge so wonderfully into an interpersonal dance of sorts. In this arabesque, the
clinician introduces himself or herself while both parties “scout-out” who this stranger
is and what are they about, hence the name of the region.
Both process and content are pivotal players in a well-executed scouting region. There
is a premium on free facilitation regions here as the opening phase unfolds, for the
patient is essentially allowed to wander wherever the patient wants to wander, through
the use of many open-ended questions and gentle commands, with a few empathic state-
ments sprinkled into the mixture. On the other hand, as much as the scouting region
emphasizes the use of process, invariably much valuable content-oriented information
will be forthcoming, with patients often spontaneously sharing critical aspects of their
histories early in the interview. Thus, the scouting region (the combination of the intro-
duction and the opening phases) is a unique type of facilic region: It is both a process
region and a content region at once, with an emphasis on attending to the engagement
process, while noting whatever pertinent data spontaneously arises.
Part II: Practical Tips for Applying Facilic Principles to

the Exploration of Regions
Using Time Effectively
The Core Conundrum: Well-Timed Tracking Versus Poorly Timed Tracking
In the first place, many interviews are made or broken before a word is spoken, because
the pre-interview planning frequently determines the success of the subsequent interac-
tion. As discussed above, the clinician needs to ascertain what demands on information
gathering are needed by the clinical situation. In an intake interview situation, as would
be undertaken at a community mental health center, college counseling center, or psy-
chiatric inpatient unit, most, if not all, of the content regions discussed earlier may need
to be addressed, many of them thoroughly. In contrast, an emergency department evalu-
ation of a patient well known to the system may require a significantly different strategy.
In this emergency room situation, the clinician may have only 20 to 30 minutes avail-
able. Consequently, a conscious decision will need to be made as to which content
regions to decrease or eliminate.
One of the most common complaints voiced by supervisees can be summarized as,
“I didn’t have enough time to gather the information I wanted!” This complaint is often
paralleled by harried clinic directors mumbling phrases such as, “My God, how much
longer is he going to take with that patient?” Both exclamations represent the end product
of a poorly structured interview.
To counteract this problem, an understanding of facilics provides the clinician with a
reassuring awareness of “where he or she is at” with regard to the thoroughness of the
database during the interview itself. From this heightened awareness, the clinician devel-
ops an ability to intentionally control the pace and flow of the interview.
When discussing the opening phase, we examined the problem of the wandering
interview, in which a patient with a loquacious manner encounters an interviewer inca-
pable of focusing the flow of the dialogue. The result can be a disappointing experience
for both participants. But many times, a patient with a normal verbal output, who could
be easily directed, meets an interviewer with poor focusing abilities. Even in this case,
the interview may become quite unproductive, because the patient does not know which
information is most needed in order to maximize treatment planning. The resultant
hodgepodge of dialogue can best be called an “unguided interview.”
One may wonder why unguided interviews are so common. The answer is relatively
simple and hinges upon the concept called “tracking.” Tracking refers to a clinician’s
ability to sensitively follow up the statements of a patient with questions pertinent to
the area discussed. At a more sophisticated level, good tracking also requires the ability
to follow up with questions pertinent to the patient’s immediate emotional state. This
ability to track well is one of the main attributes of a good listener. Indeed, the ability
to track well is a prerequisite to becoming a good interviewer.
And here lies the catch – good tracking must be accompanied by an equally good
ability to focus the patient sensitively. Many mental health trainees have developed good
techniques for tracking through the process of attentively listening to family and friends.
However, few have learned from their previous life experiences equally effective methods
of focusing. Fortunately, this crucial ability to focus sensitively can be learned.
Generally speaking, in the body of the interview, once within a content region, it is
frequently best to expand that region relatively fully (usually to completion), because
the patient will generally find such expansions to feel natural, for the topics of discussion
are essentially related. If the patient spontaneously spins off at a tangent into unrelated
topics, it is often best not to track with the patient into the unrelated topic. If one leaves
a specific content region prematurely (before garnering the information needed to help
the patient), one will have to return to that region (in order to gather the missing infor-
mation) in the same interview, sometimes several times. Obviously, if the interviewer
makes a habit of approaching most content regions in this haphazard manner, it becomes
very difficult to monitor what information has been adequately gathered. Consequently,
mistakes of omission occur more frequently.
This haphazard approach also tends to indirectly interfere with engagement and the
understanding of the person. The amount of thought and concentration required to
remember what has been missed and what still needs to be gathered becomes a signifi-
cant cognitive burden to the interviewer. This unnecessary burden, which often creates
anxiety in the interviewer as he or she becomes progressively aware that valuable infor-
mation is not being addressed and that time is running out, takes away from the con-
scious attention on engagement and understanding the human being that has sought
help. In addition, such a disorganized gathering of information makes the subsequent
creation of the finalized electronic health record, typed after the interview is completed,
remarkably more difficult and time consuming.
A Basic Paradigm for Successfully Structuring an Initial Interview

Considering the above pitfalls, one can begin to delineate a general approach to the body
of the interview that will decrease the frequency of both wandering and unguided inter-
views, while maximizing both engagement and a comprehensive database. During the
scouting region, the clinician should formulate a tentative plan for structuring the inter-
view, utilizing the data gained from PACE (see Chapter 3). From this analysis, an initial
content or process region will be chosen as an entrance into the main body of the inter-
view. Frequently, the patient’s own spontaneous discussion will have naturally led into
a specific content region, such as the history of the presenting problem and/or a diag-
nostic area, such as the depression region. If so, the clinician should expand this region
fully and then proceed to the next pertinent region as desired. Wandering patients are
gently refocused if they prematurely leave regions.
To the degree that the clinician determines which content regions are pertinent for a
particular patient in a particular clinical situation, subsequent regions are successfully
entered and expanded as the main body of the interview unfolds. By the end of the first
15 minutes, interviewers will usually have completed the scouting region as well as two
to three content expansions, often having gained a surprisingly good idea of the patient’s
main problems. In the next 15 minutes (the second quarter of the interview), the clini-
cian continues to choose specific content regions and expands them completely in a
sensitive fashion, making sure to always attend to the engagement process by effectively
employing the techniques described in our first three chapters. Naturally, as deemed
necessary, the clinician may pepper the content expansions with process areas such as
psychodynamic regions or free facilitation regions. Slowly the patient’s story emerges,
and with it an increasing sense of understanding. By 30 minutes, it is impressive how
much important information an interviewer, who is intentionally structuring an inter-
view, will have garnered.
If structuring has gone well, the third 15 minutes can be utilized for expanding content
regions deemed more important than originally expected, as well as for gathering data
from the remaining content regions felt to be pertinent for treatment planning and triage.
It is in this third 15 minutes that regions such as family history, medical history, social
history, and the cognitive mental status (if indicated) are often explored.
During the last 7, or so, minutes, regional explorations might continue, and new
questions, generated by the unfolding information, may be asked. But, truth be told,
time is tight here and most of the last 5 to 10 minutes is generally not utilized for further
data gathering. Instead, the clinician focuses on the important tasks described in the
previous chapter that are necessary for a successful closing and termination.
Recognizing and Transforming Two Structuring Gremlins

1. Overly Lengthy Scouting Region: The “Five-Minute Fix”
One of the most common structuring problems, especially earlier in clinical training, is
the tendency to let the scouting region go on and on. It is not uncommon to see scout-
ing regions moving deep into the second quarter of the interview, well past the time
necessary to ensure initial engagement and the other critical tasks of the opening phase.
If the scouting region is overly long, no matter how well structured the rest of the inter-
view, valuable information for helping the patient will inevitably be lost. There is simply
not enough time left in a 50-minute hour to garner it. Thus, this is a clinical gremlin
that it benefits all to avoid.
Fortunately, the fix is pretty simple, but requires some not-so-easy cognitive discipline
by the interviewer. In short, get into the habit of always checking out in your mind
when the first 5 minutes of your interview have unfolded. At that point, ask yourself,
what have I learned from the PACE, and intentionally decide how you are going to make
a graceful transition into the body of the interview. If engagement is weak, one can
intentionally address it and, if necessary, consciously lengthen the scouting region as
needed to ensure engagement. Using the engagement skills delineated in our opening
chapters, I think you will find that, with time, you will seldom need to lengthen the
scouting region past the typical 7, or so, minutes. Develop the habit, right from the begin-
ning of your interviewing career, to note the passing of the first 5 minutes and your scouting
regions will seldom run over-time. Your patients will reap the benefits of being both
better understood and leaving your office with more effective treatment plans for reliev-
ing their pain.
2. The Dead Zone: Two Errors in One

One of the most frequent structuring problems occurs during the second 15 minutes of
the interview. Picture an interviewer, who by 15 minutes has, thus far, skillfully struc-
tured. By 7 minutes, after securing a sound engagement, the interviewer has navigated
an effective scouting region. By 15 minutes they have proceeded to sensitively and com-
prehensively explore two or three particularly pertinent, from the patient’s perspective,
content regions. So far, so good. And now it gets interesting. Literally, that is the problem.
Both parties are now so well engaged that the patient often begins to animatedly wander
off into all sorts of interesting topics or very detailed extrapolations on the topics already
adequately explored. Because the conversation is so interesting, the clinician tracks along
into material that, although intriguing, does not provide information that can help the
patient.
From a facilic perspective, the clinician is utilizing too many free facilitation regions
and following too many spontaneous gates instead of focusing upon and completing
appropriate content regions. When this process occurs, the clinician often finds that after
30 minutes very little of the needed information for an effective treatment plan, or even
a sound triage decision, has been gathered. I have seen this disruptive process unfold so
often in supervision, that my trainees and myself coined the term “the dead zone” for
the second quarter of the interview. It is often dead to the process of uncovering useful
information.
The inadvertent creation of a dead zone in the second quarter of the interview often
begets a second error. When the clinician looks at his or her watch at 30 minutes, per-
ceiving that a substantial amount of material needs to be covered, the response to
their watch is like a track runner to a starting gun in the 100-yard dash – they’re off
and running. The clinician will proceed to force a rapid-paced and rigid structure onto
the remaining part of the interview in an effort to catch up. Phrases such as “Let me ask
just a few other questions here” or “Oh, I forgot to ask this” frequently appear en masse,
as the scramble for “needed” information takes over. The result may be a patient who
begins to perceive that the clinician is more interested in data gathering than in
listening.
This vicious cycle of disengagement can be eliminated if, during the second 15
minutes, the interviewer continues to effectively structure (consistently finishing content
regions and effectively re-focusing patients who are wandering), so that by the 30-minute
mark, the eight to ten content regions that seem most pertinent to a particular patient
have been nicely covered. Once again, it is a matter of developing a sense of time aware-
ness and discipline.
But no matter who we are, and I certainly include myself here, it is easy to slip into
the creation of a dead zone, because it is enjoyable to keep talking about “interesting
stuff” (some of which might be very useful to explore in subsequent psychotherapy but
is not particularly useful during the initial intake). Thus, most of us will occasionally
find ourselves at 30 minutes at a problematic point. Here is where we can avoid com-
pounding our first error with the second one.
If at 30 minutes one finds the interview to be far behind schedule, simply re-group.
Don’t try to gather everything you would normally want to gather. Instead, look at what
is left, consciously decide what you think is most important, and proceed to gather that
information effectively (perhaps a suicide assessment has not been done, a substance
abuse history, or an exploration of pivotal social history as with incest). Explore this
material in an engaging and normal pace. Purposely delete an exploration of the material
that is less critical for an initial assessment (for instance, you may decide to completely
drop the family history, unless you need it to help determine an appropriate medication)
and intentionally shorten other content regions. Less important material can be explored
in future sessions or by future clinicians if you are functioning as a triage agent. When
such a gradual approach is utilized, rigid focusing is seldom required, and the pace of
the interview seems appropriately unrushed to the patient.
Remember, it is okay to miss data. In fact, it is not feasible to perfectly collect all of
the data we listed under our ten categories in most interviews. As I mentioned earlier, I
don’t think I ever have! On the other hand, using the principles, strategies, and tech-
niques of this chapter, it is possible to minimize errors of omission while achieving
surprisingly comprehensive databases for creating effective treatment plans.
The Eight Golden Rules for Structuring Effectively

As can be seen, the body of the interview represents a delicate organism, whose growth
and development warrant careful attention by the interviewer. Perhaps, at this point, a
review and occasional expansion upon the basic facilic principles utilized to move grace-
fully through this area of the interview would be useful:
1. Before beginning the interview, make a tentative determination of which content

regions are most appropriate considering time constraints, the needs of the patient,
and the goals of the interview.
2. At the 5-minute point, note how well the scouting region is proceeding; make appro-
priate adjustments and a decision as to how you are going to move into the body of
the interview, thus avoiding an overly long scouting phase.
3. Begin gently, but persistently, structuring as soon as you leave the scouting region
and during the second 15 minutes.
4. Generally speaking, once within an appropriate content region, it is often useful to

expand it thoroughly. If the patient pivots into a new area, it is usually best to gently
pull the patient back to the current region until it is completed. The exception to this
principle occurs if the patient pivots into a highly charged or sensitive area such as
suicidal ideation or incest. If such topics are spontaneously raised by the patient, it
is generally best to move into them, for the patient is indicating that he or she is
ready to explore what is often a taboo topic. This invitation may disappear quickly
if not accepted promptly by the interviewer.
5. Avoid the overuse of free facilitation regions during the body of the interview.
6. During the remaining interview, occasionally (at least every 5 to 10 minutes) monitor
the progress of your data gathering and adjust your pace as needed, paying particular
attention to where you are with regard to your structuring every 15 minutes of the
interview.
7. In the second quarter, be sure to avoid creating a dead zone regarding information
gathering. If at 30 minutes you are behind, consciously decide what topics and data
to not explore, and proceed to naturalistically explore, at a normal pace, whatever
regions you have decided are necessary.
8. Leave adequate time in the last quarter for a graceful closing and termination phase.
Thus far, we have focused on the general strategy needed to determine and monitor the
regions of dialogue encountered in an interview. Next we will examine the actual process
of exploring a given region once it has been entered.
Exploring Content Regions in a Sensitive Fashion

The process of exploring a given content region is referred to as the “expansion” of the
region. Different interviewers may approach this expansion in radically different ways.
Speaking broadly, two methods, forming somewhat opposing extremes, can be defined
as “stilted expansions” and “blended expansions.” In stilted expansions the expansion
lacks a feeling of conversational flow. Instead, the interviewee is asked a series of ques-
tions that appear somewhat forced, because the interviewer is rigidly attempting to ask
specific questions regarding the needed data points of the content region. This type of
expansion may cause interviewees to experience the unpleasant feeling that they are
“being interviewed,” as opposed to talking with someone. I suppose one could call this
process a “Meet the Press” type of expansion. Rigidly structured interviews sometimes
foster this style of expansion such as illustrated below:
Pt.: The pressures at home have really reached a crisis point. I’m not certain where it
will all lead; I only know I’m feeling the heat.
Clin.: What’s your appetite like?
Pt.: I guess it’s okay …
Clin.: What’s your sleep like?
Pt.: 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 can’t concentrate enough to even read.
Clin.: What about your sexual drive?

Pt.: What do you mean?
Clin.: Have you noticed any changes in how interested you are in sex?
Pt.: Maybe a little.
Clin.: In what direction?
Pt.: I guess I’m not as interested in sex as I used to be.
Clin.: And what about your energy level? How has it been?
Pt.: Fairly uneven. It’s hard to explain, but sometimes I don’t feel like doing anything.
This particular interviewer seems doggedly intent on 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 study in contrasts, in a “blended expansion” the interviewer once again focuses
on a specific content region. However, in this expansion the interviewer attempts to blend
the questions into the natural flow of the dialogue. Rather than feeling like they are
“being interviewed,” this type of expansion creates in interviewees a sense of gentle flow,
which tends to foster a conversational feel. Moreover, this type of interviewing, by
decreasing the anxiety of the patient, may enhance both the quantity and validity of the
database as well. Earlier in the book we saw an excellent example of a blended expansion
unfolding – when exploring depressive symptoms – illustrated in Video Module 2.1 from
Chapter 2.
In the following illustration, a blended expansion unfolds, with the clinician once
again exploring the diagnostic region of depression:
Pt.: The pressures at home have really reached a crisis point. I’m not certain where it
will all lead; I only know I’m feeling the heat.
Clin.: Sounds like you’ve been going through a lot. (empathic statement) How has it
affected the way you feel in general?
Pt.: I’m depressed. I always feel drained. I’m always tired. Life seems like one giant chore.
Clin.: What are some of your everyday things that now seem like chores?
Pt.: Everything! (smiles weakly) Literally, just about everything, even checking my
Facebook page. I love Facebook. I’ve got a zillion friends. I used to check for
messages a couple of times a day, and I was always posting something or other. But
I just don’t care anymore. It just seems like another chore. It’s so strange. Everything
that was normal in my life is screwed up now.
Clin.: That sounds tough. (empathic statement) What about your sleep? Has that been
affected too?
Pt.: Absolutely. Perhaps that’s the reason I’m drained. I just can’t rest. My sleep is horrible.
Clin.: Tell me about it. (gentle command)
Pt.: I can’t fall asleep. It takes several hours just to get to sleep. I’m wired. I’m wired even in
the day. And I’m so agitated I can’t concentrate, even enough to read to put me to sleep.
Clin.: That sounds pretty bad. (another empathic statement, said gently) Once you’re
asleep, are you able to stay asleep?
Pt.: Never, I bet I wake up four or five times a night. And about 5:00 A.M. I’m awake, as
if someone slapped me.
Clin.: How do you mean? (phenomenological exploration with an open-ended question)

Pt.: It’s like an alarm went off, and no matter how hard I try, I can’t get back to sleep.
Clin.: What do you do instead?
Pt.: Worry … I’m not kidding … My mind fills with all sorts of worthless junk.
Clin.: What kinds of things do you worry about?
Pt.: I don’t know. You name it. I worry that I’ve let my family down. I worry about our
rent. I worry about my mom’s health, just everything, and I can’t stop it.
Clin.: That sounds really miserable, I bet it really causes you problems with feeling wound
up and unrested the rest of the day (empathic statement) … Does it cause any
problems with your concentration?
Pt.: Oh yeah. I just simply can’t function like I used to. Typing letters, reading, writing
notes, all those things take much longer than usual. It really disturbs me. My
system seems out of whack.
Clin.: Do you think your appetite has been affected as well?
Pt.: No question. My appetite is way down. Food tastes like paste; really very little taste
at all. I’ve even lost weight.
Clin.: About how much and over how long a time?
Pt.: Oh, about 5 pounds, maybe over a month or two …
In the above dialogue the same region was expanded as in our first illustration (DSM-5
depressive episode), but this time the questioning appeared to flow naturally, generating
an increasing flow of information. The interviewer’s questions seemed to relate directly
to what the interviewee was saying, thus creating a sense that the interviewer was “with”
the interviewee. A nice example of good tracking.
This example also illustrates an important point. While expanding content regions, one
continuously attends to the engagement process. For instance, early in the above selection
the interviewer sensitively utilized a gentle empathic statement, “Sounds like you’ve been
going through a lot.” Further empathic statements followed in a timely fashion. And later,
open-ended techniques were used, such as the gentle command, “Tell me about it,” and
the open-ended question, “How do you mean?” The interviewer thus metacommunicated
an interest in how the patient phenomenologically experienced the symptom, not just
that the patient had the symptom. Such a consistent and effective use of engagement
techniques coalesces to create a feeling in patients that the interviewer is moving with
them in a relatively unstructured fashion, while, in actuality, the clinician is gently struc-
turing the interview, harvesting an ever-more meaningful field of information.
A further point to consider concerning the expansion of regions is the usefulness of
brief excursions out of a region. For instance, while expanding the anxiety disorder
region, the patient may mention the use of Valium (diazepam). At this point, the clini-
cian may choose to expand the medication history briefly, after which he or she can
return to the anxiety disorder region to complete its expansion. Such short excursions
offer yet another flexible option for the clinician. Humor can also be utilized to further
the natural feeling of the interview.
The clinician may also choose to utilize split expansions, with a single region expanded
at several different locations during the interview. Although useful, these split expansions
can lead to serious omissions if the clinician does not keep track of what information
has been gathered. But on a limited basis, split expansions further increase the inter-
viewer’s adaptability.
The over-riding point remains the clinician’s need to develop an active and conscious
awareness of the data flow within a content region while simultaneously creating the
sensation of the natural flow of conversation. Perhaps a few facilic principles warrant
review at this point:
1. An effort should be made to achieve blended expansions as opposed to stilted expan-
sions; such blended expansions move with the patient.
2. As long as one remembers to monitor the completeness of his or her database, then
techniques such as split expansions and brief excursions can be useful, but need to
be used judiciously.
3. Always attend to engagement during the expansion of content regions, both on a
verbal and nonverbal level.
Before ending our discussion of the various methods of expanding regions, one more
point warrants attention. Although stilted expansions generally tend to disengage patients,
some patients may, ironically, prefer them. By way of illustration, this peculiar preference
may surface in the case of a patient suffering from hypochondriacal concerns, associated
with the belief that, “Nothing is wrong with my head.” Some of these patients may actu-
ally prefer the checklist flavor of a stilted expansion because it parallels the feeling gener-
ated by a medical review of systems as performed by his or her family practitioner. Hence,
the patient feels more at home with an interaction more redolent of a medical examina-
tion than of a psychiatric assessment. Once again, the art consists of adapting one’s style
to the needs of the patient.
At this time, we can move to the third and last major concern of facilics, the transi-
tions utilized between regions. The ability to master these transitions will determine the
clinician’s ultimate ability to create a smoothly flowing dialogue.
Part III: Facilic Gating – The Fine Art of Making Graceful Transitions
Gates: The Pathways of Conversational Flow
As a conversation or an interview passes from one topic to another, different types of
transitions occur. We will refer to the actual statements or questions joining two regions
as “gates.” Although there exist numerous types of gates, five major forms are 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 pro-
vides interviewers with a simple but elegant method of gracefully maneuvering an
interview.
Spontaneous Gates
The spontaneous gate, as its name suggests, unfolds without any effort by the interviewer.
Instead, the transition results from a change in topic unilaterally initiated by the inter-
viewee. 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
using phrases as simple as “Tell me more about that,” or “How do you mean?” In the
following example, a spontaneous gate provides an essentially unnoticeable movement
from the expansion of depressive symptoms into a new region:
Pt.:The past 2 months have been so horrible. I think it’s the worst time of my life. I
just can’t get away from the feeling.
Clin.: Which feelings are you referring to?
Pt.: The sadness; the heaviness.
Clin.: What else have you noticed when you’re feeling sad and heavy?
Pt.: Nothing seems worth doing. It’s late November and my yard is covered with leaves.
Usually they’d all be gone into neat little piles, like a little farm, but not now …
Clin.: Besides not having energy for chores, do you find you can still enjoy your bridge
club or other hobbies?
Pt.: Not really. Things seem so bland. I haven’t 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 human dynamo. (pivot point)
*Clin.: How do you mean?
Pt.: Oh, I used to be incredibly active, into bridge, tennis, golf, and everything. It was
hard to find anyone who could keep up with me.
Clin.: Did you ever move too fast?
Pt.: In what sense?
Clin.: Oh, sometimes one can get so energized that it gets difficult to get things done.
Pt.: Actually, there were a couple of odd times when people kept telling me to “slow
down, slow down.”
Clin.: Tell me a little about one of those times.
Pt.: About a year ago I got so wound up I hardly slept for almost a week. I’d stay up
most of the night cleaning the house, washing the car, and writing furiously. I
didn’t seem to need sleep.
Clin.: Did you notice if your thoughts seemed speeded up then?
Pt.: Speeded up. I was flying. Everything seemed crystal clear and moved like lightning.
It was strange …
In this example, two topics are being discussed sequentially. In the first content region,
the interviewee’s symptoms of depression are being explored. In the course of this explo-
ration, the interviewee unilaterally brings up a statement that suggests a different diag-
nostic region (one dealing with mania). The pivot point into a new content region was,
“In fact, there were times in the past when I could barely keep still, I was so active. I was
a human dynamo.”
The interviewer then followed this movement into a region exploring manic symp-
toms by simply asking, “How do you mean?” (indicated by an asterisk). Once within the
diagnostic region of mania, a blended expansion of mania was begun. This movement
into a new topic was practically imperceptible.
Spontaneous gates create movement that seems unblemished by effort or apparent
structuring. In this sense, a skilled interviewer will frequently make use of such gates
whenever transitions into new regions are desirable. But herein lies a potential pitfall
mentioned earlier: It is frequently not desirable to leave a region before it is fully
expanded. One does not and should not follow every pivot point with a spontaneous
gate into a new region.
Indeed, the concept of spontaneous gates and pivot points provides us with a new
way of conceptualizing both the wandering interview and the unguided interview. These
interviews occur when pivot points are followed by the clinician whenever they appear,
resulting in a consistent pattern of incomplete expansions and a subsequently weak
database.
Pivot points represent critical moments in which the interviewer can consciously
decide whether to stay within an expansion or move with the patient into a new one. If
they want to move (the current region is essentially finished), the interviewer simply
employs a spontaneous gate to enter the new region with the interviewee. If the current
expansion is incomplete, nine times out of ten the clinician will gently pull the patient
back into the current topic and fully complete its expansion.
Any clinician who can gain conscious awareness of such pivot points will gain con-
siderable control over the flow of questioning, clipping the wings of an unguided or
wandering interview before it can even take flight. In this light, I believe that the ability
to immediately recognize pivot points, as they occur, is arguably the single greatest secret
to effectively structuring interviews.
As alluded to earlier, although relatively rare in the body of the interview, a clinician
may decide it is wise to move with a pivot point by making a spontaneous gate, even in
the middle of an incomplete expansion. Such times include the following: (1) the patient
may have unexpectedly related highly emotionally charged material that needs to be
ventilated; (2) the patient may have spontaneously mentioned highly sensitive material
that may best be approached immediately, such as suicide, domestic violence, or incest;
and (3) specific memories may warrant immediate follow-up, such as screen memories,
dreams, or traumatic events.
Of course, during process regions, such as psychodynamic regions or free facilitation
regions, the clinician generally follows most spontaneous gates as they appear, utilizing
an occasional restraint. The scouting region is also often filled with “internal” spontane-
ous gates. Along these same lines, during periods of free association, as may appear in
therapy itself, spontaneous gates are essentially always followed; indeed, they are nur-
tured. But no matter what the facilic situation, we return to the all-important realization
that clinicians can exercise significant choice (intentional interviewing) as to the pattern
any given interview will pursue as long as they recognize pivot points and consciously
decide whether or not to follow them.
Natural Gates
A natural gate consists of two parts: the cue statement and the transitional question. A cue
statement consists of the very last sentence or two made by the interviewee and it contains
content material that can be creatively used as a bridge into a new region by the interviewer.
Note that the content material of the cue statement is still within the content region that is being
expanded. If the interviewer cues off this statement to enter a new region of the clinician’s
choice, the interviewee will feel that the conversation is flowing from his own speech, as,
indeed, it is. Such a transition seems both natural and caring to the interviewee.
The transitional question is the actual question asked by the interviewer that makes
a bridge from the cue statement into the new region, i.e., in contrast to the spontaneous
gate, the clinician, not the patient, is moving the conversation into a new region.
In the following excerpt we will see a transition made from the content region cover-
ing depressive symptoms (which the interviewer has been exploring for the last few
minutes and currently feels that she has enough information to make the diagnosis) into
the drug and alcohol region. This smooth transformation will be made via a natural gate.
Clin.: Have you been able to enjoy your poker games or your shop work?
Pt.: No, I just don’t feel like doing anything since I’ve been feeling depressed. It’s a
really ugly feeling.
Clin.: Tell me more about what it feels like.
Pt.: Really pretty miserable. Life doesn’t seem the same. I’m tired all the time; no sleep.
Pt.: Over the past several months sleep has almost become a chore. I’m 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.
*Clin.: Have you ever used anything like a nightcap to sort of knock yourself out?
Pt.: Yeah, sometimes a good belt really relaxes me.
Clin.: How much do you need to drink to make yourself sleepy?
Pt.: Oh, not too terribly much. Maybe a couple of beers. Sometimes more than a
couple of beers.
Clin.: Just, in general, how many drinks do you have in a given day?
Pt.: Probably … Now, I’m just guessing, but probably a six-pack or two, maybe three
(smiles sheepishly). I hold liquor pretty well. I don’t get drunk or nothing.
Clin.: What other kinds of drugs do you like to take to relax?
Pt.: 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 patient’s 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) imperceptibly 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?”
Natural gates of this sort are seldom perceived as structuring 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.
In Figure 4.1, the immense power of the natural gate, as an intentionally utilized tool
by an interviewer, is demonstrated. We shall assume that the expansion of the stressor
region has been winding down. The interviewer feels it is time to move on to new mat-
erial. The interviewer decides to cue off of a statement made by the client regarding his
stress, which can be utilized by the clinician to enter one of any number of new content
regions as illustrated. The flexibility of the natural gate is essentially only limited by the
awareness and creativity of the clinician. The ability to intentionally use natural gates is
one of the cornerstone skills for creating conversational interviews. Master clinicians use
them frequently.
Manufactured “Gates”
One valuable way of using natural gates consists of coupling several of them in a quick
succession so as to gracefully enter a particularly delicate topic that is difficult to enter
without disengagement. In essence, the interviewer manufactures a smooth transition
where one might not have been initially available. I like to call these transitions “manu-
factured gates,” although they are not really a new and distinct type of gate; in essence,
Figure 4.1 Natural gates utilized as smooth transitions.
this is merely the intentional use of serial natural gates. Let us see this sophisticated
strategy put to good use.
Imagine the following situation: About 30 minutes into an initial intake, a counselor
at a community mental health center intuitively suspects potentially dangerous domestic
violence has been perpetrated by the interviewee. In order to get to this delicate topic,
she chooses to manufacture a naturalistic transition. Note that in our illustrative dia-
logue, the interviewer has been expanding the content region regarding recent stressors
with the patient. There doesn’t immediately appear to be an apparent way to sensitively
move into the topic of domestic violence, but she realizes that if she can position the
patient into a conversation about drinking behavior, then the transition could be made
much more easily.
The counselor will use her first natural gate (“Does it ever help you to get away from
all this stress, and you have a lot of stress, by drinking?”) to enter the region of drug and
alcohol use, but she is not doing this in order to expand the region of drug and alcohol
use (which she will do later in the interview). Rather, she is using it as a stepping stone
to an exploration of domestic violence. Look for her timely use of a second natural gate
to immediately leave the topic of substance abuse while cleverly raising the new content
region of violence:
Pt.: … yeah, money is a real problem. I’ve got huge credit card debts. And the damn
creditors are harassing me constantly. Look, I don’t have the money, what do they
want me to do – plant a fucking money tree? Times are bad. I don’t have a job. The
damn repo man took my car. I’m not kidding, they actually hauled it out of my
own driveway. I’ve never really ever been this stressed out. Mind you, I’ll get out of
it. I always do. But, frankly, I don’t know if I’m coming or going.
Clin.: Does it ever help you to get away from all this stress, and you have a lot of stress,
by drinking?
Pt.: You bet. And I deserve a time-out or two. Nothing wrong with a good six-pack or
two to lighten the load, if you know what I mean. It usually works too, unless there
are just too many assholes bothering me.
Clin.: Sometimes when people drink they notice an increased desire to just let off steam,
you know, just pick a fight or something, not much, just a little brawl or two to
liven things up, a chance to flex the old “beer muscles.” Do you know what I
mean?
Pt.: Oh, yeah. I’ve been in my share of brawls. (pauses, smiles) Won a few, too.
Clin.: Has that ever carried over into other areas when you’re drinking? Like when you
and your wife are arguing, does it ever get so intense that you feel like hitting her?
Pt.: Yeah, sort of (pauses, looks away briefly). Just a few weeks ago I wanted to beat the
hell out of her. She can be such a royal pain in the ass.
Clin.: Have you ever wanted to hurt her, in an even more serious way?
Pt.: (pause) Once in a while I guess I have. And sometimes I still think she deserves it.
Clin.: Deserves what?
Pt.: (looks away, pauses, then looks the interviewer right in the eye) To be out of the
picture. It’s crossed my mind, I have to admit it. She’s like a fucking albatross
around my neck.
Clin.: What have you thought of doing?
Pt.: Cracking her upside the head with a hammer or something. I don’t know. (pauses)
I just don’t know anymore. (pauses) I don’t think I’d ever do it.
This is a wonderful illustration of skilled interviewing. How does one raise the topic of
killing one’s spouse in an initial interview while getting at the truth, without harming
the alliance or breaking unconditional regard? This appears, at first glance, to be quite a
task. It is not exactly easy to ask people if they are potential murderers.
But this counselor makes the difficult seem surprisingly easy. From previous inter-
views, she knew that the violence region could be frequently entered through a natural
gate from the drug and alcohol region, by relating violent thoughts and behaviors unob-
trusively to the poor impulse control commonly seen with drinking. Consequently, the
clinician steered the conversation into the drug and alcohol region with her first natural
gate. She thus manufactured a nice opportunity to immediately setup a second natural
gate (“Sometimes when people drink they notice an increased desire to just let off steam,
you know, just pick a fight or something …”), through which she subtly entered the
region of violence with barely a hint of structuring. She could then gracefully generalize
into the topic of domestic violence.
Her skilled interviewing might have just saved the life of this patient’s wife and, at the
very least, she uncovered a major arena for immediate therapeutic intervention. Many a
clinician would not have been able to uncover the murderous thoughts of this patient
upon their first meeting. A second meeting might be one meeting too late.
Having secured a sound understanding of how to effectively utilize natural gates –
including how they can be used to build manufactured gates – let us explore them in
more detail via a video module. Natural gates warrant our further exploration, for, in my
opinion, they are one of the most powerful and flexible tools that we have available for
creating a conversational feel to our interviews. There exist an almost inexhaustible
number of ways to creatively and gracefully transition between topics using natural gates,
of which these video illustrations are a tiny sample.
By the way, when using a natural gate to enter a particularly sensitive topic, they are
often introduced by using words such as, “Some of my patients who have been experi-
encing … (at which point the interviewer cues off of the topic of the patient’s last sen-
tence).” This added technique is known as a normalization, and we will be discussing it
in our next chapter on techniques for improving validity. It metacommunicates to the
patient that it is safe to discuss the new topic, for the interviewer has obviously heard it
from other people in similar situations. In any case, you will see this validity technique
added to our natural gates in several of the video examples. Although normalizations
are quite useful when entering a sensitive or taboo topic, they are not a typical – nor a
necessary – part of most natural gates.
VIDEO MODULE 4.1

Title: Creating Graceful Transitions Using Natural Gates
Contents: Contains both expanded didactics and annotated interviewing examples. Interview
excerpts demonstrate sensitive transitions into difficult topics such as OCD, psychotic process,
dementia, violence, and incest.
Referred Gates
A referred gate occurs when the interviewer enters a new region by referring back to an
earlier statement made by the interviewee often many minutes earlier. 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 metacommuni-
cates, “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 simultaneously a powerful engagement technique. Also, it allows the interviewer
to enter a fresh region smoothly at almost any place in an interview. It remains extremely
useful for re-entering a region that was not fully expanded earlier. Structurally, a referred
gate lacks an immediate cue statement, because the cue has been taken from a previous
area of the interview.
In the following illustration we will enter the interview at the end of a psychodynamic
process region in which the patient’s feelings concerning his siblings have been explored.
As this process region winds down, the interviewer, by referring to something said much
earlier, will enter a content region traditionally viewed to be difficult to gracefully broach
– psychotic phenomena – through the use of a referred gate.
Clin.: What was it like for you when your brother would come home from college?
Pt.: 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.
Clin.: What other feelings did you have?
Pt.: Some excitement. I really did look up to him, and when he’d come home he’d tell
me all about college, frat parties, smoking grass; and it was exciting.
*Clin.: Earlier you had told me that sometimes when you were alone you’d have scary
thoughts. Tell me a little more about those moments.
Pt.: Okay. It’s 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.
Clin.: Do the thoughts ever get so intense they sound almost like a voice?
Pt.: They are voices. They seem very real. In fact, sometimes I try to cover my ears. I just
don’t know. I don’t know …
Referred gates, such as the one illustrated above (indicated by asterisk), are unobtrusively
powerful tools for structuring. They can be used for entering new regions essentially at
will, as well as for re-entering incompletely expanded regions. Moreover, when combined
with a creative sensitivity, the clinician can utilize referred gates to enter potentially dis-
engaging regions gracefully as shown above. It is not unusual for 20 to 40% of my gates
to be referred in an initial intake.
One of these awkward regions that frequently poses problems for clinicians is the
cognitive mental status examination. As mentioned earlier in the chapter, it is often
an important aspect of interviewing patients over 50, especially if one is suspicious of
the presence of a dementia or delirium, and sometimes is also indicated with younger
patients as well. While asking questions about orientation and checking digit spans or
serial sevens, clinicians worry that patients will feel insulted by the simplistic nature
of the questions. To this end, clinicians may utter phrases such as, “I’m going to ask
you some silly questions now, I hope you don’t mind,” or “Now I have to ask you
some routine questions that I have to ask everybody.” These phrases are usually accom-
panied 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 can sense that the clinician feels inse-
cure 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 clinician’s sudden obsequious-
ness serves to signal the patient that something odd is afoot.
It is here that one of the many uses of the referred gate becomes apparent. By referring
to earlier statements of the patient concerning problems with concentration or thinking,
the interviewer can enter the cognitive examination smoothly and without a need to
apologize. Quite to the contrary, the interviewer’s interest indicates a sincere concern to
the patient as well as a display of professional expertise.
By introducing the cognitive exam with a referred gate, the interviewer metacommu-
nicates that these questions are being asked for a specific reason – to clarify collabora-
tively the degree of cognitive impairment – a point of potential concern to both the
clinician and patient. Let us take a look at such an approach in action. The patient is
suffering from an agitated major depression and had complained earlier in the interview
of problems concentrating:
Pt.: Overall, I know it’s all my fault. I should never have retired, it’s ruined everything.
But life goes on. I only hope I feel better some day.
Clin.: What do you see for yourself in the future?
Pt.: Hopefully, some pretty good stuff. I’ve 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 I’ll do a little of that too.
Clin.: That sounds sweet. I hope it works out for you.
Pt.: Yeah, me too.
Clin.: You know, a little earlier, you had mentioned that you were concerned about having
some problems concentrating and remembering things. 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. I think it would be a good idea to
check out these concerns in some more detail, does that sound okay?
Pt.: No problem. That’s why I’m here, to find out what is going on with me.
Clin.: Some of the questions will be very simple, while some of them may get fairly
challenging. Why don’t we start with some of the really simple ones first?
Pt.: Sure.
Clin.: What is today’s date?
Pt.: I think it’s September 21st, 2010.
Clin.: That’s correct. What day of the week is it?
Pt.: Wednesday.
Clin.: Good. What city is this?
Pt.: Pittsburgh.
This interview dyad moved into the cognitive mental status examination with a sense of
purpose and no hint of uneasiness on the part of the clinician. Even if the patient does
not “pick up” on the referred gate, an easy transition can be made as follows:
Clin.: Earlier you had mentioned how depressed and out of it you sometimes feel at dusk.
I am wondering if during this period of the day you notice any problems with
concentration or your memory.
Pt.: No, I don’t think so. No problems with my concentration.
Clin.: That’s very fortunate, because frequently when people feel depressed, they have
problems with concentration or organizing their thoughts. In fact, I would like to
ask some questions designed to pick up even subtle problems with concentration or
memory, because if we find some subtle problems, it may give us some idea of how
we can best help you. Does that sound okay to you?
Pt.: Yes. I don’t think I’ve got any problems here, but I guess it’s worth taking a look.
Clin.: Good, we’ll start with some very simple questions and move towards some harder
ones. To start with, what is today’s date?
We have just seen the usefulness of the referred gate in guiding the discussion into
a cognitive examination. In a similar way, referred gates can frequently decrease the
awkwardness of entering sensitive regions of discussion such as the drug or sexual history.
This effectiveness probably results from the fact that relating the sensitive material to
previous statements by the patient decreases the perceived social inappropriateness of
the question. This principle may seem a bit abstract at present, but the following illustra-
tion will clarify the concept.
In this interview, the patient was an attractive woman of about 30 years of age. She
had her blonde hair pulled back in a bun, giving an impression of a young professional.
She used her hands to sharply punctuate her words like she was furiously stabbing away
at a laptop’s keyboard. She described her various plights in a dramatic and telling
manner. After 30 minutes, numerous soap opera vignettes had been laid out on the table,
including many years of heavy drug abuse in the past, a striking lack of any stable rela-
tionships, over 100 sexual encounters, and a current investigation by the FBI of her old
friends.
She emphasized her sexual freedom early during the interview stating, “I’m not hung
up on having to like the person I have sex with. Sex is something I can easily divorce
from my feelings.” Later in the interview, as the facts of her life became clearer, I began
to wonder if I was talking with someone who might have developed an antisocial per-
sonality disorder, slickly camouflaged by an engaging interpersonal style. To this end I
wanted to expand the antisocial personality region in more detail.
I wondered if she might be involved in prostitution. Needless to say, asking a person
during an initial interview if he or she may be a prostitute can be a delicate matter. In
this case, a referred gate provided a smooth entry into this sensitive topic:
Pt.: All of my men have ended up leaving me. None of them want to be fathers. We
always fight. I’m bored by it all now.
Clin.: Earlier you had mentioned that you have been able to successfully divorce your
sexual feelings from your emotional ones as you’ve matured. I’m wondering if,
because of this ability, you’ve been able to use your body in a purely practical sense,
for instance, did you ever find that desperate financial situations made it necessary
to become involved with something like prostitution? (referred gate)
Pt.: Yeah, I’ve done that too. Back in New York I worked the streets for about 4 or 5
months, not much longer though.
Clin.: What was that like for you?
Pt.: Not really that tough. It’s a dirty business though and I’m glad I’m out of it. But it
helped when I needed it and believe me I needed the money.
Clin.: Did you ever sell drugs back then to help pay the rent and other needs?
Pt.: No. I never really sold drugs, I would use them like crazy – my life has been a wild
one. In fact, someone ought to write a novel about me. I’ve seen it all, but I never
got into pushing drugs.
This referred gate, voiced matter of factly, seemed to flow quite naturally. She did not
appear particularly flustered, and the blending remained high. Once again, to the inter-
viewee, referred gates suggest that the clinician has been listening carefully in an effort
to piece together the patient’s story. One can imagine how differently the above situation
may have unfolded if the clinician had abruptly asked without a referred gate, “By the
way, are you a prostitute?” This method of transition certainly needs a little more polish.
Such abrupt gates are the next topic of discussion.
Phantom Gates
A phantom gate appears to come from nowhere. It lacks a cue statement and also lacks
previous referential points, as seen in referred or natural gates. In short, it jolts the spon-
taneous flow, as the following example will show:
Pt.: I haven’t felt the same for months. I’m always down and I’m sick of it.
Clin.: What does it feel like to be down?
Pt.: Very unsettling. I’m like a slab. I don’t want to do anything. I don’t even have the
energy to text message my friends anymore. I’m not kidding! (pauses) The truth is I
miss doing things with Jennifer. She was my best friend. Silly as this may sound. I
really haven’t been the same since she died.
*Clin.: Was your father an alcoholic?
Pt.: No … (pauses, looks taken aback) I don’t think he was. He drank every once in a
while.
Clin.: What about your brothers, sisters, or blood relatives? Have any of them had
drinking problems?
Pt.: Not that I know of.
Clin.: What about depression? Have any of your relatives been depressed?
This interviewer’s sudden leap into the family history region certainly appeared abrupt
and ill timed. Obviously, if such phantom gates (indicated by an asterisk) occur
frequently throughout the interview, engagement can be seriously hampered. Even in

milder forms, they can quickly produce the “Meet the Press” feeling discussed earlier.
They often pop up toward the end of interviews, when clinicians suddenly realize several
things they forgot to ask, or after the creation of a dead zone in the second quarter of
the interview and the clinician ill advisedly tries to cover too much information. If
important or critical regions (such as a suicide assessment) have been incompletely
expanded or omitted, then referred gates, as opposed to phantom gates, can often return
the interviewee to these unanswered questions without substantially interrupting the
flow of the interview.
With regard to the possible utility of phantom gates, two instances come to mind.
First, when dealing with a wandering interview, phantom gates may be useful in focusing
the patient, especially if milder forms of focusing have been unsuccessful. A second use
of phantom gates arises during the exploration of certain psychodynamic regions. Specifi-
cally, if one wants to catch a patient off-guard in order to observe the patient’s spontane-
ously occurring defenses, then an unexpected phantom gate may be very effective.
Phantom gates may also help one break through the communication roadblock caused
by a patient bent on manipulating the interviewer or as a method of disrupting a
rehearsed interview when used to introduce an affective interjection as described in
Chapter 3.
In a less antagonistic sense, phantom gates may also be utilized when attempting to
help patients reflect upon themselves through the use of interpretive questions. Interpre-
tive questions may assume more bite if asked at an unexpected moment. These latter
uses of phantom gates find minimal applicability during initial interviews, but they are
more commonplace during psychotherapy interviews, once the therapeutic alliance has
been solidified.
Implied Gates
To complete our summary of transitions used during the body of the interview we can
turn our attention to implied gates. These gates are frequently used during chit-chat
between friends and may have been the predominant gate overheard as we listened in
upon the café conversation mentioned earlier.
Implied gates are structurally similar to phantom gates: they do not cue off the
patient’s immediately preceding statements (as in a natural gate); they do not refer back
to earlier statements (as in a referred gate); and the clinician, not the patient (as seen in
a spontaneous gate), 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 immediately previous region.
Put slightly differently, in an implied gate, the movement into a new region is char-
acterized 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 expand-
ing 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 content region dealing with
immediate stressors into past social history, an area frequently also ripe with stress. The
transition (indicated by an asterisk) seems relatively smooth, an effect that is probably

secondary to the similarity in content between these two regions.
Pt.:We’re 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.
Clin.: How are the kids getting along?
Pt.: The two oldest, Sharon and Jim, get along pretty well, on different tracks. They stay
out of each other’s way. But the two little ones – oh my! They live to torture each
other … pulling each other’s hair, yelling, screaming. It’s a zoo.
Clin.: I’m wondering if, with all those mouths to feed, money is a problem?
Pt.: In some respects, yes; but my husband is a lawyer and is doing well. In fact, if
anything, our income has increased recently.
*Clin.: Tell me a little bit about what it was like for you when you grew up back in
Arkansas.
Pt.: 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.
Clin.: Do you remember a specific time when her pain showed through?
Pt.: Oh, yes. I was about 5, I think, and …
As mentioned earlier, 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 dialogue.
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 increase in disparity, the implied gate becomes increas-
ingly more abrupt. Thus, with regard to smoothness, implied gates range on a con-
tinuum 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.
Implied gates can frequently be used to enter new regions smoothly. In fact, occasion-
ally, the clinician may simultaneously expand two regions whose contents are similar in
nature. For instance, one can easily expand the generalized anxiety disorder region and
the major depressive disorder region in a parallel fashion, because anxiety often plays a
role in both disorders.
Miscellaneous Gates
There are two miscellaneous gates that are used much less frequently than the five cor-
nerstone gates we have studied. They, too, merit our attention, for they have good uses
as well.
Introduced Gate
The first gate is called an “introduced gate.” In an introduced gate the interviewer literally
tells the interviewee, that a transition is about to be made. One of the few places that I
find this type of gate useful is the transition point between the body of the interview and
the closing, where it can provide a graceful transition as follows: “Well we have covered
a lot of ground so far today. We have about 10 minutes left before we wrap up, and I
think it’s a great time for me to provide some thoughts on what might be going on and
we can brainstorm together on the various options that we have to get you some relief
as quickly as possible. As we close, I’m wondering, first, if there is anything that you think
we should have talked about that I might have missed?”
Introduced gates are sometimes used to enter a transformative process region, when
a slow build-up of interpersonal tension is noted by the clinician and a decision is made
to try to dismantle the growing hesitancy. An introduced gate might be utilized as follows:
“At this point, let’s take a moment to sort of re-group ourselves, if that is okay with you.
I might be wrong here, but I’ve been feeling, for awhile, that there is something I am
saying or doing that is bothering you a bit, and I sure don’t want that to be happening,
because I really want to help. What have you been feeling about where we have been
going so far and how we have been doing it?” To which a patient may say something
like, “I think you are missing the point here, Doc, I’m not the problem, my wife is the
problem. She gets as angry as I do …” If this concern had been left hidden, there prob-
ably would be no second appointment, and an introduced gate helped to make the
uncovering unobtrusive.
Observed Gate
Our second miscellaneous gate is called an “observed gate.” It is used more frequently
than an introduced gate and is simple in nature, yet quite helpful. In an observed gate,
the clinician makes note of a patient’s nonverbal behavior, often to enter a free facilita-
tion region or a psychodynamic region. Observed gates frequently begin with phrases
such as, “It looks like you are starting to well-up, what are you feeling?” As with intro-
duced gates, observed gates may also be used to enter a transformative process region as
with, “You sound sort of irritated right now, did I say something that offended you or
you think is off base?”
THE FINISHING TOUCHES: SUMMARIZING THE PRINCIPLES OF FACILICS

At this juncture, we are nearing the end of our discussion of the various methods by
which one can flexibly and sensitively structure the body of the interview. Some of the
key facilic principles that can help us to transform a potentially rigid interview into an
engaging conversation that gathers a powerfully useful database are as follows:
a. When the patient spontaneously moves into a new region, the clinician always has
the choice of whether to follow it or not. These decision moments are called pivot
points.
b. If a premium is put upon sensitive, yet efficient, data gathering, as is the case during
the body of an initial interview, then it is often best not to follow these pivots into
new regions. Instead, the clinician can gently pull the patient back into the current
content region and continue the expansion of that region until it is completed to the
clinician’s satisfaction.
c. If a premium is put upon a dynamic understanding of the patient, then these pivots
into new regions are frequently completed by the use of simple follow-up questions,
creating a spontaneous gate. These wanderings of the patient can provide valuable
insights into the patient’s psychodynamics. These pivot points are also followed if it
appears that the patient has begun spontaneously discussing sensitive areas (such
as suicide, incest, or domestic violence) or seems to need to ventilate disturbing
emotions.
d. Natural gates, in which the clinician enters a new region by cueing directly off the
patient’s preceding statement or two, offer another method for creating smooth tran-
sitions and should be employed frequently.
e. These natural gates offer a particularly effective means of intentionally struc-
turing an interview while conveying an unstructured conversational feel to the
interviewee.
f. Referred gates, in which the clinician refers back to earlier statements by the patient,
offer effective methods of re-entering poorly expanded regions or bringing up new
regions, and once again provide a graceful tool for sensitive structuring.
g. Referred gates are also useful for tying in sensitive or awkward regions such as the
cognitive mental status examination, for the patient feels that this “new topic” appears
to relate naturally to the previously referred to dialogue.
h. Implied gates allow one to join topically similar regions and can also provide parallel
expansions of related regions (such parallel expansions should be used sparingly for
they make it hard to track what information has been gathered and what information
needs to be gathered).
i. Phantom gates should be generally avoided unless used for a specific purpose such
as a tool for derailing a rehearsed interview when using affective interjection.
Facilics provides a simple language with which to follow the complex structuring tech-
niques of both ourselves and those we supervise. To enhance this system, a supervisor’s
“shorthand” has been designed in which easily learned symbols are used to represent
regions and gates. These facilic schematics allow supervisors to quickly create a perma-
nent record of the supervisee’s interview, while providing a concrete and visual spring-
board for immediate feedback to the student or for subsequent group discussion. The
schematic system is easy to learn and to use.
For those supervisors and trainees interested in learning how to use the facilic schematic
system for supervision and/or classroom discussion, we have included an ExpertConsult.com
short, easy-to-use computerized interactive program in Appendix I. In addition, an article from
the Psychiatric Clinics of North America7 for faculty and supervisors on how to effectively use
the facilic system with trainees is also available in Appendix IV.
This is also an opportune time to review the annotated, direct transcript of an initial
interview that appears in Appendix II. In this interview, taken verbatim from an actual
clinical intake of mine, you will get a chance to see the five phases of the interview
described in Chapter 3, as they naturalistically unfold. In addition, a variety of the facilic
principles we have just examined will be brought to life for you from an interview I
performed while working in a community mental health center.
CONCLUDING COMMENTS
Once a clinician understands the principles of facilics, then the body of the interview
can be developed and altered almost at the whim of the interviewer. These tricks of the
trade can greatly increase engagement with the patient, the effectiveness of the data
gathering, and, ultimately, the validity of the database itself.
In short, initiated by the conscious decisions of the interviewer, the clinical dialogue
unfolds intentionally and in a person-centered fashion. With each unfolding, the initial
hesitancies of the interviewee gradually recede, for the interviewer, instead of opposing
these hesitancies, moves with them. Clinicians familiar with the use of natural gates and
referred gates, as well as the use of natural expansions as opposed to stilted expansions,
can more easily generate interviews that move with the gentle dynamics of an everyday
conversation. The patient feels more relaxed, defenses drop, and both the interviewer
and the patient are more likely to uncover the information and secrets that lead to
healing.
We began this chapter with a quotation concerning a master artist of China, Wang
Hsia, who painted in the 8th century C.E. He worked in a different time and in a different
medium to the one we have discussed. Yet, he, too, was a student of movement. Like
ours, his work was based on a few simple principles, practiced until discipline trans-
formed them into art. Our “painting” is the clinical dialogue we leave behind us. We,
too, strive for sensitivity and subtlety. Perhaps, with work, fellow students of interviewing
will study one of our future transcripts and find, to their admiration, that “when one
looks carefully, one cannot find any marks of demarcation in the ink.”
REFERENCES
1. Chung-yuang C. Creativity and taoism: a study of Chinese philosophy, art, and poetry. New York, NY: Harper
Torchbooks; 1963.
2. Osler W. Aequanimitas. 3rd ed. Philadelphia, PA: Blakiston; 1945.
3. Shea SC, Mezzich JE. Contemporary psychiatric interviewing: new directions for training. Psychiatry 1988;51(4):
385–97.
4. Shea SC, Mezzich JE, Bohon S, Zeiders A. A comprehensive and individualized psychiatric interviewing training
program. Acad Psychiatry 1989;13(2):61–72.
5. Shea SC, Barney C. Facilic supervision and schematics: the art of training psychiatric residents and other mental
health professionals how to structure clinical interviews sensitively. Psychiatr Clin North Am 2007;30(2):e51–96.
6. Shea SC, Green R, Barney C, et al. Designing clinical interviewing training courses for psychiatric residents:
a primer for interviewing mentors. Psychiatr Clin North Am 2007;30(2):283–314.
7. Shea SC, Barney C. 2007. p. e51–96.
CHAPTER 5
Validity Techniques for Exploring
Sensitive Material and Uncovering
the Truth
My reality is constantly blurred by the mists of words.

Oscar Wilde, Victorian playwright and dandy1
UNDERSTANDING THE CHALLENGE OF EXPLORING SENSITIVE MATERIAL

We have spent the last two chapters exploring the nuances and techniques that can help
us to gather a comprehensive database in a sensitive fashion, the second way-station on
our map. With these two chapters under our belts, you would think we’d be done with
the topic of data gathering. We’re not. One critically important caveat to uncovering a
useful database has not yet been touched upon – truth. To clarify the issue, let me return
to the metaphor with which we opened our study of the clinical interview.
Earlier we had likened the initial interview to a person exploring an old Victorian
room with only a candle in hand, the limited light source representing an exterior hin-
drance to the endeavor at hand. However, a weak light source does not represent the only
barrier to the familiarization with the antique furniture scattered about, because the
method of exploration can provide internal barriers to the effectiveness of gathering an
accurate picture of the room. For instance, one explorer may walk about with his hands
held only at shoulder level, hence missing all the curios lying upon a well-polished table.
A second explorer may underuse her sense of hearing, thus ignoring the presence of a
clock tucked away in a quiet niche beside Sarah Bernhardt’s portrait. A third explorer
may be afraid of dark corners, thus never spotting the elaborately carved chess set hidden
away in the shadows. Thus, it is not only a matter of determining what data needs to be
gathered, it is also a question of determining how one wants to go about gathering it,
for one alters the database by the style with which one elicits it.
For these reasons it is beneficial to explore the issues that determine the validity of
the database, issues that are affected not only by the defenses of our patients, but by the
defenses and idiosyncratic traits of each clinician’s style. On some occasions, it may not
be the patient who is standing in the way of accurate information, but rather the
clinician.
To understand these limitations and the interviewing techniques that allow us to

supersede them, we must first look at what we mean by the term “validity.” Statisticians
discuss a variety of forms of validity, including content validity, empirical validity, and
construct validity. To discuss all three of these concepts is beyond the scope of our study.
Instead, we will look at an admittedly simplified concept of validity, which nevertheless
sheds considerable light by its clinical application. From our perspectives as everyday
clinicians working in hectic everyday environments, validity can be formulated in a
no-nonsense fashion as the answer to a simple question, “Are we hearing the truth?”
And this is not to suggest that our patients are lying, for I have found manipulative
deceit to be relatively rare with my patients. No. There are a myriad of other factors that
prevent us from uncovering the truth including a host of unconscious defense mecha-
nisms (i.e., rationalization, intellectualization, denial, and repression), the vagaries of
memory itself, unrecognized miscommunications between clinician and patient, the
limitations of all humans to see and know the truth, and genuine fears related to stig-
matization as well as realistic concerns of “what will happen to me or my family
members, if I tell the truth?”
Indeed, one of the first rude awakenings for any of us that has ever performed a clini-
cal interview is the revelation that we basically function in the dark. We do not know for
certain what is going on in our patient’s mind. We never will. The delicate arabesques of
the mind cannot be easily transferred from one individual brain to the next. Even direct
conversation is, at best, a second-generation copy of internal experience, brimming with
all of the problems associated with second-generation copies such as information drop-
outs and distortions.
Yet our ability to sensitively uncover the troubling secrets of our patients – whether
they be thoughts of suicide, histories of incest or domestic violence, substance abuse, an
eating disorder, or any act that may create shame or guilt – is at the heart of our ability
to relieve their pain. We cannot undertake effective crisis intervention, or begin optimal
ongoing therapy, if we do not know what the real crisis, stressors, and diagnoses may be.
Besides the simple fact that we need to know the real problem and its extent in order
to maximize our ability to help (with a suicidal patient we cannot get a gun out of a
house if we do not know it is there in the first place), there is another reason that uncov-
ering hidden pain is such an important set of skills for an interviewer to master: If we
are able to help a patient to share a difficult topic, such as domestic violence, incest, or
suicidal thought, which he or she may never have shared with another human being
before, we are not only uncovering important information, we are providing a powerful
new interpersonal experience.
We will have convincingly demonstrated, directly to the patient, that he or she was
able to talk about a stigmatizing topic in detail, and the listener showed both compas-
sion and understanding. Moreover, the listener did not over- or under-react. The reassur-
ing discovery that there are people in this world that one can talk to about topics even
as taboo as incest, domestic violence, and suicide may have already set the stage for the
immediate first movement towards healing, for once the patient steps out of our office,
he or she has a very difficult decision to make: should they return? It is now this patient’s
first-hand knowledge that “it wasn’t so hard to talk with this person about my most
Validity techniques for exploring sensitive material and uncovering the truth 151
frightening secrets” that may prompt them to see us again and to follow up with our
immediate treatment recommendations. In these instances, it is the reassuring experience
of an unexpected sense of safety, which we created, that has provided the first kindling
of hope.
Sometimes the result of helping a patient to share a hidden secret in a safe environ-
ment may have an even more dramatic, yet unexpected, effect. It may save the patient’s
life at a later date. The memory of such a positive interviewing experience with us, even
when we may be functioning as a clinician at a telephone crisis center or in an emergency
department, may prompt the caller or patient, months later during a particularly desper-
ate night, to reach for a phone and not a gun.
Also of major importance are those situations in which our patients are a danger to
others as well as themselves, or perhaps only to others. We have all interacted with an
intoxicated patient, who may also be at risk for committing domestic violence (or has
recently done so). And on some occasions during a first meeting, as we have already
seen, we may become suspicious that our patient is experiencing psychotic process. At
such moments, we will need to raise and explore the possibility of psychosis in a fashion
that is not disengaging, yet allows us to uncover possibly dangerous psychotic process
directed at others, such as command hallucinations or paranoid delusions. It is here that
the skills examined in this chapter (and in our chapters on psychosis; see Part II) may
help us to prevent tragedies, such as the unpublicized killing of a parent by a teenaged
child suffering from a psychotic manic episode to the much publicized slayings at Vir-
ginia Tech or an unsuspecting movie theater in a quiet Colorado town.
As if the above reasons were not enough to emphasize the importance of learning
how to sensitively raise and explore taboo material, these skills are also useful for reveal-
ing those occasions when the patient’s intentions may not be in his or her own best
interest. For instance, a patient suffering from schizophrenia who wants to return to work
too quickly, a decision that might result in a severe relapse and perhaps prevent a return
to work for years, may not readily tell the interviewer about the persistence of serious
auditory hallucinations. On the other hand, a different patient, not suffering from schizo-
phrenia at all but actively seeking disability, may tell the clinician about a plethora of
tormenting yet non-existent voices.
Thus, it is important for the interviewer to be alert for signs that the patient harbors
a hidden agenda, such as needing a mental health professional to document that the
patient is too ill to appear in court or to provide the patient with addictive drugs. For
instance, in an emergency department setting, it is not uncommon for people with immi-
nent court appearances to seem unusually interested in hospital admission, because
hospitalization may represent a clever and logical excuse for missing the court date.
The validity techniques we are about to explore have been developed over the past
several decades by a variety of interviewing innovators across a variety of disciplines
including counseling, psychology, psychiatry, nursing, and social work. Some of these
techniques are specifically geared to decrease the likelihood of deception, thus increasing
the likelihood of valid information. They can even help a patient with antisocial pro-
pensities to share more of the truth about their problematic behaviors such as being a
perpetrator of domestic violence or other problems with the law. When utilized
effectively, these techniques can elicit sensitive material that one might think would never
be revealed during an initial contact. And, indeed, it would not have been revealed had
not the patient been provided a safe environment for sharing and the interviewer used
skilled interviewing techniques within that environment.
As we begin our study of the validity techniques that address the above issues, we will
see that they come in four clusters: (1) techniques for improving generalized recall, (2)
strategies for avoiding miscommunication, (3) techniques designed to help us raise a
sensitive or taboo topic without disengaging the patient, and (4) techniques for carefully
exploring a sensitive area once it has been raised.
VALIDITY TECHNIQUES: KEYS TO ELICITING SENSITIVE MATERIAL

Cluster One: Techniques for Improving Generalized Recall
The Dilemma
It is not only our words that bring on the mists that blur reality, as Oscar Wilde described
in our opening epigram. Neurons do. As I have interviewed over the years, it has become
increasingly clear to me how unreliable memories actually are, even those reported by
patients as, “I remember it like it was yesterday.” Neurons are not computer circuits made
of microchips; they are biological entities made of goo. This state of affairs contributes
to the fact that memories, even when first deposited in long-term biological circuits, are
not necessarily exact. Even more striking is the fact that stored memories may be altered
by new memories in a completely unconscious fashion.
Let me share two personal, non-clinical, encounters with memory drop-out and dis-
tortion that powerfully demonstrate the dilemma. I have had a rare opportunity to study
my own memory at work (or rather, not at work, as the case may be), for I have kept a
journal intermittently for 35 years.
One day I was perusing a journal entry from a trip to London I undertook when I
was a third-year medical student, fortunate to be doing my obstetrics rotation in Not-
tingham, England, as an exchange student. I had gone to London for about a week and
had become good friends with a fellow medical student I met there for the first time.
He and I, according to several detailed journal entries, had great adventures hopping
around pubs in merry old England and walking about Piccadilly Circus. And here is the
catch. Despite having clearly spent days with an individual who was important enough
for me to devote pages of journal writing to our shared experiences, I had no memory
of him. I could not picture his face, a single conversation, or a single moment of laughter.
I don’t believe this rather striking example of substantial memory drop-out can be
entirely attributed to the pints of bitter (English name for a type of pale beer) I imbibed
in our nightly escapades. At least, let’s hope not. To the contrary, it illustrates that memory
often has a fatigue to it; memory drop-out is a normal, not atypical, aspect of the human
brain.
On another day I stumbled upon a journal entry about a big argument I had had with
a relative who had inappropriately yelled and sworn at my 5-year-old son. Being the petty
person that I try not to be, I recalled this incident for several years and always got angry,
especially about his swearing at my son. I remembered it like it was yesterday. Only one
problem: He hadn’t sworn. I was so mad on the day it had happened that I had written
down exactly what he said, in quotations, because I wanted it to be available to show
him someday if I needed some interpersonal ammo. Talk about petty! But that’s another
story altogether. The point for us today is the striking memory distortion that began within
hours. In this case, my neurological goo created a “fact” that had no basis in fact. Not
only a false fact, but it was the “fact” that most upset me emotionally about the incident.
Strange indeed! I have come to believe that such strange happenings are occurring when
our patients are reporting “the facts” much more often than we might be aware.
Anchor Questions
Anchor questions are designed to address the above problems to generalized recall by
“stirring” the memory banks of the patient. The goal is to activate important memories
that we are trying to uncover by kindling memory circuits that are nearby. Anchor ques-
tions come in two main types: time-related and location-related.
Anchor Questions (Focused Upon Time)

Danny Carlat, in his outstanding primer on clinical interviewing, coined the term “anchor
question.”2 Carlat pulls on the research of Sudman and Bradburn showing that people
tend to remember significant distant events in relation to other memorable events that
were happening in their lives, or in their culture, near the moment of the memory being
recalled.3 A person might be better able to tell us when something happened, not with
a question such as, “When did you first begin drinking?” but with a question such as,
“Did you begin drinking before or after you started high school?”
Carlat suggests that a variety of events can be used to help people pinpoint the timing
of recalled events more effectively including: personal events (graduations, accidents,
buying a house, moving to a new city, starting a new job), major cultural events (the
assassination of President Kennedy, landing on the moon, the O. J. Simpson trial, 9–11),
or cultural markers (holidays like Christmas or New Year’s Eve, the turn of the century).
Let’s see the technique at work with a trauma victim, where memories are often hidden
in mists. We will picture a woman in her mid-20s who has been dating the same man
since high school. They have had their troubles off and on for years. According to her,
he has become physically abusive recently:
Pt.: Don’t get me wrong, things haven’t always been bad, or I wouldn’t be with him
still.
Clin.: It sounds like you have had many good times in the past. I don’t doubt that.
Obviously, the recent violence is very disturbing to all involved. If you can, try to
give me a better idea of when he actually started to become violent?
Pt.: Oh, that’s pretty recent.
Clin.: By pretty recent, how do you mean?
Pt.: About a year ago. (pauses) Yeah, I think that’s about right.
Clin.: I remember you told me that you moved here to New Hampshire about 2 years
ago. Had he ever hit or slapped you before you came to New Hampshire? (anchor
question focused on time)
Pt.: Hmm. Well (pauses) … yes, yes he did. I remember he slapped me once pretty bad
back in our apartment in Pittsburgh. We used to call it “The Nest.” We loved that
little place, but yeah, he did slap me there, now that I think about it.
Clin.: How about before that, say back when you were in graduate school? (anchor
question focused on time)
Pt.: We weren’t living together then.
Clin.: Oh, I know that. Can you remember though if, perhaps on a date or if he stayed
over or something, did he ever hit you or slap you back then?
Pt.: My God. (looks up, with a puzzled and surprised expression) You know, he did. I
sort of put it out of my mind. One day, after we came back from a party one of my
friends in graduate school had given, he got really mad at me, saying I was flirting
with another grad student. I wasn’t, by the way. But he got really mad.
Clin.: And what happened?
Pt.: He slapped me. Right across my face. It really hurt.
Clin.: Tell me a little more about what happened that night.
Notice the clinician slowly walking the patient back in time with the use of serial time-
related anchor questions, a strategy that sometimes yields surprising results both for the
interviewer and the patient. In this instance, the gentle uncovering of memories has initi-
ated the therapeutic process. Insight has begun, even during the first interview.
Anchor Questions (Focused on Location)

Here is a technique frequently used by cognitive–behavioral therapists that I have found
very useful in the initial interview. It is a form of anchor question, but the goal is slightly
different than with the time-focused anchor question of Carlat. It, too, jogs the patient’s
memory, but not about a date. Instead, it is used if the patient is about to describe a
specific event that occurred – a dissociated event, a panic attack, a suicide attempt, an
act of domestic violence – that one fears may be distorted or repressed. The goal is to
maximize the validity of the reporting by ensuring that the patient is picturing a specific
memory and not just a blurred collection of similar memories. If the patient can re-visit
a specific memory bank, the hope is that as they “re-live” the specific memory, more and
more details of the memory will spring back.
To accomplish this task, the interviewer asks several questions in a row about the
details of where the patient was when the experience occurred. Once locked into a spe-
cific memory bank in this manner, the subsequent details often begin to tumble out in
a more valid fashion. Naturally, with dissociated memories or violent memories, one
only uses these techniques if one feels it is important to uncover certain details and one
feels the patient can safely, in a psychological sense, re-visit these memories at that
moment.
Suppose a patient has come to you complaining of generalized anxiety, but as you
hear more of the story, you become suspicious that they are having panic attacks. In the
following dialogue, watch how the interviewer locks the patient into a specific potential
panic attack.
Pt.: I guess I’ve always just been sort of wired, but it sure has gotten out of hand.
Clin.: When you say “out of hand” does the anxiety ever come on, really suddenly, out of
nowhere, and it is really intense, sort of overwhelming?
Pt.: That doesn’t happen a lot, but it’s what has been happening more and more.
Clin.: I want you to picture the very worst episode like that. (pauses) Can you picture
when that was?
Pt.: Oh yeah, absolutely, it was pretty bad.
Clin.: Where were you when it happened? (anchor question focused on location)
Pt.: I was out driving with my son.
Clin.: What road were you on? (anchor question focused on location)
Pt.: I had just picked my son up from school. I was just outside of Concord. (the
interviewer has now tapped a specific memory bank, the patient is picturing a real
event unfolding in real time)
Clin.: And what happened?
Pt.: Well, it was really weird. I can’t really explain why it happened, but all of a sudden
I got really worried that something bad, real bad, was going to happen. I started
breathing really really fast, and I couldn’t stop. It was scary. I actually pulled the car
over and …
Tagging Questions
Carlat also describes a nice technique for cuing a patient’s memory about a concrete topic
from a list that the patient is having trouble recalling even though the topic is not a
sensitive one.4 For instance, a patient may have trouble remembering a specific medica-
tion he or she has been on, a type of psychotherapy that has been used, or the name of
a therapist.
If one asked a patient, “What medication were you on back in Pennsylvania?” and
the patient answered, “You know, I don’t really remember what it was called, I know it
was for depression.” Then one could use a tagging question. The clinician does this by
simply offering a list of medications from which the patient then tags the correct answer,
“Do you remember if it was called Prozac, Zoloft, Celexa, Effexor?” To which the patient
might respond, “Oh yeah, that’s it. It was called Celexa. It worked really well for me, but
was kind of expensive.”
Exaggeration
Before leaving the techniques related to improving generalized recall, there is a creative
technique for helping to reduce shame if we begin to see it arise as we explore sensitive
material. Sometimes, despite our best efforts to convey Rogerian unconditional positive
regard, it is obvious that an overly conscientious patient is suddenly feeling an inordinate
amount of shame about a “bad” behavior that he or she has just revealed. Although the
behavior may seem fairly insignificant, the interviewer should never forget that the
accompanying shame in the patient may be far from insignificant. If this is not addressed,
such painful moments experienced in the initial interview may drive the patient away
from the entire process of therapy. At such times, Othmer and Othmer sometimes employ
a validity technique that they call “exaggeration.”5
Exaggeration is a technique for immediately decreasing a patient’s inordinate
shame, so as to increase the likelihood that he or she will continue to share sen-
sitive material, while simultaneously securing engagement. In this sense, the tech-
nique of exaggeration is not only a validity technique, it is an effective engagement
technique.
Exaggeration works by helping the patient understand that when his or her “shameful
activity” is put into perspective with other types of human “wrongdoings,” the patient’s
activity is not of great magnitude, highlighting the fact that you, as an interviewer, are
far from aghast at the patient’s revelation. Effective “exaggeration” requires a well-timed
sense of humor by the clinician, employed in an already well-secured therapeutic alliance.
When done well, as demonstrated below, it can release a marked amount of interpersonal
tension that otherwise could have resulted in disengagement.
In this vignette, the patient is a conservatively dressed woman with her hair tied
into a meticulous bun. She is a successful department store manager with a portable
“time-clock” for a superego. She strives for perfection and expects it of herself. She
has unfortunately developed a nagging generalized anxiety disorder, for which she
has reluctantly sought treatment, despite the admonitions of her superego that “strong
people do not go to therapists.” In her social history she shares what for her is a
major sin of the past, stealing a candy bar from a drugstore when she was 10 years
old. And even worse, she got away with it. Up to this point, the interviewer has
established a nice rapport with her, but she senses the surprising intensity of the
patient’s shame:
Clin.: In the past, have you ever had any problems with the law or arrests?
Pt.: I was never arrested (pauses, eyes briefly turn to the floor). But I did steal
something once. I know it was a wrong thing to do.
Clin.: Oh, what did you steal?
Pt.: I stole a candy bar when I was about 10. I feel badly about it. I know it wasn’t right
to do (patient appears clearly uncomfortable with herself and hastens to add) – I
haven’t stolen anything since.
Clin.: So let me get this straight. At 10 years old you entered a store, pulled out a knife,
stole $200 worth of clothing, pocketed $500 of jewelry, and, as you left, kicked the
store owner’s half-blind cat (clinician smiles).
Pt.: (Absolutely aghast) Oh my gosh no! (she suddenly catches on to the humor and
smiles for the first time in 20 minutes) Of course not (sheepishly smiling). I guess
it wasn’t that bad after all.
Clin.: Not bad (said with a feigned sternness). Why, you stole a Milky Way bar, didn’t
you! One of the big ones too, I bet. My gosh, I have a mind to call the cops right
now, but the statute of limitations has probably expired.
Pt.: (laughing and smiling) Okay, okay, I get the point. I take things too seriously
sometimes (continues to chuckle).
Clin.: (with a normal tone of voice) You know, Jane, let me go out on a limb here. I bet
you tend to get down on yourself pretty hard.
Pt.: Well, I guess you could say that (smiling).
Clin.: Maybe that is something we can take a look at in the therapy. It may be one of the
reasons that you are so anxious. Does that sound like a good idea to you?
Pt.: Yes. I think that would be a very good thing to do. Although I’m a little bit afraid
to do it.
In most cases, “exaggeration” is utilized by employing much shorter phrases. When it is

done well, as with this delightful bit of interviewing, it can effectively transform some
difficult moments.
Cluster Two: Validity Techniques for Avoiding Miscommunication

Defining Technical Terms
Some terms we use, such as diagnostic terms or terms for complex symptoms, are clearly
potentially confusing. Terms such as bipolar disorder, psychosis, and paranoia are inher-
ently technical. Naturally we would always explain them. But, sometimes, a term is fre-
quently used by both professionals and the lay public (depression, addiction) and not
always in the same way. It’s easy to slip these words into a conversation and not realize
that they are being misinterpreted. It is here that Carlat has yet another nice interviewing
strategy – simply put, define the technical term even though it doesn’t sound that techni-
cal. Carlat provides such a nice example of this technique that I’ll just let him share it
himself6:
Clin.: How old were you when you first remember feeling depressed?
Pt.: Hard to say. It feels like I have always been depressed.
Clin.: Just to clarify, I’m not talking about the kind of sadness that we all experience from
time to time. I’m trying to understand when you first felt what we call a clinical
depression, and by that I mean that you were so down that it seriously affected
your functioning, so that, for example, it might have interfered with your sleep,
your appetite, your ability to concentrate, your ability to work. When do you
remember first experiencing something that severe?
Pt.: Oh, that just started a month ago. I’ve never been depressed like this before. Ever.
It’s possible that this patient is suffering from a long-term dysthymic disorder in addition
to her more recent major depression. The clinician’s interviewing skills have prevented
the mistake of viewing her as suffering from many years of a major depression, which
could have led to some missteps in treatment recommendations.
Clarifying Norms
I have found over the years that it is not just technical terms that can lead to miscom-
munication between interviewer and patient. A common problem arises when exploring
sensitive or taboo topics in which the culture, in general, or the patient’s family, in par-
ticular, has taken a traditionally enabling stance. I have seen many clinicians ask patients
questions such as, “Have you ever been sexually abused by someone” and receive a con-
vincing “no” when, in reality, there has been substantial abuse. This problem is not about
stigma. In fact, it is the opposite problem.
This phenomenon arises because the patient grew up in a family where psychological,
physical, and/or sexually abusive behavior was the norm, and the patient has no idea
(although they often have vague misgivings about the behaviors) that what was done
was inappropriate. Thus, the patient above was not minimizing; he or she literally does
not know that he or she was abused. I think you will not infrequently encounter this
type of miscommunication when enquiring about sexual abuse, physical abuse, verbal
abuse, and drinking behaviors (many families accept alcoholic behavior as normal). Be
on the lookout for it.
When raising these topics in an initial interview, I often find it useful to use a strategy
I call “clarifying norms” early on. I will use sexual abuse as an example:
Clin.: You mentioned that your dad was a heavy drinker and hit you a lot. Sometimes
when drinking and violence are around, there can also be sexual abuse. Did your
dad ever sexually abuse you that you can remember?
Pt.: Oh no, nothing like that, not that I remember (said with conviction). I mean if he
tried something like that, I wouldn’t have let him.
Clin.: Of course, problems like that can occur in different ways. At any point, as you
were growing up, did your dad try to do things like touching you in your
private areas, fondling you or doing things like asking you to watch him
undress or did he watch you undress or shower? (clarifying norms) Although
these can be hard to talk about, try to remember if he did any of those types
of things with you?
Pt.: Well, sort of. I mean, he used to watch me shower all the time (pauses) – he still
asks me to do it when I go home sometimes (the patient is 17 years old), but I
don’t let him anymore.
Clin.: When he used to do that, what exactly did he do?
Pt.: He sort of snuck in the bathroom while I was showering and just asked me to pull
back the curtains.
Clin.: When he did that, did he keep his clothes on, or did he take them off?
Pt.: No, he usually pulled his pants down.
Clin.: When he did stuff like that, did he touch himself, you know, masturbate.
Pt.: (patient looks sheepish) Yeah, now that’s the part of it I didn’t like. Maybe he
shouldn’t have done that.
Clin.: Did your mom know about this?
Pt.: Nope. (pauses) He told me he would hurt me bad if I ever told my mom. (pauses)
You know, I think my dad might have had sex with my little sister.
Here is some really nice interviewing in which important material is being uncovered.
The little sister is 12, and she is still at home. The validity technique of clarifying norms
has pulled vital information to the forefront with minimal disengagement. If the
clinician had accepted the first “no” of the patient and not clarified the norms, possibly
none of this information would have emerged.
Cluster Three: Validity Techniques for Raising a Sensitive or Taboo Topic

Normalization
In this technique, first delineated in the clinical literature in the 2nd edition of this book,
the interviewer phrases the question so that the patient realizes that he or she is not the
only person who has ever experienced the behaviors or problems under scrutiny.7 We
saw normalization demonstrated with some of the natural gates that we viewed in Video
Module 4.1 in our previous chapter. This technique can be very useful in raising essen-
tially any sensitive or taboo area. It is particularly useful with a patient who seems to be
guilt ridden or filled with social anxiety that they are odd or doing something bad.
It is a simple technique in which we begin the question by stating or implying that
we have heard this behavior from others, metacommunicating that the patient is far from
alone in having experienced these feelings or behaviors. Normalizations often begin with
words such as, “Sometimes people who have …”
Let’s look at a couple of examples to see how it works:
a. “Some of my patients who are really worried about their weight, have told me that
they will do things to make sure that they don’t gain weight like force themselves to
vomit after a meal. Have you ever found yourself doing something like that?”
b. “Sometimes when people get really angry they say things they later regret. Has that
ever happened to you?”
c. “It’s not unusual when there has been a lot of drinking in a family, like you told me
your dad was doing when you were growing up, for there to be some violence. Did
your dad ever hit you or your mom or brothers and sisters?”
Normalization is also one of my favorite ways to raise the topic of suicide as with:
“Sometimes when people are as depressed as you have been, they find themselves having
thoughts of killing themselves. Have you been having any thoughts like that?”
Numerous variations of normalization can be used to raise the topic of suicide, depend-
ing upon the painful circumstances of the patient:
“Sometimes when people have lost their spouse, and I know how much Anne meant to
you, they find themselves having thoughts of killing themselves. Have you had any
thoughts like that?”
“Sometimes when people are in as much pain as you are describing, they find themselves
having thoughts of killing themselves. Have you had any thoughts like that?”
Said with a gentle tone of voice, normalizations often allow a patient to share suicidal
thought more openly.
Let us take a look at a similar, but slightly different, validity technique, also very useful
for raising the topic of suicide, as well as many other sensitive areas.
Shame Attenuation
There are two types of shame attenuation, also first described in an earlier edition of this
book.8 In the first type, the interviewer cues off of the pain or the situational stress of
the patient to enter a sensitive topic, such as suicide. In the second type, the interviewer
cues off of the patient’s own defense mechanisms (typically rationalizations) to uncover
material that the culture views as “bad,” such as criminal behavior or substance abuse.
Let’s take a look at the first type of shame attenuation and how it can offer us yet another
graceful bridge into suicidal ideation and other sensitive topics.
Shame Attenuation Used to Bridge From Pain or Situational Stress

With the first type of shame attenuation, the patient’s own pain or situational stress is used
as the gateway to sensitive topics such as suicide or psychotic process (note that there is
no mention of any other people in the following question, as we would have seen with
a normalization). In practice, the first type of shame attenuation, when bridging off of
pain, looks like this:
“With all of your pain, have you been having any thoughts of killing yourself?”
If bridging off of the patient’s stress, this first type of shame attenuation looks something
like this:
“With everything you’ve been going through, have you been having any thoughts of
killing yourself?”
Very simple, and perhaps a tad less wordy than most normalizations. And, when said
with a gentle tone of voice, very effective. One of the things I really like about this first
type of shame attenuation when used to raise the topic of suicide (or any other sensitive
topic) is how easy it is to use, and it can be used with just about any patient, no matter
what the patient’s circumstances, for psychological pain and personalized stress are ubiq-
uitous. It is one of my favorite ways to raise the topic of suicide.
By using shame attenuation as a bridge from pain, an interviewer can sensitively raise
many other difficult topics. For instance, raising the topic of psychosis is often viewed as
difficult to do in an engaging fashion, and rightly so. It is safe to assume that not many
patients like the idea that their interviewer suspects they are psychotic. But, with the use
of shame attenuation, even this daunting challenge to engagement is surprisingly easy. I
have found the following question effective at this task: “With all of the pain you have
been having, are your thoughts ever so intense that they sound almost like a voice
to you?”
It’s a wonderfully phrased question for it arises naturally from the patient’s immedi-
ately preceding self-report of pain and also leaves a “face-saving out” for the patient with
the words, “almost like a voice.” Thus, he or she does not have to admit to hearing voices
immediately and can say something like, “Well, sort of, but I don’t think they are voices.”
With further questioning, we can sort out whether or not we feel voices may be present.
If present, we can follow up by hunting for command hallucinations (voices that are
telling the patient to do something) such as commands to kill themselves or harm
another.
As we saw demonstrated in our chapter on facilics, both normalizations and shame
attenuations are often utilized with natural gates. Their use with natural gates is particu-
larly popular for transitioning from a non-sensitive topic into a sensitive or taboo topic.
Shame Attenuation Used to Uncover Aggressive, Unethical, and Antisocial Behaviors

Let us, for a moment, take a look at our second type of shame attenuation. It can be
highly effective at entering a topic such as substance abuse or violence by cuing off the
patient’s own rationalizations and defense mechanisms for doing the behavior. Unlike
our first type of shame attenuation (in which we cued off of the patient’s legitimate pain
or reality-based stress), in the second type of shame attenuation we will cue off of a
patient’s distorted view of reality caused by common everyday defense mechanisms. Not
infrequently, what a patient states as the problem (e.g., “my boss is an asshole”) is not
necessarily the real problem (or the only problem). The patient’s behaviors may be the
main problem, as with alcoholism.
The challenge with trying to uncover behaviors viewed as bad by the culture (such as
antisocial behaviors) is the fact that if the patient answers positively to our question, he
or she may feel they are admitting that “I’m a bad person” or will get into trouble. The
natural result is a feeling of shame and/or guilt, which can clearly act as a deterrent to
open expression on the part of the patient and can also damage engagement. The word
“attenuate,” which simply means “lessen,” was used for this validity technique because
this technique is very effective at lessening the patient’s shame or guilt by phrasing the
question using the lens of the patient’s own rationalizations. The basic premise of this
form of shame attenuation is that if we can figure out the patient’s rationalizations for
why he or she is doing something and then ask the question from the perspective of the
patient’s own rationalizations, perhaps the patient may be more likely to answer openly.
To effectively use this second type of shame attenuation, the interviewer must be able
to do two things: (1) intuit how the patient has rationalized their own behaviors so that
they seem okay to do and (2) ask the question while viewing the situation through the
eyes of the patient and using the patient’s rationalizations. A shame attenuation can
either be a statement made before a question (that places the context of the question
from the patient’s perspective) or can be part of the question itself. This technique is a
little harder to understand until we see it used.
For example, picture a patient who relates feeling depressed and angry at the world.
As you move deeper into the interview, you begin to intuit that the patient is a big-time
drinker with essentially no insight into his or her drinking problem.
If a clinician chose to ask, “Do you think you have a drinking problem?” many such
patients would answer with a rather shocked “no.” In addition, the question itself might
disengage the patient. But in the following example we will see a different approach – the
application of shame attenuation – that results not only in more valid information but
causes no disengagement at all:
Pt.: I guess some of my best times are with my friends. I really would rather be with my
male friends than with my wife and some of her losers. Talk about boring, they
invented the word.
Clin.: Are these the same guys who are your drinking buddies?
Pt.: Yep. They’re the ones.
Clin.: Well where do you guys like to go for a brew?
Pt.: All over the place. We’ll tie one on anyplace anytime.
Clin.: You know, when you are out with your buddies like that, do you have a problem
holding your liquor or are you pretty good at holding your liquor? (shame
attenuation)
Pt.: Oh, I don’t have any problems holding my liquor. I’m not the best mind you, but I
can hold my own.
Clin.: How much can you put-down in a single night?
Pt.: Oh a six-pack, twelve-pack, no problem (said with a cheerful sense of pride).
Clin.: How often in a given week do you drink a six-pack or twelve-pack, in all
seriousness.
Pt.: In all seriousness … I’d say two or three nights a week. Well, make that two nights.
It’s usually only on weekend nights that I really go after it. By the way, I held down
a case one night (pauses) well I sort of held it down (smiles sheepishly).
In this example the interviewer has phrased the question in such a way (“… when you
are out with your buddies like that, do you have a problem holding your liquor or are
you pretty good at holding your liquor?”) that if the patient answers with a positive to
the last part of the phrase (“Oh, I don’t have any problems holding my liquor. I’m not
the best mind you, but I can hold my own”), then he or she is actually stroking his or
her own ego as opposed to admitting a flaw. In fact, to admit that “I have problems
holding my liquor” represents the answer more likely to produce shame.
This exchange is both more comfortable for the patient while also more likely to yield
valid data than a direct question such as, “Do you think you might have a drinking
problem?” or “Do you think you are an alcoholic?” Of course, one must also make sure
that the patient is not purely bragging. This can usually be accomplished by subsequently
delineating the actual drinking history via specific questions aimed at eliciting behavioral
specifics, as this interviewer was just beginning to do.
This technique is so valuable that we ought to see it in a different context. In this
instance the clinician is suspicious that the patient has had problems with irresponsibility
and angry exchanges on the job with his bosses. However, the patient is somewhat cagey
around this topic. The clinician has also accurately intuited that this particular patient
does not see himself as the problem. In his view, the bosses are the problem.
Consequently, the technique of shame attenuation is used to create a safer environment

for the patient to share things as he sees them “going down” at the office.
Clin.: What have your jobs been like?

Pt.: Oh, nothing special, I’ve always gotten along okay.
Clin.: Ever have any problems on the job?
Pt.: Nah, none worth mentioning.
Clin.: How about with bosses, have you had any bosses who really seemed like they
needed to be “big shots,” you know, the kind that just like to get on somebody’s
case? (shame attenuation)
Pt.: Now that you mention it, more than I care to think about.
Clin.: What do you do, when a boss gets off on a power trip like that? (another shame
attenuation)
Pt.: Oh, I let them know where I stand, nobody is going to just push me around.
Clin.: Well, what might you do if the boss seemed out of line?
Pt.: I’d tell him to get off my back, that’s what I’d do.
Clin.: How do they usually react?
Pt.: Most of them back off.
Clin.: Any of them ever get mad and fire you?
Pt.: A couple have, but I didn’t want to work for them anyway.
Clin.: How many times have you been fired, would you say five times, ten times?
Pt.: Hmm … maybe around five times, somewhere around there.
What a difference skilled interviewing makes. We went from a patient reporting, when
asked whether there were any problems on the job, “Nah, none worth mentioning,” to
an open admission of being fired several times, without even a blip in the engagement
process.
Shame attenuation can also be useful in uncovering domestic violence as well. Patients
who have anger control problems, even when they might feel they need help, can find
it very hard to share acts of domestic violence. Shame attenuation can ease their anxieties
and lead gracefully into a more useful exploration of abuse issues with questions
such as:
“It sounds like you are super stressed. Do you feel the stress has ever pushed you to do
something you really regretted, such as striking your wife or your child, something
that is just not like you?”
An important point to remember with regard to the technique of shame attenuation is

that the clinician must be careful not to side with the patient or condone the described
behavior. Such over-identification gives a false impression to the patient and also conveys
an inaccurate moral judgment.
With shame attenuation the clinician does not validate the behavior but metacom-
municates that from their clinical experience, they understand how people can fall into
such a behavior. In the spirit of Rogerian unconditional regard, the clinician attempts to
suspend judgment while voicing the question in such a manner that the patient may
respond from the perspective of how he or she sees it. Thus, although a patient with an
antisocial personality frequently sees other people as the troublemakers, the clinician
neither agrees nor disagrees with this stance. Moreover, the phrasing of the question
allows the person with the antisocial structure to express the world as it is seen through
his or her own eyes.
Induction to Bragging
In their outstanding text, The Clinical Interview Using DSM-IV,9 Ekkehard and Sieglinde
Othmer demonstrate a technique that they call “induction to bragging,” which takes
shame attenuation one step further. As with shame attenuation, they believe that it is
quite effective with people displaying an antisocial character structure. In its simplest
form, the clinician attaches a positive adjective to a behavior with a negative association,
as with the following question, “Were you a good fighter?” In this simple form it is no
different than shame attenuation. But when the clinician actually passes on a compli-
ment to the patient in a statement preceding the question, then “induction to bragging”
represents a new and distinct validity technique.
In this use of induction to bragging, the clinician begins with a complimentary state-
ment, which makes it easier for the patient to “almost brag” about a behavior that is
somewhat less than exemplary. Othmer and Othmer give as an example, “You seem to
be sly like a fox …,” a description that a person, shall we say, prone to deceit might find
a bit more to his or her liking than “You’re a deceitful son of a bitch, aren’t you?” – not
that a clinician would say the latter, although many of us have thought it. After giving the
above compliment, the clinician can then proceed to inquire about deceitful behavior in
a more productive fashion, fueled by the patient’s desire to live up to the compliment.
Let’s see how induction to bragging can help a patient to share self-incriminating
information:
Clin.: What other types of things did you and your buddies do back in high school?
Pt.: Oh, we hung out together. I’m not saying we were a gang or something, but we
were somebody you don’t mess around with.
Clin.: Well, you are obviously very big and clearly work out regularly, I bet you don’t take
any shit from anybody? (induction to bragging) How many fights have you actually
been in?
Pt.: Oh, a lot. I could really hold my own.
Clin.: Did you ever use a knife on anybody?
Pt.: Don’t need to. I got these (patient holds fists up and smiles). I used a tire chain on
some guy once.
Unlike Othmer and Othmer, I like to limit the use of the term “induction to bragging”
to those situations in which the clinician literally compliments the patient in a prefatory
statement, so as to clearly distinguish it from shame attenuation. For example, when
using shame attenuation a clinician might inquire about whether the patient may deserve
some praise (“What do you do, do you tend to take their shit or are you the kind of guy
who likes to let the boss know where you stand?”). In contrast, with induction to bragging
there is a direct, clear-cut complement (“Well, you are obviously very big and clearly
work out regularly, I bet you don’t take any shit from anybody.”).
It is not necessary, or typical, to use “swear words” with patients, such as the word
“shit” in the example above. But occasionally it may be useful. In this case, the patient
had first used the word earlier in the interview, thus the interviewer chose to mirror the
patient’s own phrasing, a process that potentially enhanced the power of the induction
to bragging. If uncomfortable with such a word, the clinician can opt to not use it, for
there are many alternative phrasings. Interviewers must use what feels natural to them.
Cluster Four: Validity Techniques for Exploring a Sensitive Topic Once It

Has Been Raised
Behavioral Incident
To begin our exploration of this cluster, we will look at a validity technique known as
“the behavioral incident,” which was developed by Pascal and Jenkins and presented in
an eminently useful fashion by Pascal in his book, The Practical Art of Diagnostic Interview-
ing.10 The basic concept can be delineated as follows.
When a clinician is particularly concerned about gaining accurate information, it is
often best to ask the patient to describe specific historical details as opposed to asking
the patient his or her opinions about these details. Once a patient is asked to give an
opinion, the validity of the data becomes more suspect, because the clinician does not
know how accurate the patient’s perceptions may be.
All kinds of factors may predispose a patient to provide distorted information when
asked for his or her opinion, including unconscious defense mechanisms, fears of stig-
matization, fears of the consequences of telling the truth, a need to appear important, a
need to minimize bad behaviors, conscious manipulation or malingering, inaccurate
perceptions caused by lack of maturity or intellectual dysfunction, a communication
misunderstanding of what the interviewer is asking, and peer pressure to distort the truth
or protect somebody.
For instance, if the clinician wants to determine whether a patient dates frequently,
an interviewee may respond to a patient-opinion question such as “Do you date fairly
regularly?” with a simple “yes,” because he or she may be embarrassed to relate a sparse
dating pattern. To sidestep this problem, the clinician could specifically ask about the
frequency of dates over the past several years and ultimately the past several months. If
the clinician finds only several dates spanning the past 12 months, then the clinician
will have discovered a lack of dating activity without necessarily embarrassing the patient.
As Pascal states, in general it is best for clinicians to make their own judgment based on
the details of the story itself, for it seems unwise to assume that patients can objectively
describe matters that have strong subjective implications.
Pascal calls the discrete historical behaviors elicited “behavioral incidents.” I like to
also utilize the term “behavioral incident” to refer to the actual interviewing technique
itself. In this sense, there are two types of behavioral incidents. In the first style (fact-
finding behavioral incidents), the clinician asks for a specific and concrete bit of behav-
ioral information or a train of thought, such as “Did you load the gun?” or “What
thoughts were going through your mind at that moment?” In the second type (sequenc-
ing behavioral incidents), the clinician simply asks the patient to “chronologically”
unfold the story with questions such as, “What happened next?” or “Right after your
friend accused you of lying, what was the very next thing you said to him?” Below are
some other examples of behavioral incidents:
1. “When you say you ‘threw a fit,’ what exactly what did you do?” (fact-finding behav-
ioral incident)
2. “Did you put the razor blade up to your wrist?” (fact-finding behavioral incident)
3. “How long did you leave it there?” (fact-finding behavioral incident)
4. “What did your boyfriend say right after he hit you?” (sequencing behavioral
incident)
5. “Tell me the next thing that went through your mind?” (sequencing behavioral
incident)
Pascal believes that interviewers frequently collect invalid data because they do not ask
specifically for such concrete information. It is an extremely useful principle, worthy of
illustration.
Let us assume that an interviewer is interested in accurately determining the amount
of open affection shared between a woman and her husband. We will look at two hypo-
thetical dialogues with the same woman but with different interviewers. In the first
excerpt, the interviewer asks primarily for the patient’s opinions, a process that yields
invalid data. In the second excerpt, the sensitive use of behavioral incidents provides a
different story.
Interviewer 1
Pt.: Basically I’ve been very busy, what with the kids and my mother getting sick.
Clin.: Do you feel happy with your husband’s support? (patient-opinion question)
Pt.: Yes … yes he’s been fairly good about it all.
Clin.: Is he very affectionate? (patient-opinion question)
Pt.: (pause) Uh-huh, affectionate enough.
Clin.: Have there been any financial strains?
Pt.: No, not really. Although the past several months have been a little tight, what with
decreased benefits and a new school year starting.
Interviewer 2
Pt.: Basically I’ve been very busy, what with the kids and my mother getting sick.
Clin.: What kinds of things does your husband do to support you? (fact-finding
behavioral incident)
Pt.: Well, he’s been a little less demanding, he doesn’t get upset if the dirty dishes stack
up a little longer or a shirt is a little wrinkled.
Clin.: When he comes home from work, what is his typical routine? (fact-finding
Pt.: That’s pretty simple. He’ll walk in the door, I usually don’t see him come in and he
goes straight back to his room to change clothes.
Clin.: And then? (sequencing behavioral incident)
Pt.: Well, let’s see, I usually knock on the door and let him know dinner will be ready.
Clin.: Do you go in and talk with him then? (fact-finding behavioral incident)
Pt.: No, I go straight back. Oh, I usually peek in and say hello, but I have to get back to
the stove.
Clin.: During the course of the night, is he the type of man who likes to hug, or does he
prefer to keep a little more to himself? (patient-opinion question)
Pt.: Well, let me see, he really doesn’t hug a lot. No I can’t say he does.
Clin.: Do you remember the last time he hugged you? (fact-finding behavioral incident)
Pt.: I honestly can’t remember (patient’s affect is becoming more sad).
Clin.: You look a little sad. How long has it been since he last hugged you? (fact-finding
Pt.: (patient looks at interviewer and pauses with a little sigh) I think the last time he
hugged me was about 6 months ago near Christmas. I remember because I was so
pleased by it. It’s rare for him to touch me like that anymore. (pause) It didn’t used
to be this way … (breaks into tears).
Clearly, the second interviewer seems to have uncovered a different and more valid story
than the first one. Through the gentle use of behavioral incidents, the second clinician
has gathered evidence that problems exist in the marriage, a situation the first interviewer
missed.
I have found Pascal’s concept of the intentional use of behavioral incidents to be one
of the most powerful interviewing techniques I have ever learned. It is elegant in its
simplicity, powerful in its execution. There is one tough clinical situation where I have
found the application of a series of behavioral incidents into a flexible interviewing
strategy to be invaluable. Specifically, when one is faced with the task of uncovering a
highly sensitive or painful incident, such as a suicide attempt or an act of domestic vio-
lence, the serial use of behavioral incidents is remarkably effective at “getting the facts.”
Here, invalid data (a patient downplaying the seriousness of his or her suicidal intent)
is a mistake that can prove to be fatal.
I like to call this strategy “making a verbal video,” a term that is very popular with
trainees because it so vividly captures the core of the strategy. In cognitive–behavioral
therapies the process is often called a “chain analysis.”
When making a verbal video, the interviewer interweaves a series of fact-finding and
sequencing behavioral incidents that prompts the patient to create a verbal “walk-
through” of what happened. If done well, the clinician should be able to see exactly what
happened in his or her own mind, allowing him or her to better evaluate the extent of
action taken towards suicide by the patient or the degree of violence involved in the act
of domestic violence. If the patient suddenly skips ahead, creating a gap in the verbal
video (we call these “Nixon Gaps”), the interviewer simply rewinds the video by asking
the patient to go back to where the gap began and prompts the story to re-start from
there with more behavioral incidents. Let’s see this serial use of behavioral incidents
at work.
Helping a Patient to Describe an Episode of Intimate Partner Violence (IPV)

We are interviewing a young woman in an emergency department late at night. She has
come in following an incident of domestic violence. We have engaged her well, effectively
tending to the array of emotional needs of a survivor of recent violence. We are at the
point in our interview in which it is critical to determine the extent of the violence, for
we need to determine whether the patient can safely return home or whether she needs
to stay with a friend or go to a shelter due to a high risk of further violence.
But here’s the rub. It can be very hard for any person, no matter how strong they may
be, to share the extent of IPV for many reasons: defense mechanisms may be masking
the extent of the violence, fears of ramifications for the perpetrator may be present,
ambivalent feelings for the perpetrator may be present, feelings of humiliation and
shame may be active, it can be painful to describe the incident, the perpetrator may have
warned of more violence if “our secret” is shared. It is an ideal situation in which to
utilize a verbal video composed of behavioral incidents:
Pt.: … I never expected it to get to this point. I’m not even certain what I want to do.
Should I stay with him, should I leave him? I just don’t know, I just don’t know.
Clin.: Just how bad was it tonight?
Pt.: Not that bad (sighs). I mean he better not do it again, but he’s been worse.
Clin.: Anne, if you can help me to get a better feel for exactly what happened tonight, I
might be better able to help. You said he was yelling at you and he had been
drinking heavily, is that right?
Pt.: Yeah, that’s right.
Clin.: And then you told me he hit you. How did it go from yelling to hitting?
Pt.: He was screaming about my not holding up my end of things financially. And I
mean screaming.
Clin.: Where were you in the house? (fact-finding behavioral incident, note it is also an
anchor question focused on location, to enhance recall)
Pt.: Oh, we were in the kitchen. He likes to drink in the kitchen.
Clin.: What happened next? (sequencing behavioral incident)
Pt.: He said, excuse the language, “Get the fuck out of here!” (shakes her head from
side to side with a weak smile of disbelief). I told him I’m not getting the fuck out
of here because I live here, in fact it’s my house.
Clin.: And then what happened? (sequencing behavioral incident)
Pt.: He screamed, “you little bitch” and he hit me. (looks down and tears well up)
Clin.: It sounds very frightening to me. (gentle empathic statement, clinician hands
patient a box of Kleenex)
Pt.: Thanks.
Clin.: Did he hit you with his fist? (fact-finding behavioral incident)
Pt.: Yeah, it really really hurt?
Clin.: Where did he hit you? (fact-finding behavioral incident)
Pt.: Right here (points to her temple).

Clin.: Did it knock you to the ground? (fact-finding behavioral incident)
Pt.: Yeah (note that such a blow can be dangerous and, from a factual perspective, it’s
not really consistent with her previous description of the violence being “Not
that bad.”)
Clin.: Then what happened? (sequencing behavioral incident)
Pt.: I don’t know, it just took its course and he left. (here we have a “Nixon Gap”)
Clin.: Go back for a moment to right after he hit you. What exactly happened next?
(clinician returned to where the gap began and re-started the verbal video with a
sequencing behavioral incident)
Pt.: He started screaming again.
Clin.: And then? (sequencing behavioral incident)
Pt.: He picked up a knife and said, “I ought to shut you up but good.” I told him, look
I’ll leave, if that’s what you want. It was sort of scary. And then he said something
like, “Fuck you, I’m leaving.” And he left.
Clin.: What did he do with the knife? (fact-finding behavioral incident)
Pt.: Oh, he had already thrown that down.
Clin.: What was the last thing he said? (fact-finding behavioral incident)
Pt.: (sighs) He said, I’d better watch myself or I’d be really sorry.
Clin.: Where’d he go? (fact-finding behavioral incident)
Pt.: I don’t have any idea.
Clin.: I assume he has a key? (fact finding behavioral incident)
Pt.: Oh, yeah, he’s got a key alright.
Clin.: You know, he sounds like he could still be pretty dangerous, for all we know he is
drinking as we speak and I don’t think that sounds too good.
Pt.: Yeah, you’re probably right, (pauses) but what can I do?
This interviewer has earned her pay tonight. She might also have just saved this patient
from making a very dangerous decision. The facts uncovered through her skilled creation
of a verbal video certainly suggest that it would not be wise for the patient to return
home on this particular evening, and the patient has discovered, through her own words,
the seriousness of the situation.
Also note that the interviewer, near the end of the verbal video, specifically asked what
the parting words of the perpetrator of violence were (“What was the last thing he said?”).
If the patient does not spontaneously share the last words of the perpetrator, I recom-
mend using a direct question to uncover the information as this interviewer illustrated.
Sometimes, as the perpetrator exits, he or she will share a specific threat such as, “I’m
gonna get you bad, I’m going kill you real good, real soon.” With this question, one
sometimes uncovers material clearly indicating immediate or near danger for the patient,
suggesting the need for a safe haven.
Limitations of Behavioral Incidents

Before we wrap up on the behavioral incident, there remain a few points worth mention-
ing. First, this form of questioning can be time consuming, and in initial assessments
the clinician will need to utilize verbal videos judiciously in areas in which he or she
deems validity to be of particular importance.
Second, the great utility of the behavioral incident does not mean that patient-opinion
questions are not useful. Quite to the contrary; as we have seen earlier, as person-centered
interviewers, we find the patient’s perspective to be of paramount importance. Interview-
ing techniques are generally neither good nor bad. Interviewing techniques are merely
more, or less, useful for specific tasks.
Patient-opinion questions are invaluable for understanding the patient’s perspectives,
needs, opinions, and goals. We have also seen how they allow us to naturalistically
observe the patient’s defenses and they provide the foundation for collaborative problem
solving. They are just not particularly good for getting at the facts. In contrast, behavioral
incidents are poor at all of the above tasks. But when it comes to uncovering the truth,
put your money on Pascal’s behavioral incident.
Gentle Assumption
With this technique, the clinician, using a gentle tone of voice and non-accusatory
wording, assumes that a suspected behavior is occurring. This gentle assumption meta-
communicates the reassuring message to the patient that the clinician has already encoun-
tered the behavior in other patients.
The technique was first developed by sex researchers, Pomeroy, Flax, and Wheeler,11
who discovered that questions such as, “How frequently do you find yourself masturbat-
ing?” 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 with, “How often do you find yourself mas-
turbating, 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 non-judgmental.
The definition of a 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 patient has engaged in a given behavior (e.g., often beginning with
words such as “Have you ever …”) is by definition not a gentle assumption. For example,
when utilizing a gentle assumption to uncover other street drug abuse, after having
explored the patient’s use of marijuana, the clinician would not ask, “Have you ever tried
any other street drugs?” Instead, the clinician would matter-of-factly inquire, “What other
street drugs have you ever tried?” Only the latter type of question demonstrates the tech-
nique of gentle assumption.
Some prototypic examples of gentle assumptions are:
1. “What other ways have you thought of killing yourself?”

2. “What other problems with the law have you had?”
3. “What other types of problems have you been having with your courses this
semester?”
4. “In the past month, how many doses of your medication do you think you may have
missed?”
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 allowing the patient to feel less odd or
deviant. They may also indicate that, at some level, the clinician may be expecting to
hear a positive answer and it is okay to provide one.
It is important to note that gentle assumptions are powerful examples of leading
questions (a defense attorney on Law and Order would be on his feet objecting with each
and every one of them). They must be used with care.
More specifically, gentle assumptions should not be used with patients who feel com-
pelled to please the interviewer (e.g., a patient with a histrionic or markedly dependent
personality disorder) or who might feel intimidated by the interviewer (e.g., a child or
patient with limited intelligence). In such cases, gentle assumptions can lead to a patient
reporting something that is not true, for they feel they are “supposed” to have had the
experience or behavior in question. In my opinion, 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.
Denial of the Specific

Originally delineated in the first edition of this book,12 “denial of the specific” has
evolved into a technique that can be best conceptualized as a process whereby the clini-
cian asks about specific items from a theoretical “list,” such as a list of potentially abused
street drugs or a list of potential suicide methods. Strategically, clinicians tend to use
denial of the specific directly after a patient has responded with a not-very-believable
“no” to a gentle assumption. Sometimes it can ferret out the deceit. At other times it
works by simply jogging the memory of a patient who is not being deceitful, but has
literally forgotten something on the list.
For example, if a patient said “none” after being asked, “What other ways have you
thought of killing yourself?” and the clinician suspected deceit, the clinician might ask,
“Have you been having any thoughts of hanging yourself?” If the patient admits to such
thoughts, the extent of planning and action taken on hanging would be explored by
creating a verbal video with behavioral incidents. If the patient answers negatively, the
interviewer proceeds to the next method of which the interviewer is suspicious the patient
may be withholding, as with “Have you been having any thoughts of shooting yourself?”,
and so on, until the interviewer is done with the list. Remember, denials of the specific are
only used if the interviewer is suspicious that information is being withheld.
As we shall see in Chapter 17 on suicide assessment, patients who are in great pain
and at imminent risk of suicide may be hesitant to share their “method of choice” for
suicide. With such patients, denials of the specific can be useful at helping them to share
this potentially life-saving information.
One of the powers of denial of the specific is the fact it is generally more difficult to
shade the truth in response to a specific question as opposed to a generality. Each separate
question also allows the clinician to scan carefully for nonverbal evidence of deceit. In
the following example, after using a gentle assumption that results in a negative answer
from the patient, the clinician will use a series of denials of the specific to tease out the
truth:
Clin.: What other street drugs have you tried in the past?
Pt.: Oh … Not much, really.
Clin.: How about coke? (denial of the specific)
Pt.: No, no, not really, it’s too expensive.
Clin.: How about if someone gives it to you?
Pt.: (patient smiles) Hey, I’m no fool. Sure, I’ll run in the snow if it’s falling.
Clin.: Would you say 5, 10, 15 times a week?
Pt.: Nah, maybe three, four times a month.
Clin.: How about when you were younger, has there ever been a time when you used
more coke?
Pt.: Oh sure, when I was in the first couple of years of college, I was probably snorting
a couple of lines a day.
Clin.: Have you ever tried speed, even once or twice? (denial of the specific)
Pt.: Now that’s a drug that I can take or leave. (note that if he can “take it or leave it,” it
suggests he has indeed tried it, a fact that leads the interviewer to use a gentle
assumption)
Clin.: What’s it like for you? (gentle assumption)
Pt.: I just don’t like it that much. I don’t like coming down off it, crashing is no fun.
Clin.: Even though you don’t like it very much, how many times have you used it in the
last month?
Pt.: The last month, let’s see, hmm, maybe two or three times.
Clin.: Was there ever a time in the past where you speeded for days at a time?
Pt.: Sure, when I was in college I might speed for 2, 3 weeks at a time. Hey, I was a
Hunter S. Thompson. I was on the road to Vegas (patient chuckles), sort of wish I
was there now.
Clin.: Have you ever used some type of downer like Valium or Xanax? (denial of the specific)
Pt.: Well … some … not a lot. When I was speeding I’d sometimes use some shit like
that if I needed to come down. But nothing in years.
Clin.: How about marijuana, have you ever used marijuana? (denial of the specific)
Pt.: Yeah, now that’s something I’ve used a little more of. (pauses) And now that it’s
legal, I plan to use a lot more of the stuff (patient smiles).
The clinician’s persistence is paying off. It is not infrequent for patients initially to deny
or downplay the use of a drug. But if asked specifically about past use, a patient may
then admit to heavier usage. Thus it is often a good idea with a drug history to probe
both for the recent past and the distant past.
It is important to frame each denial of the specific as a separate question, pausing
between each inquiry and waiting for the patient’s denial or admission before asking the
next question. The clinician should avoid combining the inquiries into a single question,
such as, “Have you thought of shooting yourself, overdosing, hanging yourself, or jumping
off of a bridge or building?” A series of items combined in this way is called a “cannon
question.” Such cannon questions frequently lead to invalid information because patients
only hear parts of them or choose to respond to only one item in the string – often the
last one. In addition, with each use of a single denial of the specific, the interviewer has
an opportunity to observe nonverbal indicators of lying or minimization. Cannon ques-
tions undermine this process, for the patient only has to lie once.
Catch-All Question
One of my favorite features on our website for the Training Institute for Suicide Assess-
ment and Clinical Interviewing (www.suicideassessment.com) is our interviewing “Tip
of the Month.”13 In this feature, which has well over 150 interviewing tips archived, visi-
tors to our website or participants from my workshops submit interviewing tips that they
have found to be particularly useful in their everyday work. Over the years, I’ve learned
an immense amount from these tips and one of my favorites was submitted by Sarah
Davila.14 Her tip, like denial of the specific, helps an interviewer to finish a list. In fact,
it is often used after a string of denials of the specific if the clinician is suspicious that
an odd outlier may have been missed. Davila’s tip was focused upon uncovering unusual
methods of suicide. I’ve broadened its use to other topics and we now call it the “catch-
all question.” Let’s see it at work, first with suicide.
With patients in which one remains suspicious that an important or rather unusual
method of suicide has been withheld, the interviewer asks, “We’ve talked about a lot of
different ways that you’ve been thinking of killing yourself today, is there any method
you’ve thought of, even briefly, that we haven’t talked about?” The answers are sometimes
surprising. This question can also prompt the patient to share that he or she has done a
web search on suicide, offering further glimpses of the patient’s intent.
The catch-all question is useful in many situations other than suicide assessment; here
are some prototypic examples:
1. “We’ve talked about a lot of things that your son is doing at school or at home that
are upsetting to you; are there any that we haven’t talked about yet?”
2. “Are there any other bad experiences you had over in Iraq, perhaps even with fellow
soldiers, that we haven’t talked about?” (may uncover sexual assault)
3. “We’ve talked about a lot of things that your wife is upset about with you; are there
any we haven’t talked about yet?”
4. “Is there any street drug, or perhaps a prescription drug, that you have used to get
high that we haven’t talked about yet today?”
Symptom Amplification
This technique, also originally delineated in the first edition of this book,15 is based upon
the fact that patients sometimes downplay the frequency or degree to which they have
indulged in disturbing behaviors, such as the amount that they drink or the frequency
with which they gamble. Symptom amplification allows a clinician to bypass these dis-
torting mechanisms without disengaging the patient, a disengagement that might have
occurred if the interviewer had directly challenged the patient’s minimization. In fact,
with the use of symptom amplification, the clinician allows the patient to naturalistically
use minimization as a defense.
This task is accomplished by setting the upper limits of the quantity in question at
such a high level that, when the patient downplays the amount, the clinician is still aware
that there is a significant problem. For a question to be viewed as symptom amplifica-
tion, the clinician must suggest an actual number in the question. This technique is only
used if one is suspicious the patient is going to minimize.
For instance, a clinician suspicious that he or she is in the presence of a heavy drinker
can, once the topic of drinking has been raised, ask about the extent of the drinking
behavior as follows, “How much liquor can you hold in a single night, a pint, a fifth?”
When the patient responds, “Oh no, not a fifth, I don’t know, maybe a pint,” the clini-
cian is still alerted that there is a problem, despite the patient’s minimizations. To be
effective, when using a symptom amplification, it is important to start with a high
number and go even higher.
Here are some other examples of symptom amplification:
1. “How many physical fights have you had in your whole life, 30, 40, 50?”
2. “How many times have you tripped on acid in your whole life, 25, 50, 100 times or
more?”
3. “How many times have you actually struck your wife, 20, 40, 60 times?”
4. “On your very worst days, when you are thinking the most about suicide, how many
hours do you spend thinking about it, 8 hours, 12 hours, 15 hours?”
There is one important caveat to the use of symptom amplification. The clinician must
be sure that he or she does not set the upper limit at such a high number that it seems
absurd or creates the impression that clinician is unfamiliar with the topic at hand.
Perhaps the funniest example of this error that I’ve had the fortune (or misfortune) to
encounter was when a trainee asked a street-wizened junkie the following question,
“When you’ve used peyote buttons, how many have you used at a time, 100, 200?”
Besides providing an extremely hearty chuckle for the junkie, who immediately began
imagining the single most nauseated human being in recorded history, it also provided
the clinician with a mildly uncomfortable moment when the patient queried, after con-
taining his glee, “You don’t know much about peyote, do you Doc?”
Validity Technique Combinations

Sometimes the effectiveness of validity techniques can be enhanced by combining them
into doublets. For instance, one could link normalization with gentle assumption as with,
“Some of my patients tell me it is easy to forget their medications, especially when taking
them several times a day (normalization); in the past month how many doses of your
medication do you think you may have missed, just roughly (gentle assumption)?”16 In
this case, the normalization has “softened” the subsequent gentle assumption.
In the following dialogue with a late-adolescent who presented to our emergency
department requesting admission because, “I’m really suicidal and crazy,” we will see
that it can be very effective to insert one validity technique directly inside another one.
One of my favorite applications of this strategy involves inserting a shame attenuation
inside a gentle assumption or behavioral incident, as illustrated by this direct transcript
from my original interview with this adolescent:
Clin.: What about, how frequently have bosses, you know, taken you aside, and
complained to you, or harped to you, about your work, saying that you’re not doing
a good job or what they want?
Pt.: I had one boss, and that’s after the accident, I worked at the deli on Murray Avenue,
I was kinda new there so he couldn’t really harp on me, you know, every day he
would tell me you’re doing this really slow …
With this patient, I inserted a shame attenuation (“or harped to you”) directly into the
middle of a gentle assumption, for I felt the patient frequently viewed bosses and other
authority figures as problematic. By tapping his bias, I thought I might enhance the power
of my gentle assumption to uncover the truth. Very shortly, in our next video module,
which is based upon this patient, we will see this specific clinical exchange brought to
life, and I believe you will see the naturalistic conversational flow that can be generated
using doublets.
Clinicians may sometimes find it advantageous to create triplets, as I could easily have
done with above: “… how frequently have bosses, you know, taken you aside, and com-
plained to you, or harped to you, about your work, saying that you’re not doing a good
job or what they want, 10 times, 20 times, 30 times?” (adding a symptom amplification).
In this instance we see the coupling of three validity techniques: gentle assumption,
shame attenuation, and symptom amplification.
At this point, let me clarify something that, left unaddressed, is sometimes confusing.
All of the techniques we have been discussing are specific and cleanly distinct from one
another. One will not confuse a shame attenuation with a symptom amplification. This
clarity (and lack of overlap) is one of the reasons they are easy to use and easy to teach.
But there is one exception.
Almost all of the techniques, in some variant or another, can be simultaneously
viewed as being an example of a behavioral incident, for they are often requesting con-
crete facts, thus fitting the definition of a “fact-finding behavioral incident.” For instance,
the gentle assumption above (“… how frequently have bosses, you know, taken you aside,
and complained to you, … about your work, saying that you’re not doing a good job or
what they want?”) is simultaneously a behavioral incident. Indeed, some validity tech-
niques are always simultaneously a behavioral incident, as is the case with symptom
amplification in which case the interviewer is always requesting a number.
In supervision, we explain this overlap area with trainees and relate that if a technique
is both a behavioral incident and another more specific validity technique, we will tag it
with the name of the more specific technique, for it illustrates better the use and power
of the technique. Once explained, we find that trainees have no problems with this defi-
nitional overlap.
Now is an opportune time to watch a variety of our validity techniques being utilized
clinically. In the following video module, we will be meeting a rendition of the
late-adolescent patient introduced above. We will discover that telling the truth is not
exactly second nature to him. His presentation will prove to be an ideal setting to put
our validity techniques to the test.
VIDEO MODULE 5.1

Title: Validity Techniques: Effective Use
Contents: Contains both expanded didactics and various annotated interview excerpts
demonstrating techniques such as shame attenuation, the behavioral incident, gentle assumption,
denial of the specific, symptom amplification, induction to bragging, and examples of effective
doublets.
Important note to the reader: After viewing Video Module 5.1 you can proceed directly with the
text below regarding techniques for uncovering malingering OR you may view Video Modules 5.2
and 5.3, which are OPTIONAL modules that can be used to consolidate your understanding of
the material from Video Module 5.1.
VIDEO MODULE 5.2

Title: Validity Techniques Illustrated: Complete Interview with Ben without Didactics and without
Labels for Interviewing Techniques
Contents: The interview excerpts from Video Module 5.1 appear here as they naturally occurred
(without any didactic material inserted), providing a chance to better experience the actual flow of
the interview. The labeling of the specific interview techniques as they appeared at the bottom of
the video in Video Module 5.1 have also been removed. Thus this module can be used by the
reader (individually) or by faculty (within the classroom) to function as a springboard for discussion,
consolidate understanding, or as an opportunity to test one’s ability to correctly identify the validity
techniques as they appear sequentially during the interview.
VIDEO MODULE 5.3

Title: Validity Techniques Illustrated: Complete Interview with Ben without Didactics but with
Labels for Interviewing Techniques
Contents: This module is identical to Video Module 5.2 except for the return of the labels for the
individual validity techniques. With the identifying labels returned as each validity technique is
demonstrated, this format provides an ideal method to once again consolidate an understanding
of the validity techniques as well as the chance “to check the answers” if one used Video Module
5.2 as an opportunity to test one’s abilities to identify the validity techniques.
Miscellaneous Tips for Specific Situations Where Validity Is a Concern

Malingering
Although most of our patients are doing their best to share the truth, some patients are
malingering. The reasons for such deceit can vary from easily understood (a patient
providing false symptoms to get into a hospital because of homelessness) to more prob-
lematic reasons (seeking drugs, attempting to procure inappropriate disability monies,
seeking hospitalizations to avoid court appearances). Several diagnoses are easier to fake,
such as post-traumatic stress disorder (PTSD) and depression, for the symptoms are
subjective. Others, such as psychotic process, are chosen if the patient feels a very serious
or dangerous picture needs to be presented to gain the desired goal (such as admission
to a hospital or as a prequel for an insanity defense).
One of the clinician’s best assets for spotting malingering is a detailed knowledge of
what symptoms are present in what diagnoses, how these symptoms appear when really
present, and what the pain is like that people feel when these real symptoms are present.
Through this person-centered knowledge, we can carefully weigh what the potential
malingerer is describing with what patients coping with the real thing actually experience.
Taking this a step further, some psychological tests for detecting malingering employ
formal scores to measure the patient’s claims of having experienced rare or improbable
symptoms, such as the Structured Interview of Reported Symptoms.17 Rare symptoms
should be just that – rare. If a patient presents with numerous rare symptoms, the likeli-
hood of malingering goes up substantially.
For use in everyday clinical interviews, Phil Resnick describes a technique he calls the
“endorsement of bogus symptoms.”18 With this technique, the interviewer asks the patient
if he or she is experiencing a symptom that the clinician knows is highly atypical for the
disorder being feigned. If the patient endorses having such a symptom, the likelihood
of malingering goes up.
The endorsement of bogus symptoms can be particularly useful when ferreting out
psychotic symptoms, for many patients who are feigning psychosis think that almost any
“crazy-sounding” process is probably found in disorders like schizophrenia or psychotic
manias. As we will see in future chapters, this belief is far from the truth. Psychotic
symptoms have distinctive phenomenologies and symptom pictures.
Resnick suggests that questions such as, “When people talk to you, do you sometimes
see the words they speak spelled out?” or “Have you ever believed that automobiles were
members of organized religion?” may result in positive responses in patients who are
malingering, whereas such experiences would be highly unusual in cases of legitimate
psychotic process. Resnick emphasizes that such questions must be asked in the context
of other questions more typical of psychotic ideation to prevent them from standing out
as unrealistic. With malingers who “hear voices,” I have found subtle questions such as
“Do your voices often slip under the door?” or “Do your voices tend to slam into the
back of your head?” to be effective for eliciting malingered responses. Although voices
could be experienced in these fashions, it is a rarity.
Here are other examples of the endorsement of bogus symptoms for use in differing
disorders:
1. “When you have your flashbacks, do they occur in black and white?” (PTSD: note
that patient flashbacks – re-experiences of traumatic incidents – are not typically
experienced as black and white images.)
2. “When you have your panic attacks, do they tend to stay with you, hammering at
you, for many hours on end?” (Panic attacks are time-limited, seldom lasting in full
intensity past an hour or two; they are usually significantly shorter.)
3. “During your most severe periods of depression, do you usually find that you wake
up feeling pretty good, but as the day progresses the depression becomes devastating
so that it is frankly hard for you to function, despite your best efforts?” (With major
depressions, patients rarely awaken refreshed; indeed they often awaken earlier than
they want, barraged by an onslaught of unsettling worries.)
Let us return to Ben, our patient from Video Module 5.1. If you will recall, Ben had
presented to our emergency department saying, “I’m really suicidal and crazy.” As already
noted, at the time of his interview I was suspicious that Ben was malingering, which we
now know was later determined to be true subsequent to his admission. In Video Module
5.4, we will see that it was Ben’s response to my first use of an endorsement of bogus
symptoms that made me strongly suspicious that Ben was indeed malingering.
VIDEO MODULE 5.4

Title: Interviewing Techniques for Uncovering Malingering
Contents: Contains both expanded didactics and an annotated interview excerpt demonstrating
the endorsement of bogus symptoms.
Gauging Motivation
Leston Havens developed an interviewing strategy for gauging a patient’s motivation to
pursue a self-initiated behavior (e.g., pursue a job change) or recommendation from
others (e.g., attend alcoholics anonymous). Techniques for improving motivation, as
first delineated by Miller and Rolneck,19 are so important that we devote the whole of
Chapter 22 to them. At this point though, Haven’s technique – called “soundings” – is
an example of an interviewing strategy not designed to increase motivation, but to
accurately determine its current level. The following description is adapted directly from
Haven’s lucid writings.20
Curiously, soundings drew its name and its methodology from a most unexpected
“clinician,” Samuel Clemmons, or Mark Twain as he is more commonly known. Few
know that Twain drew his pen name from an everyday 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!” This measuring process was called “soundings.”21 It was an accu-
rate way of seeing what could not be seen – the bottom of the river. Havens became
intrigued by the idea that a similar approach might be of use in helping a clinician to
see what could not easily be seen with a patient, the depth of the patient’s motivation.
With soundings, the interviewer tosses out a series of statements of inquiry, which we
first came upon in the Degree of Openness Continuum (DOC; statements of inquiry are
statements in which the inflection at the end transforms the statement into something
that needs to be addressed by the patient as with, “You found having a child to be more
difficult than you had imagined?”). With soundings, this series of statements of inquiry
is carefully sequenced in a progressive fashion so as to probe deeper and deeper into the
patient’s level of motivation. The patient’s verbal and nonverbal 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 man, the clinician
acquires a more accurate feeling for what is hidden.
This strategy is more easily understood by way of an example. Let us take a look a
common clinical conundrum – trying to accurately determine a patient’s intention to do
something that is difficult to do, perhaps leave an abusive marriage. Watch as the clini-
cian in this prototypic conversation below helps both the patient and herself to ferret
out the patient’s intention. The patient will announce that she intends to leave her
husband soon. But what does this really mean? How much intention is behind this
statement? The interviewer will toss out a series of soundings, always done with a gentle
tone of voice – never in a challenging tone of voice – to see where the depth of the
intention actually lies:
Pt.: I really feel that somehow I need to get out of this relationship. I know in my heart,
Jim is bad for me. I’ll get out soon.
Clin.: You dream of this? (a sounding)
Pt.: As a matter of fact, I think of it every day. I know that Jim is perhaps my biggest
problem.
Clin.: You might want to do this then, to leave Jim? (a sounding)
Pt.: Yeah, I might need to do it.
Clin.: You feel you can do it? (a sounding)
Pt.: (patient sighs) Well, I guess so … I think so.
Clin.: You feel you will be able to do it within a month or two? (a sounding)
Pt.: Well, I doubt that … No I don’t think that is in the cards in the near future.
Although often used to determine a patient’s motivation to proceed with beneficial

activities that may be hard to do, as with following therapeutic recommendations, it can
also be utilized to determine activities best not done. For instance, it can be used to
determine the depth with which a patient believes in a delusion and may subsequently
act upon it.
Let us imagine a patient presenting in an emergency room with a delusion that he is
being “constantly watched” by his neighbor who he thinks might be plotting to poison
him. The following series of soundings can help the clinician to decide the level of con-
viction the patient has regarding his delusion, a concept called how much “distance” a
patient has from the delusion:
“You may sometimes wonder, can this really be true about your neighbor?”
“You feel that there’s too much evidence to doubt it?”
“There doesn’t seem any doubt at all in your mind at his point?”
The clinician pauses after each of these soundings to see how the patient responds both
verbally and nonverbally.
Later in the interview, when evaluating the level of the patient’s intention to act on
the delusion (perhaps to violently confront his imagined persecutor), the following
soundings might be of use, once again pausing after each one to listen to the patient’s
response:
“You’ve thought of doing something about your neighbor?”

“You feel you need to do something about him?”
“You’ve planned to do something to stop him?”
To such a series of statements of inquiry, the interviewer might discover that a gun has
been purchased that the patient plans to bring along, “just in case it’s needed,” when he
confronts his unwary neighbor about his supposed schemes.
Taking a Sexual History

Taking a good sexual history can be uncomfortable for both the beginning clinician and
the patient. Some of the techniques described earlier can be of value, but it takes practice
with these techniques before one feels progressively at ease. In this regard, the familiar-
ization process can be speeded up by the use of role-playing or practicing the questioning
while in front of a mirror. These drills help the clinician to focus on his or her paralan-
guage and body language, both of which play a pivotal role in helping the patient to
relax during the sexual history. The clinician’s nonverbal behavior should be identical to
his or her nonverbal behavior during the rest of the interview. Sexual questions asked
with a calm matter-of-factness are more likely to result in matter-of-fact responses.
Some forms of leading questions can put patients on the spot as well. For instance,
the question, “Do you have orgasms about 80% of the time?” may suggest to the patient
that a response of less frequency is unusual or abnormal. This unwanted effect can be
minimized simply by asking, “How frequently do you reach orgasm during sex, if at all?”
But some clinicians feel that this approach, in which no number is proffered by the
interviewer, can also generate anxiety, because it leaves the patient alone with his or her
projections of what he or she thinks the clinician is expecting. This can be alleviated by
asking a question that provides a range without any indication of what is wanted, but
communicating, via the range, that any number is fine. By combining this approach with
the use of normalization, the question takes on a non-threatening tone as with, “Women
vary a great deal on how frequently, if ever, they have an orgasm. What percentage of the
time do you think you have an orgasm – 5%, 20%, 80%, or almost never?”
Concerning sexuality, some patients will feel guilt about activities for which there is
no reason to feel guilt, caused by cultural stigmatization, such as homosexuality or mas-
turbation. Once again, the clinician attempts to raise the topic in such a way that the
patient does not feel awkward. For example, one useful method of approaching possible
homosexual orientation is via the developmental history, utilizing normalization, as
follows: “As adolescents mature, they frequently experiment with different lifestyles and
sexual orientations. When you were an adolescent, did you ever experiment with homo-
sexual contact, perhaps to see what it was like?” One can continue the questioning into
adulthood simply by asking, “In the long run, some people discover that the most natural
sexual orientation for them is a homosexual or bisexual orientation as opposed to a

heterosexual one, or vice versa. At this point in your life, with what orientation have you
found yourself to be most comfortable?”
Moving to a different topic, the question of childhood sexual abuse can be difficult
to discuss at times. Naturally, the topic will be spontaneously raised by the patient in
some instances; however, sometimes there is nothing to suggest its presence. As we saw
in our chapter on facilics, and well worth reviewing here, a good way to screen for a
history of sexual abuse often presents itself while the clinician is taking the family history
for other psychiatric disorders. Suppose it has been uncovered that one of the patient’s
parents had alcoholism, then the following question, using a natural gate, (with a nor-
malization embedded inside it), can be quite effective, “With your dad’s problems with
drinking, it is not uncommon for people to tell me that there was also a history of vio-
lence in the family or sexual abuse. Was that true in your family?”
Another question for sensitively raising the topic of sexual abuse is, “When you were
growing up did anyone in your family, or someone outside of your family, touch you
sexually in a way that you felt uncomfortable or wish that they hadn’t?” Even a brief
pause by the patient may suggest a history of abuse that can be gently uncovered with,
“It looks like that question struck a chord with you, what are you remembering?” I
sometimes add at this delicate moment, “It can be difficult to talk about such things.
Just share what you feel comfortable sharing, it might really help me to help you.”
Interview Illustrating the Use of Various Validity Techniques

In this chapter we have explored a large number of validity techniques, from anchor
questions to behavioral incidents and shame attenuations. Perhaps, at this point, an
interview excerpt can help us to see how an interviewer can intentionally interweave these
individual techniques into a graceful tapestry. With patience and skilled timing, the truth
of the patient’s history will slowly emerge within the fabric of the interview.
In the following dialogue, you can see 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 not only cut away the patient’s distor-
tions but also to effectively cut away the interviewer’s assumptions and/or projections
that can also cast a mist of distortion on the story. We will pick up the conversation well
into the body of the interview, at a point when the clinician decided to expand the region
of IPV.
Pt.: My wife and I haven’t really gotten along well in years (pause). Last weekend we
really went at it.
Clin.: Tell me what happened. (behavioral incident)
Pt.: Well … She just started on me about needing to get a job, that’s her big thing now.
She wants me to go down to the unemployment office today not tomorrow. Today.
So she starts ragging and yelling and I (pause) I just couldn’t take it anymore so I
lost it on her.
Clin.: What do you mean that you lost it on her? (behavioral incident, said gently)
Pt.: I left. Just took off in a fit of anger. I waited till she went out to the kitchen, and I
went out the back door, and I didn’t come back for 2 days. I didn’t call her. I didn’t
look for a job. I just bagged it all. Screw her.
I think many clinicians, including myself, would have interpreted the phrase “lost it on
her” as probably indicating physical violence. The behavioral incident dismantles this
clinician assumption and uncovers a much less disturbing, albeit strikingly passive-
aggressive, behavior. Although this assumption would have been in error here, the clini-
cian’s intuition of violence will soon prove to be on the mark. The doorway to an
exploration of domestic violence is opened through an effectively used “validity triplet”:
Clin.: Sounds like you two really do go at it. At such moments, sometimes people have a
hard time controlling their emotions (normalization). With all of the pent-up stress
you two have been under (shame attenuation), how many times have you found
yourself stressed to the point that you may have lost your temper and perhaps hit
her? (gentle assumption)
Pt.: I’ve not really done that.
Clin.: When you say “not really,” what do you mean? (behavioral incident, said in a
non-accusatory tone)
Pt.: Oh, I’ve never actually hit her.
Clin.: Sometimes people mean different things by the same word; to make sure I’m not
being confusing here, let me explain what I mean by the word “hit.” I’m including
anything like using a fist, slapping with an open hand, or pushing her. (clarifying
norms)
Pt.: (sighs) Well, (pauses, shrugs shoulders slightly) I guess you could say I slapped her
a few times.
Clin.: Did you ever slap her so hard that it caused some bruises? (behavioral incident)
Pt.: Not really (pauses, purses his mouth) Maybe a black-eye once or twice.
Clin.: How many times do you think you have slapped her, 20 times, 30 times, 40 times?
(symptom amplification)
Pt.: Not that often. (pauses to reflect) Maybe six, seven times.
Clin.: Has she ever had to get stitches or go to the emergency room? (behavioral incident)
Pt.: Oh no, shit no, never.
At this point, the interviewer is becoming suspicious that the patient may have an antiso-
cial personality disorder and has decided it warrants some further exploration, for the
presence of such a personality structure might have important ramifications for designing
an appropriate referral for therapy. The problem is that the criteria for an antisocial per-
sonality disorder (from childhood problems, such as fire-setting and torturing animals, to
adult behaviors, such as problems with the law and chronic lying) can be potentially dis-
engaging to explore in an initial interview. Let’s see how this interviewer, with the skilled
use of validity techniques, accomplishes this exact task in a surprisingly engaging fashion
just as I demonstrated in our video with Ben:
Clin.: How about outside the house. It sounded to me earlier like you grew up in a really
tough neighborhood where you probably had to know how to fight just to survive.
(shame attenuation) Is that true?
Pt.: You better believe it. There were several kids from my high school killed in
shootings, probably drug shit, I don’t know.
Clin.: You look like you take pretty good care of yourself. I bet you could hold your own
even in a neighborhood like that. (induction to bragging) What types of fights, if
any, did you get into back then? (gentle assumption)
Pt.: Oh, I got into a few fights. Trust me on that one. I didn’t pick them, but the guys
who did wished they hadn’t.
Clin.: Did you hurt anybody so bad they had to go to the hospital or anything?
(behavioral incident)
Pt.: Nothing like that. But I beat them up pretty good.
Clin.: Even though someone else started them, (shame attenuation) did you ever end up
getting arrested? (behavioral incident)
Pt.: Nope. Can’t say that I have.
Clin.: Did you ever get into trouble with the law in some way that we haven’t talked
about? (catch-all question)
Pt.: Oh yeah, I was picked up for vandalism and that kind of shit, but never arrested. I
stopped all that shit as soon as I got out of high school.
Clin.: I know you got yourself out of that neighborhood as fast as you could, that’s for
sure, and that was clearly a smart thing to do. How about after you left there, when
you moved to Los Angeles, did you have any troubles with the law then? (anchor
question, time-focused)
Pt.: Hmmm. (pauses) Well, I guess you could say so, I got fired once for fighting on the
job, and they called the cops then, I wasn’t arrested or anything.
Clin.: Billy, you told me earlier about all the abuse your father did to you, and it sounded
like pretty bad abuse to me, do you think it ties in to some of your own angry
outbursts, like with your wife or this episode back in LA?
Pt.: Absolutely. I’m no therapist, but if you get hammered like that in life, you’re going
to hammer some people back, that wouldn’t surprise me. It’s just the way it is.
Clin.: Another thing that some of my patients have told me, who have had very abusive
parents like your dad was, is that they had to lie to protect themselves, do you
know what I mean by that? (normalization)
Pt.: Hell yeah. After he’d had a drunk on, you’d tell the old man whatever he wanted to
hear. If he asked me if my homework was done and it wasn’t, I’d tell him it was all
done and then I’d get my ass out of Dodge. If he found out that my homework
wasn’t done, he’d beat the crap out of me, I mean he’d beat the crap out of me …
(pauses) Sometimes I had to lie to protect my mom or my little sister too. Yeah, he
was a real bastard.
Clin.: Some people with similar histories of abuse, especially if they had to keep lying
over and over again to protect themselves like you did, tell me that the lying sort of
becomes a habit and they find themselves lying even when they are older and
sometimes when they don’t even realize they are doing it. (normalization) Have
you ever found that to be true for you?
Pt.: (smiles) Well (pauses) … let me put it this way, I’ve been known to tell a lie or two
… if I need to. (smiles again)
Clin.: Have you become a pretty good liar over the years? (shame attenuation)
Pt.: (bigger smile) Let me let you in on a secret, Doc. I’m a super good liar. (pauses)
And I ain’t lying to you. (chuckles)
Clin.: (smiles) Now it also sounds to me like your mother, as well as your father, was
abusive to you. She sounds like she was very verbally abusive, did you ever run
away from home to get away from it all? (shame attenuation)
Pt.: Yeah.
Clin.: How many times do you think, 10 times, 15 times, 20 times? (symptom
amplification)
Pt.: I don’t know, maybe around five or six times. But I always came back in a day or
two. I don’t know why, but I did.
Clin.: To get back at them, (shame attenuation) did you ever do things that you knew
would annoy them or frighten them, like set fires?
Pt.: Hell no, he’d have killed me.
Clin.: How about something they couldn’t see? Did you ever try to take what you felt was
justifiable revenge by hurting something that your parents loved like one of your
dad’s dogs, you told me he had several dogs? (shame attenuation)
Pt.: You know, I was so afraid of him, I’d have never risked that, but you know, I sort of
thought of it, because I did like to tease cats for awhile.
Clin.: What would you do? (behavioral incident)
Pt.: We’d stick a cat in a can and then kick it or sometimes we sprinkled the cat’s tail
with lighter fluid and then lit it. You should have seen them fly!
Clin.: How do you view those behaviors now when you look back?
Pt.: That was pretty weird. (pauses) I sort of feel bad about it. I don’t think I’d do any
of that type of stuff now. I’ve learned that there’s no use hurting things in this life,
I’m really pretty much of a pacifist. I’m not out to hurt anybody or anything. Just
mind my own business.
In this illustration, the clinician is eliciting a powerful history, filled with evidence of
antisocial behavior, and yet the patient appears to feel comfortable. Part of this comfort
may be related to this patient’s innate tendency to not feel guilt, but a considerable part
seems to be related to the clinician’s skill in exploring sensitive material adeptly. On a
disturbing level, some of the uncovered antisocial material hints at true sociopathy (with
people and animals being viewed by the patient with a disturbing lack of empathy). Note
how the clinician is skillfully able, without any damage to the therapeutic alliance, to
raise often highly disengaging topics such as the patient participating in animal torture
or fire-setting by tying the topics into the patient’s own rationalizations via shame attenu-
ation (e.g., the patient potentially viewing such behaviors as okay to do because of his
parent’s abuse).
We have concluded our exploration of the four clusters of validity techniques and
have covered a lot of ground. It may be useful to summarize what we have learned in
each cluster:
Cluster 1: techniques for improving generalized recall (anchor questions, tagging ques-
tions, and exaggeration)
Cluster 2: techniques for avoiding miscommunication (defining technical terms, clarify-
ing norms)
Cluster 3: techniques for raising a sensitive or taboo topic (normalization, shame attenu-
ation, induction to bragging)
Cluster 4: techniques for exploring a sensitive topic once raised (behavioral incident,
gentle assumption, denial of the specific, catch-all question, and symptom
amplification)
We have also examined validity techniques for miscellaneous tasks such as Resnick’s
endorsement of bogus symptoms for spotting malingering and Haven’s soundings for
gauging motivation.
Our efforts will not go unrewarded. Through the creative and flexible use of the
validity techniques described in this chapter, we will be much better able to help our
patients to share sensitive topics about which it is often difficult to talk. We will have
gone a great way towards gently cutting through the “mists of words” that Oscar Wilde
alluded to in the epigram that opened our chapter. The result will be a clearer picture
of the reality of the problems that are facing our patients and the behaviors that may
be leading them to cause harm to either themselves or to others, and sometimes both.
It is our patients who will be the beneficiaries of our hard work and our studies. The
art of interviewing will have taken its much-deserved place as the first step in the art
of healing.
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1987.
4. Carlat D. 1999. p. 27.
5. Othmer E, Othmer SC. The clinical interview using DSM-IV, vol. 1. Fundamentals. Washington, DC: American
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p. 402–3.
8. Shea SC. 1998. p. 393–5.
9. Othmer E, Othmer SC. 1994. p. 77.
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2007;30(2):219–25.
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Williams & Wilkins; 2006.
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CHAPTER 6
Understanding the Person Beneath
the Diagnosis: The Search for
Uniqueness, Wellness, and
Cultural Context
Every physician must be rich in knowledge, and not only of that which is written in books;
his patients should be his book, they will never mislead him …
Paracelsus, Renaissance alchemist and physician1
INTRODUCTORY ILLUSTRATION: THE PERSON BENEATH THE DIAGNOSIS

As the clinician integrates the processes of the first two way-stations on our map of the
initial interview – engagement and data gathering – a curious phenomenon emerges.
Gradually, the clinician begins to gain an understanding of the world through another
person’s eyes. This process does not happen suddenly or dramatically. Instead, like the
imperceptible clearing of a mist, the clinician’s conceptualization of the patient’s perspec-
tive crystallizes. To return to our analogy of the Victorian room, the nooks and crannies
of the environment gradually become more familiar. As interviewers, we are no longer
strangers.
Indeed, we have reached the third way-station on our map – a deeper understanding
of the person sitting before us. This way-station overlaps with the first two, for an under-
standing of the patient will not occur unless there is adequate engagement. Moreover,
accurate understanding emerges from the facts, feelings, and opinions culled in the
process of data gathering. Despite this overlap, from the perspective of person-centered
interviewing, the process of understanding warrants a closer examination.
It is our understanding of the unique qualities, circumstances, and cultural determi-
nants of the patient that will lead us not only directly into the fourth way-station on our
map – accurate assessment and diagnosis – it will also have a profound impact on the
fifth and final way-station on our map – treatment planning. Put succinctly, the success
of a treatment plan is ultimately dependent upon the clinician’s ability to understand
the person beneath the diagnosis. Clinicians arrive at this understanding by uncovering
a compassionate, sophisticated understanding of the multiple systems – from biological
and psychological to familial, cultural, and spiritual – that continuously coalesce to create
the patient, the clinician, and the patient/clinician dyad.
As we shall see in our next chapter, there are a variety of assessment perspectives that
serve as nice complements to one another for accomplishing this integrative task, includ-
ing differential diagnosis using the DSM-5, viewing the patient as a matrix of intersecting
and interacting systems (matrix treatment planning), and understanding the patient’s
core pains. An interviewer can shape a useful formulation of what is right and what is
wrong with the patient through a skilled delineation of the information needed to utilize
these three assessment frameworks. Indeed, these three frameworks provide the classic
foundations for collaboratively developing an initial treatment plan by the end of the
interview, and these are good foundations. Consequently, we will examine them in detail
in the next chapter.
But if one looks at our interview map (Figure 6.1), one will notice that, in addition
to an arrow leading from diagnosis and assessment to treatment planning, there is a
second arrow that leads to treatment planning. It is the arrow that originates from the
understanding of the patient.
Many a well-intentioned interviewer has been trapped by the inviting misconception
that ideal treatment plans can be generated by strict algorithms stemming directly from
specific DSM-5 diagnoses. The spirit behind this goal is an admirable one, to improve
quality of care by ensuring that the best possible evidence-based therapies are utilized.
Unfortunately this concept misses a rather simple, but often-overlooked, reality: an
“ideal” treatment plan that doesn’t work is not ideal, it is foolish. It is the patient’s inter-
est in and agreement with the treatment plan – as well as his or her ability to follow
through with the treatment plan – that will determine whether or not the treatment plan
will work. One cannot simply look at a DSM-5 diagnosis and conclude that one can
Understanding the person beneath the diagnosis 189
apply a pre-determined best treatment plan dictated by the diagnosis, for it can’t possibly
be the best plan for the patient if the patient does not like it and, consequently, will not
do it. Treatment plans are created for people, not for diagnoses.
Moreover, effective treatment plans are not really made for people by clinicians, they
are co-created by people with their clinicians. This fact is true not only in psychiatry, but
in all branches of medicine. A clinician cannot help a patient to control diabetes, asthma,
or hypertension unless the patient personally chooses, and helps to sculpt, the treatment
plan, and is not blocked by external circumstances (lack of money, problematic circum-
stances, and cultural roadblocks) from following through with the treatment plan that
he or she has chosen.
The art of treatment planning achieves its greatest healing power when it is guided by
a sophisticated understanding of the person sitting before the clinician. The search for
this understanding during the initial encounter will often reveal many factors, including
psychodynamic, interpersonal, and cultural factors, that have little to do with the DSM-5
diagnosis per se, that can suggest powerful ideas for treatment planning. In addition, it
is our understanding of the person beneath the diagnosis that will determine whether
or not we can collaboratively create a treatment plan that the patient will embrace during
the initial interview and in subsequent therapy. Perhaps an illustration will make this
point more clear.
Imagine a clinician at a busy community mental health center who is in the midst of
an initial intake. Further imagine that at this particular center the “intake clinician” is
supposed to triage the patient to whatever clinical program would best be able to help
that individual, ranging from outpatient individual therapy or group therapies to psychi-
atric care or other specific programs, such as an incest survivor’s group, an eating disor-
ders group, or a DBT (dialectical behavioral therapy) group.
Now imagine that the interviewer is quite talented at all of the skills we have been
discussing thus far, from engagement techniques to facilic principles for creating flowing
conversational interviews. The patient is a young woman of about 18, still living at home,
hoping to go to college next year if finances can be worked out, who unfortunately has
become fairly seriously depressed; indeed, there is a strong family history of depression.
We will call our imagined patient, Jennifer.
As the interview is nearing its closing phase, the clinician has become convinced that
Jennifer is suffering from a moderately severe, major depressive disorder from the diag-
nostic perspective of the DSM-5 system. The clinician is also concerned about the depth
of the depression and feels that rapid intervention is indicated, although there is no
suicidal ideation. The clinician decides to recommend a combination both of a referral
to the psychiatrist for medications and to one of the outpatient psychotherapists. The
decision to recommend medications is certainly reasonable considering her diagnosis
(which is accurate) and the rapid progression of Jennifer’s symptoms and the severity of
her pain. Jennifer seems reasonably comfortable with the both recommendations and
states she feels she has benefitted from the interview, thanking the clinician in a genuinely
warm fashion. There is only one problem: Jennifer never appears for either her meeting
with the psychiatrist or her therapist.
Now imagine the exact same scenario with the same patient, but with a different clini-
cian. Once again, this is a talented clinician and empathic interviewer. Indeed, she gathers
essentially the same database as our first clinician. She, too, feels the patient meets the
criteria for a moderately severe major depressive episode by DSM-5 criteria. She, too,
feels that the rapid progression of the depression and the of the depth of Jennifer’s pain
suggests the wisdom of using an antidepressant.
On the other hand, during the body of the interview, she does one thing differently
than our first clinician. It relates to something that she noticed – a piece of jewelry. A
cross is hanging from a simple chain around Jennifer’s neck. It has some decorative ele-
ments that suggest it may be an heirloom; perhaps it’s Victorian. Although not expensive,
it is clear that the owner of this cross, Jennifer, has taken meticulous care of it:
Clin.: I can’t help but notice the cross you are wearing. It’s quite pretty, was it a gift?
Pt.: (Jennifer smiles) Oh, oh, thank you. It was a gift. My gran gave it to me on my 16th
birthday. It was hers as a child.
Clin.: That’s a very wonderful gift.
Pt.: You think so?
Clin.: Sure. You had told me earlier what a kind person your gran was, and to have such a
gift from her own childhood I’m sure is special to you.
Pt.: Yeah, I really love her and it’s a neat old cross. (Jennifer looks downward and seems
to be suddenly a little ill-at-ease)
Clin.: You seem lost in thought. (observed gate) Is there something bothering you?
Pt.: (Jennifer looks up at the interviewer). There’s something I probably should have
told you, that I really didn’t explain very well earlier.
Clin.: What’s that? (said gently)
Pt.: Remember when I told you, I was pretty religious?
Clin.: Yes. You told me you had a Christian background. And it seemed to me you
had some very reassuring beliefs and had been praying to God for some
guidance.
Pt.: Right. And that’s all true. But what I didn’t tell you is how religious my family is.
Clin.: That’s alright. Fill me in.
Pt.: Well, we’re all born again. (looks a little sheepish) And here’s the part I
probably should have told you. My whole family, and I mean my whole
family, including Gran, were strongly opposed to me seeing you. I mean
strongly opposed.
Clin.: Oh, I bet that was sort of messy. What happened?
Pt.: They spent almost a half-hour trying to convince me not to come. My mom told
me that God would heal me, and I needed to just pray harder. I told her I’d been
praying for months and God told me that I should seek help.
Clin.: What did she say?
Pt.: She just kinda shook her head. I think she’s pretty disgusted with me.
Clin.: I see. Are you still glad you came?
Pt.: Oh yeah (said with genuine enthusiasm). But I tell you, it was tough. Everybody
was really angry with me, including my two brothers. Right as I was going out the
door, my mom yelled at me, “Mark my words, they’re going to tell you to take a
medication. That’s their answer for everything. It’s not God’s answer. Whatever you
do, don’t let them drug you.”
When this clinician reached the closing phase of the interview, despite the fact that, on
a theoretical level, she felt an antidepressant might help significantly, she said the fol-
lowing, “You know, Jennifer. There’s lots of different ways we might be able to help you.
But I think a really good way to start is with one of our therapists, you know, a talking
therapy. You have been very easy to talk with, and I think you would genuinely enjoy
working with one of our therapists. And the two of you could see if talking some stuff
out might help with your depression and some of your stresses. How does that sound
to you?”
The clinician chose not to mention medications, not because she didn’t believe that
an antidepressant might help, but because she felt that if she suggested a medication
(just as the family had predicted she would), it would never be taken. And, worse than
that, it might risk alienating Jennifer, perhaps leading her to not proceed with any rec-
ommendations from the interviewer. Instead, she chose a treatment plan that began with
psychotherapy, which also has a good track record with the type of moderately severe
depression that Jennifer is describing.
In addition, if the psychotherapy did not provide adequate relief in the ensuing weeks,
then it would be the psychotherapist who would be suggesting the use of a medication.
If Jennifer had bonded well with the therapist, the therapist’s recommendation for medi-
cation would likely have a more positive reception from Jennifer than the same sugges-
tion made by an initial interviewer. Here is a plan that has a shot at working. It is not
an ideal plan from an ivory tower, but a realistic plan from the practical world of the
clinical trenches where we all work and in which Jennifer lives. The following week Jen-
nifer appears promptly for her session, a cross reassuringly dangling from her neck and
an open mind sitting atop it.
As Paracelsus suggested in our opening epigram, this clinician’s treatment plan was
implemented by the patient because the clinician used her patient as her book. She read
the nonverbal and cultural cues from the pages of this book to collaboratively develop
a treatment plan that resonated with the uniqueness of Jennifer’s family milieu and her
own spiritual story. In this chapter we will focus upon the art of learning to more astutely
understand what patients are saying in their book, as well as learning how to read
between the lines of what they are saying in that very same book. Our goal is to view
not only the patient in isolation but the patient as part of an ever changing set of psy-
chodynamic forces and cultural systems that point to the person beneath the diagnosis.
In this way, we adhere to the age-old wisdom to not judge a book by its cover, a misstep
that can occur if a clinician relies too heavily on a DSM-5 diagnosis alone.
To effectively undertake this search for a more sophisticated understanding, in this
chapter we will look at three topics that help clinicians to understand the patient
beneath the diagnosis: (1) phenomena that can hinder this understanding (focusing
upon ways to avoid them), (2) phenomena that can further it (focusing upon ways to
enhance them), and (3) an introduction to cultural diversity and its role in the initial
interview.
PART I: PHENOMENA THAT HINDER THE UNDERSTANDING OF THE PERSON

Parataxic Distortion
It is clear that the initial interview is an interpersonal process. Both the patient and the
interviewer develop perceptions about each other that will shape both their trust in each
other and their affinity towards each other. One could assume that these interpersonal
perceptions are created primarily via conscious and/or preconscious processes in both
parties. If only it could be so simple. Unfortunately, the patient’s developing image of
the clinician and, for that matter, the clinician’s developing image of the patient are
influenced by unconscious processes as well. Unknown to the clinician, he or she may
resemble a family member of the patient or an ex-spouse, or fill a stereotype of a concrete
prejudice. As Sullivan put it, “The real characteristics of the other fellow at that time may
be of negligible importance to the interpersonal situation. This we call parataxic
distortion.”2
This distorting process can affect the patient or the clinician and sometimes both
parties. In actuality, parataxic distortion may evolve from the early seeding of both trans-
ference and countertransference; as such, its formation and resolution may play a pivotal
role in subsequent therapy. But in the initial interview, such undetected early distortions
may beleaguer an already fragile alliance. Moreover, parataxic distortion can lead to
remarkably difficult roadblocks to understanding the person beneath the diagnosis. Such
unconscious distortion by the patient may lead a patient to mistrust the interviewer with
a resulting hesitancy to share critical material necessary for a sophisticated understanding
of the patient. Parataxic distortion occurring within the clinician can lead to false impres-
sions and inaccurate “gut instincts” about the patient. Either way, an accurate understand-
ing of the patient is made less likely.
Fortunately, intense parataxic distortion is atypical. But when it does occur, it generally
displays itself either through unusually poor blending or by atypically high levels of
anxiety in the patient, perhaps even frank antagonism. This weakening of the engagement
process represents one more area in which monitoring of the blending process can
provide important clues to the engagement itself. Once such weak engagement is recog-
nized, the clinician can begin repair work.
The first step in the repair process consists of questioning whether one’s own actions
are somehow disengaging the patient. At times these interviewer self-defeating behaviors
may be related to countertransference issues with the patient (parataxic distortion on the
part of the clinician as with a patient who unconsciously reminds the clinician of a
patient who was deceitful and antagonistic towards the clinician in the past or reminds
the clinician of an abuser from the clinician’s own family). In such a situation the clini-
cian may inadvertently “hear” the patient’s story differently than it was described, become
overtly suspicious of the truth of the patient’s story, or be repulsed or judgmental about
the views of the patient. These unconscious clinician tendencies can prevent a clear
picture of the patient from emerging.
When a clinician finds himself or herself having a strong visceral negative reaction to
a patient, two self-directed questions can lead to the uncovering of parataxic distortion
at play with the clinician: (1) Does this patient remind me of any previous patients? (2)
Does this patient remind me of any of my family members, friends/enemies, employers
or public figures? Clinicians must be keenly aware of their own beliefs based upon cul-
tural biases, including racial, religious, and political biases. It is surprising how quickly
and powerfully a clinician can develop a dislike for a patient who holds a differing politi-
cal or religious worldview. I have been disturbed by the intensity of stereotyping I’ve seen
from both ends of the political spectrum with supervisees who are either Progressives or
Conservatives when they discover that their patients are of an opposite political persua-
sion, a problem that has intensified as America has become a more politically divided
nation.
If the clinician discovers that he or she is free of such processes, the clinician can then
legitimately wonder whether parataxic distortion is at work in the patient’s mind. If such
distortion is suggested, an open exploration may decrease the growing antagonism. For
instance, the clinician can ask, “I’m wondering what you’re feeling as we are talking,” or
“I sense you are feeling a little displeased with the interview so far, and I’m wondering
what’s going on?”
This type of non-defensive statement may help to defuse the situation, because it
brings hostile feelings into the open, where they can at least be approached. Moreover,
the clinician should not be afraid to uncover specific feelings of ill will, such as, “I find
you very controlling,” because these feelings can be tapped for clues of psychodynamic
significance, which may be addressed later in the interview with questions such as, “When
have you felt similar feelings in the past?” Once again, the emphasis rests upon allowing
the patient to openly express his or her view of the world, in this case, of the interview
itself. This emphasis upon understanding the patient’s view of the world provides the
gateway to a better understanding of who the patient really is.
Sullivan, who died in 1949, is viewed as a pivotal innovator in what he called the
interpersonal theory of psychiatry.3 His work pioneered the realization that patients are
not social isolates. To understand a person, one must delve into the person’s current
interactions with family, friends, culture, and even the therapist’s unconscious itself. More
recently, theorists such as Ogden have expanded the study of the specific interactions
occurring unconsciously between the therapist and the patient, a psychoanalytic concept
called “intersubjectivity.”4
Intersubjectivity teases apart the dynamic interplay between the therapist’s subjective
experience during the interview with the patient’s subjective experience, highlighting the
fact, as we saw with Sullivan’s parataxic distortion, that an interviewer’s own unconscious
may have the potential to distort both the conscious and unconscious “facts” of the
patient’s story, thus hiding the real person beneath the diagnosis. Jonathon Dunn, refer-
ring to intersubjective theorists, succinctly summarizes as follows:
These theorists see the analyst and the patient together constructing the clinical data from
the interaction of both members’ particular psychic qualities and subjective realities. The
analyst’s perceptions of the patient’s psychology are always shaped by the analyst’s
subjectivity.5
I love Dunn’s use of the words “constructing the clinical data,” for they serve to remind
us that the “facts” garnered in an interview are actually educated guesses of what hap-
pened. These guesses are sculpted by the interplay of what really happened with the chisel
strokes made by both the patient’s and the clinician’s unconscious processes. The inter-
viewing instrument in an initial interview – the clinician – is not a thermometer that has
been calibrated for accuracy. The interviewer is more of a human eyeglass that may have
been fitted by personal history with lenses that are prone to see a world with some dis-
tortion. The real patient sitting before the clinician may be a good deal different from
the one sitting inside the clinician’s head.
Further Problems With Inaccuracy: The Issue of Reliability

In our chapter on validity, we have seen that there are many issues regarding the patient’s
propensity to relay the truth that can clearly cause problems with developing a realistic
understanding of the patient. The problems highlighted by the concept of intersubjectiv-
ity actually address a concept similar to validity but distinct from it – reliability. In a
statistical sense, reliability can be defined as follows:
Reliability is an indication of the extent to which a measure contains variable errors; that
is, errors that differed from individual to individual using any one measuring instrument
and that varied from time to time for a given individual measured twice by the same
instrument. For example, if one measures the length of a given object in two points of time
with the same instrument – say, a ruler – and gets slightly different results, the instrument
contains variable errors.6
One can translate the above somewhat obtuse concept into practical interviewing terms
by remembering that our own interviewing style functions as our measuring instrument.
The question then becomes: Does our way of asking questions change from one indi-
vidual to another and, if so, do we bias patients towards certain answers? Here we see
that the unconscious and habitual patterns of the interviewer may not only distort the
interpretation of the data, as suggested by intersubjectivity, but may actually change how
the measuring instrument is actually used.
This issue of interviewer reliability can be framed within two problem areas, although
many other areas also exist: (1) The interviewer changes his or her style of asking a ques-
tion and is not aware of the impact of this change, and (2) the interviewer has good
reliability (asks questions in the same manner from patient to patient) but unfortunately
reliably evokes invalid information. We will briefly examine each of these potential
pitfalls.
Specific clinical settings predispose to the problem of unconsciously changing styles
(note that this potentially negative process is distinctly different from the positive attri-
bute of consciously and intentionally changing interviewing style to suit the needs of the
patient or clinical situation). This problematic unconscious shifting of styles frequently
shadows the presence of countertransference or emotional strain in the clinician. For
example, if an interviewer feels pushed for time or begins to dislike an interviewee, subtle
changes in interviewing style frequently emerge. The interviewer may cut-off the patient’s
responses or actually cast a disarming scowl. In other cases, in which a clinician might
ordinarily have requested a pleasant patient to explain a vague response further, the same
clinician might ask for no further clarification from a sarcastic patient, resulting in a
shortened interview and a less valid database. In this sense, processes such as parataxic
distortion can not only distort patient information but impact directly on how the patient
is being asked for information in the first place.
Such changes in style can significantly decrease the reliability of the interviewing
instrument, with subsequent deficits in the validity of the data. All clinicians will experi-
ence such negative emotions. There is nothing innately wrong with these negative feelings
as long as their potential impact is considered and they are not allowed to interfere with
the interview process. Indeed, at times an awareness of such emotions may provide us
with clues to the inner workings of both the clinician and the patient.
The second area of concern focuses on the knotty issue that I shall loosely label as
being “reliably invalid.” In brief, it is possible that some interviewers develop habits that
consistently increase the risk of obtaining invalid data. Actually, we have already seen an
example of this process, because an interviewer who seldom uses behavioral incidents is
probably reliably invalid. Furthermore, as normal humans, most of us have developed
other rather clever ways of not hearing what we do not want to hear. Such ingenious
devices may get us through some touch-and-go dinners with our in-laws, but if unchecked,
these habits may cause problems during a clinical interview. In a more precise fashion,
I am describing processes such as cajoling desirable answers from patients through
choices of words and tone of voice.
Interviewers may not want to hear positive responses to questions concerning sensitive
topics such as suicidal ideation, homicidal ideation, child abuse, or even the emergence
of certain target symptoms such as depression. The hesitancy to uncover positive replies
to such questions probably results from the fact that such responses may demand
increased time from the clinician, legal action, or even generate fear or a sense of failure
in the clinician. Consequently, as we saw with negative statements of inquiry in Chapter
3, clinicians may unconsciously develop methods of decreasing the risk of a positive reply
by including in their closed-ended questions a negative (e.g., “not” or “don’t”), as follows:
a. “You don’t really feel more depressed, do you?”

b. “You’re not feeling any chest pain today, are you?”
c. “You’re not having thoughts of hurting yourself, are you?”
d. (Said to your mother or father-in-law) “You’re not really thinking of spending the
whole week here, are you?”
An “unusually sophisticated” clinician will reinforce the negative bias by adding a subtle
shake of the head from side to side. In essence, this negative approach to asking for a
“yes” or “no” answer strongly biases the patient to say no. The reason for this negative
bias most likely relates to the fact that the patient feels a need to please the clinician
with a negative response. This biasing remains one of the most common errors I see
during supervision. It represents a particular nemesis when employed around issues of
high sensitivity such as sexuality or suicidality, areas in which patients are hesitant to
share positive answers to begin with, and answers which clinicians are occasionally afraid
to hear.
Another reliably invalid type of questioning consists of habitually asking multiple
questions disguised as a single query, the so-called “cannon question.” In Chapter 5 we
saw how cannon questions can cause problems when trying to finish a list, as when the
clinician is using the validity technique of denial of the specific. Cannon questions can
also cause problems with simple fact-oriented inquiries as demonstrated below:
Pt.: I just don’t feel the same, there’s no question about that. Even my weekends seem
bland.
Clin.: When did you begin to feel depressed, to feel hopeless, to feel like life was not
worth living?
Pt.: Probably back around May. Everything seemed to be collapsing back then, near our
anniversary.
In this excerpt, the clinician has unwittingly set up a confusing situation. He or she does
not know if the patient’s depression or the patient’s hopelessness or the patient’s death
wishes began back in May. It is possible, even probable, that the patient’s depression
began much earlier than the deep sense of hopelessness. Only further questioning could
clarify this murky issue that resulted from the use of a cannon question. In addition,
cannon questions are frequently employed during a review of physical systems, such as:
Clin.: Are you having any problem with your eyes, ears, heart, or stomach?
Pt.: No.
Clin.: Have you noticed any coughing, constipation, diarrhea, headache, backache, or
change in bowel habits?
Pt.: No, I don’t think so.
Although time constraints may sometimes lean the interviewer towards cannon ques-
tions, it remains important to realize that such questions may be confusing to patients.
Only one of the words may stick out in their minds, and such confusion can cause con-
siderable problems with validity.
PART II: PHENOMENA THAT DEEPEN THE UNDERSTANDING OF THE PERSON

BENEATH THE DIAGNOSIS
Sullivan’s Interpersonal Perspective Revisited
It seems naive to assume a simple causative agent for most examples of human anxiety.
For instance, research in neuroscience has unmasked many physiologic as well as psy-
chosocial precipitants to anxiety. In this section we will focus on some of the interper-
sonal forces at work in the creation of anxiety as it unfolds in an initial interview. Much
of the following discussion is borrowed directly from the work of John Whitehorn,7 as
well as further insightful work by Harry Stack Sullivan,8 both pivotal pioneers of inter-
personal psychology.
To begin our discussion, the following question is worth considering as the interview
proceeds: “How does this patient feel that he or she is viewed by others?” In many
instances, the answers to this question will provide clues to the patient’s immediate pres-
ence in our office. Guilt, shame, inadequacy, and fear of failure – these concerns are the
stuff of neurosis. Many of the paralyzing defenses developed by people are erected to
deflect such painful feelings. Whitehorn cogently expressed this idea, “Even in deadly
warfare one’s greatest apprehension is not of death but of being maimed or of failing in
one’s duty, and that, in large part, because one dreads the reactions of other persons.
This is not to downplay the fear of death but rather to emphasize the fear of life.”9
In another sense, developmentally speaking, the child appears to incorporate its sense
of self-worth through a synthesis of perceived parental and family attitudes towards it.
Indeed, persons demonstrating poorly developed personality states, such as the border-
line personality and the narcissistic personality, have frequently evolved from chaotic
childhoods. These developmental issues highlight the importance of interpersonal issues
in the birth and feeding of unpleasant affects such as anxiety and depression. An actress
once told me, “I can play any role once I understand what the character feels guilty
about.”
With regard to the art of understanding the person at a more sophisticated level in
the initial interview, these concerns suggest the utility of a sensitive search for answers
to the question “How does this patient feel that he or she is viewed by others?” In par-
ticular, certain questions concerning the adolescent years may help to open the interper-
sonal door a bit, such as:
a. “What were some of your teachers like?”

b. “Tell me a little bit about the kids in your neighborhood where you grew up.”
c. “What was it like for you to walk home from school or go on the bus?”
d. “Which of your brothers or sisters are you most like?”
e. “Who do you think is the happiest in your family?”
f. “Who do you admire most in your family?”
g. “What do you think are some of your parents’ concerns for you?”
h. “What was gym class like for you?”
i. “What was report card day like for you?”
j. “Did you enjoy social networking on the web?”
k. “Did kids say bad things about you or harass you on the web?”
l. “Have you ever been flamed or physically threatened on the web?”
This list could almost be endless, but these questions represent samples of pathways into
interpersonal affect related to past and perhaps current symptomatology. Of course,
besides these reflections on the past, the interviewer will also pay heed to the patient’s
immediate concerns about spouse, family members, friends, bosses, and fellow employ-
ees, as well as any current harassment problems on the web.
Of even more immediate concern to the interviewer is the generalization of the

patient’s interpersonal fears to the interview itself. As mentioned earlier, the patient’s
self-system may be activated by the perceived threat of rejection or disapproval from the
interviewer, or problems with parataxic distortion may undermine a newly emerging
therapeutic alliance. Whitehorn, once again, crystallizes the idea, “The patient’s attitudes
are not likely to appear at first, in answer to prepared questions, but later, in reaction to
what he feels is the interviewer’s response to his statements.”10 In this regard, the clini-
cian may be aptly rewarded by reflecting upon the following two queries: (1) How is this
particular patient trying to come across to me? and (2) Why does he or she feel a need
to present himself or herself in this fashion?
Some patients may feel that either the clinician or their friends think that they must
be weak or “nuts” to be “seeing a shrink.” This anxiety can seriously hamper engagement
and may be partially alleviated by allowing some ventilation later in the interview with
questions such as, “What has it been like for you to come to see a mental health profes-
sional?” Such a question may provide reassuring feelings of interpersonal safety for the
patient, because he or she realizes that the clinician is aware of the all-too-human anxiet-
ies associated with admitting a need for help.
Another possible method of gaining insight into interpersonal issues arises from
asking patients to describe their attitudes toward others. As Whitehorn states, “A fruitful
field of study lies in a consideration of his sentiments or prejudices, that is, his attitudes
toward father, mother, siblings and other significant others, toward church and state,
toward his home town and toward secret societies, antisemitism, Socialism, Fascism, and
other ‘isms.’ In the discussion of such matters, the patient reveals more clearly than in
response to direct questions the character of his ideals and the way in which he has come
to dramatize his role in life.”11
During an interview with an adolescent boy of about 14 years of age, the wisdom of
this approach became apparent to me. The boy was suffering from a severe depression
and seemed reluctant to talk about himself, but to my surprise he was not reluctant to
talk about others. The request, “Tell me about some of the things you would change at
school,” led to a long and revealing discussion of complex social issues such as his
school’s policy towards racial integration and his own contempt for prejudice. Clearly
this was not a boy interested only in the next football game or party. His detailed analysis
suggested that he was a person preoccupied with powerful moral concerns, which, when
on overtime, could transform into harsh superego admonishings. His world was tense
and dotted with rights and wrongs, creating an intrapsychic field of land mines.
This boy’s interview also raises another pertinent issue, “Can an interviewer probe too
much or too quickly?” Generally speaking, when questioning is done sensitively, it infre-
quently goes too far. But the trick lies in being attuned to the degree of interpersonal
guilt generated by the patient’s responses. If the questions generate too much guilt, the
initial interviewer may find that an impressively thorough database has been gathered
but that there is no patient present with whom to discuss this database at the second
appointment.
To avoid this problem, the interviewer can watch vigilantly for signs of embarrassment
or shame in the patient, perhaps indicated by an averted gaze or a hesitant first step into
speech. This awareness is combined with a common sense attitude towards which subject
areas typically produce anxiety. When present, these signs may suggest the presence of
potentially disengaging guilt, at which point the clinician may opt to reduce the tension
by gently asking a question such as, “What has it been like for you to share such com-
plicated material today?”
Asked calmly and sincerely, such questions demonstrate Rogers’ unconditional posi-
tive regard while allowing patients to ventilate fears of clinician rejection, discovering to
their surprise that such rejection is not imminent. The clinician can further decrease
tension by positively reinforcing the patient’s courage for sharing delicate material with
phrases such as, “You’ve done an excellent job of sharing difficult material. It’s really
helping me to understand what you’ve been experiencing.”
A combination of these techniques was useful in allaying the intense interpersonal
anxieties generated in a man of about 30 years of age who had presented for an initial
assessment. Ostensibly requesting self-assertiveness training, he eventually related a strik-
ing list of paraphilias, including voyeurism, exhibitionism, and frotteurism (rubbing
one’s genitals against people in crowded public places). As he spoke, eye contact van-
ished, while his hands picked at one another. Near the end of the session, the dialogue
evolved roughly as follows:
Clin.: John, I’ve been wondering what it has been like for you to share this material? You
look like you’re feeling a little upset.
Pt.: It’s been very unsettling. I have never shared this stuff with anybody, it’s so weird,
… uh … uh … I, I feel ashamed every time I meet someone new, afraid of … what
they might think.
Clin.: What have you been afraid I might be thinking?
Pt.: Oh, that I’m really sick or disgusting.
Clin.: Has there been anything I’ve done or said that has conveyed that to you?
Pt.: (pause) No, no, I can’t say there has been.
Clin.: Good, because I have a feeling there is only one person in this room who feels you
are sick or disgusting, and that person isn’t me.
Pt.: (patient nods head and smiles gently) That could be. (patient visibly relaxes)
Clin.: Why don’t we try to find out more about why these unwanted behaviors developed
so that we can look at potential ways of changing them. It’s important we can talk
about them openly and you’ve done an excellent job so far.
Pt.: Oh, that sounds real good to me.
Clin.: Tell me what you were feeling the last time you exposed yourself.
Pt.: I had had a bad day, I was really angry at a sales clerk …
John went on to be successfully treated using cognitive–behavioral techniques. The above

interaction had helped him to dismantle a powerful projection, a projection that threat-
ened to disrupt the therapy before it even began.
As clinicians, we need to consider carefully the impact of our probings, recognizing
that certain patients may not be ready to discuss certain issues, whereas others might
actually benefit from our exploration. At these moments during the initial assessment,
we must rely upon our ever-growing experience to guide us, keeping in mind a most
relevant statement made by a wizened monk in the novel The Name of the Rose by
Umberto Eco: “Because learning does not consist only of knowing what we must or we
can do, but also of knowing what we could do and perhaps should not do.”12
Phenomenological Inquiry
We now have a moment to re-examine the process of engagement and phenomenological
interviewing from Chapters 1, 2, and 3. As we have seen, both engagement and its reflec-
tion (blending) can be improved by utilizing a style of questioning that can lead directly
to a clearer understanding of the patient. This style has its roots in the fields of existen-
tialism and phenomenological psychology, to which the book Existence, by Rollo May,13
remains an excellent introduction. While employing a more phenomenological style, the
clinician attempts to see the world as the person experiences it, to literally see the world
through the patient’s eyes, to understand the phenomenon of being that person.
The emphasis rests upon what Medard Boss called “Daseins-analysis,” a German word
translatable as “analysis of being-in-the-world.”14 In short, the clinician attempts to know
what it would be like and what it is like to be the person sitting across from himself or
herself. To this end, it is often useful to emphasize the world of the senses by asking
specifically about what the patient is seeing, hearing, feeling, smelling, or tasting. From
this sensate inquiry, doors may open into the patient’s feelings, attitudes, and thoughts.
To borrow a phrase from Aldous Huxley and William Blake, it is “through the doors of
perception” that one may enter a patient’s unique way of being, the patient’s inner home.
Indeed, this home may be turbulent, beautiful, or terrifying, but once experienced, the
clinician’s understanding cannot help but be clearer.
Moreover, such sensitive questioning can convey to the patient that the clinician is
interested in the patient as a person, not merely as a new case or diagnosis. In this regard,
in the first interview the clinician may decide to include brief (or sometimes not so brief)
forays into the phenomenology of the patient. These dialogues may be similar to the
following one involving an overweight woman whose eyes see only deadness:
Pt.: I guess I was just sick of everything … everything … so I wanted to get away, to be
by myself away from everybody who can hurt me. So I went into my room and shut
off the light. I lit a few candles and I sat there.
Clin.: What were you looking at as you sat there?
Pt.: Nothing really … occasionally I watched the candlelight flickering, it made the
shadows of the vase dance around on the wall.
Clin.: Do you remember anything else that caught your eye?
Pt.: Uh huh, I remember looking at my high school prom picture.
Clin.: And?
Pt.: I thought how cruel it was the way relationships have to break up. The person in
that picture meant nothing to me now, and I don’t think I really meant anything to
him ever (patient sighs).
Clin.: What else are you feeling in the room?
Pt.: Lonely and empty. I just wanted to crawl up into a tiny ball like a cocoon.
Clin.: What does the world feel like to you in your cocoon?
Pt.: It feels distant, dark, and numb. I feel, feel sort of blank, but I also am angry. I’m
angry at my mother for never really caring, for putting me in the cocoon in the first
place. I don’t ever remember her hugging me (begins crying gently). I remember
going away for the summer once to stay with my grandparents. And at the train
station I felt very frightened and sad. I kept wondering what my mother would do
when she said good-bye – would she hug me or kiss me, and for how long? And
you know what she did? She did nothing. She said good-bye.
Clin.: That must have hurt.
Pt.: It really did, it really hurt … (perks up) But that’s the way it’s always been.
Clin.: Do you expect people to hurt you?
Pt.: … Yes, yes I do, maybe I’m growing accustomed to it, maybe I even like it.
Clin.: Going back to that night in the room with the candle flickering, did you have any
thoughts of wanting to kill yourself?
Pt.: Yes, I did. As I sat there it all seemed sort of silly, so I began thinking about taking
some pills. I’d stored up some Valium.
Clin.: What thoughts went through your mind?
From this dialogue the clinician can begin to feel the resounding hollowness of this
patient’s world, the intensity of her pain. One gains a sense of her neediness and her
latent expectation of rejection, an expectation that may very well create the very bitterness
that seeds actual antagonistic behavior from others put off by the patient’s hostility. In
any case, the patient seems somehow more “real.” Moreover, this phenomenological
excursion has provided many hints for the clinician of potentially productive regions of
future exploration, another example of intuition guiding further analysis. Indeed, one
wonders if this hollow world represents one petal in the abated flower we call a border-
line personality.
This excerpt began with an active investigation of the room with the patient, moving
into associations generated by this phenomenological exploration. When exploring in
this way, sometimes the patient will share associations experienced at the time being
discussed, while at other times new associations stirred by recounting the experience may
surface. In either case, rich material may become accessible to the clinician. Phenomeno-
logical inquiries are not necessarily based on questions dealing with the five senses.
Frequently the patient’s experience of the world is entered by questions exploring atti-
tudes, opinions, recollections, and by an immediate sharing of feelings as they arise
within the clinician–patient dyad.
Before leaving this excerpt, a quick perusal reveals an interesting twist. Notice that
the clinician switched tenses from past tense to present tense with the phrase, “What
else are you feeling in the room?” Such a switch sometimes facilitates a regression in
the patient to a point where images become more real and less memory-derived. This
type of maneuver can unlock repressed memories and emotions, as witnessed here by
the unexpected emergence of anger directed towards a parent figure perceived as cool
and distant. If one feels the interviewee cannot tolerate such a regression, as in an
unstable patient or a psychotic patient, one would not utilize such a technique. In
conclusion, phenomenological inquiry provides one more powerful method by which

understanding may be increased.
The Search for Wellness: Patient Strengths, Skills, and Interests

For decades, one of the cornerstone characteristics of client-centered counseling and,
more recently, person-centered medicine has been a belief in the importance of uncover-
ing the inherent strengths of the patient, maximizing them, and realizing that the patient
brings many healing factors to the table. As noted in Chapter 4 on facilics, in addition
to the concept of the “presenting problem,” I like to talk about the importance of uncov-
ering the patient’s “presenting solutions” as the interview proceeds. This concept recog-
nizes the wellness of the patient as well as his or her illness. Patients have often tried a
variety of measures for recovery and problem solving, some of which may have had some
degree of success. We want to draw upon these inherent strengths, and capitalize on their
utility during our subsequent efforts at collaborative treatment planning during the
closing phase of the interview.
Several decades of research on the nature of happiness, spearheaded by researchers
such as Seligman, Peterson, and others,15–19 has evolved into the exciting field of posi-
tive psychology. Positive psychology attempts to delineate the characteristics and etiolo-
gies of positive states of mind such as happiness, resilience, psychological strength, and
social well-being in a somewhat similar fashion that diagnostic systems sculpt out the
attributes of psychopathological states. Used together, both approaches form a synthetic
balancing of complementary ways for creatively helping patients with difficult times
and symptoms.
To me, there are three markers of wellness: strengths, skills, and interests, which we
will simply refer to as the “wellness triad.” These wellness markers, when skillfully
explored by an interviewer, not only help to flesh-out the person beneath the diagnosis,
they may immediately provide suggestions for treatment planning based upon the idea
of maximizing these wellness attributes to help the patient navigate whatever life circum-
stances or mental disorders he or she is encountering.
In the following sections I attempt to provide a quick overview of the wellness triad,
so that the reader has a familiarization of these areas and the interviewing techniques
that can be used to explore them. I refer the interested reader to the many outstanding
books on the subject of positive psychology, such as the work of Seligman,20 and more
recently Robert Biswas-Diener,21,22 as well as my own work on creating resiliency in both
ourselves and our patients during difficult times.23
Before proceeding, I would like to add a note of reassurance to clinicians early in their
careers who, as they have read the chapters in this book thus far, may be struck by the
voluminous amount of material that appears to be important to uncover in an initial
interview. The amount of material to be covered in an initial interview may seem intimi-
dating at first, and to some degree it is. But it need not be overwhelming. I want to
emphasize that I am not suggesting that in an initial interview one can explore all of the
areas of the wellness triad, nor ask all of the questions about to be described. It is simply
impossible.
In fact, much of the process of uncovering the numerous aspects of the patient’s well-
ness triad is a part of ongoing therapy. In the real world of a busy clinic, during the initial
interview a clinician may only be able to barely touch upon these areas. On the other
hand, an awareness of the importance of these wellness markers can help an interviewer
to explore them as efficiently as possible, when possible, in the initial encounter. Moreover,
the questions described in this section can subsequently be utilized in ongoing therapy.
This is also a good time to re-emphasize another reassuring point made earlier. A
clinician could never cover all of the questions or explore fully all of the content regions described
in this book during an initial intake and should not try to do so. By the end of any intake,
time limitations will have forced us to leave untapped many questions that we wish we
could have covered, from diagnostic questions using the DSM-5, to questions concerning
wellness and aspects of social history. It is just a fact of life.
On the other hand, the resulting omissions do not have to be left to the chaotic whims
of chance. If left to chance, critical data for helping the patient are often missed, perhaps
never to be found, even in subsequent therapy. Instead, one of the major themes of this book
is that a clinician who has become familiar with what topics are most important to explore, and
what interviewing techniques are available for sensitively exploring them, can gather a surpris-
ingly sound database in 50 minutes.
This knowledge of what to ask and how to ask it, coupled with a sophisticated under-
standing of the facilics of an interview, can result in conversational interviews that are
brimming with the information that is pivotal for successful treatment planning. Clini-
cians can, and should, create intentional interviews in which wise decisions are made
about what to delete, when to delete it, and how to delete it. With confidence, the inten-
tional interviewer can make these decisions while noting what it is they want to further
explore in later sessions. Even when time limitations become acute, as in emergency
department interviews, the principles of this book allow the clinician to make wise deci-
sions as to what to delete, while maximizing both engagement and the information
needed for safe triage.
In essence, although we are focusing upon the initial assessment interview in this
book, assessment is an ongoing process. A good clinician will continue to perform assess-
ment in all succeeding sessions of therapy and/or medication management. Whether we
are addressing aspects of the wellness triad or re-thinking our DSM-5 diagnostic formula-
tions, the assessment process continues. Even in the last session of psychotherapy, a clini-
cian is carefully assessing how the patient is handling termination itself. Indeed, it is
only with the soft sound of the door shutting as the patient leaves our office for the very
last time that the process of assessment actually ends.
Exploring Component #1 of the Wellness Triad: Patient Strengths

For both interviewer and patient, the concept of strengths can appear to be a nebulous
subject, possibly because both parties seldom focus upon the delineation of strengths.
In 2004, Peterson and Seligman24 created an inventory of character strengths called the
Values in Action Inventory of Strengths (VIA-IS), which provides a heuristically pleasing
and practical listing of 24 potential human strengths, placed in six categories as follows:
Strengths of Knowledge:
1. Creativity
2. Curiosity
3. Love of learning
4. Perspective (wisdom)
5. Open-mindedness
Strengths of Courage:
6. Bravery
7. Persistence
8. Integrity
9. Vitality
Strengths of Humanity:
10. Capacity to love and receive love
11. Kindness
12. Social intelligence
Strengths of Justice:
13. Citizenship
14. Fairness
15. Leadership
Strengths of Temperance:
16. Forgiveness/mercy
17. Modesty/humility
18. Prudence
19. Self-regulation
Strengths of Transcendence:
20. Appreciation of excellence and beauty
21. Gratitude
22. Hope
23. Humor
24. Spirituality
For ongoing work with a patient, a well-validated self-administered assessment survey,

which helps patients to spot their own strengths on the VIA-IS using a 240-item ques-
tionnaire, is available for free on the web and can be used quite effectively in ongoing
counseling (www.authentichappiness.sas.upenn.edu).25
For the initial interviewer, the above list serves a slightly different function. I find that
the list helps me to recognize patient strengths more readily, for I find it to be surpris-
ingly easy to miss them in an initial interview. Such omissions occur for a natural reason.
Patients present to us not because they intend to discuss their strengths but because they
are worried about their weaknesses. As they describe their presenting crises and as we
explore the immense database required to provide optimum help during the initial
session, it is easy to lose sight of the patient’s strengths.
For instance, if I am interviewing a soldier’s spouse, the above list can help me “to
see” not only the obvious bravery and persistence of the patient’s spouse in Iraq, Afghani-
stan, or wherever the soldier may be deployed, but the less obvious bravery and persis-
tence of the patient in front of me. The patient may be single-handedly maintaining the
well-being of the family, while dealing with the intense fear that his or her loved one
could be killed at any moment. At times we might also find that we are not the only
person in the room who has lost sight of these strengths.
In an initial interview, I find that occasionally I have time to uncover these types of
processes through the use of statements that both explore and simultaneously acknowl-
edge the patient’s strengths as with the following, “However do you find the toughness
to keep everything going at home when your husband is in Iraq and everyday you are
dealing with the fear that he might be killed? It’s really quite remarkable.” Such a sensi-
tive statement can powerfully enhance engagement, while also opening the door to a
useful exploration of the patient’s strengths and self-image. There is much to be learned
if the patient responds, “I don’t know. I’ve never viewed myself as tough.”
In a different fashion, a clinician can decide, initially, to mentally file an observed
strength, purposefully choosing to relay it later during the closing phase of the interview.
Genuine complements provided during the closing phase regarding the strengths one
has seen in an interview often pleasantly surprise a patient. They also can be used for
treatment planning purposes at that time, as with, “How do you think we could tap your
ability to organize material so well, as we develop a plan for helping with your burn-out
at work?” Closing on strengths also tends to provide a positive feel to the ending of the
initial session, better ensuring that there will be a next session.
In some interviews, one may have the time to ask directly about strengths with open-
ended questions such as:
1. “When you look at yourself, what would you view as some of your best strengths?”
2. “What do you think your wife would say are your best strengths?” (insert husband,
partner, best-friend, parents, boss or whomever is appropriate)
Some patients may feel a bit awkward about discussing their strengths openly, and some
cultures may support such reluctance. Robert Biswas-Dienar has found that the following
comment, which acknowledges the cultural taboo of speaking highly of oneself, can
create a “local culture” between interviewer and patient in which the patient can feel
more free to open up: “I know it may feel strange, like you are bragging, but I assure you
I will not take it that way. I am genuinely interested in what you do well.”26
Exploring Component #2 of the Wellness Triad: Patient Skills

Unlike patient strengths (which represent generalized characterological traits), the
concept of patient skills is more specific. A patient skill is an actual ability that can
be taught, improved, and consciously used to achieve a specific goal. A thorough
listing of potential skills is well beyond the goals of this book and might well fill the
remaining pages. On the other hand, it is useful to have a short list that can function
as a framework for exploring patient skills both in the initial interview and during
subsequent therapy:
Creative Skills:
1. Musical
2. Artistic
3. Mathematical
4. Writing/journaling
5. Reading
6. Web design, app design, or blogging/web journalism
7. Web or console game design
Task Related:
8. Problem-solving skills
9. Organizing skills
10. Marketing skills
11. Selling skills
12. Buying skills
13. Financial planning skills
Interpersonal Skills:
14. Listening to others
15. Providing comfort
16. Nurturing others
17. Teaching and mentoring
18. “Reading” people
19. Interviewing others
20. Being interviewed
21. Public speaking
22. Web-related skills such as social networking
Athletic Skills:
23. Skills in a particular sport
24. Coaching skills
25. Conditioning, nutrition, healthy living, body building, yoga, meditation, martial
arts, etc.
Manual Dexterity:
26. Specific craft or discipline such as carpentry, gardening, auto bodyshop work
27. Precision technical expertise such as metal lathe, woodworking, etc.
Specific Career Training:

28. Everything from teaching, to health services, to managing a store, to web
marketing
There exist many more categories and each of the above categories could have many other
entries. This list gives us a starting point. As was the case with patient strengths, patient
skills may indirectly be uncovered when the patient spontaneously raises them or
describes situations where they naturally arise. But unlike patient strengths, which might
seem a little awkward to directly raise in the initial interview, patient skills are relatively
easy to raise in the initial assessment. When exploring the social history, one routinely
asks about schooling and job history, thus opening the door to inquiries about specific
skills.
Asking about skills is a particularly rich arena for uncovering the person beneath a
diagnosis. Not only can it uncover skills that can be directly used as part of collaborative
treatment planning, it also provides an open door into the patient’s sense of self-esteem,
secret ambitions, lost dreams, psychodynamic defenses, and interpersonal pressures from
the expectations of others. To enter the region, one can ask directly, as with, “We all vary
on what types of skills we have, what would you say are some of your skills?” If a patient
seems to be a little hesitant to respond, I might add, “What do you think some of your
friends or teachers or family might view as some of your skills if I were to ask them?”
With the right patient (powerfully engaged thus far in the interview, strong ego
strengths, and a clear demonstration of humor earlier in the interview), a clinician can
sometimes use wit to open the topic of the patient’s skills in a rather paradoxical, yet
highly effective, fashion. In the following illustration we will see the power of a well-
timed use of humor and genuineness, as Egan described the concept in Chapter 2, to
swing open the door hiding the patient’s skills. What is behind such doors is sometimes
unexpected, almost always useful, and, occasionally, of significant psychodynamic inter-
est, as we are about to see.
Let us picture a Black male with smartly styled dreadlocks in his early 20s whom we
shall call Jamal. He has presented complaining of depression, which he feels has resulted
from his problems finding a job after graduating from college during a deep recession.
Jamal wears a matter-of-fact, no-nonsense attitude towards life that protects him from
the harshness of reality that he has all too often faced. Tall in stature, he enters the office
with a bent posture, as if his depression was pushing downwards on his shoulders.
Pt.: … there is simply nothing I can do right now. There are no jobs. I’ve been killing
myself looking for 7 months now, it’s just nuts. My girlfriend Tasha and I are really
strapped for money. We’re living together and rent is becoming a problem.
Clin.: It sounds really tough. You certainly have been tenacious at looking. That is evident
from your history. (the interviewer makes explicit an implicit strength from the
patient’s history in an intentional effort to help the patient see a potentially
forgotten positive aspect of himself)
Pt.: Yeah, yeah, that’s true (pauses and looks towards the interviewer with a somewhat
beaten look) – hasn’t gotten me much though, but I suppose it’s good that I try,
not everyone would I suppose.
Clin.: Absolutely not. I assure you I have many people who sit in that very chair who
don’t have your strength or persistence (Jamal smiles). You know, one thing you
could do that could help me get a better handle on how you might approach the
stress of hunting for a job would be if I had a better idea of what you think some
of your skills are, you know, what you think you might have to offer on a job
market. We all have things we feel skilled at and a few things we feel unskilled at.
For fun let’s start with the unskilled? What are you terrible at? (said with a straight
face followed by a smile)
Pt.: (patient chuckles) Where do I start? … You mean it?
Clin.: Sure, what are you really, remarkably terrible at?
Pt.: (patient chuckles again) Let me put it to you this way, you don’t want to hear me
sing.
Clin.: I guess American Idol is out? (clinician smiles)
Pt.: (patient laughs out loud) American Idol is definitely out. But, I’m not devoid of
any musical ability. I used to be a pretty good drummer.
Clin.: Oh, what type of drumming?
Pt.: Different kinds, but my favorite shit is heavy metal.
Clin.: How good were you?
Pt.: I was pretty awesome. (catches himself and sheepishly smiles) I wasn’t Mike Smith,
you might not know him, but he played in a band called Suffocation, now that
brother can really play. But I was pretty good. I even won several drumming
competitions while I was in high school. (seems lost in thought for a moment)
Truth be told, I really wanted to make it as a drummer.
Clin.: It sounds like you probably could.
Pt.: Yeah. I probably could have. (shrugs his shoulders) I think I could have made it as
a studio drummer. I would have loved that, but I decided to go to college instead.
Clin.: I’m curious. Did you do that because your parents gave you some pressure to go to
college? I ask that because sometimes parents, with all good intentions, try to push
their kids away from a career in music, recognizing it’s a rough way to make a
living.
Pt.: You know, strangely enough, the answer to that is “no.” In fact, my dad thought I
was very talented and on several occasions, both before I went off to college and
while I was in it, he told me I could take off for a year or two and try to make it as
a drummer and he would support that.
Clin.: I wonder what stopped you?
Pt.: (more deeply lost in thought for a moment) I don’t know. (looks up) I really don’t
know.
Clin.: What do you think you might have been afraid of, that made you choose to shy
away from your own dream?
Pt.: I never thought of it that way. But I guess I must have been afraid of something
about pursuing the drumming (long pause) … failure maybe? I don’t know, but it’s
a really good question.
Clin.: You know Jamal, it doesn’t have to be a question about the past. It can be about
the future?
Pt.: I don’t follow.
Clin.: Last time I heard, the world still needs good drummers.
Pt.: Hmmm (Jamal’s eyebrows raise with the look of cognitive surprise). Maybe. At least
I’d have plenty of time to practice. (smiles again)
Clin.: Who knows? You might enjoy drumming again, simply because you seemed to love
doing it so much in the past, and your face lit up just now while you were talking
about it. It might even help with the depression a bit. I don’t know. I’m also
wondering if there is anything else you might be able to do with it, even to help
with the financial problems you and your girlfriend are having?
Pt.: You mean, like tutor somebody for money?
Clin.: I’m not certain, but that’s not a bad idea. I really don’t know the field, but maybe
there’s something to be said for checking it out. You seem to really like people, and
it’s a chance to help some kid who could really use the help. I bet you’d be a good
teacher.
Pt.: Yeah, I sort of like teaching, but never thought of it as something I could do with
the drumming. Sort of an interesting idea (pauses) … Tasha and I really, really need
the money.
This highly productive exchange is not the norm for an initial interview, but an initial
interviewer interested in uncovering patient skills, and trained to do so effectively as this
interviewer illustrates, is much more likely to have such encounters. Our clinician has
skillfully uncovered a specific patient skill set, clearly enhanced the therapeutic alliance,
demonstrated his own competence to the patient, and gently parlayed into an explora-
tion of the psychodynamics of the patient while providing some collaborative ideas on
treatment planning. Not bad for 4 minutes of an initial interview, aptly demonstrating
that explorations of patient skill can be successfully integrated into the first encounter.
Exploring Component #3 of the Wellness Triad: Patient Interests, Hobbies,

and Pastimes
How a human being spends his or her time when not involved in making a living is a
direct reflection of not only who may be beneath the diagnosis, but also of how the
person beneath that diagnosis may unconsciously wish to be perceived. Beneath hobbies
and pastimes, psychodynamic defenses are busily at work.
It is here that the importance of “reading between the lines” of the patient’s book
often makes itself clear. In the same way that the manner in which a house is decorated
reflects the person who is living in the house, hobbies are interpersonal decorations that,
in addition to personal interests, often reflect psychodynamic needs such as the need to
be loved, to be left alone, or to be special at something. In this regard, the following
question sometimes leads to surprising windows into a patient’s needs to feel special or
appreciated by others, “I’m curious, Anne, what types of photos do you like to post on
Facebook (or whatever social media the patient uses)?” Patients reporting an unusually
persistent and frequent posting of things they’ve made, accomplishments in sports, items
they’ve bought, or pictures of their kid’s accomplishments are, not infrequently, reflecting
their inner needs to be recognized by others.
In this regard, in addition to uncovering what interests the patient pursues, it can be
valuable to read between the lines as to what these pursuits may imply about the psy-
chodynamics of the patient. An adolescent or young adult who spends entire weekends
engaged in role-playing games at a local comic and manga store may have strong attach-
ments to the group to which such an activity is appealing. The unassuming back-room
of that little alley shop may be a place of safety, self-growth, and interpersonal refuge for
a student who otherwise would be left alone to deal with the pangs of being an outsider
in the hallways of his high school. Hobbies sometimes become identities, whether one
is an athlete, biker, or goth. Depending upon the expressed interests of the patient, ques-
tions such as the following can lead to revealing dialogues:
1. “Do you view yourself as a ‘biker’?”

2. “What do other students think of your goth friends?”
3. “How bad would it be for you, if you couldn’t tailgate at the Steeler games?”
Curiously, the same hobby can range from being one that requires highly developed
social skills to one that allows a person who is missing such skills to flee social interac-
tion. It is worth finding out how a specific patient approaches a hobby before assuming
what it means in a stereotypic fashion about socializing. For instance, one might assume
that patients collecting sports cards or vinyl LPs might spend much of their time holed
up alone in their homes perusing their treasures or listening to their finds. Yet both of
these types of collectors could equally choose to hang out at card shops or attend “record
shows” where they eagerly pursue social banter and even enjoy the high-level social
exchanges required when wrangling over price, an art that requires not a small touch of
ego strength. Web activities also range dramatically in their social interaction. The fol-
lowing type of question can provide some surprising insights in this regard: “When you
are playing World of Warcraft online, do you play as a single or do you seek out a party?”
If they seek out a party, it can be revealing to find out whether the party consists of
friends, family members, strangers, or a combination.
As we saw with both strengths and skills, an exploration of interests can point towards
treatment planning ideas based upon already present attributes of the patient that the
patient has simply not thought of using to solve current stressors. We saw this earlier
with Jamal, who had thought of his drumming neither as a potential antidote to his
depression nor as a source of income. As a further example, a person coping with
obsessive–compulsive disorder (OCD) who spends much time on Facebook and feels
quite comfortable on the web, may not have thought to use these skills to utilize a chat
room for people coping with OCD. They might not even know that such chat rooms
exist. More and more crisis centers are providing chat and texting arenas, manned by
expert crisis providers, for patients who are having suicidal thoughts but may be afraid
to talk with someone on the phone.
One can raise the topic of outside interests and hobbies in a variety of straightforward
fashions as with, “When you are not working, how do you like to spend your time?”,
“What types of things do you like to do in your spare time?”, “Do you have any hobbies,
sports, or things you really like to do a lot, like watch television or go online?”, or “Do
you like to use Twitter or other social media very much?” In closing, the very act of asking
about the patient’s interests can enhance engagement. Especially if the patient enjoys a
rather unusual hobby or interest, a gentle command such as, “Tell me more about that,
I’m not very familiar with it, it sounds very interesting,” when done with a genuine inter-
est, can be surprisingly engaging. Such interludes may even “break the ice” in an interview
where engagement has been lukewarm thus far.
PART III: UNDERSTANDING CULTURAL DIVERSITY – ITS VITAL ROLE IN THE

INITIAL INTERVIEW
Culture and psyche make each other up.27
Richard Shwerder, cultural psychologist
We do not solely interview patients. We interview cultures as well. It is an illusion to

believe that a human being exists outside of the culture in which the person developed.
Equally, it is an illusion to believe that human cultures would exist without individuals.
Thus the pains of our patients are the pains of the cultures in which they were raised
and in which they now live. The pains of the culture are the aggregate pains of the people
who walk the streets of the culture, abide and break its rules, obey and create its gods.
Kitayama and Cohen elegantly describe this curious paradox of identity in which
people and culture exist within one another, a concept technically called “mutual
constitution”28:
… culture is not a “thing” out there; rather, it is a loosely organized set of interpersonal
and institutional processes driven by people who participate in those processes. By the same
token the psyche is also not a discrete entity packed in the brain. Rather, it is a structure
of psychological processes that are shaped by and thus closely attuned to the culture that
surrounds them. Accordingly, culture cannot be understood without a deep understanding
of the minds of people who make it up and, likewise, the mind cannot be understood
without reference to the sociocultural environment to which it is adapted and attuned.29
The answer to the question as to why it is vitally important in person-centered interview-

ing to understand the role of culture in the initial interview is a simple one: From the
perspective of mutual constitution, we cannot fully understand the person beneath the
diagnosis unless we understand the culture that shaped, and is still shaping, the mind
of the person waiting there. Moreover, to effectively help the patient, the clinician must
understand the culture to which the patient is returning, for a treatment plan that does
not take into consideration the cultural demands of the person seeking help may very
well be doomed to failure by that very same culture. We saw the importance of this
principle in the opening vignette of this chapter. The second clinician wisely shaped the
initial treatment recommendations for Jennifer to fit the familial and spiritual culture to
which Jennifer returned and which gave birth to the simple, yet powerful, cross that
dangled from her neck.
To deeply understand, and perhaps equally importantly, to effectively empathize with
the concerns of patients, the clinician must understand that the patient’s concerns, symp-
toms, and even their diagnoses will be partially determined by the culture of both the
patient and the clinician. At the interface of these two powerful forces – the culture of
the patient and the culture of the clinician – the initial interview will unfold. As noted
in an earlier chapter, not only the patient will be changed by the initial encounter, so
will the clinician. Even more mysteriously, whether aware of it or not, by the end of the
hour the patient and the clinician will have subtly changed the culture in which they
find themselves, for they are integral elements in its never-ceasing evolution.
This deepening of the clinician’s understanding of cultural diversity, a process that
will continue throughout the clinician’s career, is addressed in a variety of ways through-
out the remaining pages of this book. We will later devote an entire chapter (Chapter
20) to the topic of culturally adaptive interviewing, at which point we will look at specific
interviewing techniques and strategies for exploring the cultural beliefs of the patient,
especially the patient’s world view and spiritual frameworks. We will also explore in more
detail what we mean by concepts such as “culture” and “cultural competence” as they
are applied to interviewing in a practical everyday sense.
In the meantime, throughout the chapters of this book, we will see that processes we
have already explored – such as empathy and the therapeutic alliance – are affected by
cultural factors. By way of an introduction to this interface, in this chapter we will explore
two specific arenas in which the forces of culture clearly impact on the clinician’s under-
standing of the person beneath the diagnosis: (1) potential misperceptions of each other,
by both participants of the interview, created by cultural biases and (2) roadblocks to
effective treatment planning, as well as fresh opportunities for effective treatment plan-
ning, that are created by cultural factors.
Misperceptions Related to Cultural Biases: Impact on the Initial

Therapeutic Alliance
Franz Boas, one of the founders of American cultural anthropology, created a wonderful
metaphor – “kulturbrille.” Kulturbrille is the set of “cultural glasses” that each of us wears
at all times. These cultural glasses, like all lenses, have both the power to clarify the world
the patient is describing and the ability to distort the view of that very same world.30
Such distortions are far from unilateral in nature. Each participant in the interview
dyad peers outwards through his or her own cultural spectacles, potentially unaware of
what distortions are being created. In essence, whereas Sullivan’s parataxic distortions
are caused by the unconscious processes of both parties, “kulturbrille distortions” are
caused by the unconsciously created biases of the cultures from which we all grow. If not
understood by the interviewer, these bi-directional distortions can damage the inter-
viewer’s ability to engage the patient, to understand the patient, to collaboratively plan
treatment with the patient and, ultimately, to help the patient. It is thus of critical impor-
tance for clinicians to understand the impact of both sets of eyeglasses being donned in
the initial encounter, even though they may be as invisible as a pair of contacts.
Expectations of “what should happen in therapy” can be discordant, depending upon
cultural attitudes. For instance, cultures may vary on how they address the concept of
time and timeliness. Compared to a White American’s concept of time, a Native American
may have a more relaxed attitude towards time (based upon a feeling of how time seems
to almost imperceptibly pass during the turnings of a day in Nature as opposed to the
tickings of a clock).31 Consequently, a Native American patient may consistently appear
late for appointments. An interviewer not aware that the patient is simply following
acceptable cultural norms may misinterpret the patient’s behaviors as signs of resistance
or irresponsibility. On the flip side, a Native American patient may find a White American
therapist’s demands for timeliness, as well as their attempts to “pin-down” when subse-
quent appointments should occur – and for exactly how long (50 minutes) – somewhat
puzzling. Both parties may also have different views as to the importance of ending the
sessions “right on time.” A Native American who perceives a clinician as being overly
focused upon such time issues during an initial interview may find himself or herself
feeling uncomfortable with the interaction. The patient could even come away with the
feeling that this particular clinician is a “pushy” person “who seemed more interested in
time than me,” a perception that could easily diminish the likelihood of a second
appointment. Let us look at a different possible area for a cultural disconnect.
All of the largest racial/ethnic subcultures that might be encountered in the United
States (including Asian American, Indian American, White American, African American,
Hispanic American and Native American) hold in high regard the quality of trustworthi-
ness. All of these cultures value a person who is honest, a person who stands by his or
her word. Thus clinicians – no matter what their culture of origin, from Latino/a to Black
to White – also tend to view trustworthiness as an important component for successful
therapy.
Of the cultures listed above, all of which value trust, there is a difference in how the
cultures approach the seemingly unrelated concept of expressing disagreement, especially
when disagreeing with a figure of respect or authority. Yet these two apparently unrelated
cultural values can sometimes intertwine to create a curious misperception by an inter-
viewer. Let’s see how it might unfold.
We will picture an interviewing dyad composed of an Asian graduate student on a
visa sitting with a non-Asian university counselor (the counselor could be Black, White,
Latino/a, or Native American, etc.). The patient is suffering from a depressive episode
during his first year of graduate school.
This patient’s Asian background will provide us with a vivid example of how inter-
viewers naive to cultural norms may inadvertently misattribute negative qualities to a
patient. Compared to the cultures of the non-Asian potential counselors mentioned
above, many (not all) Asians or Asian Americans may tend to shy away from the direct
expression of disagreement and/or confrontation.
Consequently, as the Sommers-Flanagans point out, if an Asian American is hesitant
about a specific treatment recommendation, the patient may not directly say so, for it
would be viewed, within his or her culture, as a sign of possible disrespect to the therapist
with whom they are meeting for the first time.32 Consequently, the patient may generate
the mildest (yet still unwanted) affirmative response available. The mildness of the agree-
ment would be interpreted as a possible or even a probable “no” in the patient’s culture
of origin. But, to the non-Asian therapist, raised in a culture where disagreement is voiced
much more readily, it appears quite obvious that the patient has given a “yes” to the
treatment recommendation.
When, in the next appointment, it becomes apparent that the patient did not do “what
he agreed to do,” it is very easy for the non-Asian therapist to view the patient as being,
at best, ambivalent in nature and, at worst, unmotivated, irresponsible, or even prone to
deceit. Clearly the “cultural glasses” of Franz Boas are at work here. Such kulturbrille
distortions can result in a remarkably shaky therapeutic alliance.
For a moment we will stick with this combination of a non-Asian American therapist
and an Asian American or recent Asian immigrant or visitor, for it introduces another
aspect of culture that can interfere with the accuracy of clinician perception – nonverbal
norms. Compared to the other cultures mentioned above, Asians may handle eye contact
differently.
The Asian cultures have a rich, and deeply rooted, heritage of respecting elders. Con-
sequently, during the first meeting with an elder, or any respected figure such as a physi-
cian or mental health professional, direct eye contact may be relatively minimal. A gently
reduced level of eye contact is often the culturally accepted way of expressing deference
to a respected person. Direct and persistent eye contact could be viewed as a sign of
disrespect.33 Unaware of this cultural norm, the non-Asian therapist (whether White,
Black, Latino/o, etc.) could misperceive the lowered eyes and poor eye contact of the
patient as evidence of poor blending, shyness, lack of confidence, or even “attitude” if
the patient happened to be an adolescent.
Culture Impacting Directly on Treatment Planning in the Initial Interview

The insights of the anthropologist Ward H. Goodenough shed light on the impact of
culture on the process of the initial encounter and the treatment planning created within
its confines, for patients come to us as agents of change. As Goodenough highlights, it
is culture that may ultimately determine the patients’ actual interests in changing and
how they approach it:
Culture, then, consists of standards for deciding what is, standards for deciding what can
be, standards for deciding how one feels about it, standards for deciding what to do about
it, and standards for deciding how to go about doing it.34
In our opening vignette with Jennifer, we already witnessed the power of a subculture
– a strict fundamentalist perspective by her family – to create concrete roadblocks to
treatment planning. As Goodenough suggests, it is not only the treatment options for
the patient that may be limited by culture. Such limitations affect all elements of the
treatment team, including the clinicians. We all are wearing the kulturbrille spectacles
that Franz Boas described earlier. Cultures can limit the ability of the clinician to see
viable treatment options that may be appearing in the dialogue of the interview – effec-
tive treatment options that would be readily apparent to a clinician familiar with the
patient’s culture.
As clinicians walk into initial interviews, they enter with distinct biases about treat-
ment planning. Some like to use medications; some don’t. Some like psychotherapy;
some don’t. Those who like psychotherapy may prefer cognitive–behavioral therapies,
others may prefer psychodynamic models, and some embrace both. Some routinely
involve family members in treatment planning. Others seldom do, except in inpatient
settings. Some are open to alternative therapies, others do not believe in them.
Of critical importance to us, as students of the initial interview, is the recognition that
these biases (and we are all entitled to our individual beliefs about therapeutic interven-
tions) can sometimes distort what we “hear.” At times, clinicians tend to “hear” in the
database those bits of data that support their predispositions towards their preferred
therapeutic interventions. Such a distorting process is potentially damaging, for it can
prevent a clinician from seeing the value of an intervention that is new to the clinician,
but perhaps of great importance to the patient’s subculture. The success of the therapy,
and even the validity of the database upon which it is based, may be dependent upon the
clinician’s ability to spot these kulturbrille distortions.
Cultures and subcultures can provide unique resources for treatment planning pur-
poses, if the clinician is willing to listen to the culture. For example, many clinicians in
the United States and Canada find themselves working with the Hmong, who have had
a significant immigration to North America. Within this culture, shamans can play a
major role in community function and in the approach to healing. Understanding this
cultural fact, an interviewer may opt to invite the patient’s shaman, if requested by the
patient, to consult upon the treatment plan. If one is working within a culture where
shamans or medicine men play a major role (such as the Hmong, Native Americans in
the United States, and First Nations people in Canada), it can be useful to ask, “Have you
talked to a shaman (or medicine man) about your problems?” If the answer is “yes,” by
then asking “What were his opinions?”, unexpected yet useful ideas for treatment inter-
vention may be shared, ideas that the patient is already predisposed to pursue. An open
and respectful discussion of the shaman’s recommendations by the interviewer can meta-
communicate that the clinician is not culturally bigoted or narrow in his or her approach.
This metacommunication can be remarkably powerful in securing initial engagement.
After brainstorming on a treatment plan in the closing phases of an intake interview,
it can also be wise to ask, “What do you think your shaman might think about our plan?”
If there are going to be culturally related roadblocks to treatment planning acceptance,
an astute interviewer will want to know about them beforehand, not after the patient
returns, having already decided against the treatment plan because of the cultural antago-
nism with which it was met. Alerted to such a potential impasse, the clinician may be
able to prospectively transform it.
As the Sommers-Flanagans point out, some cultures, such as the Asian American
culture, tend to downplay the role of individual decision making.35 Most personal deci-
sions by an individual are viewed as directly reflecting the values, worth, and integrity of
the larger family unit. Hence, some Asian American patients may believe that these deci-
sions should be made by the family as opposed to the individual. If this is the patient’s
belief, it is important to involve family members in treatment planning early on. With
almost all young Asian Americans, the following type of question may be both useful
and revealing: “What do you think your parents will think of our ideas for using psycho-
therapy (medications, etc.)?”
Latino/a cultures traditionally place strong emphasis upon the father as the “head of
the family.”36 As with the Asian American patient, it may be useful to ask questions such
as, “What do you think your father will think of this treatment?” If a father disagrees
“back home,” the clinician may need to give considerable support to the patient’s
personal choice for treatment, for such parental opposition can be strikingly intense. The
pressures on Latina patients by paternal dictates can be remarkably stressful, literally
destroying a treatment plan before it is begun.
Although we have been focusing on situations in which cultural roadblocks to treat-
ment planning may be related to cultural biases, at times clergy and key family members
can become strong advocates for beneficial treatment interventions that the patient, and
perhaps even the patient’s culture, may be wary of utilizing. For instance, a patient lost
within the terrors of a psychotic process may be more likely to agree to the use of poten-
tially life-saving antipsychotics, not by the entreaties of a clinician from a different
culture, but by the respected words of a trusted figure within the patient’s culture.
I would like to end this chapter by sharing one of the clearest examples I have encoun-
tered of this exact phenomenon. I believe it nicely illustrates some of the key principles
of this chapter. It highlights the importance of trying to understand the patient beneath
the diagnosis in the initial assessment, as well as the fact that to do so, one must under-
stand the cultural context of that patient and of the patient’s symptoms.
It began when I met Anna for the very first time. Anna had been admitted to an inpa-
tient unit dedicated to helping people with schizophrenia. When I entered the room, I
was met by a pair of eyes that had the paradoxical quality of being both piercing and
frightened at the same time. Anna was a 24-year-old African American who had been
admitted the night before, through the emergency department, suffering from what
would prove to be her first break of schizophrenia. She wore a colorful shawl wrapped
tightly about her somewhat overweight body, as if she had enveloped herself in a protec-
tive suit of magical armor. I would soon learn that she was protecting herself from a
hoard of demonic voices and fears of possession.
Anna was strongly opposed to the use of medications. In the initial interview I learned
that she belonged to a Pentecostal church in which her own mother was the minister.
Her mother was, quite naturally, steeped in the beliefs and rituals of her chosen faith,
being quite adept at speaking in tongues and performing exorcisms. I was concerned that
her mother’s religious beliefs were going to be “problematic” from my viewpoint, in the
sense that she might disagree with the diagnosis of schizophrenia and be strongly
opposed to the use of an antipsychotic. She would soon prove me to be very wrong
indeed.
In a subsequent session alone with Anna’s mother, we both shared and listened to
each other’s beliefs shaped by our respective subcultures about what was wrong with
Anna. Her mother had, indeed, been concerned that Anna was possessed and had already
performed an exorcism. When I asked about the impact of the exorcism and also the
presentation and actions exhibited by Anna since possession, she described her church’s
efforts in some detail. I asked about other possessions she had seen, other exorcisms that
had worked effectively, and what she felt the future would hold for both her daughter
and herself. After talking extensively about her previous experiences with exorcism, she
paused for moment and then queried, “What do you think is going on?”
I subsequently shared thoughts about the symptoms of schizophrenia, the potential
role of the brain and neurotransmitters, and some of the subtle pre-psychotic phenom-
enology of psychotic process (social withdrawal, problems with sleep, wariness, mild
agitation, moments of being lost in thought, all of which often predate for weeks or
months the onset of delusions or hallucinations). It was here that Anna’s mother seemed
particularly interested, nodding on several occasions, the type of nod accompanied by a
quiet “hmmm,” as if nonverbally acknowledging, “I might have seen that.” At one point
she gave a little sigh, and asked, “If Anna has this schizophrenia thing, do you think you
can help her?” Later she commented, “I’m not so sure she is possessed. It’s not like any
possession I’ve ever seen.” Apparently, through her careful listening, she had indepen-
dently arrived at her own personal conclusion that her daughter’s behavior seemed to fit
the description of schizophrenia better than the possibility of possession.
As she was about to leave my office, she turned and commented, “You know, Dr. Shea,
I agree that Anna is probably suffering from what you call schizophrenia, but there is
something important for you to know.” I asked, “What is that?” She said, “Just keep in
mind that Satan causes it. He is always behind our suffering.” She smiled, and walked
out the door.
Two cultures met, both cultures saved face, and both cultures agreed to join forces.
This anecdote serves as poignant reminder that some of the most important culturally
powerful interviews are not necessarily the ones with our patients. They are sometimes
the ones we have with the people who love our patients.
Anna’s mother subsequently convinced Anna to give the antipsychotic a try. The results
were exciting, with an excellent remission within 1 month. Interestingly, during this
episode of her daughter’s illness, Anna’s mother was comfortable asking Anna to not
attend church services, “until God has healed the chemistry of your brain, for I don’t
think it’s a good idea for you to be around thoughts of possession and exorcism until
your brain is working the way God intended it to.” Anna agreed.
I am convinced that Anna’s suffering would have been remarkably more intense and
prolonged (she remained in good remission) had it not been for the interventions of her
mother, whose religious beliefs were open enough to a different perspective to decide
upon an atypical approach to healing from her culture’s perspective. I would like to think
that the openness and genuine respect of the interviewer, myself in this instance, of her
beliefs and her previous successes at healing, set the tone for her reciprocal openness to
my ideas. We will never know for sure.
What I am sure of, however, is that for about 20 minutes, two people – Anna’s mother
and myself – were able to remove their cultural glasses. The kulturbrille effect was sus-
pended, and each participant saw the other with a more accepting eye. More importantly,
it gave us the chance to see that we both shared the same mission – to help Anna with
her great pain. And, appropriately enough, it would be Anna who would ultimately gain
the most from our clearer vision.
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CHAPTER 7
Assessment Perspectives and
the Human Matrix: Bridges to
Effective Treatment Planning in
the Initial Interview
We shall not cease from exploration

And the end of all our exploring
Will be to arrive where we started
And know the place for the first time.
T. S. Eliot
Little Gidding1
We have already seen how a deeper understanding of the person beneath the diagnosis
can suggest powerful methods for securing a sound initial treatment plan, while simul-
taneously maximizing engagement and the likelihood of a second meeting. One critical
way-station on our map of the initial interview remains untapped – the cognitive art
of assessment. By “assessment” we are referring to the fashion in which the clinician
“puts all of the puzzle pieces together” from the patient’s history. The clinician will
arrive at his or her initial formulation of what the problems are, what are the various
forces at work contributing to the patient’s problems, and what are some of the pos-
sibilities for transforming these problems. This fourth way-station in our map is arguably
the major gateway to our fifth, and final way-station – collaborative treatment planning
(Figure 7.1).
In our first six chapters we have focused upon clinician behaviors as manifested in
specific interviewing techniques and strategies. But it is not only the interviewer’s behav-
iors that define an interview; interviewing is also a cognitive art. In this regard, the initial
interviewer’s mind is alive with assessment possibilities – potential clues to healing.
Much cognitive work is occurring while the interview unfolds, for the interviewer, in
addition to gathering the database, must also “listen” to the database as it reveals itself.
The ultimate goal of the initial interview – in addition to enhancing the likelihood of a
second interview – is to collaboratively develop an initial treatment plan that seeds hope
by the end of the interview and, indeed, begins the healing process. It is from the inter-
viewer’s and patient’s assessment of what is right and what is wrong that treatment
options come to mind. It is this cognitive assessment that creates the bridges leading into
effective treatment planning. These cognitive skills, utilized throughout the initial encoun-
ter, are the focus of this chapter.
I must emphasize that this is not a chapter about how to choose specific therapies
and design concrete treatment plans. Such a topic as treatment planning is both complex
and vast – well beyond the scope of a book focused on the interviewing process. The
interested reader is directed to the many outstanding texts on treatment planning.2–4
Instead, this is a chapter about the cognitive processes and decisions that a clinician must
make during the interview itself about what data to gather in the first place and how to
use this data to collaboratively develop treatment plan options with the patient. I believe
that a fundamental familiarity with the basic principles of treatment planning is an
essential part of an interviewing course, for a clinician cannot truly understand how to
interview effectively if one does not understand the reason for the interview – what
information is needed for a treatment plan and why.
This chapter explores three assessment perspectives by which clinicians can organize,
during the interview itself and immediately afterwards, the massive stream of informa-
tion encountered in an initial interview in such a way that the database provides sign-
posts pointing towards possible treatment options. In essence, a sound assessment
perspective can generate a listing, in the interviewer’s mind, of possible treatment inter-
ventions to collaboratively share with the patient. Such ongoing organization can also
significantly enhance the clinician’s ability to rapidly create a final assessment document
(whether dictated, typed, or written), a skill of marked importance in this age of managed
care and tight time constraints, as well as representing the final task of the initial
interview.
Frequently I have seen clinicians falter, not because they lack adequate knowledge
about the use of specific treatment modalities, but because the use of certain modalities
never comes to mind. They become lost in the database, emphasizing certain information
Assessment perspectives and the human matrix 223
while ignoring, or not even obtaining, other pertinent data. We are dealing with an
information processing problem, a not unexpected dilemma considering the vastness of
the information involved in understanding another person’s problems. In this chapter
we will study a common-sense approach to creating a realistic list of viable treatment
options. No attempt is made to suggest the pros and cons of any specific treatment; rather,
the focus is upon bridging from the process of data gathering in the body of the interview
to collaboratively creating an initial, albeit tentative, treatment plan in the closing phase
of the interview.
This chapter also demonstrates that the treatment opportunities that come to mind
for the clinician appear to be directly related to both the data collected and the method
of organizing the data. For example, a clinician who does not learn to ask questions
concerning the neurovegetative symptoms suggestive of a medication-responsive depres-
sion will most likely not think to utilize such a medication. Likewise, a clinician is less
likely to think of intervening via social work channels if current stressors are ignored.
To avoid such tunnel vision, clinicians can organize their data into schemata that
emphasize conceptualization from multiple viewpoints. In this chapter we will look at
three such systems. Through them, the power of a well-organized database to lead to
effective treatment planning will become apparent.
We shall look at the following three assessment perspectives: (1) the diagnostic per-
spective provided by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5
version),5 (2) matrix treatment planning, and (3) the perspective provided by under-
standing the “core pains” of the patient. Although overlapping at their interfaces, each
of these perspectives generates unique clues for treatment planning. Consequently, it is
often expedient to create an initial treatment plan utilizing all three perspectives. I have
found single-perspective treatment planning to be generally unsatisfactory, akin to begin-
ning a watercolor with only half of the necessary paints. The value of multi-faceted treat-
ment plans, which integrate care longitudinally, has been well described in a variety of
areas by authors such as Kim Mueser and Robert Drake concerning dual diagnoses6 and
McKinnis-Dittrich with elders.7
Each of the three assessment perspectives provides the following benefits for usefully
organizing clinical information:
1. An easy and rapid method of checking, during the interview itself, whether pertinent
data regions for treatment planning have been explored, thus decreasing errors of
omission
2. A reliable method of reminding the clinician to borrow from different data perspec-
tives when collaboratively formulating a treatment plan with the patient
3. A flexible approach to delineating a list of potential treatment modalities with the
patient
In addition, outside of the domain of the initial interview, a clinician who understands
how to effectively utilize these three bridges into treatment planning will have learned
a set of skills that are invaluable in ongoing treatment planning, especially when there
appears to be a roadblock. These treatment-planning perspectives often allow treatment
teams to create new and refreshing transformations of stalled moments in ongoing care.
We will begin by reviewing a database gleaned from an actual initial interview. Following
this presentation, the information from each of the three perspectives mentioned above
will be examined, observing the utility in the initial interview provided by each
viewpoint.
CLINICAL PRESENTATION: THE INITIAL INTERVIEW

When I first saw Ms. Baker (Debbie) she was sitting in the waiting room. Her eyes were
hiding behind a pair of large, pink-framed sunglasses. These frames were bordered by
her shortly bobbed brown hair. She had a round face and a rather short frame. She was
wearing a neon-pink T-shirt and a pair of freshly washed jeans. Wrapped around her left
wrist was a wide leather band with the name Paul tooled into it.
When I asked if she was “Ms. Baker” she pertly looked up, smiled and replied, “Yes,
I’m Ms. Baker, but not for long.” I asked what she meant, and she replied, “Oh, I’m
getting married in a month.”
Once in my office, she related a story of a longstanding problem with fluctuating
moods. She spoke in a quiet voice, frequently casting her eyes to the floor, as if to avoid
seeing the impact of her words upon my face. She displayed no evidence of derailment
(loose associations), thought blocking, pressured speech, or illogical thought. She gave
no evidence of responding to hallucinations and denied both auditory and visual
hallucinations.
With regard to her moodiness, she stated that her moods frequently changed through-
out the day. It was not at all unusual for her to feel various moods, including anger and
rejection, during the course of a single day. Although she reported intermittent periods
of feeling decreased energy, decreased interest in activities, decreased libido, and difficulty
falling asleep, she denied any periods of 2 weeks or more in which these symptoms were
persistent. She denied manic or hypomanic symptoms past or present.
She lived in a world of imagined fear, persistently worried that she would be aban-
doned. At night she would become angered if her partner fell asleep first, because she
would quickly become engulfed by her fear of being alone. These fears fostered an intense
dependency, which she readily admitted was a major handicap. She went out of her way
to please her partner, allowing all major decisions to be made by her, including the
upcoming wedding plans. This dependency also surfaced with the string of therapists
lying in her wake. Her most recent therapist had to have her forcibly removed from his
office by the police, an act marking the end of their contact.
As one might have surmised, impulse control was not a strong point. For instance,
several years earlier she had managed to toss a picnic table bench through a friend’s
picture window while enraged. Moreover, she had a history of popping pills in small
suicidal gestures about every 2 to 3 months over the past 3 years.
Her relationship with her parents was very strained, and she felt she had always been
marked as the black sheep of the family. She had one sister 2 years older than she, who
was employed as an accountant and was reported as happily married. One of her earliest
memories consisted of standing behind the front door weeping as her father walked away
down the stone path. As she cried, her mother shook her violently, pulling her away from
the doorway.
To my surprise, the wristband bearing the name Paul had nothing to do with past or
present friends or her partner. Instead it referred to herself, for she often fantasized that
she was Paul Newman. This vivid fantasy game was indulged by her partner, who would
call her Paul when they decided to play this game of pseudo-identity. At no time did
Debbie, nor her partner, lose sight that this was merely a fantasy, although she longed
to be anyone but herself. When talking of her fantasy identity, she would occasionally
cry softly, as if punctuating her story with tears.
THE DIAGNOSTIC PERSPECTIVE OF THE DSM AND ICD SYSTEMS

The Healing Power of Differential Diagnosis
For clinicians, differential diagnosis serves one major purpose – to discover information
that may lead to more effective methods of helping the patient. Diagnosis should not
be an intellectual game or a pastime used to placate insurance companies. Over the years
I have found the DSM systems (Diagnostic and Statistical Manual of Mental Disorders),
including the DSM-IV and the DSM-5,8 as well as the International Classification of
Diseases (ICD) nomenclatures,9 to be invaluable in helping me to initiate the healing
process, serving as a robust bridge to treatment planning. A formal diagnostic schema
provides this bridge to treatment planning in many ways.
Like the common language we have developed for discussing the interviewing process
itself, the art of differential diagnosis allows one to conceptualize the complexities of the
patient’s presentation more clearly, while alerting the clinician to hidden problems. Dif-
ferential diagnosis can also provide valuable information concerning prognosis, possible
treatment modalities, and pitfalls to be avoided in dealing with certain syndromes (i.e.,
a psychotherapist who has spotted that the patient fits the criteria for a dependent per-
sonality disorder in the initial interview will be careful to avoid psychotherapeutic mis-
steps in subsequent sessions that could lead to a pathologic dependence on the
therapist).
A particularly important benefit of performing a sound differential diagnosis with all
patients in an initial interview is the ability of a clinician adept at such skills to uncover a
hidden diagnosis that a patient will not share spontaneously because of problems with
stigma, embarrassment, or lack of self-awareness that a problem exists. Such a hidden
diagnosis, if left hidden, can lead to problems, including severe ramifications such as
untreated substance abuse and even suicide, all because the patient was afraid to share
the symptoms unless directly asked about them, a surprisingly common phenomenon.
For instance, as we saw in Chapter 2, many patients with obsessive–compulsive dis-
order (OCD) will develop reactive depressions to the problems caused by having the
OCD. Because of fears of appearing crazy or strange, they will present to the therapist
complaining only of their depression or marital problems. Likewise, a college student
presenting with depressive or anxious symptoms may have severe bulimia or substance
abuse underlying it, which is not shared spontaneously secondary to stigma. For these
reasons, the art of diagnostic formulation remains a cornerstone of sound assessment
during an initial interview.
In my opinion, many treatment failures are the result of such untreated hidden diag-
noses. Studies such as the National Comorbidity Survey (NCS) have shown marked
comorbidity among commonly presenting mental disorders including depression, panic
disorder, OCD, and alcohol dependence.10 In a community sample, over 56.3% of
patients presenting with a major depression had another current psychiatric disorder.11
The rate of comorbidity is even higher with another commonly presenting disorder –
generalized anxiety disorder – where rates of comorbidity have been reported of more
than 90% in both a clinical and community sample.12 By doing a sound differential on
all patients, no matter “how obvious” the presenting symptoms may be for a mood or
anxiety disorder, one may uncover a disorder that is even more problematic or might
even be the root of the patient’s problems.
In addition, diagnostic systems such as the DSM-5 and ICD-10 allow both clinicians
and researchers the opportunity to share their successful experiences in treating a specific
disorder in a common language. When a clinician discovers a treatment plan that is
useful in relieving a resistant major depression, these findings may be applicable to a
patient being treated by a fellow clinician, who might benefit from the shared knowledge.
Formal differential diagnosis is a practical passport to the knowledge housed in journals,
books, and the minds of our fellow clinicians.
A clinical vignette will make this abstract discussion more concrete. I was working
with a couple whose marriage was riddled with a nasty streak of passive aggression and
strained communication. After several sessions, the marital therapy seemed to be bogging
down. The husband, a rather narcissistic man, kept insisting that nothing was being done
for him. In reviewing my notes, I discovered that the referring clinician had diagnosed
the husband as suffering from a dysthymic disorder. I had recently read an article report-
ing that certain types of dysthymic disorders responded well to antidepressant medica-
tion. My patient fit one of these descriptions and consequently was begun on an
appropriate antidepressant. He quickly found significant relief.
However, to the chagrin of both the patient and his spouse, their marital friction
remained painfully present. Up to this point, he had balked at couples therapy, categori-
cally stating, “My problems are all from my depression. Trust me, there is nothing wrong
with my marriage.” With marked marital discord remaining despite relief from his
depressive symptoms, he no longer had an excuse for avoiding the work of therapy,
thanks to the antidepressant suggested by his DSM diagnosis. Suddenly the marital
therapy could move ahead more effectively. This vignette illustrates the power of a
common diagnostic language to provide a clinician with knowledge discovered by others.
Without the diagnosis of dysthymia, and its relation to the article that I had just read,
this pivotal treatment intervention would not have been tried.
Let us explore in more detail how diagnoses can be valuable in suggesting possible
treatment modalities. For instance, major depressions frequently respond to antidepres-
sants and may also benefit from concurrent psychotherapy or, frequently, from psycho-
therapy alone. Bipolar disorder (manic phase) is usually approached with lithium,
antipsychotic medications, or antiseizure medications such as carbamazepine, lamotrig-

ine, and valproic acid. Phobias are frequently alleviated by using cognitive and behavioral
techniques. Mild to moderate forms of major depression can be approached using
dynamic and cognitive psychotherapies, behavioral approaches, or numerous counseling
techniques. Uncovering the presence of a borderline personality disorder can suggest the
use of specific evidence-based interventions such as Marsha Linnehans’ dialectical behav-
ioral therapy (DBT)13 or recent time-limited transference-based therapies.14 The above list
merely represents a terse survey, but it nevertheless highlights the power of a diagnostic
system to help in developing a diverse treatment approach.
Finally, diagnosis can play a key role in the healing process from a completely differ-
ent perspective than the clinician’s viewpoint. Correct diagnoses, shared sensitively, can
be surprisingly comforting to patients who have had no idea what was plaguing them
other than there “must be something really wrong with me” or “I must be a weak person.”
Underlying biologic disorders such as bipolar disorder or adult attention-deficit disorder
not only can destroy effective functioning, they can savage self-esteem and self-image.
Such patients often go for years without any knowledge that they have an underlying
biologic disruption, which has been the root cause of their ruined marriages, lost jobs,
failed grades, and financial collapses. In such cases, patients often view themselves as the
sole creators of their distress and failures. These types of self-degrading cognitions can
lead to untold suffering and can also provide fertile soil for suicide. Learning that there
exists a different explanation for their inability to function – than they had believed –
can be powerfully healing, as we saw with the woman who presented with depression
but had severe OCD as her primary diagnosis in Chapter 2.
Limitations of Formal Diagnostic Systems Such as the DSM and ICD

Before proceeding, it seems expedient to review some of the important limitations of
traditional diagnostic approaches, such as the DSM-5. Only through knowledge of a
system’s weaknesses can its strengths be utilized safely.
One of the most obvious limitations remains the fact that diagnoses are labels. As
labels, they can be abused. One such abuse occurs when clinicians fall into the trap of
using diagnoses as stereotypical explanations for human behavior. It should be remem-
bered that a diagnosis provides no particular knowledge about any given patient. It
merely suggests possible characteristics that may or may not be generalizable to the
patient in question. In addition, as we saw in Chapter 6, it is critical to uncover the person
beneath the diagnosis, a point elegantly stated by the gifted physician Sir William Osler,
many years ago, when he commented, “It is much more important to know what sort
of patient has a disease than to know what sort of disease a patient has.”15
Moreover, diagnostic formulations are evolving processes and as such should be peri-
odically re-examined. There is a realistic danger that patients can become stuck with
inappropriate diagnoses, a problem that can only be avoided through persistent reap-
praisal. In a similar fashion, the clinician should remain healthily aware of the potential
ramifications of certain diagnostic labels with regard to the patient’s culture and family.
By way of example, the label of schizophrenia can result in the loss of a job or in the
development of a scapegoating process within a given family. Considerations of these
problematic aspects of diagnosis related to cultural issues should be integral parts of

sound clinical care.
In this regard, the kulturbrille effect, introduced in our last chapter, can cause prob-
lems such as over-pathologizing, if the interviewer is not aware of cultural norms. For
instance, where I trained in medicine at the University of North Carolina in Chapel Hill,
it was not uncommon for patients to talk about “root-working,” which was a culturally
accepted folk belief that some people could perform malicious magic by burying and
manipulating certain roots. Obviously, with some people who were suffering with schizo-
phrenia this became part of a delusional belief system. But it was important for clinicians
to realize that all patients who discussed root-work were not necessarily psychotic. In
some patients it was merely an accepted belief and not evidence of psychopathology. In
advanced diagnostic systems such as the DSM nomenclature and ICD, it is stressed that
clinicians should be aware of such cultural norms so as to avoid such misattributions.
The issue of the significance of a specific diagnostic label to the patient himself or
herself can be of marked importance. For this reason, I frequently ask patients if anyone
has given them a diagnosis in the past. If the answer is “yes,” one can follow with ques-
tions such as, “What is your understanding of the word schizophrenia?” or “Do you think
that diagnosis is right?” The answers to these questions can provide valuable insight into
the patient’s self-image, intellectual level, and previous care.
With these limitations in mind, we can now begin our exploration of the DSM-5 in
more detail. In 1980, the DSM-III system introduced many of the innovations, such as
multiaxial formulation, that formed the foundation of the contemporary DSM systems.
A bridge between the two systems called the DSM-III-R appeared in 1987, and added its
own new ideas and refinements. The DSM-IV itself was published in 1994. In 2000, the
DSM-IV-TR (Text Revision) was published, which did not change any diagnostic criteria
but added much useful information about psychopathology and the subtleties of the
diagnostic system to enhance the system as an educational tool, while keeping its mat-
erial updated to reflect advances in evidence-based research.
It is to the DSM-5 system that we will now turn. We will not attempt to review diag-
nostic criteria now, because these are discussed in subsequent chapters. Instead we will
look at those principles that help to make diagnostic formulation possible in the first 50
minutes. As diagnostic systems evolve they necessarily experiment with various changes,
many of which are good, and occasionally, a few are not so good. There are some signifi-
cant improvements in the DSM-5, but we will begin our study by noting what I, person-
ally, feel is a potential regression in the system. This book focuses on contemporary
practice, but I feel that this brief exploration of historical context can help the reader to
be a better clinician both now and in the future.
The Loss of Multiaxial Formulation: a Historical Footnote

To me, one of the most compelling aspects of the DSM-III and the DSM-IV-TR was the
fact that these systems pushed the interviewer to consider various contextual perspectives
while formulating a diagnostic picture. Each perspective was placed upon one of five
axes.
On Axis I, clinicians were prompted to delineate the patient’s presentation in terms

of the classic psychiatric diagnoses such as major depression, bipolar disorder, schizo-
phrenia, anorexia nervosa, OCD, and post-traumatic stress disorder (PTSD). Indeed, all
psychiatric disorders – with the exception of personality disorders and intellectual dis-
abilities – were listed on this first axis. It was on Axis II that clinicians were to list per-
sonality disorders as well as personality traits, whether the traits were problematic or
sometimes beneficial in nature. Medical disorders and other biologic conditions such as
pregnancy were placed on the third axis. It was on Axis IV that the clinician could help
place the patient into their contextual matrix by addressing processes such as family,
friendships, living conditions, financial concerns, and cultural issues. Finally, on the last
axis, the interviewer considered in what fashion the above concerns and disorders were
impacting on the patient’s relatively recent and immediate functioning.
The beauty of the system was the fashion in which it emphasized a holistic approach
to conceptualizing the patient’s presentation while simultaneously preventing biological
reductionism. This multiaxial approach metacommunicated that the field of psychiatry
emphasized the importance of a contextual understanding of the patient. Indeed, the
multiaxial system demanded that clinicians look at the patient contextually.
The DSM-5 has removed the mutiaxial system and, to my knowledge, is now the
only major international diagnostic system that is not multiaxial. I mention it as being
odd (a personal opinion) in that it seems to fly in the face of the current emphasis
upon person-centered medicine, whether one is dealing with diabetes and cancer or
schizophrenia. It should be noted that the final arbiters of the DSM-5 still felt that
contextual factors, whether they be cultural, interpersonal, or environmental are impor-
tant. Indeed, they recommend that such factors be routinely addressed in separate
notations with all patients, but this recommendation seems to be undermined by the
elimination of specific axes where it was required that these factors would be routinely
addressed.
I feel that the lack of these axes, especially in our current age of time constraints, may
invite a lack of attention to core aspects of care by harried clinicians. For instance, placing
personality function and disorders on a separate axis in the DSM-IV-TR reminded clini-
cians that it is always important to understand the personality functioning of the patient
and how it might impact on Axis I disorders such as OCD or schizophrenia. It further
pushed clinicians to sensitively uncover the unique personality attributes of each patient,
for such personality predispositions can be invaluable in understanding how a patient
responds to his or her symptoms as well as in collaboratively developing treatment plans
that fit the needs of that patient’s unique personality traits.
In any case, despite the lack of formal axes in the DSM-5, I myself find it useful when
listing the DSM-5 diagnoses to always address the presence or absence of personality
disorders and medical disorders separately, to remind myself (and the reader of my clini-
cal assessment) of the importance of such factors. By way of illustration, in the chapters
on differential diagnosis in Part II of this book, I will demonstrate how to do so in our
clinical vignettes.
Later in this chapter, we will see that factors such as psychological, social, and spiritual
aspects are comprehensively addressed in the two other treatment planning frameworks
that I suggest routinely employing in addition to the DSM-5: matrix treatment planning
and understanding the core pains of the patient.
Major Psychiatric Disorders (Other Than Personality Disorders)

At first glance the DSM-5 may appear confusing because of the large number of diagnostic
entities that it contains. But there is little need for concern. The craft in using this system
lies in approaching the task by first uncovering the general diagnostic probabilities and
then delineating the specific diagnoses (Figure 7.2).
As the initial interviewer listens during the opening phase and the body of the inter-
view, the symptoms of the patient will suggest diagnostic regions worthy of more elabo-
rate expansion. This primary delineation will lead the clinician to one or more of the
following easily remembered regions of adult psychopathology:
1. Schizophrenia Spectrum and Other Psychotic Disorders

2. Mood Disorders (including major depressive disorders, bipolar disorders, etc.)
3. Anxiety Disorders
4. Obsessive–Compulsive and Related Disorders
5. Trauma/Stress-Related Disorders (includes acute stress disorder, PTSD, adjustment
disorders, etc.)
6. Dissociative Disorders
7. Somatic Symptom and Related Disorders (somatic symptom disorder, illness anxiety
disorder, conversion disorder, etc.)
8. Feeding and Eating Disorders
9. Substance-Related and Addictive Disorders
10. Neurocognitive Disorders (delirium, dementia, etc.)
11. Other miscellaneous disorders (gender dysphoria, disruptive and impulse-control
disorders, sleep–wake disorders, paraphilic disorders, etc.)
12. Mental disorders due to a general medical condition (e.g., personality change sec-
ondary to a frontal lobe tumor, etc.)
13. V-codes and other conditions that may be a focus of clinical attention
Looked at in this simplified fashion, the first step in utilizing the DSM-5 appears con-
siderably more manageable than at first glance. In order to succeed, the clinician must
be well grounded in psychopathology, as will be discussed in Part II of this book. This
knowledge base will allow the interviewer to quickly determine which of the thirteen
areas are most pertinent. As the interview progresses, the clinician can reflect upon
whether each of these broad areas has at least been considered, thus avoiding errors of
omission.
Once the primary delineation has been made, the interviewer can proceed with the
secondary delineation, in which the specific diagnoses subsumed under the broad diag-
nostic areas are explored and the more exact DSM-5 differential diagnosis is determined.
Thus, if the clinician suspects a mood disorder, the clinician will eventually hunt for
criteria substantiating specific mood diagnoses such as major depressive disorder, bipolar
disorder, dysthymia, cyclothymic disorder, other specified or unspecified depressive
Patient's symptoms
and history
Primary delineation:
– – – – – – – –
Schizophrenia OCD Dissociative Eating Mental disorders Bipolar Somatic Other miscellaneous
spectrum related disorders disorders due to a general disorders symptom disorders and
disorders medical condition disorders V-codes
– – – – + –
Anxiety Trauma / Neurocognitive Neurodevelopmental Depressive Substance
disorders stressor disorders disorders disorders related
disorders disorders
Secondary delineation:
+ – – – –
Major Premenstrual Depressive Depressive
Dysthymia
depressive dysphoric disorder due to disorders specified
disorder disorder medical condition or unspecified
+ = Symptoms are suggestive of
– = Symptoms are not suggestive of
Figure 7.2 Basic approach to diagnostic utilization with adults (patient with a major depressive disorder).
disorders, and other specified or unspecified bipolar disorders. This secondary delinea-
tion would be performed in each broad diagnostic area deemed pertinent.
As already described in Chapters 3 and 4, these explorations occur during the main
body of the interview. Most importantly, they are done in a highly flexible fashion, always
patterning the questioning in the style most compatible with the needs of the patient
and the clinical situation. Consequently, the clinician expands these diagnostic regions
in a unique fashion with each patient, mixing them with various other content regions
and process regions. When done well, the result is an interview that feels unstructured
to the patient yet delineates an accurate diagnosis.
V-codes represent conditions not attributable to a mental disorder that might be useful
as areas for the focus of therapeutic intervention. Examples include academic problems,
occupational problems, uncomplicated bereavement, low interest and follow-through
with medications, marital problems, parent–child problems, and others. Sometimes
these codes are used because no mental disorder is present, and the patient is coping
with one of the stresses just listed. They can also be used if the clinician feels that not
enough information is available to rule out a psychiatric syndrome, but, in the meantime,
an area for specific intervention is being highlighted. Finally, these V-codes can be used
with a patient who carries a specific psychiatric syndrome but for whom that syndrome
is not the immediate problem or the focus of intervention. For example, an individual
with chronic schizophrenia in remission may present with marital distress.
Personality Disorders
The basic approach to differential diagnosis with personality disorders follows the same
two-step delineation that we found to be useful in delineating the non-personality related
psychiatric disorders above. In the first delineation, one asks whether the interviewee’s
story suggests evidence of long-term interpersonal dysfunction that has remained rela-
tively consistent from adolescence onwards. If so, the patient may very well fulfill the
criteria for a personality disorder or disorders.
After determining that a personality disorder may very well be present, the clinician
proceeds with the secondary delineation in which specific regions of personality diagno-
ses are expanded. This secondary delineation will result in the generation of a differential
from the following list:
1. Paranoid personality disorder

2. Schizoid personality disorder
3. Schizotypal personality disorder
4. Histrionic personality disorder
5. Narcissistic personality disorder
6. Antisocial personality disorder
7. Borderline personality disorder
8. Avoidant personality disorder
9. Dependent personality disorder
10. Obsessive–compulsive personality disorder
11. Other specified personality disorder

12. Unspecified personality disorder
In Chapter 14 we will examine in great detail the many fascinating subtleties involved
in exploring personality structure during an initial interview. One area not covered by
the DSM-5 but sometimes of great value in understanding personality functioning is the
role of defense mechanisms. Defense mechanisms range from those commonly seen in
neurotic disorders such as rationalization and intellectualization to those seen in more
severe disorders such as denial, projection, and splitting.
Understanding a person’s unconscious defense mechanisms (in classic psychoanalytic
thought, defense mechanisms are viewed as being generally unconscious) can help the
interviewer to uncover a more accurate picture of the person beneath the diagnosis.
Defense mechanisms represent unconscious coping skills that protect a person from
intense anxiety and/or unconscious ideas, images, or desires that would create intense
guilt or shame. A detailed exploration of the various defense mechanisms, as they unfold
in ongoing psychotherapy, is beyond the scope of this book, but the interested reader
will find an excellent survey of them in the DSM-IV-TR, where a proposed possible axis
called “the Defensive Functioning Scale” is outlined.16
Non-Psychiatric Medical Conditions

Non-psychiatric medical conditions such as diabetes, hypertension, seizures, etc., were
listed on Axis III in the DSM-IV-TR. In the DSM-5, such disorders are now merged into
a listing of the psychiatric disorders that are present.
The importance of an awareness of the potential presence of non-psychiatric medical
disorders cannot be emphasized too much. In my opinion, all patients who exhibit
psychological complaints for an extended time period should be evaluated by a physi-
cian, nurse clinician, or physician’s assistant to rule out any underlying physiologic
condition or causative agent. To not perform this examination is to risk a real disservice
to the patient, because entities such as endocrine disorders and malignancies can easily
present with psychological symptoms. The astute clinician will always keep in mind that one
can easily misattribute depression or anxiety that is being caused by an undiagnosed medical
illness, such as hyperthyroidism, a low-grade encephalitis, or a frontal lobe brain tumor, to a
current stressor. Just about anybody who develops a medical illness will have unrelated concurrent
stressors in his or her life, for stress is a common aspect of living.
A person with an undiagnosed, slow-growing brain tumor that is resulting in a mod-
erately severe depression with angry outbursts could be undergoing a severe financial
loss with foreclosure that is completely unrelated to the brain tumor. An unwary clinician
can quickly ascribe the depression and anger to the foreclosure (because the patient also
is ascribing the depression and anger to his finances and loss of his house), thus missing
the real cause of the mood disturbance and disruptive behaviors – a potentially fatal
brain tumor. Proceeding with psychotherapy, without having uncovered the malignancy
via a referral to a medical specialist, will result in precious time lost as the malignancy
continues to grow and potentially metastasize. A keen persistence in ruling out the
presence of a contributing non-psychiatric medical disorder can help clinicians to avoid

such potentially dangerous red herrings.
It should also be remembered that the presence of a serious medical condition such
as diabetes or congestive heart failure (even when it is unrelated to any psychiatric symp-
toms or disorders) represents a major stressor to the patient. Such conditions can signifi-
cantly impact on the patient’s resiliency and ability to cope with his or her psychiatric
disorder. Such considerations are of immediate importance in collaborative treatment
planning and mobilizing familial/social/medical supports.
In this same light, a medical review of systems and a past medical history should
become a standard part of an initial psychiatric assessment. Other physical conditions
that are not diseases may also provide important information concerning the holistic
state of the interviewee. For instance, it is relevant to know if the interviewee is pregnant
or a trained athlete, because these conditions may point towards germane biologic and
psychological issues, sometimes indicating potential strengths, such as routine exercise
or yoga practice, that can be capitalized upon as parts of the treatment plan.
Psychosocial Context and Stressors

Although there is no specific axis for assessing psychosocial factors in the DSM-5, their
importance is emphasized. Indeed, the DSM-5 recommends routinely assessing psychoso-
cial factors and documenting the assessment as a special notation in all diagnostic assess-
ments. Unfortunately, as mentioned earlier, I fear that without the mandate of a specific
axis requiring an exploration of these factors, they may frequently be under-explored.
Nevertheless, this exploration, when done well, allows the interviewer to examine the
crucial interaction between the patient and the environment in which he or she lives. All
too often interviewers can be swept away by the complexities, intrigues, and symptoms
of specific psychiatric disorders, failing to uncover the reality-based problems confronting
the people coping with these disorders. These reality-based concerns frequently suggest
avenues for therapeutic intervention as well as uncovering unexpected support systems.
By way of illustration, an interviewer may discover that secondary to a job layoff, the
home of the patient is about to be foreclosed. Such information may suggest the need
to help the patient make contact with a specific social agency or may suggest referral to
a social worker.
This area of inquiry also remains of paramount importance in the successful use of
crisis intervention counseling, time-limited therapies, and solution-focused therapies.
Any time a patient presents in crisis, it is generally useful to determine what perceived
stressors have brought the patient to the point of seeking professional help. A question
such as the following is often useful: “What stresses have you been coping with recently?”
or “What was going on for you that made you decide to actually come here tonight as
opposed to coming tomorrow or some other time?”
Level of Current Functioning and Impairment

Once again, the DSM-5 has eliminated a designated axis for recording information
regarding the patient’s level of function (formally Axis V in the DSM-IV-TR). However,
the DSM-5 does acknowledge the importance of such explorations. In this regard, the
World Health Organization’s Disability Assessment Scale (WHODAS) is included in
Section III of the DSM-5, but the WHODAS is not easy to use in the tight time constraints
of an initial assessment. The absence of a designated axis for requiring a sound assess-
ment of current functioning, to me, invites potentially inferior exploration.
A robust assessment of actual current functioning pushes the clinician to carefully
review evidence of immediate coping skills as affected by symptomatology. It is impor-
tant to utilize behavioral incidents in this exploration, for patients, if merely asked
for their opinions, may give misleading answers. By way of example, an acutely psy-
chotic patient who does not want to be admitted to hospital may reply with a simple
“not often” when asked, “Are the voices bothering you frequently?” Utilizing validity
techniques such as behavioral incidents and symptom amplification as described in
Chapter 5, the clinician may find that the dialogue develops more along the following
lines:
Clin.: Looking at the last 2 days, how many times have you heard the voices per day, 10
times a day, 30 times a day, 60 times? (symptom amplification)
Pt.: (pausing and glancing away for a moment) Probably, well … maybe a good 30
times a day.
Clin.: What types of things do they say? (behavioral incident)
Pt.: (pause) They tell me I’m ugly. So what else is new.
Clin.: What do you feel when the voices say mean things like that to you? (behavioral
incident)
Pt.: It hurts, but I try to push them out of mind.
Clin.: Do they ever tell you to hurt yourself? (behavioral incident)
Pt.: You could say that.
Clin.: What exactly do they tell you? (behavioral incident)
Pt.: They tell me to kill myself because I’m too ugly to live.
By starting with a symptom amplification and then repeatedly using the behavioral inci-
dent technique, the clinician has found not only that the voices are bothersome but also
that they are frequent and potentially dangerous.
The clinician may find it to be opportune, during the exploration of current function-
ing, to ask directly about elements of the wellness triad, hunting for strengths, skills, and
interests as described in Chapter 6, for all of these attributes may be of value in helping
the patient to cope more effectively with their current problems. Also keep in mind with
regard to current functioning that sources outside the patient, such as family, friends,
roommates, and employers frequently provide more valid information than the patient.
Once again, when questioning collaborative sources, behavioral incidents can be used
to enhance validity.
Clinical Application of the DSM-5

To begin applying our first assessment perspective, the DSM-5, we must first organize our
data. We will then ask ourselves what, if any, treatment modalities are suggested by the
diagnoses we have generated. With regard to major psychiatric diagnoses (other than
personality disorders), Debbie’s presentation suggests several diagnostic entities. The
primary delineation suggests that her symptoms are those of some type of mood disorder.
Regarding the secondary delineation into the specific mood disorders present, she does
not appear to currently fit the criteria for a major depressive disorder, but she may rep-
resent a variant of persistent depressive disorder (dysthymia). As mentioned earlier, the
presence of this disorder might suggest the short-term use of an antidepressant. Dysthy-
mia can also be approached using a variety of psychotherapeutic modalities, including
cognitive–behavioral therapy (CBT) and psychodynamic models.
Her history suggests no strong evidence for entities such as schizophrenia or other
psychotic processes, although the clinician may want to explore her vivid fantasy produc-
tions in more detail to rule out the possibility of delusional material or dissociative
identity disorder. There is no evidence of a neurocognitive disorder such as delirium or
dementia. Several areas not well explored are the areas of anxiety disorders, obsessive–
compulsive disorders, trauma-related disorders, and dissociative disorders. In a later
interview these omissions can be easily addressed.
Here we see how the use of a diagnostic paradigm can help prevent problematic errors
of omission. Even the best clinician, and I have encountered this process many times in
my own work, will not have time to scan for all potentially pertinent diagnoses because
of the tight time constraints under which we all work. Through the use of a diagnostic
schema such as the DSM-5, one can quickly, and reliably, spot diagnostic areas that were
inadvertently missed, opening up the chance to appropriately explore for potentially
hidden diagnoses in the next interview. To miss a diagnosis such as PTSD (possibly related
to childhood abuse) in a patient with Debbie’s presentation could lead to missed oppor-
tunities for treatment intervention, including such opportunities as a survivor’s group.
Regarding personality dysfunction, several possibilities are emerging that may provide
important clues as to how to proceed. Many of her symptoms, such as her frequent angry
outbursts, her numerous overdoses, and her deep fears of abandonment and being alone,
suggest the possibility of the diagnosis of a borderline personality and perhaps a depen-
dent personality. Both of these diagnoses serve to warn the clinician that Debbie may be
predisposed to becoming overly dependent upon the clinician. Dependency issues may
be important areas for focus in the upcoming therapy. Also of importance is the fact that
a large body of literature exists concerning the treatment of the borderline personality,
literature that can be easily tapped by the clinician. As a triage agent, the diagnostic label
of a borderline personality may also suggest the wisdom of not assigning this patient to
a newly trained or poorly skilled therapist, because such patients are frequently difficult
to manage. Regarding personality dysfunction, one might further explore entities such
as a histrionic personality, a schizotypal personality, or an antisocial personality.
As mentioned earlier, all patients should be conceptualized within the context of
their personality structures and predispositions, no matter how striking the presenting
symptoms of the patient’s non-personality related symptoms may be. In this fashion,
diagnoses such as borderline personality will not be missed. By not recognizing processes
such as the potential for borderline dependency early in therapy, the therapist risks
missing the diagnosis until well into therapy, by which time the patient may have already
become markedly enmeshed and dependent on the therapist. By this point, much painful
acting out may have occurred for the patient, and smooth transitions to other treatment
options, such as DBT, will have been made more difficult. All of this pain could be
avoided by screening for this diagnosis in the initial interview, as was done with Debbie.
An exploration of possible non-psychiatric medical conditions brings many important
points to mind. In the first place, Debbie’s depressive symptoms suggest the possibility
of a mood disorder due to a general medical condition. She needs a medical examina-
tion. If the initial clinician is a psychiatrist, then this clinician has omitted a good medical
review of systems. This omission will need to be rectified. Pertinent laboratory work will
be ordered, and a physical examination may be indicated.
But the exploration of non-psychiatric medical conditions does not end here. The
history of episodic violence may suggest an underlying seizure disorder (caused by head
trauma) that may have been routinely missed by previous clinicians. Once again, the
interviewer will want to ask questions pertinent to this diagnosis and may consider order-
ing an electroencephalogram (EEG) or referral to a neurologist. Her worsening of symp-
toms near her menstrual periods also adds the possibility of a premenstrual dysphoric
disorder, which may suggest the use of medications to relieve cramping and an antianxi-
ety agent used for a day or two near her periods to decrease her premenstrual tension or
the addition of a low-dose selective serotonin reuptake inhibitor (SSRI) antidepressant.
A final medical consideration concerns Debbie’s obesity. One wonders whether there
may be an organic etiology for her obesity, such as hypothyroidism or polycystic ovarian
disorder. One also wonders as to whether her weight represents a powerful psychological
concern, which she was hesitant to discuss because of stigma.
Even though there is no specific axis devoted to assessing psychosocial factors, as
mentioned earlier the DSM-5 system suggests that a careful exploration of psychosocial
factors should be a part of any evaluation. With regard to Debbie, one questions what
the impact of the upcoming wedding will be. Even for the most stable of people, wed-
dings are stressful. Her wedding stresses may be further amplified by cultural bigotries
related to same-sex marriage, once again an arena for supportive counseling in future
sessions. A review of psychosocial factors also indicates that the interviewer has not
explored current stressors very well yet. With regard to triage and the determination of
when Debbie should be seen next, it would be useful for the interviewer to have a much
clearer picture of the current stressors.
Regarding Debbie’s current functioning, the information is sparse here, reflecting a
relative weakness in the database thus far collected. Keep in mind that such database
weaknesses are common, and inevitable, in initial interviews, for there is not enough
time to collect a perfect database. But it is our diagnostic perspective that prompts us to
recognize these weak areas, a recognition that will allow us to explore these important
topics in future sessions. A more thorough examination of current functioning would be
of value in determining disposition. One also wonders what skills Debbie may possess
that may be utilized in her treatment. For instance, her possibly overactive fantasy life,
if toned down, may represent a fertile imagination, which could be an asset in her devel-
opment as an individual. Current functioning and the availability of immediate social
supports clearly warrant further exploration.
The above discussion illustrates the immense power of diagnostic systems such as the
DSM-5 or the ICD-10 as methods of organizing data in a fashion that generates treatment
options and also for “pointing out” areas of important clinical information that may
have been overlooked. In addition, if utilized as intended, a clinician employing the
DSM-5 system should be routinely looking for the person beneath the diagnosis by better
understanding the patient’s personality functioning, biological health, and the complexi-
ties of the patient’s psychosocial and environmental stresses.
But these factors may be under-emphasized or overlooked by clinicians because of
the absence of specific axes emphasizing their inherent importance in the DSM-5 system.
In addition, there are other elements of a holistic assessment (such as spirituality, family
dynamics, and cross-cultural nuance) not emphasized by the system. Consequently, even
when used as intended, in my opinion, this assessment perspective alone can yield an
incomplete picture of the patient. We will now turn to an assessment system that directly
focuses upon the areas of relative weakness in the DSM-5, perspectives that may provide
us with new insights into Debbie and how to help her.
MATRIX TREATMENT PLANNING

Nothing exists in isolation. Whether a cell or a person, every system is influenced by the
configuration of the systems of which each is a part, that is, by its environment.
George L. Engel17
Introduction
Matrix treatment planning provides a stimulating and practical method of organizing
and utilizing the data gained from the initial interview that complements the DSM-5
or the ICD-10. The term “matrix treatment planning,” which I am introducing to the
clinical literature in this chapter, is a recent term that I prefer to the more standard and
traditionally accepted term “biopsychosocial treatment planning.” They describe the same
system.
Although they describe the same system, as we shall soon see, I believe there are
advantages to the newer term and the re-emphasis it places upon the interactional prin-
ciples behind the biopsychosocial model as it was first delineated.
The goal in this section is to provide the initial interviewer with a reasonable concep-
tualization of what matrix treatment planning offers, how it is used, and its ramifications
concerning what information needs to be gathered in an initial interview (as well as
during ongoing psychotherapy). To accomplish this task in the sophisticated fashion that
it warrants, we will examine exactly what is meant by matrix treatment planning, includ-
ing the ideas from which it evolved (the biopsychosocial model) and from which it is
still evolving.
As with our exploration of the DSM-5 system, there is no attempt to describe the pros
and cons of specific treatment interventions here. Rather, the intention is to describe how
to maximize the use of matrix treatment planning during the collaborative planning
undertaken with the patient in the closing phase of the interview. Although not the
intention of this chapter, I believe the reader will find that these principles will also be
of use in long-term treatment planning.
Indeed, initially, our exploration of matrix treatment planning will require a some-
what extended side-trip from our interviewing map. The type of sophisticated under-
standing that a clinician needs in order to effectively undertake collaborative treatment
planning, in the closing phase of the initial interview, will demand a focused attention
upon some of the core principles of treatment planning itself.
Before we begin our exploration of the interface between the initial interview and
matrix treatment planning, I would like to add a cautionary note to the reader. At times,
some of the nuances of matrix treatment planning may appear somewhat complex,
perhaps even overwhelming. Truth be told, they are complex. They are also intricate,
delicate, and richly practical.
The goal of this chapter is not for the beginning student to understand and be able to
immediately utilize all of the principles of matrix treatment planning delineated in the
following pages. The goal is to leave the reader with a fascination and a genuine appre-
ciation of the power of matrix treatment planning to heal. If successful, the reader will
leave the chapter with a lively motivation to learn how to effectively employ the concept
of the human matrix.
As you read, you will develop a sophisticated understanding of how matrix treatment
planning principles can be elegantly interwoven into the initial intake. I believe it is
important, in a beginning course on interviewing, to immediately see how this integra-
tion is gracefully achieved by a skilled interviewer, so as to have a model from which to
work from the very beginning of your initiation into clinical interviewing.
As you continue into your more advanced years of training, you will participate in a
variety of courses, internships, and clinical rotations that will provide you ample oppor-
tunities to learn how to implement the principles described in the following pages.
Indeed, it is my hope that in the remaining years of your training (and post-training)
you will frequently return to this chapter to help you integrate the many new skills you
will be encountering.
Thus, sit back and enjoy the ride. The following pages describing the interface between
the initial interview and matrix treatment planning are intended to provide an enticing
and practical preview of the process. Nothing more. It will hopefully provide, in the years
to come, a goal towards which you can work and a model from which you can more
easily achieve that goal.
Basic Paradigm and History of the Biopsychosocial Treatment

Planning Model
George Engel, an internist in medicine with many interests in psychosomatic medicine,
was an elegant proponent of utilizing a biopsychosocial approach to treatment plan-
ning.18 Indeed, he can be viewed as one of the founders of the biopsychosocial model.
More recently, many authors, including Glen Gabard and Jacqueline Barkley, have pro-
vided cogent reminders of the importance of this approach to treatment planning for
clinicians across all mental health disciplines.19–23 Engel’s work was an extension of what
can be called systems theory or analysis. The following depiction of matrix treatment
planning parallels Engel’s work, but applies it directly for use by mental health
professionals.
The term “matrix” has several definitions. With regard to treatment planning it refers
to the idea that a matrix is the “stuff” from which something, in this case the patient and
the clinician, are created. In matrix treatment planning, human beings are seen not so
much as static “things” with permanent characteristics but rather as an intertwining series
of processes. The patient is viewed as a moment in time, in which various processes
intersect and interact to create what we call a human being. In short, the patient and the
clinician are both viewed as ever-changing processes, evolving with each passing moment.
Since the various systems of a matrix, by definition, represent fields of interdependent
interaction, changes in one system of a matrix almost always create changes in the other
systems within the matrix. If a change in one system has a positive effect on another
system it is called a healing matrix effect. If a change in one system creates a negative
impact on another system it is called a damaging matrix effect. Sometimes a problem in
one system of the matrix can cause such marked problems in a different system that it
appears to the interviewer that the primary problem resides in this secondary system,
when, in reality, this is a misperception – a phenomenon called a red herring effect. Each
system of the patient’s matrix offers a potential wedge for therapeutic intervention.
Guided by such a theoretical understanding, an initial interviewer understands at once
the importance of gathering information from all the systems impacting upon the
patient. To not do so, the interviewer risks making misjudgments as to what is right or
wrong with the patient during their initial encounter. Moreover, the patient may feel as
if he or she is being viewed as an object or mere diagnosis taken out of context, a feeling
that can result in significant disengagement.
In addition, the matrix perspective – because it emphasizes that changes in one wing
may cause unexpected changes in other wings – alerts the clinician that beneficial matrix
effects from unexpected fields of the patient’s matrix may be waiting to be tapped. In
addition, it simultaneously cautions the initial interviewer to carefully weigh finalizing
recommendations until the ramifications of such interventions on more distant fields of
the patient’s matrix can be more accurately assessed.
In matrix treatment planning, each person is viewed as representing the conjunction
of the following six progressively larger systems: (1) the biologic system, (2) the psycho-
logical system, (3) the dyadic system (including intimate relationships), (4) the family
system, (5) the cultural, societal, and environmental system, and (6) the patient’s world-
view or framework for meaning. Each smaller system is subsumed by the system above
it. In matrix treatment planning, each of these systems is known simply as a “wing” of
the matrix. Each of these wings can be used as a level in which to organize data and
subsequently develop a list of potential treatment modalities. The six wings of the human
matrix are illustrated in Figure 7.3.
The original biopsychosocial model, as envisioned by innovators such as Engel and
as implemented extensively by pioneers in the fields of social work, clinical psychology,
and nursing, emphasized that changes made in one system often created changes in the
other wings, whether intended or not. In fact, Engel’s original delineation focused heavily
ramework for meaning

F
al, environm
, societ ent
ral al
ltu wi
u ily w ng
C Fam ing
dic wing
Dya
y. wing
Ps
Bio
Figure 7.3 Wings of the human matrix. (Bio, biological wing; Psy. wing, psychological wing.)
upon the idea that treatment planning, at a sophisticated level, often found ways of
transforming a problem in one wing of the matrix by making changes in another wing
of the matrix.
A clinical example from Engel’s world of internal medicine brings this interactional
quality to life. Picture a man in his mid-50s and his wife presenting to an emergency
room at 2:00 A.M. on a drizzly Saturday, the man having been awakened by a crushing
sensation in his chest. We shall call our hypothetical patient Mr. Franklin. On this par-
ticular night, Mr. Franklin, whose belt cannot quite adequately contain his belly, is wiping
away the profuse sweat pouring from his forehead, a rather odd phenomenon for such
a cool October night.
As the triage nurse rapidly assesses the situation, she accurately recognizes that Mr.
Franklin is suffering from an acute heart attack and must be triaged rapidly to advanced
care. A life-threatening emergency has arisen in the biological wing of Mr. Franklin, where
millions of cardiac muscle cells are being starved for oxygen because one of his coronary
arteries, which is supposed to bring them their supply of oxygen, has abruptly clogged.
The faster his heart beats, the more oxygen is needed and the more cells will abruptly
die from lack of oxygen. If enough cells die, Mr. Franklin dies. Here we clearly see a
problem that is solely related to the biological wing of Mr. Franklin’s matrix. Or is it?
The phenomenon that innovators of the biopsychosocial model, whether internists,
nurses, or social workers, found to be fascinating had to do with what happened next.
A palpable anxiety and urgency engulfed the triage room. It could be seen in the eyes of
the triage nurse, the sudden rapid movements of the emergency room staff, and the
increasingly frightened questions of both Mr. Franklin and his wife, “What is happening?
What’s going on?” Terse answers were provided by rushing staff, for all staff recognized
the need for rapid intervention. Both Mr. Franklin and his wife became progressively
more agitated and frightened as the environmental wing of their matrix – the emergency
room triage area – erupted into an anxiety-provoking blur of intervention. As Mr. Franklin
was wheeled away, he called out, “I want my wife with me, I need my wife with me.” His
entreaties, however, rapidly vanished behind the fluttering curtains of the emergency
room as he was whisked off to receive what would prove to be excellent biologically
oriented emergency room care.
But therein lies the problem. Non-biological processes were now negatively interacting
with the biological wing of Mr. Franklin. Curiously, these damaging matrix factors were
inadvertently triggered by the actions of the treatment team. The ramifications of these
factors could prove to be deadly. Complicating the situation was the fact that these non-
biological factors were completely hidden from the treatment team. Let us examine the
situation in more detail.
The fear, on the psychological wing of Mr. Franklin’s matrix, generated by the medical
staff’s rushed behaviors, on the environmental wing of Mr. Franklin, had created a change
on the biological wing of Mr. Franklin. His heart was beating wildly, triggered by his
ever-growing fear and anxiety. More and more oxygen would be needed to keep his heart
cells alive because of their sharp increase in activity, yet no increase in oxygen could pass
through the blocked artery. Consequently, the area of the heart attack was growing larger.
Thousands of Mr. Franklin’s heart cells were now unnecessarily dying, and Mr. Franklin
was more than a few steps closer to death.
The last thing that any emergency room team would want for a man suffering from
a heart attack would be a rapid increase in his heart rate. Yet it was the unintended actions
of the team that were creating this exact result in Mr. Franklin. A more compelling
example of a damaging matrix effect may be hard to come by – a problem on the envi-
ronmental wing (the urgent behaviors of the staff) was creating a damaging matrix effect
on the psychological wing of Mr. Franklin (fear), and this fear (on his psychological
wing) was now creating a second damaging matrix effect on his biological wing (a dan-
gerous increase in his heart rate). The emergency room staff were creating, inadvertently,
the exact opposite change in Mr. Franklin’s heart to what they intended.
From the perspective of matrix treatment planning, some creative proactive measures
could be taken that might prevent this damaging matrix effect from unfolding. What if
emergency rooms had volunteer staff available, trained to rapidly and effectively impact
on the environmental wing of the matrix, exactly in such life-threatening situations. Such
trained volunteers could quickly intervene, providing, in a calming voice, immediate
information to both Mr. Franklin and his wife. They might be making comments such
as, “I’m going to be here for you Mrs. Franklin, throughout the night, to let you know
how things are going and to be a support for you,” and, addressed to Mr. Franklin, “Don’t
worry Mr. Franklin, I’ll take good care of your wife. And the team of doctors and nurses
you are about to meet will take good care of you. I know them personally and they are
really great.” With such interventions, there is a reasonable chance that the heart of Mr.
Franklin, and the hearts of thousands of other Mr. Franklins around the world in similar
emergency rooms, would be beating a good deal more slowly. The chance for Mr. Franklin
to see the light of a new October morning just became a good deal more likely.
Here a change made on the environmental wing of Mr. Franklin produced healing
matrix effects on the interpersonal wing of the worried couple, as well as on the psycho-
logical wings of both Mr. Franklin and his wife. More remarkably, these psychological
changes created a healing matrix effect on the biological wing of Mr. Franklin. Quite
literally, a change on the environmental wing caused a profoundly important change on
the biological wing of a precariously poised heart. By adding the calming influence of a
well-trained volunteer, the heart of Mr. Franklin was beating a good deal more slowly, a
potentially life-saving consequence. From the biopsychosocial perspective, even in the
sterile confines of an emergency room, we do not treat hearts, we do not even treat
people, we treat systems. Everything interconnects in matrix theory.
Note that in the original biopsychosocial model, clinicians look for two types of clini-
cal interventions: (1) intra-wing interventions (interventions occurring within the same
wing as the identified problem) and (2) inter-wing interventions (healing interventions
implemented on an entirely different wing than the identified problem). In the first
category, intra-wing interventions, the clinician surveys each wing of the patient’s matrix,
and if a problem is found, then an intervention is considered that occurs directly in that
wing. Thus, if one finds there is a problem with hypertension on the biological wing,
then one uses a biological intervention (a medication).
In the second category, inter-wing interventions, the clinician surveys each wing of the
patient’s matrix, and if a problem is found, then an intervention is used from a different
wing of the matrix that indirectly changes the wing where the problem is occurring. Thus,
if one finds there is a problem with hypertension on the biological wing, then one uses
a technique from a different wing of the matrix such as meditation or stress reduction
(psychological wing) to impact on the biological problem. In the original biopsychoso-
cial model, as aptly demonstrated in our above illustration from an emergency depart-
ment, there was a heavy focus upon inter-wing interventions as a means of jump-starting
stalled treatment plans and maximizing as many useful interventions as might help the
patient.
It has been my observation that over the decades this original emphasis upon interac-
tion between wings has sometimes deteriorated among treatment teams. Instead, the
emphasis is often upon intra-wing matrix interventions. Is there something wrong on the
biological wing and, if so, is there a medication we can use? Is there something wrong on
the psychological wing and, if so, should we use individual psychotherapy? Is there some-
thing wrong on the dyadic wing and, if so, should we use couple’s therapy? Is there some-
thing wrong spiritually and, if so, should we refer the patient for spiritual counseling or
to a clergy? This intra-wing initial treatment planning is excellent in its own right for it
ensures a holistic approach, but it is only a part of the biopsychosocial model as origi-
nally designed, for it has left out the second step involving interventions done between
different wings (inter-wing interventions) that was the hallmark of the original model.
By staying true to the original model’s emphasis upon interventions implemented
between differing wings, an entire array of new interventions may come to mind to the
treatment team, as well as the patient. Such “out of the box” solutions arise if the fol-
lowing types of questions are routinely asked: If there is a problem on the biological
wing, is there something we could do on the psychological wing that might change the
biochemistry of the brain (such as CBT changing the pathophysiology of the brain in
OCD)? If there is a problem with a couple’s marriage, is there something we might do
on the biological wing to one member of the couple that could help to save the marriage
(as with a medication alleviating a severe depression in one-half of a couple, thus helping
to heal the relationship)? Such creative thinking is at the very heart of the original bio-
psychosocial model.
With true matrix treatment planning, where there is an emphasis on tapping inter-
wing healing matrix effects as well as intra-wing interventions, an almost innumerable
number of fresh treatment ideas can be developed. With its renewed emphasis upon
inter-wing interventions, the matrix treatment model is filled with hope and possibilities.
It helps patients, initial interviewers, and the treatment teams they are a part of, to view
each potential roadblock to healing as a new beginning for brainstorming. I am reminded
of the wise words of the Zen master, Shunryu Suzuki:
In the beginner’s mind there are many possibilities, but in the expert there are few.24
Matrix treatment planning allows us, even as experts, to once again become “beginners”
who see many possibilities. To a clinician trained to be a matrix treatment planner, for
every roadblock encountered on one wing of the patient’s matrix, there is the potential
that a solution may be found on a different wing of the patient’s matrix. In this sense
each problem is usefully viewed as a new beginning, for it opens the door to searches
for solutions on new wings. It also allows us to share the optimism of this beginner’s
mind with our patients as we collaboratively treatment plan.
Over the decades, there has been another change in the biopsychosocial model – this
time a positive one. There has been a greater recognition of the importance of both cul-
tural and spiritual aspects in the formation and functioning of an individual, as was
emphasized in the last chapter. A variety of authors have delineated the importance of
this framework for meaning, or as Alan Josephson coined the term, “worldview.” Indeed,
it is now common to refer to “biopsychosocialspiritual treatment planning.” Josephson
and Peteet elegantly emphasize this point, as well as provide a cogent example of an
inter-wing intervention, in an article of direct relevance to the initial interview, “Talking
with Patients about Spirituality and Worldview: Practical Interviewing Techniques and
Strategies” (complete article available in Appendix IV):
Simply put, inquiry in this area [spirituality and worldview] has the potential to enhance
how we can help people and improve our treatment planning. The term “biopsychosocial-
spiritual” reflects the fact that spirituality may, along with biologic, psychological, and
social factors, impact a variety of issues related to clinical care including contributing to
the risk of developing clinical disorders and serving as protective factors … For example,
could an intervention consistent with the patient’s spirituality (e.g., meditation or listening
to Gregorian chant) have a positive impact on the patient’s biology, perhaps accentuating
or replacing the use of an antianxiety agent?25
An innovative matrix-based model of treatment planning has been developed by Danilo

E. Ponce that highlights the importance of cultural/societal and worldview factors in
treatment planning. Ponce describes how to adapt the matrix model of treatment plan-
ning to the unique needs of a specific culture – Filipino – in his insightful book Caring,
Healing, and Teaching.26
One of the advances made by Ponce is his concept that when addressing each wing
of the patient’s matrix, clinicians and case managers can conceptualize their interventions
as embracing three clinical functions: (1) caring, (2) healing, and (3) teaching. In his
model, the interviewer looks at each wing of the patient’s matrix as suggesting possibili-
ties for intervention from these three standpoints: First, from the caring perspective
(safety and security) the clinician looks at each wing of the matrix as to how it can be
utilized to provide basic needs (food, clothing, shelter) and a basic sense of human safety
and security (some degree of certainty, continuity, and predictability in the patient’s
everyday experience) held together by a basic sense that this clinician/team “cares about
me.” Second, from the healing perspective (wellness) the clinician looks at each wing of
the matrix through the lens of providing physical, psychological, social, and spiritual
alleviation of disease, distress, disability, dysfunction and disorder. Finally, from his third
perspective – teaching – Ponce urges clinicians to look at each wing of the matrix as a
potential avenue for enhancing the patient’s sense of self-respect and competence by
teaching specific skills, attitudes, and knowledge bases that provide an ever-improving
sense of mastery and trust that one can function reasonably well in the world.
A Revitalizing Change in Language

Language counts. Words shape how clinicians view and interpret the clinical world and
what they attempt to uncover during the initial interview itself. Terms such as biopsy-
chosocial can become “tired” in usage. Once this occurs, clinicians can become less
enthused about a system, no matter how useful the principles of the system may be, for
the system appears to be “same-old, same-old.” Each generation benefits from a language
that resonates with the gestalt of that generation.
This need for an ongoing renewal in language is why I prefer the term “matrix treat-
ment planning” to “biopsychosocialspiritual treatment planning,” for I believe the latter
term has become a tired one. First, if we are honest with ourselves, the term “biopsycho-
socialspiritual treatment planning” doesn’t exactly roll off the tongue. Moreover, it is
often a relatively awkward terminology to use with patients, potentially sounding abstract
and cold. Second, the term does not emphasize the original spirit of the model, which
is creating interaction between the wings. Indeed the term tends to highlight each wing
as if it were a separate silo from the other wings. In sharp contrast, the term “matrix,”
by its very definition, indicates a set of interlacing systems. It reminds all clinicians of
the importance of seeking out creative interactional opportunities while both interviewing
and collaboratively treatment planning.
Moreover, I have found the term “matrix” to be immediately recognized and under-
stood by millennial, and even younger, clinicians. Indeed, to anyone under the age of
35, the term “matrix” immediately triggers images of a guy bedecked in a black trench
coat and shades bending backwards like a Gumby on acid, his body deftly avoiding a
hail of hissing bullets. Nevertheless, these very same millennial clinicians know exactly
what a matrix is from their understanding of the exploits of Neo in the Hollywood
blockbuster The Matrix. They immediately view the concept of a matrix as a cogent
reminder that the world is a not exactly what it seems to be – a world of separate objects
and individuals. Instead they are reminded that the world is perhaps better conceived as
a unified and interlaced set of interactional fields where a change on one wing of the
matrix invariably causes changes in the other wings. They recognize that healing in the
biochemistry of the brain may not always mean the use of medications (CBT causing
beneficial changes in the cytoarchitecture of the basal ganglia in OCD), and that, in some
instances (the psychotic hyper-religiosity in schizophrenia), damage in the spiritual wing
may be repaired through the use of medications.
We can turn to the wisdom of C. Robert Cloninger, who applies the importance of
such a worldview to psychology:
The science of well-being is founded on the understanding that there is an indissoluble

unity to all that is or can be. The universal unity of being is recognized widely as an
empirical fact, as well as an essential organizing principle for adequate science. The uni-
versal unity of being is not an arbitrary philosophical assumption, and it is not an optimistic
assumption. Rather the universal unity of being is the only viewpoint consistent with any
coherent and testable science … Psychology, like particle physics, must postulate a universal
field in which all aspects of each person are bound together at the same nodal point in
space and time.27
As we shall soon see, the matrix model of treatment planning shows interviewers and
clinicians exactly how to navigate the exciting possibilities envisioned by Cloninger’s
world of therapeutic interaction. Indeed, matrix treatment planning (both its name and
its methods) dovetails nicely with contemporary perspectives on the reality of the uni-
verse, such as quantum mechanics and the particle physics mentioned by Cloninger. Such
contemporary schools of science view the world as unified interlacing fields of potential
interaction in which each field interacts with all other fields. In addition, the advent of
the web, social media, and wireless interconnectivity allows changes on one wing of the
human matrix to impact on other wings in a remarkably fast fashion.
It is always nice when a term, such as the term “matrix” fits with the gestalt of a culture.
In addition, I have found that patients find the concept of collaboratively “changing their
matrix” to be understandable, exciting, and self-empowering. Moreover, when clinicians
utilize the concepts of matrix treatment planning, the possibilities generated can
subsequently be translated into actual applications for teams of clinicians and multidis-
ciplinary teams. This process is in line with the concept of “integrative care,” where the
practical implementation of matrix interventions must be communicated and coordi-
nated effectively over time between all persons/organizations involved in addressing the
patient’s problems. Thus matrix treatment planning is a valuable first step in the creation
of truly integrated care that underlies all person-centered health care. In any case, we will
use the term “matrix treatment planning” throughout this book to refer to this re-vitalized
concept of the biopsychosocialspiritual model.
We have now completed our historical, theoretical, and contextual side-trip regarding
matrix treatment planning. We possess the information needed to see how we can effec-
tively apply this material to the clinical interview. Indeed, it is time to see how it was
applied to Debbie herself in the real world of a busy outpatient clinic.
Matrix Treatment Planning: General Clinical Principles and Specific

Applications to Debbie in the Initial Interview
As the interview proceeds, the clinician asks himself or herself whether enough informa-
tion, if any, has been gathered in each of the six wings of the human matrix. Such self-
reflection minimizes errors of omission while maximizing the usefulness of the database
as a treatment-planning platform. Even as the information from a given wing is revealed,
treatment options – both intra-wing and inter-wing – may “pop into the mind” of the
interviewer. Just as was the case with the diagnostic assessment perspective of the DSM-5,
if the clinician carefully listens to the patient’s problems, the problems begin to suggest
their own solutions. It is the organization of the data that provides this momentum. Let
us examine each wing in order.
First Wing of the Matrix: Biologic

On the first wing of the matrix, the interviewer focuses on the biological makeup of the
patient. This wing overlaps with the DSM-5 system. In it the clinician hunts for evidence
of biologic wellness and illness, as well as the presence of symptoms suggesting that
somatic treatments may be of value.
Biological Intra-Wing Interventions

From the perspective of intra-wing interventions, possible biological interventions include
antidepressants, antipsychotics, other medications including herbal approaches such as
St. John’s wort in the case of mild to moderate depressions, antianxiety agents and mood
stabilizers, hormonal replacements in the case of diseases such as hypothyroidism,
addressing nutrition and healthy diet, or electroconvulsive therapy (ECT). Note that all
of these interventions are biological interventions being utilized when one suspects bio-
logical disruption. The matrix model offers little difference from the DSM-5 assessment
approach from this intra-wing matrix perspective, both assessment systems providing
valuable frameworks suggestive of treatment interventions.
Biological Inter-Wing Interventions

However, on the inter-wing perspective – interactions between wings – matrix treatment
planning opens a door into a room filled with new potential treatment interventions for
the interviewer and interviewee to collaboratively explore. To open these doors, inter-
viewers can ask themselves two questions during the interview itself, after the interview,
and in subsequent treatment planning sessions: (1) Could there be interventions on the
biological wing that may have healing matrix effects on other wings? and (2) Could there
be interventions on a non-biological wing that could heal the pathophysiology of the
brain itself?
Question #1: Healing Matrix Effects Arising From the Biologic Wing
Over the years, I have consistently noticed how patients who do not seem to be benefit-
ting from psychotherapies on the psychological wing (individual therapy), dyadic wing
(couples therapy), or group/societal wing (group therapy) are actually often floundering
because of biological depressions. Once an antidepressant or biologically active herbal
remedy is utilized, the patient’s ability to effectively benefit from these therapies some-
times strikingly improves – a nice example of a biological intervention having a healing
matrix effect on a non-biologic wing, in this instance enhancing non-biologic interven-
tions themselves. In fact, to expect a patient with a severe biologic depression, belea-
guered by an intense loss of energy, drive, and motivation, to be able to effectively utilize
family therapy, is often unrealistic, in my opinion. Many a marriage or employment situ-
ation has been saved by the judicious use of medications and other biological interven-
tions, which have helped not only the underlying biologic dysfunction, but have also
“jump-started” a stalled psychotherapy on the psychological wing of the patient.
With regard to Debbie, perhaps the use of a mood stabilizing medication, such as
Depakote, might decrease her tendency for affective lability, a potentially key trigger to
her angry exchanges on the interpersonal wing of the matrix – an example of a biological
intervention producing a healing matrix effect on the interpersonal and family wings of
Debbie’s matrix. Such mood lability and anger (she had to be forcibly removed by police
from a previous therapist) could naturally disrupt her ability to benefit from psycho-
therapy. Hence, the mood stabilizer might help her to optimize her individual
psychotherapy.
Question #2: Healing Matrix Effects to the Biologic Wing From Other Wings
We can now turn our attention to our second inter-wing question: Could there be inter-
ventions on a non-biological wing that could change the pathophysiology of the brain?
In some instances, wellness interventions on the psychological or worldview wings of
the matrix may actually change brain physiology.28 Examples could include the healing
matrix effects of interventions such as meditation,29 relaxation techniques and biofeed-
back,30 and disciplines from the spiritual wing of the matrix, such as prayer31; it has been
documented that these psychological and spiritual techniques can have significant
changes on brain function.
To give just one example of the multitude of interventions that inter-wing matrix
treatment planning could bring to the table with regard to changing pathophysiology,
let us return to Debbie’s problems with rage. On a speculative and theoretical level, the
more often her neuronal circuits fire with regard to anger and rage, it is possible that
synaptic plasticity and pruning may be resulting in the emergence of increased synaptic
production in these circuits, resulting in an increased propensity for the firing of these
very same maladaptive circuits, a potentially maladaptive positive feedback loop. In this
instance, some of the psychological techniques inherent in therapies such as CBT, DBT,
and mindfulness-based therapies, by decreasing the firing of these circuits, may actually
result in decreased synaptic production in these circuits changing the neurocircuitry itself
– in short, a healing matrix effect (psychological intervention changing the biologic wing
of the matrix).
Second Wing of the Matrix: Psychological

In the second wing, the psychological system, one enters an area that only partially over-
laps the DSM-5 in relation to considerations of personality development. Consequently,
it suggests many interventions not as readily suggested by the DSM perspective.
Psychological Intra-Wing Interventions

At this level the clinician attempts to understand the patient both in a phenomenological
sense as a unique human and in a psychodynamic sense as a product of past develop-
ment. Each interviewer will have preferences for which psychological theories seem rel-
evant, whether they be Freudian, Jungian, Rogerian, behaviorist, interpersonal, or some
combination of the numerous viewpoints available. But the important point remains
that the clinician attempts, once again, to understand the person beneath the diagnosis.
In this wing of the matrix, interviewers expand their lists of treatment options by con-
sidering the use of individual psychotherapies or counseling techniques.
As the psychological wing of Debbie’s matrix is explored, including her psychological
symptoms, a more personalized view of Debbie emerges as she becomes at once more
complicated and more human. Several conflictual issues are readily apparent, including:
(1) fears of abandonment, (2) problems with anger and impulse control, (3) ongoing
problems with low self-esteem, (4) non-lethal self-harming behaviors, and (5) problems
with identity and sense of self. By beginning to delineate these areas during the first
interview, the clinician can begin to generate options for treatment on the intra-wing of
her psychological matrix – psychological interventions for psychological problems.
For example, in addition to the CBT and DBT interventions already mentioned, from
an analytic viewpoint, one could look at disturbances in her sense of self as indicating
the potential usefulness of specific psychotherapeutic approaches developed by clinicians
such as Kohut, Kernberg, or Masterson. In a similar vein, Debbie’s low self-esteem and
difficulties in accepting herself may bring to mind the usefulness of psychotherapies such
as Acceptance and Commitment Therapy (ACT).
Furthermore, a survey of the information garnered in her psychological matrix reveals
that not much psychogenetic data has been garnered yet, a deficit that can be addressed
in future sessions. Here we see the application of a matrix perspective during an initial
interview functioning as a method to help the interviewer spot, and perhaps alleviate,
potential omissions of useful data for treatment planning. The important point remains
that by conceptualizing in the psychological wing, interviewers prompt themselves to
consider areas of intervention utilizing individual psychotherapy, as well as checking to
see if this region of highly pertinent information has been adequately tapped.
Psychological Inter-Wing Interventions

Once again, the inter-wing perspective of matrix treatment planning is ripe with potential
interventions. In each wing of the matrix, the same two questions can be asked by the
interviewer of himself or herself. With regard to Debbie’s psychological wing: (1) Could
there be interventions on the psychological wing that may have healing matrix effects on
other wings or therapeutic modalities being used on other wings? (2) Could there be
interventions on a non-psychological wing that could change Debbie’s psychological
matrix?
Question #1: Healing Matrix Effects on Other Wings Arising From the Psychological Wing
In a generic sense, recent research has shown progressively more robust evidence that
classic forms of psychotherapy may impact on brain pathophysiology. One of the most
striking examples being the power of CBT to impact on the biological dysfunctions
related to OCD. Research has shown the power of CBT to change pathophysiology, with
resulting symptom improvement in obsessions and compulsions in OCD, as illustrated
in the patient self-help book Brain Lock by Schwartz,32 which I highly recommend. There
is growing hope that some forms of CBT may decrease the frequency of auditory hallu-
cinations in diseases such as schizophrenia, or dampen the intensity of the patient’s
response to hallucinatory phenomena, once again perhaps related to changes in neuronal
circuitry prompted by a decreased firing of circuits related to CBT response-prevention
techniques.
With regard to Debbie, one could look at the potentially precarious nature of the
strength of her dyadic wing of her matrix, involving tremendous strains on the relation-
ship with her partner. Naturally, one can address these intimacy strains directly on the
dyadic wing with couple’s therapy. In addition, from a matrix perspective, one could
focus upon psychological techniques for shoring up Debbie’s fragile sense of self-esteem,
for these psychological problems may be fostering the extreme dependency needs that
threaten the very heart of her relationship with her partner, a classic example of a damag-
ing matrix effect. It is her lack of self-esteem and sense of a core self that may be at the
center of her oddly angry responses to her partner’s going to sleep first. Changes on the
psychological wing – the enhancement of her self-esteem – could have major healing
matrix effects on the intimate wing of Debbie’s matrix.
Question #2: Healing Matrix Effects to the Psychological Wing From Other Wings
Could there be interventions on a non-psychological wing that could change Debbie’s
psychological matrix? As already mentioned, the use of medications can often have
marked healing matrix effects on psychological functioning. Other wings can also be
creatively tapped. For example, with Debbie, on her spiritual wing she was re-kindling
her interest in her Christian beliefs and she was also being influenced by Eastern thought.
Knowledge of her evolving worldview could lead a clinician to see if participation in a

more structured spiritual outreach might kindle an understanding of compassion and its
role not only in accepting others but in accepting herself (a healing matrix effect on her
psychological wing). This might also cause better acceptance of the needs of her partner
(resulting in a healing matrix effect on the dyadic wing of her matrix as well). Cloninger
provides insight into the pivotal role that such self-acceptance often plays in the initial
stage of healing, describing such self-acceptance as, “It is being willing to see what we
are in reality without wanting to become something else.”33
Third Wing of the Matrix: Dyadic

When we move to the third level, the dyadic wing, the patient is viewed as one compo-
nent of the numerous two-person interactions that fill the patient’s day-to-day commu-
nications, including highly supportive and intimate relationships as with a spouse,
partner, or parent. The patient’s interpersonal skills are assessed.
Dyadic Intra-Wing Interventions

Does the patient have adequate verbal skills and social skills? Some patients suffering
from schizophrenia or schizoaffective disorder may act oddly or may share their delu-
sions with others without realizing the disengaging impact of these activities. Such
patients may benefit from social skills training. In a similar vein, people with problems
along the autistic continuum or with permanent deficits in intellectual functioning rep-
resent another category of patients with whom social skills training may yield gratifying
results.
The interviewer should also bear in mind that the patient’s interaction with the inter-
viewer provides direct and immediate information concerning the strengths and weak-
nesses of the patient in this wing of the matrix. Unfortunately, this immediately available
direct evaluation of the patient’s interpersonal skills is frequently overlooked by clini-
cians. Reminding oneself to examine each wing of the patient’s matrix helps to prevent
such important omissions.
In the case of Debbie, the dyadic system focuses attention on her style of relating to
other individuals. One wonders if her angry outbursts may be reactions to a chronic style
of passively deferring to the needs of others. Such a situation may suggest the utility of
self-assertiveness training.
This wing refocuses attention on the impact of the patient’s physical appearance and
behavior. Debbie’s loud sunglasses and T-shirt may indeed strike an unappreciative chord
in some people upon first contact. Debbie may be unaware of the ramifications of her
behavior, and social skills training may be useful at some point.
In the end, all of these interpersonal issues are of relevance to her relationship with
her partner. Upon my first contact with Ms. Baker in the waiting room, the importance
of her relationship with her partner immediately emerged, as she quickly announced her
upcoming wedding and change of her name. It was as if she could hardly wait to shed
her identity, washing her hands of her own name with a brisk shrug as she first met me.
On a positive note of wellness, her relationship with her partner had endured for several
years and may represent a potentially powerful resource in therapy. To increase light on
their relationship, the clinician might consider the use of a joint assessment session with
the couple and perhaps the ultimate use of couple’s therapy.
Dyadic Inter-Wing Matrix Effects

Once again, inter-wing matrix effects may prove to be invaluable, both healing matrix
effects to other wings arising from interventions on her dyadic wing, to healing matrix
effects on her dyadic dysfunction coming from interventions on other wings of her
matrix. A change in a possibly pathologic interdependency, on her dyadic wing, between
the two partners might lead to healing matrix effects on other wings such as a new will-
ingness by Debbie to spend time on community activities or new relationships with
friends, family members, church members, or participation in an outpatient support
group or day hospital. At the time of the initial interview, she was shying away from such
interactions because she wanted to spend all of her time with her partner. Moreover,
matrix treatment planning reminds the interviewer of the importance of uncovering
hallmarks of wellness (the strengths, skills, and interests of the “wellness triad” from the
last chapter), as well as the possible psychopathology of her partner, who might herself
be suffering from a biologic depression or psychological trauma, which if addressed
could have major healing effects not only for the partner but for Debbie as well.
Fourth Wing of the Matrix: Family

As we look at the fourth wing of the human matrix, the family, we come upon one of
the most powerful systems affecting all humans. To conceptualize patients during an
initial interview without considering the dynamics of their family is to see half a picture
at best. To plan treatment without considering the needs and opinions of the patient’s
family invites treatment failure.
Moreover, whether interviewers like to admit it or not, the patient’s family is psycho-
logically present in any interview, representing a powerful determining force on the
patient’s behavior. The interviewer should always consider the utility of a family assess-
ment or eventual employment of family therapy.
Familial Intra-Wing Interventions

Ideally, a clinician may actually be presented with an opportunity to interact with the
family as a unit in a joint interview. For example, in an emergency room situation, the
patient is frequently accompanied by family members. On these occasions the clinician
can directly observe the process of family interaction.
But even within the confines of an individual assessment, an enormous amount of
information can be gained concerning family dynamics by gently probing. Pertinent data
will emerge simply by learning some of the background facts and pieces of demographic
information. The clinician can begin a familiarization with the family matrix by inquir-
ing into where various family members have chosen to live. It is probably not merely
chance that leads to a situation in which all the children have moved thousands of miles
away from Mom and Dad. Nor should one ignore the implications of a family in which
most members have chosen to live on the same block.
I remember a young woman seeking help for severe marital discord, who complained
that she could not get her mother “to mind her own business.” Later in the interview I
was surprised to find that the patient had recently moved back into the same apartment
complex where her parents lived, ostensibly for convenience. The issue of inappropriate
attachment to her parents appeared as a psychodynamic theme throughout the remain-
ing therapy.
Another important area reveals itself when one inquires about which people are living
under the same roof with the patient. Such questioning may uncover unexpected find-
ings, such as a domineering grandparent whose ideas of discipline clash with the con-
cepts of the parents.
On a more specific level, further questioning may directly begin to unravel the com-
plexities of the family, such as:
a. “What were holidays like at your house?”

b. “What kinds of things did your brothers or sisters like to do?” (often yields clues to
sibling rivalry)
c. “Describe the physical appearance of your brother.” (another nice gate through which
to explore sibling rivalry)
d. “Whom do you share secrets with in your family?”
e. “Who makes the decisions in your family?”
f. “Who do you think you are most like in your family?”
g. “Tell me a little about what kinds of things your parents used to argue about.”
h. “Did you go to the same schools as your brother? (and if so, “what was that like?”)
i. “Did you share a room with any siblings?” (and if so, “what was that like?”)
With questions such as the above, the initial interviewer can begin to determine whether
a family assessment may be indicated.
An analysis of the family system is not emphasized in the DSM-5, once again high-
lighting the utility of applying several assessment grids when planning treatment. Further
discussion of this critical area of assessment would take us away from the topic of this
book, but the interested reader may find the writings of Stephen Fleck useful in building
a foundation for a more specific approach to family assessment.34,35
In addition to learning more about the patient contextually as shaped by family pro-
cesses, matrix treatment planning also reminds us of the added mission of helping to
relieve the pain of family members and other loved ones who have family members suf-
fering from severe mental disorders, from schizophrenia to PTSD, OCD, and bipolar dis-
order. Indeed, there is an entirely different “initial interview” that we all undertake – our
first meeting with family members. An enormous amount of good can be done in these
sessions, which benefits not only the patient but also the patient’s family. Murray-Swank
and colleagues have written an elegantly practical article of direct significance to the
initial interview, “Practical Interview Strategies for Building an Alliance with the Families
of Patients who have Severe Mental Illness” (complete article available in Appendix IV).36
Turning towards the impact of her nuclear family, Debbie’s poignant early memory
of being tugged away from the door as her father vanishes conveys the sense of a deeply
troubled childhood. Clearly, more information in this region will be enlightening, and
the clinician is reminded, once again, of the potential utility of family assessment or
therapy.
Cultural issues can play major roles in understanding the family matrix in an initial
interview. For example, powerful control is often exerted by men over Latina women,
both with spouses and with daughters. While being careful not to stereotype, it is impor-
tant that, as treatment possibilities are touched upon in the closing phase with a Latina
patient, questions such as “What do you think your father (or boyfriend) might think
about this idea?” are considered by the interviewer. In such instances, even a nonverbal
such as the hint of a patient rolling her eyes may speak immeasurably of the powers at
work in her family matrix.
Another important cultural issue may be at work in some immigrant families when
considering the family matrix: In many cultures, the parental generation commands
respect and has implicit power assigned to it, simply because the parents have more
experience and familiarity with day-to-day life, culture, and stresses. However, in families
in which the parental generation does not feel comfortable integrating into the new
culture and society, it is the children who may know more about the family’s new envi-
ronment. These children will have gained much insight from listening to popular music,
utilizing street language, actively engaging friends and strangers on social media, and
interacting with peers regarding moral, sexual, and ethical expectations. Suddenly, a
15-year-old may actually be a better authority on the surrounding culture than the father,
mother, or grandparents living in the same house. Such a reversal of informal power can
lead to a profound disruption in the family matrix.
Familial Inter-Wing Matrix Interventions

As with previous wings of the matrix, interviewers should keep an open mind to various
healing and damaging inter-wing matrix effects. When reviewing this chapter with a
noted innovator in the care of patients with autism and related disorders, Larry Welkow-
itz,37 he offered the following example of such a healing matrix effect, related to an
understanding of both familial and cultural diversity issues:
One of his patients of a Hispanic background, who was coping with Tourette’s syn-
drome, would often find a marked increase in Tourette’s symptomatology when his
family visited from Columbia. Upon questioning, it was discovered that his parents and
siblings expressed a culturally normal exuberance and affective intensity common to
Latin cultures, with much hugging, joking, dancing, and close interpersonal spacing.
Apparently, this cultural and familial exuberance seemed to trigger the patient’s Tourette’s
symptoms. A careful and gentle explanation of the possible link communicated by the
therapist to the patient’s family members resulted in a subtly, but noticeably, quieter
interpersonal milieu upon visits. The result was a striking decrease in the patient’s
Tourette’s symptomatology, a result greatly appreciated by both the patient and his
family. Here we see an intervention, by a savvy clinician, on the family wing of the matrix
that impacted directly on the biological and psychological wings of the patient, resulting
in a decrease in disruptive behaviors.
Fifth Wing of the Matrix: Cultural, Societal, and Environmental

In the fifth wing, the cultural, societal, and environmental wing of the matrix, the inter-
viewer investigates the patient’s ability to function within groups outside of the family.
In particular, one looks at the patient’s relationships at work, school, and with networks
of friends, including the society at large and the patient’s everyday living and online
environment.
Cultural, Societal, and Environmental Intra-Wing Interventions

A pivotal issue concerns the patient’s abilities to handle authority figures such as employ-
ers. The clinician keeps an eye open for evidence that the patient is generalizing feelings
from family members onto other relationships, such as sibling rivalry reappearing as
intense competitiveness at the workplace.
It is also valuable to search for subcultures to which the patient may look for values
and support. Such cultures could include the drug culture, the club culture, the jock
culture, or problematic ideologic entities such as the Ku Klux Klan. An ignorance of a
patient’s cultural subgroup can lead to major errors in treatment planning. Substance
abuse treatment will probably serve little purpose if the patient immediately returns to
the club scene for a rendezvous with designer-drug buddies. While contemplating this
wing of the matrix, the interviewer should consider whether group therapy might be of
value. Moreover, it is important to remember that one can utilize subcultures for thera-
peutic effect, such as recommending Alcoholics Anonymous or tapping veteran peer-to-
peer programs. While reviewing the information gathered at this level concerning Debbie,
the clinician is reminded of the possible advantages of group therapy or perhaps a day
hospital or drop-in center. On a behavioral level, as therapy progresses, it may be benefi-
cial to steer her towards rewarding group activities such as volunteer work.
Another critical subculture, as discussed in our last chapter, is the web and social
media. In this chapter, I want to emphasize the amount of interpersonal abuse that is
now occurring on the web and via smart phones. Despite the numerous gifts electronic
media have provided, one serious problem has been the use of smart phones (via texting)
and the web (through social media such as Twitter and Facebook) to provide abusers
with an almost constant access to their victims. This type of ongoing wireless harassment
is frequently focused on various personal aspects of victims, such as sexual orientation,
looks, social status, intelligence, social awkwardness, and their cliques. As initial inter-
viewers, especially with adolescents and young adults, this damaging aspect of social
media, including harassment by posting damaging YouTube material, including sexual
photos or videos of the target of the harassment or flaming, is critical to a sound assess-
ment of the cultural, societal, and environmental wing of the matrix.
Patients, especially adolescents, may be hesitant to share such harassment because of
shame unless directly asked with questions such as:
1. “Do you like using social media?”

2. “Does anybody post mean or degrading comments about you on Facebook or
Twitter?”
3. “Has anybody ever made fun of you or posted a demeaning video of you on YouTube?”
4. “Does anyone send you vicious or disturbing texts?”
At the end of the initial interview, little was known about the functioning of Debbie at
a group level. Indeed, the absence of her mentioning friends piques our interest, perhaps
suggesting problematic relationships or none at all. There also seems to be a conspicuous
absence of support groups or outside activities.
As introduced in our last chapter, the power of culture and social forces is immense
in understanding the person beneath the diagnosis. Matrix treatment planning pushes
the interviewer to always look for the various social forces shaping the patient’s function-
ing within the community. These forces include economic, political, institutional, and
social class factors.
As Engel’s quotation at the beginning of this section suggests, the patient’s environ-
ment should always be considered. For some patients this will include issues relating to
immediate environment and safety (akin to Abraham Maslow’s first level of needs) such
as availability of adequate food, shelter, and personal safety (as compromised by a dan-
gerous neighborhood, a war zone, or a region of genocide). All of these conditions are
intimately related to the political climate of the patient’s county, federal, and state
governments.
It is also possible that a patient’s society is problematic, disabling the patient through
prejudice or violence related to race, religion, sex, and/or sexual orientation. By way of
example, I find it of use to ask any patient of an Islamic background if they, or their loved
ones, have experienced any problems with harassment since 9/11 and the rise of ISIS.
Similarly, it is of value to ask Jewish patients if they have or are currently encountering
prejudicial treatment. Depending upon geographic location in the world, anti-Semitism
remains very active. Even in the United States, according to the Hate Crime Statistics
compiled by the FBI, the highest rate of hate crimes against religious members in the
United States are perpetrated against people of the Jewish religion (such crimes being
committed at five times the rate towards Jews than any other religious group).38
Once again, the interviewer must remember not to focus solely on individual dynam-
ics, because the patient is part of many different systems, any one of which may be
malfunctioning. It remains a basic tenet of assessment interviewing that one must under-
stand the patient’s culture in order to understand the patient’s behavior.
In this light, the issue of Debbie’s sexual orientation warrants an understanding of
her culture. Interviewing in both the initial and subsequent meetings (re-emphasizing that
matrix assessment is impossible to complete in one session and represents an ongoing process that
is simply begun within the opening meeting) revealed that a possibly powerful support
system had not been well tapped by either Debbie or her partner. They were not well
integrated into the local resources of the LGBT (lesbian, gay, bisexual, and transgender)
community. From an intra-wing perspective, helping both parties to explore the possibili-
ties of support in their local LGBT community could be well worth considering.
Within the societal and environmental wing, one other crucial system is worth noting
when planning treatment, namely, the mental health system itself. The clinician needs
to be aware of the actual resources available for follow-up. It is useless to recommend
behavioral therapy to a patient if there is no behavioral therapist available to the patient.

Indeed, such “pie in the sky” thinking can frustrate patients, hanging false hopes before
their eyes. Similarly, a common error at academic centers is the tendency to generate
complex treatment plans for patients referred from community centers that these centers
cannot implement when the patient returns to them. Such state-of-the-art treatment
planning is, in reality, an example of poor assessment formulation, because its imprac-
ticality breeds frustration in the patient and anger in the treating clinicians.
To finish our discussion of the societal system, an important mental health resource
for Debbie was uncovered by further interviewing. An excellent day hospital had been
providing intermittent support for Debbie over the past year or so. As we will soon see,
this community system suggested a future area for more intensive support.
Cultural, Societal, and Environmental Inter-Wing Matrix Interventions

We will use this arena to look at a specific matrix effect that we hinted at earlier, but have
not yet had a chance to examine in detail. A healing matrix effect on one wing of the
matrix may have unexpected consequences on other wings, often good, but occasionally
bad – a damaging matrix effect. This fact highlights a key aspect of matrix interviewing
in the initial interview: caution is required when first designing treatment interventions
until one has explored what the impacts on other wings might be.
Further interviewing revealed that Debbie and her significant other had been forced
to deal with considerable ostracism within their apartment building and neighborhood
related to their sexual orientation. At first glance, this ostracism seems totally at odds
with Debbie’s further development, but there is a curious paradox here. In essence, this
easily identified enemy had served as a common threat around which Debbie and her
significant other had mobilized, thus stabilizing their relationship.
A clinician might prematurely suggest that immediately moving to another neighbor-
hood could be beneficial, but such a suggestion could be a serious miscalculation. One
of the most powerful glues for this relationship could be their unified need to protect
each other from this community’s psychological attacks. If placed in a new and more
benign community prematurely, the relationship could begin to collapse, fulfilling Deb-
bie’s great fear of abandonment. In this example, it might be better to get the relationship
on more solid ground before suggesting such a move.
A real-world example of such an unexpected damaging matrix effect can help to
illuminate the effect more clearly. At the end of a recent presentation on matrix treat-
ment planning, a workshop participant related the following. She was a clinician in an
innovative Veteran’s Affairs (VA) system. They had developed an outstanding program
addressing the growing problem of homelessness in veterans returning from Iraq and
Afghanistan and it was helping many veterans. She commented, “I wanted to share an
unexpected impact on one of our vets that demonstrates the importance of ‘being on
the lookout’ for unexpected damaging matrix effects that you were just talking about.”
(As an aside, I cannot emphasize enough how impressed I am with these programs.
The following example is provided merely to illustrate an example of where matrix
awareness during the initial interview can help any team to generate person-centered
solutions.)
In this example, the program had unexpectedly backfired with a specific vet, whom
we shall call Ted. Shortly after finding Ted an apartment, his condition deteriorated. He
became seriously depressed, essentially apartment-bound, and developed suicidal
thoughts. When homeless, Ted had been living with a group of vets who had pitched
makeshift tents near a bridge. Ted later reported that the tent city had reminded him, in
a strangely reassuring fashion, of how he had been living in Afghanistan (providing a
sense of community on the patient’s societal and environmental wing of his matrix). It
also offered a sense of familiarity and hence safety, as Ponce talks about in his “caring”
aspect of matrix treatment planning. There were several vets less fortunate than himself
that he enjoyed helping on a daily basis (providing a sense of mission on the wing
devoted to his worldview and framework for meaning). He had also developed some
very good friends (the most powerful driver of his dyadic wing), as well as a sense of
group camaraderie (the glue for the cultural, societal, and environmental wing of his
matrix).
His nice apartment, a real find during the difficult financial problems of the times,
was unfortunately many miles away from the “bridge community.” In addition, for what-
ever reason, Ted intensely disliked public transportation such as the bus system and the
subway (perhaps related to some PTSD phenomenon), so he was unwilling to travel to
a local center that had been set up as a day center for returning vets. The result: with one
single “positive” move (finding a home for a homeless man), severe damage occurred
on almost all other wings of his matrix, resulting in the collapse of the “moment in time”
we call Ted. He was now sitting “at home” in a dimly lit room, television flicker flashing
across the lenses of his glasses hour after hour, reflecting the harsh reality that with the
procurement of improved housing, Ted’s real home had been lost.
One of the advantages of matrix treatment planning is that it gives new meaning to
the concept of understanding the person beneath the diagnosis. Diagnoses (or labels)
are not limited to systems such as the DSM or ICD. Words such as “homeless,” “lonely,”
and “survivor” are all “diagnostic labels” of a sort. But, of course, all homeless people
are not identical, and the solution to homelessness in each case may not be as simple
as “this patient will benefit from our homeless program.” Once again, it becomes impor-
tant to uncover the person beneath the diagnosis of “homeless” – to understand the
invariably interdependent impacts of the patient’s uniquely intersecting matrices. Often-
times this can enable us to sculpt programs collaboratively with the patient, beginning
in the initial interview itself.
A useful question for interviewers to ask themselves when collaboratively treatment
planning during the closing phase of an initial interview is, “What are some of the poten-
tial impacts on other wings of this person’s matrix if we do this intervention?” This
internal question transforms into a useful external question for patients, which I like to
call the “matrix question.” The matrix question can have many variants, but in all its
variations it does not slant the patient towards consideration of healing or damaging
matrix effects, it merely finds out what the patient imagines may result from a proposed
intervention. In the resulting discussion, a patient’s hopes and concerns about the pro-
posed intervention frequently emerge in a naturalistic fashion. One of my favorite varia-
tions of the matrix question is perhaps the simplest: “How do you think your life might
change if we find you an apartment (add an antidepressant, invite your husband to join
us next session, get you into our eating disorders group, get you food stamps – whatever
the proposed intervention might be)?”
For a moment let us imagine a clinician using the matrix question during the closing
of his initial mental health intake with Ted at the VA. We will enter the interview a few
minutes after the clinician had first mentioned the program, an idea that initially seemed
very appealing to Ted:
Pt.: You know this program could really help me out. It’s gonna get cold, real cold, real
fast, soon enough.
Clin.: Oh yeah, we have helped a lot of vets with this program. How do you think things
will change for you if we get you a place to live? (matrix question)
Pt.: For the better, that’s for sure. I’m not looking forward to winter and it would be
amazing to have a shower. (pauses) …You know, will this apartment be near the
bridge?
Clin.: What bridge do you mean?
Pt.: You know, the one where we’ve pitched our tents?
Clin.: Oh … (pauses) … it could be, but probably not. I can’t tell you for sure where the
apartment will be, they’re sort of all over the city, but it will be nice. It will have a
shower, trust me (smiles).
Pt.: Good. (looks a bit introspective) Will I be moving with a group of the vets, you
know, sort of together.
Clin.: We often try to do that. It’s not always possible. Are you worried that you might not
be seeing some of your buddies?
Pt.: (Ted looks up immediately) … Yeah, that’s sort of something that might bother me
a little.
Clin.: You don’t have to worry about that, we have several centers set up around the city
that are right on the bus line, where vets can hang out during the day. They are very
popular.
Pt.: Hmmm (pauses) … I guess it’s better than living under a bridge, that’s for sure.
Clin.: You have really developed some great friendships under that bridge haven’t you?
Pt.: Oh yeah, these are my guys. They’re my family.
Clin.: Ted, could I make a suggestion.
Pt.: Sure.
Clin.: Well, I think we should try to get you on our waiting list for our housing program.
But you know what, I think we should note that you really want to wait and move
only with a group of vets into a shared apartment or shared apartment building.
Now I got to tell you, that could drop you on this list for quite a while. If I’m
honest with you, it could take us well into the winter months. But, I don’t know. I
sense this is pretty important to you, to be near your friends, I mean.
Pt.: (looks a lot brighter) Oh yeah, I would really prefer that plan. I don’t really like
buses too much either, so I’m willing to wait, if that’s okay with you.
Clin.: Sounds good to me (smiles). We better look into getting you a parka, if you know
what I mean.
Pt.: (chuckles) Don’t worry, it got plenty cold at night in the desert.
From this exchange one can see the value of using the matrix perspective as an organiz-
ing lens, even in the first interview. Hopefully it cogently demonstrates why an
understanding of treatment planning is so important in a book on initial interviewing,

for the two processes are entwined. Here, a well-timed use of the matrix question in an
initial intake might have resulted in a profoundly different outcome for Ted.
Sixth Wing of the Matrix: Worldview (Framework for Meaning)

On the sixth level, the interviewer examines the patient’s framework for meaning or what
Josephson and Peteet call the patient’s “worldview.” Although in actuality this wing of
the matrix could be conceived of as part of the psychological wing already discussed, it
is so important that it is best viewed separately. To understand the patient more fully, it
becomes necessary to understand his or her religious beliefs, philosophical beliefs, and
ethical standards as part of the patient’s cultural milieu, once again emphasizing the
importance of culture and diversity in understanding the patient. At times the patient’s
symptoms may be directly related to unrest within the patient’s worldview.
Worldview Intra-Wing Interventions

Josephson and Peteet emphasize that the concept of worldview is multi-tiered. It can
include concrete philosophical belief systems such as religious affiliation, agnosticism,
or atheism. But in a broader sense it includes what can be called spirituality, which may
have no affiliation with a specific religious system. In an even broader sense they empha-
size that it can include any belief systems that provides a framework for understanding
the world and/or a personal sense of mission. In this light, the patient’s worldview can
include patriotism, his or her family, an organization such as Alcoholics Anonymous, or
an identification with a street gang or a sports team.
Josephson and Peteet suggest a variety of nuanced and specific interview questions
and strategies for exploring worldview in their article, mentioned earlier, “Talking with
Patients about Spirituality and Worldview: Practical Interviewing Techniques and Strat-
egies”39 (complete article available in Appendix IV). We will also address the realm of
spirituality in great detail in Chapter 20: Culturally Adaptive Interviewing: The Challeng-
ing Art of Exploring Culture, Worldview, and Spirituality.
One way of conceptualizing the patient’s worldview is to ask yourself “what are the
beliefs that make this patient tick?” I have found this exact concept, when phrased as the
following question, to be an excellent doorway into this wing of the matrix: “What is it
that make you tick?” The open-ended quality to this question allows it to touch upon
all tiers of Josephson’s concept of worldview, with answers ranging from family and/or
country to specific religious beliefs and “my relationship with God?”
Information uncovered when exploring this wing of the patient’s matrix may suggest
the utility of individual psychotherapy slanted towards ethical or spiritual issues. It may
also serve to remind the clinician of the availability of clergy and pastoral counselors in
the treatment of the patient. Sometimes one of the most powerful interventions available
to clinicians is the ability to help patients re-unite with a religious or spiritual discipline
that has become dormant over the years or to separate from one that has proven to be
a problematic match for the patient.
Worldview Inter-Wing Matrix Interventions

With regard to inter-wing matrix effects, I have seen changes in the spiritual wing of the
patient’s matrix lead to profound healing matrix effects, at times on numerous wings of
the matrix from biological to family.
In the initial interview, this region was left relatively poorly explored in the case of
Debbie. Later interviews revealed a paucity of religious and philosophical supports at
this level, although her interest in her Christian upbringing and Eastern thought was
emerging as an important avenue for change, as mentioned earlier.
Conclusion: Matrix Treatment Planning Redux

But every man is more than just himself; he also represents the unique, the very special
and always significant and remarkable point at which the world’s phenomena intersect,
only once in this way and never again. That is why every man’s story is important, eternal,
and sacred …
Herman Hesse
from the preface of Demian40
We have now concluded a brief survey of the six levels used in matrix treatment planning.
Although there exists some obvious overlap with the DSM-5, a matrix analysis provides
many new areas in which to deepen an understanding of the person beneath the diag-
nosis from the perspective of person-centered interviewing, as well as suggesting new
areas of intervention. The concept of the human matrix also provides a more realistic
picture of the patient as one process inextricably woven among the other systems of the
world at large.
Two books for advanced reading on the concepts of the human matrix (one for clini-
cians and one for patients) may be of interest to the reader. For a compelling clinical
exploration of the science and ramifications of different systems on the development of
human behavior (essentially a book about the human matrix), I find Feeling Good: The
Science of Well-Being by C. Robert Cloninger to be a remarkable synthesis of current sci-
entific, clinical, and philosophic knowledge on how we are created by the interactions
of the processes around us. As a bonus, it is also a remarkably compelling read.41 For
patients, Happiness Is: Unexpected Answers to Practical Questions in Curious Times was
written by myself to provide insights on how people (both the general public and people
currently in therapy) can use the knowledge of healing matrix effects, damaging matrix
effects, the red-herring principle, and other nuances of the human matrix model to solve
everyday problems, stresses, and crises.42
Before we move to an exploration of our third assessment perspective – the patient’s
core pains – I would like to revisit a working premise of this chapter. Throughout this
chapter I have tried to illustrate the importance of addressing the basic principles of treat-
ment planning when teaching interviewing itself. Hopefully I have effectively shown the
three benefits of this understanding for the early trainee, as outlined at the beginning of
this chapter. Our assessment approaches provide the following three bridges into treat-
ment planning for the initial interviewer:
1. An easy and rapid method of checking, during the interview itself, whether pertinent
data regions necessary for effective treatment planning have been explored, thus
decreasing errors of omission
2. A reliable method of reminding the clinician to borrow from different data perspec-
tives when collaboratively formulating a treatment plan with the patient
3. A flexible approach to actually delineating a list of potential treatment modalities
with the patient
Yet there is one more utility to introducing basic treatment planning principles (as we
have done in this chapter) simultaneously with clinical interviewing itself (keeping in
mind that the actual specifics of treatment modalities and the advanced principles for
treatment planning are to be addressed by their own courses later in training). As trainees
learn the basics of creating an effective initial interview, they do not want to learn bad
habits, only to have to “break” them later in their graduate training or in subsequent
clinical practice.
Thus, learning the art of how to think about treatment planning while one is concur-
rently moving through the various stages of the initial intake, in my opinion, should be an
integral part of the clinician’s way of functioning. It should be introduced in the very
first course on clinical interviewing and refined with each successive course in graduate
training. To view treatment planning as an “afterthought” that occurs once the interview
is done, or only during treatment planning sessions, is unrealistic, for the database col-
lected and the structure of the interview itself are dependent upon how the interviewer
intends to treatment plan. To view the interview and treatment planning in such an
artificial fashion, as if they were separate silos, is, in my opinion, a potentially bad habit.
Moreover, especially when using matrix treatment planning (which requires a good
deal of analytic thought and mental discipline), the clinician is able to see the patient
in a critically holistic and contextual fashion. The real person beneath the diagnosis
emerges. Sometimes this process of seeing the person beneath the diagnosis is viewed as
being solely the result of the interviewer’s innate empathy and intuition. It is not. Natu-
rally there exist clinicians gifted with intuition, but even such clinicians are not bound
by the limits of their “gifts.” Their innate skills can be enhanced.
I am often asked, “Can intuition be taught?” My answer is a simple, “No.” Neverthe-
less, I am convinced that it can be nurtured. James Carse, when describing the poetical
power of Robert Frost, makes a point of significance to us as clinicians:
Frost was a master builder of word walls. He had learned the assorted techniques of putting
words together in a way that made them poetry. But learning the techniques of poetry does not
by itself make great poetry any more than building a well guarantees the vitality of a spring. Just
as the poet has to let the ego step aside, technique too must be abandoned at just the right
moment, allowing the poetic to enter on its own terms.43
Part of the art of interviewing is the clinician’s ability to “let go” of techniques at just
the right moment and to allow oneself to move purely with intuition. To be able to do
so effectively, like Frost, one first spends enormous energy on learning techniques.
Whether one is a poet, a martial artist, or a clinician, it is the disciplined practice of
techniques and their analytic application, over and over again, that allows the techniques
to become part of oneself. Paradoxically, it is at that moment that the poet, martial artist,
or clinician will be able to “let go” of these very same techniques.
Here we come to a clinical paradox of sorts. I believe that by consciously applying the
matrix perspective over and over again, from the first patient to the last, the process of
thinking about the matrix becomes ingrained into the clinician. It becomes absorbed
into the very essence of the clinician. It is taught as part of the beginner’s mind so that
it eventually becomes a part of the expert’s soul. This is why basic treatment planning
from a matrix perspective, in my opinion, is best begun as part of early training. It is why
it appears in the first section of our book on core principles, not in our last section on
advanced principles.
If done in such a disciplined fashion, I assure you that your rewards will be great.
From years of the disciplined analysis of seeing people through the lens of the human
matrix, one’s intuition will be sharpened until one creates interviews like Frost wrote
poetry. As with Frost, such a clinician will have moments in the initial interview when
his or her technique, related to matrix treatment planning, will drop away. At those
moments, they will feel or see something that other clinicians may not have felt or seen.
The clinician, because of years of disciplined matrix thinking will “get it” – perhaps rec-
ognizing a matrix effect that others would have missed. It may be a matrix effect that is
about to trigger an imminent suicide attempt or create the dangerous undertow of an
emerging psychosis, or it may be the intuitive hint of a patient scarred by childhood
abuse.
At such moments a curious reciprocity occurs between clinician and patient. Not only
will the clinician “get it,” but the patient will know that the clinician “gets it” – that this
particular clinician sees what others have missed, that this clinician “sees the real me”
that others glanced past, that this clinician sees my life as a complex interplay of processes
that others may have felt to be unimportant. At such moments, the alliance will be made
vibrant. Healing will begin. A second meeting will be secured. It is the type of moment
in clinical interviewing that somehow goes beyond words. I don’t want to sound too
magical, but truth be told, there is something magical about such moments.
ASSESSMENT OF CORE PAINS

I can see behind everyone’s masks. Peacefully smiling faces, pale corpses who endlessly
wend their tortuous way down the road that leads to the grave.44
Edvard Munch, 19th century expressionist painter
Although Munch depicts a somewhat grim picture of human existence, he was a man
keenly aware of the pains that all of us endure by our very nature of being human. His
ability to intuitively sense underlying pain represents a gift that all clinicians hope to
possess. Indeed, this ability to understand pain provides a major gateway through which
therapeutic trust is born.
Throughout this book, an emphasis is placed on combining intuition and analysis,
and the relationship between the two as just described. Many times the clinician will be
able to intuitively sense the pains of the interviewee, but this intuition is enhanced when
guided by an increased awareness of underlying themes. One of the more fascinating
themes is the co-existence of the complexity of human nature with the simplicity of that
same nature. Nowhere is this curious paradox more conspicuous than with the issue of
psychological pain. Patients frequently present with complicated histories and concerns,
sometimes even involving bizarre delusions and idiosyncratic perceptions. But the under-
lying pains from which these patients are fleeing are few in number.
Skilled clinicians possess the knack of cutting through the complexities until the bare
wounds, the core pains, are understood. An understanding of these core pains is a pow-
erful clinical tool. This empathic understanding can suggest avenues for treatment plan-
ning. Even more important, it can also guide the interviewer towards methods of
navigating the patient’s hesitancies that can develop during the interview itself, because
the seeds of such hesitancies are often attempts to avoid these core pains by the patient.
We have already had a glimpse of this process when we discussed methods of transform-
ing communication breakdowns and patient fears in the opening phase of the interview
in Chapter 3.
In any case, an understanding of core pains, and the increased sensitivity such an
understanding can bring, provides an assessment perspective that complements both the
DSM-5 and matrix treatment planning. It is based on the principle that clinicians should
intermittently ask themselves, “What are the core pains that are hurting this patient at
this time?” Or as Edvard Munch would have it, what is behind the mask?
The relevance of the concept of core pains was made plain to me by a psychotic patient
when I was least expecting it. The patient was a young woman in her mid-20s who pre-
sented violently and was riddled with terrifying delusions. During the initial interview
she described her sincere belief that aliens were speaking directly into her mind, taunting
her sanity. Her world was convulsed with a pricking sensation of paranoia. She had
become convinced that the aliens were about to kidnap her to a distant world. Her affect
was intense, and she spoke in a disorganized fashion with a loosening of associations.
At this point, I asked her why she felt the aliens were coming for her. To my surprise
she looked at me as if I had not been listening. Her affect calmed, her speech became
coherent, and she said, “Don’t you understand? I am alone here. No one cares for me. I
have no family, no friends. And I have no reason to be here. Wouldn’t you want to leave
this horrid place if you were me?” At which point she promptly popped back into her
psychotic language and refuge.
In a sense she was right concerning my inadequate listening, because I had become
overly involved in diagnosis and systems analysis. A balancing perspective was needed
– a sense of her pathos on a human level. She provided me with a lesson that led me to
think more carefully about the presence of core pains and methods of conceptualizing
them more clearly even as the interview itself proceeds.
Towards this goal, one can generate a list of core pains that singly, or in combination,
appear to be driving any given individual. Each clinician may have a unique list. The
following serve only as a platform for discussion. To me the core pains are as follows:
1. Intense loneliness
2. Feeling worthless or bad
3. Feeling rejected or wronged

4. A sense of failure
5. Loss of external control
6. Loss of internal control
7. Fear of the unknown
8. Loss of meaning
With Debbie in mind, one can survey these pains, examining their usefulness in both
treatment planning and in understanding the dynamics of the interview itself.
The fear of being ultimately alone remains one of the most powerful and common
pains. In the case of Debbie, it appears to be surfacing in one of its frequent guises,
intense dependency. As such, it serves to remind the interviewer that some patients may
seek an unhealthy dependency on the clinician even during the initial interview. Debbie
would be one such person in whom this process could occur, as reflected by her intense
feelings of abandonment when her significant other goes to sleep.
Her dependency needs may be intimately related to the second core pain, a sense
of worthlessness or of being a bad person. Debbie was convinced of her ultimate
inability to cope with life. In this sense, she probably avoids situations in which she
could modestly succeed, thus depriving herself of the positive reinforcement needed to
gain a sense of mastery. With these factors in mind, the clinician might consider assign-
ing Debbie small, easily accomplished homework tasks, resulting in a gradually increas-
ing sense of worth. In addition, the clinician might employ problem-solving skills
therapy. Such therapy may not only improve her ability to navigate life’s difficulties, it
might have a marked impact on her self-esteem as she moves from a sense of inadequacy
to, “You know, I’ve really learned something about how to cope with life and problem
solve.” In addition, a cognitive therapy approach might reveal that Debbie has a dis-
torted self-image (perceiving herself as a bad or defective person, not uncommon in
people coping with borderline process) maintained by tendencies for negative thinking
and inappropriate self-blame. In this light, techniques such as cognitive restructuring
might be of use.
Like its predecessor, this core pain appears to lead naturally into a discussion of the
next core pain, a sense of rejection or being wronged. This fear reared its head throughout
the interviewing process. Debbie demonstrated poor eye contact and frequently com-
mented, “That’s a stupid thing for me to say.” Such anxieties can hamper the progress of
the initial interview as the patient expends inordinate amounts of attention attempting
to please the interviewer. Alert to this situation, the interviewer may purposely reassure
the patient. For instance, the clinician might choose to say, “You are doing a very good
job of discussing difficult material. It’s really helping me to get a clearer picture of what
has been going on.” Even such a simple statement can make a patient such as Debbie
feel considerably more comfortable, decreasing her fear of imminent rejection.
The fourth core pain, a feeling of failure, overlaps with a sense of worthlessness, but
has an intensity all its own. The initial interviewer needs to attend to this particular pain,
because the patient may bring it into the initial interview. Specifically, the patient may
predict an impending failure in therapy and consequently decide not to appear for
follow-up. If left as a hidden issue, the risk of losing the patient is real. In the closing
phase of the interview, the clinician may opt to bring this fear to the surface with ques-
tions such as, “Now that we have talked about possible therapies, I’m wondering what
you think about their usefulness for you?” or “If you tried outpatient therapy, how do
you think it would go?” The interviewer may be able to cite the patient’s success in han-
dling the initial interview as evidence that the patient has the necessary abilities to
succeed in therapy.
The fear of losing external control, the fifth core pain, can be extremely frightening
to patients, because suddenly it seems as if nothing they can do will alter their situation.
This combination of fear and anger can present a fertile field for suicidal ideation. A
feeling of “being trapped” is viewed as one of the significant warning signs for suicide
in recent work by Van Orden and company.45 If one listens to the steelworker laid off
indefinitely or the Detroit factory worker who watches the closing of an automobile
plant, the roar of this pain can certainly be heard. While interviewing elderly patients or
patients coping with chronic illnesses, one should bear in mind that they may be dealing
with a sense of the ultimate loss of external control, death itself. When this core pain
appears particularly prominent, the initial interviewer can make an effort to consciously
increase the patient’s sense of control within the interview itself by using statements such
as, “At this point what do you think would be the most important area we should focus
our discussion on?” Such modest, yet timely, intervention can significantly return some
feeling of control to the patient.
The sixth core pain, the fear of loss of internal control, surfaces in patients who are
becoming increasingly frightened of their own impulses, such as drives towards suicide
or violence. I doubt that this pain could be more vividly portrayed than in patients who
are moving into progressively more psychotic or manic behavior. In Debbie’s case, her
history of episodic violence, as evidenced by her throwing a picnic table bench through
a picture window, suggests that this core pain may be a frequent motivator of her behav-
iors. Fortunately, in her initial interview she appeared to be in good control.
In other situations, the interviewer may find a patient who reports feeling imminently
unstable. In such cases, it is generally, if not always, sound to attend to these fears on
the spot. If the interviewer chooses to ignore these feelings, he or she risks driving the
patient to an act of violence. Ironically, the patient’s own increasing fears of losing control
may act to spur further anxiety, perhaps pushing the patient even closer to a loss of
control. The clinician can gently probe to see what the patient is afraid may happen and
ask the patient if, indeed, he or she feels in control. The appearance of this core pain
may suggest the usefulness of an antipsychotic medication.
We now come to the seventh element in the assessment of core pains, the fear of the
unknown. As described in Chapter 3, most patients are probably experiencing this pain
during the interview itself, because they are frightened of what the results of the interview
will be. As mentioned earlier, a few minutes spent performing a sound introduction can
greatly relieve the patient’s unnecessary fears. In Debbie’s case, her fear of the unknown
may add to her dependent patterns, making her reluctant to try things on her own. With
regard to treatment planning, one sometimes finds that patients such as Debbie do not
have the communication skills or the assertiveness to find out what the future may hold,
thus locking them into the paralysis of the moment. Their lack of assertiveness may
prevent them from asking appropriate questions, even of the interviewer. The presence
of this core pain should alert the clinician to the potential use of assertiveness training
and social skills work, as well as to the need to address unasked questions.
The eighth and final core pain, loss of meaning, addresses the type of material
addressed in the worldview wing of matrix treatment planning. The loss of a framework
for meaning is a common precipitant of anxiety and depression, or it may appear in
response to an ongoing psychiatric disorder such as schizophrenia or bipolar disorder.
Patients may have a variety of differing ways of searching for meaning. With Debbie, we
had already discussed some of her burgeoning interests in her religious roots as well as
Eastern thought. But there was another endeavor that would prove to be powerfully
important in her search for meaning – her interests in creating poetry and artwork.
We have now reviewed our third assessment schema. I have not explored the use of
this system in detail; we will do this in upcoming chapters. Instead I have tried to survey
this assessment system, which provides yet another set of pathways toward treatment
planning. This particular schema provides more on-the-spot information pertinent to altering
the course of the interview itself than either the DSM-5 or the human matrix model, for it sug-
gests various engagement strategies that can transform patient hesitancy or fear before it consoli-
dates. Together, these three assessment perspectives complement each other, helping the
interviewer change a potentially impotent mass of data into a crisp and practical formu-
lation, bridging directly into the treatment planning process.
As the clinician becomes familiar with using these three systems, one of their most
appealing aspects surfaces – their speed. Once familiar with their use, after the interview
the clinician can assess the known database while generating a powerful list of treatment
options in about 5 to 10 minutes. This rapid integration of a large database can be a
godsend in a busy clinic or private practice. Furthermore, the clinician can review the
ongoing treatment plan quickly and with a fresh perspective as time passes.
Before wrapping up this chapter, it may be gratifying to review the course and ultimate
outcome of Debbie in therapy, while also looking at the actual selections that were made
from the lists of potential treatments generated by the above perspectives.
REVIEW OF THE CLINICAL COURSE OF MS. BAKER

In the first place, despite her chaotic history, Debbie brought to therapy a variety of
healthy coping skills. She displayed motivation, intelligence, and a keen capacity for self-
reflection. She also possessed the often-too-rare quality of compassion. Indeed, it was
her apparent inability to recognize and accept her strengths that stood as one of the
major obstacles to her development. In a large measure, therapy consisted of an
attempt to help Debbie develop the attributes hinted at during her moments of high
functioning.
The rest of her eventual treatment plan evolved directly from the data gathered in
the initial interview. Regarding psychiatric disorders, she did not fulfill the criteria for a
major depressive disorder. She did appear to meet the criteria for dysthymia, which, as
mentioned earlier, may respond to antidepressant medication. In her case, I opted to
forgo an antidepressant at first, hoping that psychotherapeutic measures would be more

effective. In particular, because of her long-established pattern of self-debasement and
a sense of worthlessness, I was concerned that she would immediately deny any credit
for improvement if an antidepressant could be pointed to as the curative agent. If she
had developed a major depressive episode or if the chosen treatment track had failed,
I would most likely have promptly added an antidepressant. In the long run, the goal
was to enable her to gain an increasing sense of self-worth and mastery over her
environment.
Her problems with the development of a stable self were reflected by her primary
diagnosis of a borderline personality disorder. She also met the criteria for a dependent
personality. In any case, these diagnoses suggested the need to attend to her dependency
issues quickly, a generalization extrapolated from the diagnosis and borne out by her
long history of dependent relations (police being called to remove her from her last
therapist’s office). Consequently, in the closing phase of the initial interview, the issues
of possible dependency upon me were discussed openly and mutually decided upon as
a major concern to be avoided.
To sidestep a maladaptive dependency upon myself, she was seen only on a weekly
basis. Moreover, we agreed to adopt a long-term treatment plan built around the concept
of meeting for 3-month periods in which we focused on a specific problem list generated
by her. At the end of each 3-month period, we would break from therapy for progres-
sively longer periods of time as she began functioning more and more independently.
These successful breaks from therapy allowed her to discover for herself, by practicing
her new-found skills, that she was indeed improving and gaining a gently evolving sense
of self-mastery.
This treatment approach characterized by intermittent stretches of therapist-free time
was only possible because of considerations made with regard to the cultural/societal/
environmental wing of her matrix. Specifically, it was discovered that a day hospital was
available that could offer appropriate support when needed, as she underwent the pangs
of separating from me. Thus she received enough support to gain the additional sense
of independence offered by successfully navigating her loss of me. Only through the
cooperation received from this agency of the mental health system could the treatment
plan be made operational, a nice example of the power of integrated care, as emphasized
in person-centered health care.
During her 3-month period of active therapy, specific tasks were assigned as home-
work, which she mastered easily, increasing her sense of worth. She also became adept
at utilizing cognitive restructuring, which helped her to decrease her tendency for over-
generalization, splitting, and inappropriate self-blame. These cognitive techniques were
implemented while simultaneously considering the psychodynamic issues of the devel-
opment of her core sense of self. These cognitive and psychodynamic techniques all
represent intra-wing treatment approaches in which psychological problems (low self-
worth/weak self-identity) were addressed with psychological interventions (psychody-
namic and cognitive–behavioral therapies).
It was here that an interesting inter-wing intervention would prove to have a major
healing matrix effect on Ms. Baker’s sense of self-identity. As I mentioned earlier, one of
her main pathways for finding spiritual stability was her ongoing creation of poetry and
artwork. I decided to place some increased emphasis on this well-established strength
with the hope that further successes in this arena might provide her with a stronger sense
of accomplishment and self-respect using the spiritual wing (artwork) to make a healing
matrix effect on her psychological wing (self-identity).
When first entering this part of the therapeutic process, Debbie would timidly show
me some of her artwork. One could see her fears of rejection, reflected by her almost
sheepish looks for approval and the hesitant handing over of her artwork to a perceived
“master judge.” Even more striking was the signature on the painting, “Paul.” If you recall,
she liked to fantasize that she was Paul Newman. She always used her fantasy identity
when signing her artwork or poetry. As therapy continued, much positive feedback was
provided by both myself and the staff at the day clinic on her artistic progress. Indeed,
her skills improved at a brisk pace.
One day, several years into the therapy, Debbie handed me a piece of her artwork. She
presented it with a quick and confident gesture, commenting, “I like this one a lot, Dr.
Shea.” She passed it to me looking me directly in the eye. I looked down, impressed by
its quality. I then looked down more intently. When I looked up, she was smiling broadly,
“Yeah, it was done by me.” She had signed it “Debbie.” It’s the type of moment in therapy
that one does not easily forget.
Furthermore, as therapy proceeded she stopped wearing her wristband with the false
identity, a behavioral change paralleled by a significant decrease in her fantasy activity.
Several years after her therapy was completed, I saw one of her poems in the local paper.
Her real name sat quietly at the bottom.
Another inter-wing matrix effect was used by utilizing a biologic intervention (medica-
tion) to impact on her anxiety and poor impulse control during her premenstrual unrest
(psychological wing). Specifically, small doses of the antianxiety agent Xanax (alpra-
zolam) were used as deemed necessary by Debbie, and carefully monitored by me, during
her premenstrual phase. The medication proved efficacious. Moreover, she was pleased
by her ability to wisely use the medication in a limited fashion and felt good about
herself that she was maturely controlling a behavioral problem that had previously been
highly problematic. In addition, a behavioral system (an intra-wing intervention), in
which she played a major role in developing, was employed to help her to prevent sui-
cidal and violent activity. The emphasis remained on her to help herself, using her
decreased need for my “parenting,” as reinforcing evidence of her ability to manage
independently.
A further area for intervention appeared in the family assessment. To this end, a
session was arranged for Debbie and her partner (dyadic wing of her matrix). By explain-
ing to her partner certain aspects of the overall plan for increasing Debbie’s indepen-
dence, her partner was better able to support progress. It was also discovered that her
partner appeared to be a loving and dependable support system. This session also served
to decrease her partner’s anxieties concerning the therapy itself, thus decreasing the risk
of resistance generated by her partner. During the course of therapy, several joint sessions
with her partner proved to be valuable. These interventions all demonstrate intra-wing
interventions.
With regard to her relationship with her partner, greatly strained by Debbie’s demands
on her partner’s time, a decision was made to partially heal the relationship by using an
inter-wing intervention. Specifically, an attempt was made to relieve Debbie’s dependen-
cies on her partner by nurturing group relationships at the community day hospital.
Group therapy was utilized successfully in this regard. Her relationship with her partner
strengthened considerably as she spent more time with others, while developing more
mature social skills. These interventions on the “group wing” of her matrix had healing
matrix effects both on the dyadic wing with her partner but also on her psychological
wing where she began to view herself as a more worthwhile and capable person.
By 2 1 2 years into the therapy, Debbie had been involved in three 3-month therapy
courses separated by increasingly large interludes. Her mood shifts had stabilized mark-
edly, as had her relationship with her partner. She had only two minor suicidal gestures
in this time period. In the subsequent year and a half, the length between courses of
therapy increased with an eventually uneventful termination of therapy. Needless to say,
police intervention was not required.
CONCLUSION
In this chapter we have looked at the process of effectively organizing the information
gained from an initial interview. It has become apparent that the methods chosen for
conceptualizing data can greatly affect the ultimate usefulness of the data. The three
organizational methods discussed here – the diagnostic perspective of the DSM-5, matrix
treatment planning, and an understanding of the patient’s core pains – when deftly
combined can provide a practical and flexible method for generating a list of viable treat-
ment options during the interview itself. These three assessment systems also establish
a reliable method of noting pertinent gaps in the database.
In the long run, the major reason for performing an assessment interview remains the
generation of a sound treatment plan. Unlike T. S. Eliot in our opening epigram, we are
not undertaking an exploration to know a place, we are undertaking an exploration to
try to know a person. But like T. S. Eliot, “we come to know the place for the first time”
by arriving where we started, the words of the patient during the interview itself. The
treatment plan arises from our attempt to understand the patient and the ever-changing
matrix from which the patient evolves. Ultimately, this understanding must come from
our ability to sensibly organize what the patient is trying to communicate through his
or her words. Once we have gained this ability to quickly organize the seemingly chaotic
information coming our way, treatment plans naturalistically come to mind; it almost
seems as if the database speaks for itself. Our task becomes one of learning to listen, for
the patient’s past history points towards the patient’s future healing.
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CHAPTER 8
Nonverbal Behavior: The Interview
as Mime
And now a dark cloud of seriousness spread over her face. It was indeed like a magic mirror
to me. Of a sudden her face bespoke seriousness and tragedy and it looked as fathomless
as the hollow eyes of a mask.
Herman Hesse
Steppenwolf1
INTRODUCTION
In this chapter we will explore the intricate processes known as nonverbal behavior. Few
studies are more intriguing or more pertinent for the clinician. It is only fitting that as
we wrap up our review of the fundamental principles of clinical interviewing in Part I,
we should address nonverbal behavior, for nonverbal processes have an impact on all of
the way-stations delineated on our map of the clinical interview. Nonverbal cues play an
obvious and critical role at way-stations such as engagement, data gathering, and in
understanding the person. They even indirectly impact assessment processes, such as
diagnosis, as well as enhance our ability to communicate as we collaboratively treatment
plan in the closing phase of the interview. We will also see that nonverbal behaviors play
a vital role in deciphering and effectively utilizing cross-cultural cues during the initial
interview.
Our study will include not only body movements but also those elements of verbal
communication that are concerned with how the words are spoken. In the early 1980s,
one of the pioneers in the study of nonverbal behavior, Edward T. Hall, speculated that
communication is roughly 10% words and 90% “hidden cultural grammar.” He states,
“In that 90% is an amalgam of feelings, feedback, local wisdom, cultural rhythms, ways
to avoid confrontation, and unconscious views of how the world works. When we try to
communicate only in words, the results range from the humorous to the destructive.”2
A decade later, a review of the more recent research on nonverbal behaviors by Burgoon
showed that Hall’s speculations foreshadowed what would eventually be validated by a
more empirical evidence base, which has suggested that 60–65% of social meaning is
derived from nonverbal behaviors.3
The practical relevance of Hall’s words can be readily seen in the following clinical
vignette. During an afternoon of supervision, I had the opportunity to watch two
interviewers interact with the same patient in back-to-back interviews. The patient, a
male in his early 20s, sat with a slumped posture, his head seemingly pulled to his
chest by an invisible chain. His legs were open, and his hands lay resting quietly on
his lap.
The first interviewer was a young woman, who spoke in a quiet but persistent voice.
The blending between the two was weak at best, provoking an occasional upward nod
from the patient, rewarding the starved interviewer with a momentary scrap of interest.
When the second interviewer entered the room, an intriguing process unfolded.
Within 5 minutes, the patient sat more alertly in his chair. Eye contact improved signifi-
cantly and was accompanied by some actual animation in his voice, albeit mild. By the
end of the interview, the conversation was proceeding naturally, and a reasonably good
therapeutic alliance had been formed. Both interviewers were relatively young women,
both of whom conveyed a caring attitude. One wonders what factors resulted in the
clearly more powerful blending of the second interview.
Some of the answers may lie in the communication channels each of these interview-
ers used in an effort to engage the patient. The first interviewer spoke in a quiet tone of
voice intermixed with numerous nods of her head. Such head nodding frequently appears
to facilitate interaction. Unfortunately, visual cues lose their impact if the patient refuses
to look at the clinician. In short, her facilitating efforts were on the wrong sensory
channel. In contrast, the second interviewer spoke in a more lively tone of voice, which
appeared to grab the patient’s attention. More important, her words were frequently
punctuated with auditory facilitators such as “uh huh” and “go on.” The first interviewer
verbalized few such auditory facilitators. The patient had been stranded in the room,
responding with detachment to the clinician’s monotone voice. Like the first clinician,
the second interviewer also utilized head nodding, but her nods became progressively
more effective as the patient met her eyes more frequently.
This example demonstrates the usefulness of flexibly employing different communica-
tion channels depending on the receptiveness of the patient. If the patient’s head is down,
one can increase the number of facilitatory vocalizations. With a deaf patient, one can
increase head nodding. Perhaps more important, this example emphasizes the overall
influence of the interviewer’s nonverbal communication on the patient. It suggests that
we may be able to consciously alter our nonverbal style in an effort to create a specific
impact on the patient – yet another example of intentional interviewing.
This possibility brings us to one of the most important challenges of this chapter. In
order for interviewers to flexibly alter their styles, they must become familiar with the
baseline characteristics defining their own styles. From such a position of self-
understanding, flexibility emerges.
Thus, study of nonverbal behavior provides two distinct avenues of exploration. First,
as the opening quotation from Steppenwolf suggests, one can learn an immense amount
about the patient by studying their nonverbal cues. This aspect of nonverbal behavior is
the most commonly acknowledged. Hesse’s protagonist quickly perceives his compan-
ion’s change of affect as “a dark cloud of seriousness spread over her face.” Second, as
our clinical vignette illustrates, one can discover the impact of one’s own nonverbal
behavior on the patient and subsequently alter it as appropriate.
Nonverbal behavior: the interview as mime 277
The goal of this chapter is to provide concrete examples of how to use a knowledge
of nonverbal behavior to effectively navigate the above two avenues in a busy clinical
setting. In addition, my hope is to provide an appropriately sophisticated understanding
of the theory and language used to describe nonverbal behaviors by experts in the field.
Such a knowledge will enable the reader to rapidly and effectively explore the fascinating
literature on nonverbal behaviors outside the pages of this book – a literature rich with
clinical implications.
Basic Terminology of Nonverbal Behavior

Before proceeding, it may be expedient to examine the definition of nonverbal behavior,
for this term can have different meanings. In their excellent book, Nonverbal Communica-
tions: Science and Applications, Matsumoto, Frank, and Hwang provide a lively, descriptive
definition:
Nonverbal behaviors intrigue us. We see the way a person looks, the way he or she moves,
and how he or she sounds. Nonverbal messages are transmitted through multiple nonverbal
channels, which include facial expressions, vocal cues, gestures, body postures, interpersonal
distance, touching and gaze. We call these channels because, like channels on a television,
they are each capable of sending their own distinct message.”4
Operationally, in our book we will view nonverbal behavior as the general category of
all behaviors displayed by an individual other than the actual content of his or her
speech. Note that, as Matsumato and colleagues state, various factors can impact upon
nonverbal behaviors, including such elements as the speed and intensity of a person’s
movements, interpersonal distance, and the pacing, loudness, and tone of voice used
when speaking. To effectively address these elements from a clinical perspective, I have
found it useful to split the broad category of nonverbal behavior into two general sub-
categories: (1) nonverbal communications and (2) nonverbal activities.
Nonverbal Communications (Emblems)

In the first category, nonverbal communications, the patient is using a commonly accepted
symbol associated with a specific meaning. You will sometimes see the word “emblem,”
as coined by Ekman and Friesen,5 used as a synonym for nonverbal communications.
An irate American football fan “throwing the finger” to the quarterback of the visiting
team is displaying a piece of rather vivid nonverbal communication. Entire subcultures
or organizations may develop a set of emblems for internal use. To once again use Ameri-
can football as a reference, the referees use a complex set of emblems to communicate
the various penalties that have been committed by the players. Emblems may also be
used in situations where speech is not possible (skin diving) or where it might not be
practical (raising a hand for a question in a classroom).
Generally speaking, nonverbal communications (emblems) are relatively easy to inter-
pret, for they evolved to communicate specific messages, but a word of caution is in
order, which is of immediate importance to initial interviewers: Different cultures may

attach significantly different meanings to the same nonverbal communication.6
The American “okay sign,” which indicates that one approves of the current suggestion
or situation, is viewed as somewhat vulgar in Brazil, and in France simply means “zero.”
On the other hand, in Arab countries the exact same “okay sign” is viewed as a rude
sexual gesture. An initial interviewer using an okay sign to indicate to a patient in the
closing phase of the interview that the patient has nicely understood a complex recom-
mendation could result in a puzzling or discordant communication if it is to an Arab
patient who is naive to the use of this emblem in American culture.
The Arab culture also provides a bridge into our second word of caution, which relates
to the ease with which nonverbal activities can be misinterpreted as being forms of non-
verbal communication. For example, a non-specific nonverbal activity from the clinician’s
culture may be seen as a quite specific nonverbal communication in the patient’s culture
or vice versa. For instance, Americans cross their legs frequently in everyday conversation,
a nonverbal activity that often results in their companions seeing the bottom of their
foot. Indeed, if a clinician crosses his or her legs with one ankle on the opposite leg’s
knee, the bottom of the clinician’s foot may be facing the patient at times. Unfortunately,
in the Arab culture, showing the bottom of one’s foot is viewed as an extreme insult,
representing a quite specific emblem. Even when interviewing an Arab patient familiar
and comfortable with the Western interpretation of such a posture, a wise clinician may
choose to avoid it – for why risk a possibly deep-seated unconscious negative response
in the patient?
A basic principle for clinicians evolves from these caveats on nonverbal communica-
tions. If a clinician has moved to a different culture or has begun to practice in a part of
the country in which a large immigrant population is being served, it is advisable for
him or her to ask experienced clinicians in that setting to describe the relevant cross-
cultural emblems as soon as possible. Some early, and unnecessary, missteps in engage-
ment may be averted from such a simple survey.
Nonverbal Activities
In the second, vastly larger category – nonverbal activities – the overt behavior does not
have a single commonly agreed upon meaning, and the sender may not be consciously
trying to convey a message. Hand gesturing, facial expressions, and even more directive
acts such as chain-smoking cigarettes all represent nonverbal activities. A nonverbal activ-
ity, such as fidgeting with a pen, may indeed be usefully interpreted by the observer as
having a meaning, perhaps indicating anxiety; however, this interpretation is inferred
and may be wrong. In short, nonverbal activities may have numerous meanings.
Ekman and Friesen categorized nonverbal activities into four classes: illustrators and
regulators (which, respectively, play a direct role in either descriptive gesturing or the
regulation and flow of speech) and adaptors and affective displays (both of which may
convey secrets to underlying emotions, feelings, and attitudes).7
Illustrators are hand gestures used to complement, expand, and clarify spoken lan-
guage. Deictic illustrators are used to point at an object while speaking about it. A
different style of illustrator (iconic) involves using the hands to outline or suggest an
object that is being described. With the use of iconic illustrators, a person can suggest
characteristics such as size and shape. Gifted public speakers are masters of iconic
illustration. Sign language, as used with the hearing impaired, partially evolved from
iconic illustration and, in my opinion, often achieves a gracefulness deserving of the
term “art.”
Regulators consist of facial movements, hand gestures, and body movements that serve
to control, adjust, and sustain the flow of a conversation. Bente and colleagues have
referred to these behaviors collectively as “dialog functions.”8 They describe specific uses
of regulators such as turn-taking signals (eye contact) and managers of communication
flow (such as head nods, suggesting the speaker should go on and that they are being
understood).
Adaptors are behaviors that are performed, for the most part without conscious inten-
tion, to allow oneself to feel more comfortable. They can include various hand behaviors
such as stroking the face, picking at ones nails, or rolling a pen, as well as more general-
ized body movements such as changing posture, stance, or position in a chair. As with
all nonverbal activities, adaptors may mean many things. On a mundane level, they may
simply indicate that the person needed to change position for the person’s body was
simply growing tired or strained in a particular position. On a more psychodynamic level,
they may indicate various underlying feelings or attitudes, from anxiety to a feeling of
being socially uncomfortable, perhaps a tell-tale sign of patient deceit, as we shall see
later.
Affective displays are generally facial movements (furrowing the brow, tensing the jaw,
intense staring) that tend to spontaneously occur when a human is feeling a particular
emotion. Learning to read affective displays is a critical skill for any interviewer. Promi-
nent affective displays are usually fairly easy to read, for they often have an almost uni-
versal meaning that can generally be inferred regarding emotions such as anger, disgust,
fear, happiness, sadness and surprise (Ekman’s original list of core emotions),9 as well
as more subtle emotional states including amusement, contempt, contentment, embar-
rassment, excitement, guilt, pride in achievement, relief, satisfaction, sensory pleasure
and shame (Ekman’s expanded list of core emotions). Some highly skilled clinicians are
naturally adept at “picking up” on subtle affective displays, a skill that is often viewed
as intuition. On the other hand, interviewers can learn methods for more rapidly and
accurately spotting affective displays, a highly useful skill for any clinician. For the inter-
ested reader, such behaviors are nicely described and illustrated by photographs in Paul
Ekman’s book, Emotions Revealed.10
A Cautionary Note on Interpreting Nonverbal Behaviors and

Nonverbal Research
As clinicians we are interested in understanding the significance of both nonverbal com-
munications (emblems) and nonverbal activities (illustrators, regulators, adaptors, and
affective displays). It is important to keep in mind that nonverbal activities are generally mul-
tiply determined. It seems unwise to begin assuming that one “knows” exactly what any
given nonverbal activity means. Even nonverbal activities generally viewed as obviously
representing a specific mood state, such as laughter, can be misinterpreted, depending
upon the interpersonal and cultural context of the laughter. The kulturbrille effect can
be quite striking here.
For instance, in the Japanese culture laughter generally means what it does in Western
culture – the patient is finding something to be humorous. But this common affective
display has several uncommon uses, from a Western interviewer’s perspective, in the
Japanese culture. It can be utilized as a way of covering up or controlling displeasure, as
well as concealing embarrassment, confusion, and shock.11 An interviewer unaware of
these uses of laughter could view a Japanese patient who is laughing intermittently in
an initial session to be demonstrating a powerful degree of blending, when, in reality,
the patient is feeling highly uncomfortable and will not be making a second appearance
with this particular clinician.
In this regard, Wiener and associates criticized some psychoanalytically oriented
researchers as immediately positing unwarranted unconscious meanings to nonverbal
activities.12 Considering this context one is reminded of the old psychoanalytic saw in
which the astute clinician detects that the patient is experiencing severe marital discord
because she is playing with her wedding band. Such interpretations of nonverbal activi-
ties are invaluable if kept in perspective. However, the clinician needs to think about
other possible causes of the stated activity. For instance, this patient may be playing with
her wedding band because she feels intimidated by the interviewer. She releases her
anxiety by playing with objects in her hands. Normally she rolls a pencil back and forth,
but because no pencil is available, she twists her ring. Other interpretations may be
equally correct. To ignore these other possibilities while assuming the marriage is trou-
bled is to ignore sound clinical judgment. On the other hand, having considered the
various possibilities, the experienced clinician may gently probe to sort out which is
correct and may indeed uncover marital discord.
From this discussion, it is reasonable to make the following generalization: Nonverbal
communications are relatively easily deciphered (but even here there are caveats), whereas
nonverbal activities should be cautiously interpreted, because more than one process
may be responsible for the behavior. This point deserves emphasis because both in clini-
cal and popular literature, the idea that exact meanings of nonverbal activities can be
directly read is put forward by some authors. They imply that one can read a person like
a book. In a similar vein, the concept of “body language” suggests that nonverbal activi-
ties are more codified than they actually are.
A similar degree of caution is required as one surveys the research concerning non-
verbal behavior. The body of research appears both vast and promising, but there exist
many limitations. Nonverbal interactions are so complex that it remains difficult to suc-
cessfully isolate variables to study. For instance, suppose a piece of research was designed
to prove that it was the paralanguage (how the words were said) of the second interviewer
in our opening clinical vignette that directly increased blending. An attempt to isolate
this single variable would prove difficult, for a variety of other variables could have had
an impact, such as the interviewer’s physical attractiveness, the distance between seats,
and even the fact that there were two interviews.
Even when one successfully isolates the relevant variables, the very act of isolation
poses serious problems. Nonverbal elements seldom function as isolated units.13 Instead,
the various nonverbal elements exert their influences jointly, making the findings of
research based on single channels such as paralanguage or eye gaze somewhat artificial.
A different approach, the functional approach, attempts to study the various nonverbal
elements as they function in unison.
Finally, two cultural elements of academia impact on the quality of nonverbal research.
First, the most common sampling methods used in many studies tend to focus upon
Western cultures, and even within that sample it is common practice to recruit subjects
from undergraduate students – hardly a group that is representative of the general popu-
lation.14 Second, like many other research arenas, research in nonverbal behavior has a
paucity of replication studies, i.e., where published research is repeated to ensure that
the results are valid. In fact, much of the research has not been duplicated for a variety
of reasons including: funding agencies are sometimes unwilling to support replication
studies; researchers often do not want to replicate the work of others, but would rather
“do their own research”; and academic institutions tend to value and reward “original
research” more highly. Thus, in both the academic and popular literature, findings about
nonverbal communication are sometimes cited as being “evidence based,” when the
research may have been of poor quality and/or may never have been replicated.
These research issues are worth mentioning because it is important for the clinician
to realize that relatively limited knowledge exists on nonverbal behaviors that can be
called “factual.” It is safe to say that this body of exciting research is still in its adoles-
cence. In this regard, the material of this chapter is best viewed as opinion concerning
an evolving craft or art. The material itself is culled from a variety of sources, including
clinical work, supervision, research literature, personal communications, and even
popular literature15,16 if it seems to shed light on clinical issues. But despite the lack of
an extensively validated evidence base, I want to reassure the reader that my trainees and
I have found the following material on nonverbal behavior to be invaluable, both in
interviewing and in ongoing psychotherapy.
Organization of the Chapter

The chapter is divided into three sections. In Part 1, the classic fields of study
in nonverbal behavior will be briefly surveyed, emphasizing those theoretical founda-
tions that are immediately clinically relevant. As with previous chapters, we shall
develop a concrete language through which to study the phenomena in question. The
following three areas will be addressed: (1) proxemics (the study of the use of space),
(2) kinesics (the study of body movement), and (3) paralanguage (the study of how
things are said).
Using our understanding of these three cornerstones of nonverbal study, in Part 2 we
shall adopt a functional perspective, carefully investigating the interplay of these areas
as directly applied to clinical practice. The broad clinical tasks studied include assessing
the nonverbal behaviors of patients, actively engaging patients, and calming potentially
violent patients.
In Part 3, we will wrap up the chapter by exploring a remarkably exciting new arena
for clinical interviewing, the web and its associated world of wireless connectivity, from
texting to chatting. We will find that, within this world, many of the possibilities and
limitations are directly related to nonverbal issues.
PART 1: CORE FIELDS OF STUDY IN NONVERBAL BEHAVIOR

Proxemics
Edward T. Hall was quoted at the beginning of the chapter. Few people would be more
suitable for introducing the topic of nonverbal behavior, because Hall coined the word
“proxemics,” a term that defines one of the major topics of interest in the field of non-
verbal communication. It was in his book The Hidden Dimension that he defined proxe-
mics as “the inter-related observations and theories of man’s use of space as a specialized
elaboration of culture.”17
Proxemics deals with the manner in which people are affected by the distances set
between themselves and objects in the environment, including other people. As Hall
notes, humans, like other animals, tend to protect their interpersonal territories. As
humans move progressively closer to one another, new feelings are generated and new
behaviors are anticipated. Hall postulates that people learn specific “situational person-
alities” that interact with the core traits of the individual, depending on the proximity
of other individuals. This set of expected behaviors and feelings can be used by the clini-
cian to improve blending. By observing the patient’s use of space, the clinician may even
uncover certain diagnostic clues.
Hall delineated four interpersonal distances: (1) intimate distance, (2) personal dis-
tance, (3) social distance, and (4) public distance. With each of these distances, different
sensory channels assume various levels of importance.
At the intimate distance (0 to 18 inches), the primary sensory channels tend to be
tactile and olfactory. People feel at home with the specific scents they associate with lovers
and children. At these close distances, thermal sensations also play a role, especially when
making love or cuddling. Visual cues are of diminished importance. In fact, at the inti-
mate distance, most objects become blurred unless specific small areas are focused upon.
Voice is used sparingly. Even whispered words can sometimes create the sensation of
more distance.
As one moves to the personal distance (11 2 to 4 feet), kinesthetic cues continue to be
used and olfactory and thermal sensations diminish in importance. With their decline,
the sense of sight begins to assume more importance, especially at the further ranges of
this interpersonal space.
Upon arriving at the social distance (4 to 12 feet), we have reached the region where
most face-to-face social interchange occurs. Touch is less important, and olfactory sensa-
tions are markedly less common. This region is the play-land of the voice and the eyes.
Most conversations and interviews unfold within the range of 4 to 7 feet.
At the public distance (12 feet or more), vision and audition remain the main chan-
nels of communication. Most important, as people move further and further away, they
tend to lose their individuality and are perceived more as part of their surroundings.
A respect for these spaces is of immediate value to the initial interviewer. In general,
people seem to feel awkward or resentful when strangers, such as initial interviewers,
encroach upon their intimate or personal space. With this idea in mind, it is probably
generally best to begin interviews roughly 4 to 6 feet away from the patient. If an inter-
viewer is by nature extroverted, by habit the interviewer may sit inappropriately close to
the patient, intruding upon the patient’s personal space. Obviously, such a practice can
interfere with blending and should be monitored.
It should be kept in mind that patients do not determine a sense of interpersonal
space by slapping yardsticks down between themselves and clinicians. As observed by
Hall, it is the intensity of input from various sensory channels that creates the sensation
of distance. An interviewer with a loud speaking voice may be invading a patient’s per-
sonal space even when seated at 6 feet. Once again, clinicians must examine their own
tendencies in order to determine how they come across to patients.
To emphasize the point that it is sensory input, not geographic distance, that deter-
mines interpersonal space, one need only consider the impact of a patient who seldom
bathes upon friends, family, and strangers (even clinicians). Such patients frequently
create a sense of resentment, because, in essence, olfactory sensations are supposed to
occur only at intimate and personal distances. These patients invade the intimate space
of those around them even when seated at a distance. The same principle can explain
why even pleasant odors such as perfume can also be resented if they are too strong.
If a clinician intrudes into a patient’s personal space, the clinician can set into motion
the same awkward feelings and defenses commonly encountered in elevators. The artifi-
cial intimacy created by invading the patient’s space results in a shutdown of interactive
channels, so as not to further the intimate contact. Like a person in an elevator, the
patient will avoid eye contact and move as little as possible. The patient’s uneasiness may
even predispose the patient to decreased conversation. In effect, the clinician might just
as well be conducting the interview in an elevator, hardly the image of an ideal office.
This “elevator effect” can also occur if the clinician ignores cultural differences.
Hall’s distances were determined primarily for White Americans. These distances may
vary from culture to culture. One piece of research found that Arab students spoke louder,
stood closer, touched more frequently, and met the eyes of fellow conversants more
frequently.18 Sue and Sue relate that Latinos, Africans, and Indonesians like to converse
at closer distances than do most Anglos.19 They go on to describe that when interviewing
a Latino, a White American interviewer may feel a need to back up, because the inter-
personal space feels crowded. Unfortunately, this need for distance by the clinician could
be perceived as an element of coolness or indifference by the patient (a kulturbrille
effect). In a similar light, the clinician may make the mistake of immediately feeling that
the patient is being socially invasive, when in reality the patient is merely interacting at
the appropriate distance for a Latino/a culture.
Race may also play a role during the interview. Research suggests that Black Americans
may prefer greater distances than White Americans.20 Moreover, Wiens discusses the
finding that the sexes of the participants can affect the preference for interpersonal dis-
tance.21 One study demonstrated that male–female pairs sat the closest, followed by
female–female pairs. Male–male pairs sat the furthest apart. More recent work has sug-
gested that psychological gender is a better indicator of the patient’s feeling of comfort-
able seating distance. People with a feminine orientation tended to interact at closer
interpersonal spaces no matter what their biologic sex.22
Kinesics
Kinesics is the study of the body in movement. It includes “gestures, movements of the
body, limbs, hands, head, feet, and legs, facial expressions (smiling, frowning, furrowing
the brow, etc.), eye behavior (blinking, direction and length of gaze, and pupil dilation),
and posture.”23 In short, kinesics is the study of how people move their body parts
through space with an added attempt to understand why such movements are made.
Both nonverbal communications and nonverbal activities are broadly subsumed under
the term kinesics. As a field, it is a natural companion to proxemics. Like proxemics, it
had its own avatar, Ray T. Birdwhistell, who first elaborated his work in 1952 with the
book Introduction to Kinesics: An Annotation System for Analysis of Body Motion and Gesture.24
Birdwhistell was an anthropologist and emphasized understanding body movements
in the context of their occurrence. He also pioneered the study of videotapes in an effort
to decipher the subtle nuances of movement. Through his microanalysis he attempted
to define the basic identifiable units of movement. For instance, he coined the term
“kine” to represent the basic kinesic unit with a discernible meaning.25
Albert Scheflen, a student of Birdwhistell’s, expanded these notions to the study of
broad patterns of kinesic exchange between people. In this context, Scheflen postulated
that kinesic behavior frequently functions as a method of controlling the actions of
others.26 By way of example, hand gestures and eye contact may be used to determine
who should be speaking at any given moment in a conversation (“regulators” as defined
by Ekman and Friesen).
Kinesics plays a role in all interviews. Specific activities may shut down or facilitate
the verbal output of any given patient. Early kinesic studies emphasized the accurate
description, delineation, and definition of facial/body movements and gestures (the
explicit aspects of kinesics). More recently, researchers and clinicians have come to realize
that “how” movements are done may be as important as “what” movements are done.
This newer aspect of kinesic study has been called the “implicit behavioral qualities” of
movement.27 Some studies suggest specifically that dynamic qualities such as speed,
acceleration, complexity, and symmetry of body and facial expressions may have a great
impact on how nonverbal behaviors are interpreted (both how we interpret our patients
and how they interpret us).28 A smile done with abruptness by a harried clinician when
first meeting a patient in the waiting room may be far more disengaging than
engaging.
Both explicit and implicit kinesic factors can greatly change the meaning of the words
spoken by either the patient or the clinician. Once again cross-cultural factors may lead
to significant misunderstandings if the kinesic norms of a culture are not understood. A
poignant example of this kinesic kulturbrille effect is described by Elizabeth Kuhnke:
Maria was working in Japan with a Japanese colleague, preparing a patient presentation.
She asked him if he was pleased with the work they had done together. He told her that,
yes, he was. A couple of days later Maria heard through the grapevine that her colleague
wasn’t happy with the result and wanted to rework the presentation. When she asked him
why he’d told her that it was all right when it wasn’t, he replied: “But I told you with
sad eyes, Maria.”29
Besides yielding information that may help the clinician to foster engagement, the study
of kinesics can provide valuable insights into the feelings and thoughts of patients. Freud
phrased it nicely when he stated, “He that has eyes to see and ears to hear may convince
himself that no mortal can keep a secret. If his lips are silent, he chatters with his finger-
tips; betrayal oozes out of him at every pore.”30
Paralanguage
The study of paralanguage focuses on how words are delivered. It may include elements
such as tone of voice, loudness of voice, pitch of voice, rhythm and fluency of speech.31
You will sometimes see paralanguage called vocalics or paralinguistics in the literature.32
The power of paralanguage is immense and popularly acknowledged. Phrases such as,
“It’s not what you said, but the way you said it, that I don’t like,” are considered legiti-
mate complaints in our society. Moreover, actors and comedians are well aware of the
power of timing and tone of voice as it impacts upon the meaning of a statement. The
comedian Jon Stewart is phenomenally adept at changing meaning through the use of
paralanguage, transforming a statement that sounds complementary, at first glance, into
a wickedly funny sarcastic slight, with a delightful twist in his tone of voice.
By way of illustration, the phrase “that was a real nice job in there” appears compli-
mentary at first glance. But one cannot determine its meaning unless one hears the tone
of voice used in its conveyance. It could be far from pleasant if it was said with a sar-
castic sneer by a displeased supervisor following an interview observed via a one-way
mirror.
Besides the tone of the voice, speech is characterized by a number of other vocaliza-
tions. Although not words per se, vocalizations can play an important role in communi-
cation. One set of vocalizations consists of “speech disturbances.”33 Under the heading
of flustered or confused speech, these disturbances include entities such as stutters, slips
of the tongue, repetitions, word omissions, and sentence incompletions, as well as famil-
iar vocalizations such as “ah” or “uhm.” Such disturbances occur roughly once for every
16 spoken words. As would be expected, under stressful conditions these disturbances
increase significantly. Thus they can serve to warn the clinician of patient anxiety as the
interview proceeds.
There is more to vocalizations than just their appearance or lack of it. Some vocaliza-
tions serve to enhance blending, as seen with the frequently used facilitatory statements
“uh huh” and “go on.” But, once again, the way in which these vocalizations are used
can significantly alter their effectiveness, as shown in the following vignette.
The interviewer in question possessed a pleasant and upbeat personality. He was a
caring clinician, but he found patients shutting down at times during his interviews.
Videotape analysis revealed an interesting phenomenon. As he listened to patients, he

frequently interspersed his silences with the vocalization “uh huh.” His “uh huhs” were
said quickly with a mild sharpness to his voice. He also used vocalizations such as “yep”
and “yeah,” also stated with a curt tone of voice.
The net result was the creation of the feeling that he was in a hurry, wanting just the
facts. And that is exactly what his patients gave him. This habit, combined with a ten-
dency to over-utilize note taking, fostered a business-like persona, despite his natural
warmness in daily conversation. It was a habit well worth breaking and once again high-
lights the power of paralanguage.
Cross-cultural differences also affect paralanguage. Sue and Sue describe the variations
in paralanguage that can interfere with the blending or assessment process when working
with people outside the clinician’s culture. For instance, silences are frequently inter-
preted as moments when the patient, for conscious or unconscious reasons, is holding
back. Silence may also signal that the patient is ready for a new question. At other
moments, silence can create a feeling of uneasiness in both interviewer and interviewee.
But, as Sue and Sue clearly state, the obvious may be too obvious, once again demon-
strating the potentially disruptive power of the kulturbrille effect.
Although silence may be viewed negatively by Americans, other cultures interpret and use
silence much differently. The English and Arabs use silence for privacy, whereas the Rus-
sians, French, and Spanish read it as agreement among parties. In Asian culture silence
is traditionally a sign of respect for elders. Furthermore, silence by many Chinese and
Japanese is not a floor-yielding signal inviting others to pick up the conversation. Rather,
it may indicate a desire to continue speaking after making a particular point. Oftentimes,
silence is a sign of politeness and respect rather than lack of desire to continue speaking.
A counselor uncomfortable with silence may fill in and prevent the patient from elaborat-
ing further. An even greater danger is to impute false motives to the patient’s apparent
reticence.34
Immediacy and Context: the Delicate Interface of Proxemics, Kinesics,

and Paralanguage
Immediacy
Immediacy is a term describing the sensation that one is in the immediate presence of
another person and the positive or negative feelings of warmth, closeness, involvement,
and acceptance experienced in that presence, as created and/or reflected by their nonver-
bal behaviors. It is a major component (in addition to the actual words being exchanged)
of what we have been calling blending. As such, the ability to interpret and use the non-
verbal cues of immediacy is one of the keys to identifying the underlying real engagement
of our patients.
One can argue, and indeed, Peter Andersen, the author of one of the core textbooks
on nonverbal communications, has done so, that the most central function of nonverbal
behavior is the exchange of immediacy.35 Immediacy results from the interface of factors
from all three of our core elements of nonverbal behavior (proxemics, kinesics, and
paralanguage). Immediacy can be communicated by how close we sit or how far forward
we decide to lean (proxemics). Our emblems, illustrators, regulators, adaptors, and affec-
tive displays all play a marked role in the conveyance of immediacy (kinesics). Tone of
voice, loudness, and pacing of speech further sculpt the sensation of immediacy
(paralanguage).
A variety of nonverbal behaviors impact on immediacy.36 Eye contact, and even pupil
dilation, contribute to it. In a classic study, Hess and Goodwin37 showed subjects pictures
of mothers holding their infants. The pictures were identical except for one small detail
– in some photographs the mother’s pupils had been retouched to appear larger. The
response by the subjects was remarkable, with an overwhelming number perceiving that
the mothers with enlarged pupils loved their babies more. This phenomenon has not
gone unnoticed by marketers, who frequently increase the size of the pupils of individu-
als in their advertisements using Photoshop, in an effort to entice the consumer into a
“closer relationship” with the model or celebrity who is plugging their product.
Other immediacy behaviors include smiles, head nodding, hand gestures, synchronic-
ity of nonverbal behaviors between conversants, and paralanguage. Touch remains one
of the most powerful indicators of immediacy and, consequently, should be used very
cautiously by clinicians, a topic we shall address later in this chapter.
As we saw with empathic statements, one can ascribe a valence to immediacy behaviors
ranging from low valence (the behaviors are not particularly powerful at communicating
immediacy) to high valence (the behaviors strongly communicate immediacy). As with
empathic statements, there is a time and place for both low- and high-valenced imme-
diacy behaviors, a critical principle for understanding how to effectively engage patients
battling with paranoid process or on the brink of violence, another topic we shall soon
examine in detail in Part 2 of this chapter.
Nonverbal Context
Immediacy provides a natural bridge into the role of context in nonverbal behaviors. We
can see from our discussion that immediacy generally is the result of the constellation
of many nonverbal factors, simultaneously interpreted by the patient. Even a culturally
accepted emblem may be received quite differently, depending upon the context in which
it occurs. A close friend of many years might “throw the finger” in a joking fashion at a
friend, following a playful criticism. A variety of other nonverbal activities (such as
smiling, a twinkle in the eye, and a joking tone of voice) indicate that this emblem should
not be interpreted in its normally aggressive fashion, because it was delivered in a humor-
ous context.
Many experts feel that context is one of the most important concepts for understand-
ing and effectively using nonverbal communication. Ekman includes the following ele-
ments as crucial to understanding context: the nature of the conversation, the history of
the relationship, whether the nonverbal behavior is occurring while speaking versus
listening, and how well the identified behavior is congruent with other simultaneous
nonverbal activities such as facial expressions and tone of voice.38
Arguably, this last factor – the congruence among all simultaneous nonverbal activities
– has been viewed as one of the most significant determinants of meaning in actual
practice.39 Take for example a smile by a patient. A genuinely warm smile is not limited
to facial movement near the mouth. A genuine smile often has significant muscular
movement around the eyes, with the appearance of smile lines beneath and at the corner
of the eyes, and a narrowing of the lids. Sometimes a genuine smile is also accompanied
by a gentle nodding of the head up and down. But there are many other types of smiles
including the smiles of anxiety or of discomfort with a topic, as well as more hostile
smiles, as seen with repressed irritation, anger, or contempt. During deceit, if the deceiver
feels that a smile is indicated, a weak version of a smile may be consciously attempted.
In contrast to a genuinely warm smile, all of the latter may have minimal contextual
movements of the muscles around the eyes or head, allowing a clinician to more adeptly
recognize that all is not as it seems.
As clinicians, another major factor regarding context is the impact of psychopathology.
A well-intentioned, genuine smile from a clinician can be interpreted as hostile (by a
person coping with paranoid psychotic process) or as flirtatious (by a person with an
underlying histrionic personality structure).
PART 2: CLINICAL APPLICATION OF NONVERBAL BEHAVIOR

Section A: Assessment of the Patient
Nonverbal Hints of Hidden Psychopathology
Sir Denis Hill made the following observations during the 47th Maudsley Lecture in 1972:
Many experienced psychiatrists of an earlier generation believed that they could predict
the likely mental state of the majority of the patients they met by observations within the
first few minutes of contact before verbal interchange had begun. They did this from
observation of nonverbal behavior—the appearance, bodily posture, facial expression,
spontaneous movements and the initial bodily responses to forthcoming verbal
interaction.40
Sir Denis Hill was concerned that the ability to observe nonverbal behavior astutely
represented a skill that had fallen by the wayside. Let us hope this demise is not the case,
because experienced clinicians today as much as yesterday need to utilize nonverbal clues
throughout their clinical work. The knowledge available today concerning nonverbal
behaviors is significantly more advanced than 40 or 50 years ago. It is to this knowledge
that we now turn our attention.
Uncovering Hidden Psychotic Process

To begin our discussion, we will look at another statement by Sir Denis Hill: “An
important difference between the disturbed mental states which we term ‘neurotic’ and
those we term ‘psychotic’ is that in the latter, but not in the former, those aspects of
nonverbal behavior which maintain social interactional processes tend to be lost.”41 An
awareness of these potential deficits in the psychotic patient can alert the clinician to
carefully probe for more explicit psychotic material in a patient whose psychotic process
is subtle.
Perhaps an example will be useful at this time. I was observing an initial assessment
between a talented trainee and a woman in her mid-20s. The patient had been urged to
the assessment by her sister and a close friend. Apparently the patient’s mother was cur-
rently hospitalized with major depression.
By the end of the 50-minute intake, the clinician seemed aware that the patient was
probably also suffering from major depression or some form of a mood disorder. But
the severity of the patient’s condition did not seem to have registered and the clinician
was about to recommend outpatient follow-up. However, the patient’s nonverbal behav-
ior was telling the clinician to take another look.
In the immediately subsequent second interview, which I performed, the patient
disclosed a recent weekend brimming with psychotic terror. She had felt that her long-
dead father had returned to the house to murder her. She was so convinced of this
delusion that she had shared her secret with several young siblings, not a good idea
if one is trying to get baby brother and sister to sleep. Eventually she ran from her
house to escape her father’s wrath. Even in the interview she could not clearly state
that her father’s return was an impossibility, although she hesitatingly said she thought
it was.
Let us return to the interview in order to uncover the nonverbal cues that suggested
the possibility of an underlying psychotic process. The patient, whom we shall call
Mary, answered honestly and appeared cooperative. She displayed no loosening of
associations or other overt evidence of thought process disorganization, but she dem-
onstrated some oddities in her communicational style. With regard to paralanguage,
she demonstrated long pauses (about 4 to 8 seconds) before beginning many of her
responses. This gave her a somewhat distracted appearance as if muddled by her think-
ing. This effect was heightened by a mild slowing of her speech as well as a flattening
of the tone of her voice.
As we have seen, silences, especially of this length, are generally avoided in daily
conversation. Everyday social protocol would ordinarily pressure Mary to answer more
quickly. This breakdown in normal communicational interaction was one suggestion that
all was not well and represents a disruption of the empathy cycle. Her body also spoke
to her internal turmoil.
Although for the most part she had reasonably good eye contact, there existed pro-
tracted periods of time when she looked slightly away from the interviewer in a distracted
fashion, whether she was talking or listening. This lack of “visual touching” during con-
versation is unusual.42,43 In fact, if one had a sound understanding of nonverbal com-
munications, it would have been apparent that Mary was displaying difficulties in her
dialogue function, as displayed by an odd use of the nonverbal activities Ekman called
regulators. As stated earlier, these regulators provide the cues for the timing of everyday
back-and-forth conversation.
Frequently, before beginning to speak, the intended speaker glances away briefly. As
he or she looks back, speech will begin. While talking, the speaker will frequently look
away. But as the end of the speaker’s statement is reached, the speaker will look towards
the listener. This glance signals to the listener that the speaker’s message is over. The
speaker and the listener glance at each other’s eye regions for varying lengths of time,
usually between 1 and 2 seconds, the listener giving longer contact. This complex eye
duet was frequently missing with Mary. In depression, the eyes are frequently cast down-
ward, but it was the peculiar manner in which Mary tended to stare past the clinician
that hinted at the possible presence of psychotic process. As Sir Denis Hill had suggested,
Mary had lost some of the nonverbal cues that maintain social interaction.
Mary was also showing disruption of other aspects in her dialogue function. In this
case, the problem with “marking her speech”44 was related to her dysfunctional use of
her hand gestures as conversational regulators. For instance, hand gestures are generally
made as one initiates words or phrases. As the speaker finishes commenting, the hands
tend to assume a position of rest. To keep one’s hands upwards, in front of oneself, can
indicate that one is not done speaking or will soon interrupt.
In Mary, these hand regulators were generally diminished. She sat stiffly with her feet
flat on the floor. Her head seemed to weigh her body down as she sat slightly hunched
over with her fingers interlocked. She displayed little hand gesturing, leaving the inter-
viewer with the odd sensation that it was not clear when Mary was going to start or stop
speaking. Most likely, Mary’s lack of movement was an associated aspect of her major
depression, but it may also have been a ramification of her psychotic process.
A more striking nonverbal clue to the degree of Mary’s psychopathology lay in her
method of dealing with unwanted environmental input, in this instance the questions
of the interviewer. Apparently Mary had been concerned for some time that she might
be “just like her mother,” who was currently in the hospital. In addition, her sister had
experienced a psychotic depression approximately 6 months earlier. Mary had been
attempting to hide from herself the evidence of her own psychotic process, while the fear
of an impending breakdown nagged at her daily. During the interview, as questions
directed her back into her paranoid fears, she began to realize the extent of her problems.
At this moment she did something out of the ordinary.
Mary leaned forward slowly, her elbows perched upon the tops of her knees, with her
head cupped between her hands. In this position her hands literally covered her ears, as
if keeping out unwanted questions or thoughts. All eye contact was disrupted. Mary
remained in this position for a good 5 minutes, answering questions slowly but coopera-
tively. She appeared detached from the world around her. This type of nonverbal adaptor
has been studied under the rubric of “cut-offs.”45 Cut-offs represent nonverbal adaptors
made to dampen out environmental stress. When exaggerated to the degree of appearing
socially inappropriate, as was the case with Mary, they may be indicators of psychotic
process. Indeed, catatonic withdrawal represents a prolonged and drastic cut-off.
One must also attempt to compare nonverbal activities to the patient’s baseline behav-
ior. Mary was normally a high-functioning secretary and most likely possessed better than
average social skills. In this light, her preoccupied conversational attitude, and in particu-
lar her prolonged cut-off, represents very deviant behavior for her. A subsequent interview
with Mary’s friend revealed that Mary had been observed at work sitting and staring at
the phone for long periods.
For a moment I would like to take a brief sidetrack on the issue of cut-offs. We have
been discussing dramatic forms of cut-off behavior, which may indicate underlying psy-
chotic activity; however, mild forms of cut-off behavior occur routinely in our work with
nonpsychotic individuals and frequently do not hint at psychopathology per se. These
more subtle forms of cut-off are not without meaning and warrant some discussion.
Morris46 described four such visual cut-offs, to which he attaches some descriptively
poetic names.
With the “Evasive Eye,” the patient shuns eye contact by looking distractedly towards
the ground, as if studying some invisible object. It can create the feeling that the patient
is purposely not attending to the conversation and may frequently accompany the speech
of disinterested adolescents. In the so-called “Shifty Eye,” the patient repeatedly glances
away and back again. With the “Stuttering Eye,” the patient now faces the interviewer
directly, but the eyelids rapidly waver up and down as if swatting away the clinician’s
glance. Finally, in the “Stammering Eye,” the patient once again faces the clinician but
shuts the eyes with an exaggerated blink, sometimes lasting as long as several seconds.
These four eye maneuvers represent nonverbal activities whose meaning may be mul-
tiple. They may indicate that the patient at some level no longer wants to communicate.
Perhaps a specific topic has been raised that is disturbing to the patient, resulting in a
nonverbal resistance. At such moments, a simple question such as, “I am wondering what
is passing through your mind right now,” may uncover pertinent material. Such cut-offs
may also represent objective signs of decreased blending and movement into a shut-
down interview. Exaggerated examples of these cut-offs can also be part of a histrionic
presentation and in this sense could also be seen in both wandering and rehearsed
interviews.
Nonverbal Hints of Classic Psychiatric Diagnoses

Returning directly to the topic of nonverbal hints of psychopathology, investigators have
also looked at the promising possibility that nonverbal activities could provide even
more specific diagnostic clues, but at this point the research results remain tentative.47,48
Moreover, the results appear to be in accordance with what common clinical sense would
predict.
Concerning the classic psychiatric diagnoses, schizophrenia appears to be accompa-
nied by some distinctive nonverbal behaviors. Studies show that schizophrenic presenta-
tions are marked by a tendency for gaze aversion. A flattening of affect with decreased
movement of the eyebrows is noted (which can alternatively be secondary to antipsy-
chotic medication). Patients’ postures are slumped, and they have a tendency to lean
away from the interviewer. Naturally, the type of schizophrenia and the stage of the
process can significantly affect the type of nonverbal behavior present, emphasizing a
cautionary note to these generalizations.
Depressive disorder has also been investigated. Researchers have noted that nonverbal
behaviors vary depending on whether one is observing an agitated depression or a
withdrawn depression. In subgroup 1 (agitated depression), patients demonstrated “a
puzzled expression, grimacing and frowning, gaze aversion, agitated movements, a

crouched posture, and body leaning towards the interviewer. Subgroup 2 (withdrawn
depressions) showed some increase in gaze, slowed movements, self-touching, an emo-
tionally blank expression, and a backward lean away from the interviewer.”49 In many
respects, these findings have limited usefulness, because they simply seem to confirm the
obvious.
But at a different level, especially with depressive patients, these findings emphasize
the importance of nonverbal behaviors as clinical indicators of improvement.50 The
return of routine hand gesturing may herald an oncoming remission even before the
patient admits to much subjective improvement. As the clinician becomes more aware
of such behaviors as spontaneity of facial expression, smiling behavior, and eye contact,
the informal monitoring of such cues to improvement can become a routine element of
clinical follow-up.
Nonverbal Hints of Specific Personality Diagnoses

With regard to personality disorders, less research is available. Consequently, we will
emphasize principles derived from clinical observations. Observations made during the 7
or so minutes of the scouting phase may provide important diagnostic clues. In this sense,
these cues can help determine which diagnostic regions to emphasize in the body of the
interview, for, in the limited time available, it is generally not feasible to explore all areas
of personality dysfunction. The following three clinical vignettes illustrate the usefulness
of nonverbal activities in suggesting the presence of possible character pathology.
In the first example, I was observing an interview performed by a psychiatric resident
during morning rounds on an inpatient unit. The patient was an adolescent girl with a
head of curly light-reddish hair. The interviewer was sitting on a couch in a group activity
room. The patient pertly entered the room and promptly plunked down beside the clini-
cian. At first she leaned towards him with her right arm straddling the back of the couch
behind his shoulder, but she quickly withdrew the arm. Her final perch was with her
right knee up on the couch resting a few inches from the clinician’s body.
In a proxemic sense, she had positioned herself well within the personal distance zone
and actually very close to being within the clinician’s intimate zone. Her speech was
bright and snappy, percolating from a face rich with expressions and playful eyes. All this
activity occurred in a matter of a few seconds. The clinician immediately responded by
leaning away from the patient and crossing his legs by placing his left ankle over his right
knee. This brief territorial excursion by this patient is not a typical initial interaction,
even with adolescents, who frequently feel more comfortable with “chummier” interper-
sonal distances. Instead, this type of interpersonal game is sometimes seen in people
with underlying histrionic personality traits or borderline personality traits. This observa-
tion in no way indicates that this patient had these traits. It merely suggests that it might
be worthwhile to do more specific diagnostic interviewing within these specific
diagnoses.
In the second example, the patient was a woman in late middle age, with graying hair
pulled back in a bun. Before the interview she had had to wait longer than usual before
entering the room. Initially, the clinician gently apologized for the inconvenience with
a warm smile on his face. She made cool eye contact. Her lips did not so much as con-
sider returning his smile. She fluctuated between a baseline of mildly cooperative answers,
with a reasonably lengthy duration of utterance (DOU), to brusque shut-down remarks.
A peculiar piece of body movement gradually evolved as she continued with her
acerbic tone of voice. She tended to lean back in her chair and gradually proceeded to
stretch her legs out in front of her towards the interviewer. The movement was inge-
niously slow but as steady as a barge pulling into a dock. As usually happens, the dock
was gently bumped – by her feet bumping against the interviewers – at which point she
did not pull away. Instead, the “dock” recoiled – with the interviewer quickly tucking his
feet beneath his chair.
Her nonverbal activities may be multiply determined, but one possibility well worth
exploring would be underlying passive-aggressive traits. Later historical information from
the interview tended to further substantiate this diagnostic hunch.
The third and final example is a patient who carefully orchestrated a relatively unap-
pealing opening gambit. She was a tall woman in her mid-20s with long black hair
hanging limply about her body. She was dressed in jeans and a black pullover sweater.
Her first noticeably unusual action consisted of reaching over to pull up a second chair,
which she promptly used as a footstool. She stretched her body out, making herself
conspicuously at home. This settling in did not signify the beginning of an easy engage-
ment, because she proceeded to visually cut the female interviewer off throughout most
of the interview. She would look down at her hands, frequently using the Evasive Eye
movement described earlier.
All of this display was topped with a convincingly dour facial expression. Concerning
paralanguage, she managed to push through her disinterested facial mask an equally
disinterested and mumbling voice. Her attitude visibly disturbed the interviewer. She also
demonstrated one other nonverbal communication with a set meaning. Specifically, she
held her coat on her lap throughout the interview, perhaps communicating an eagerness
to leave.
Her collection of behaviors, all present during the first few minutes of the interview,
suggested a variety of personality traits worth exploring later. Her lack of concern for
making the interviewer feel more at ease could suggest a possible hint of antisocial lean-
ings. Along similar lines, her obvious attempt to display disinterest could be part of the
manipulative trappings of a borderline personality or perhaps of a narcissistic personal-
ity. And, as we saw with our previous example, some passive-aggressive tendencies may
be present. Her behaviors in no way prove that she has any of these disorders, but they
do provide suggestions as to which disorders warrant additional consideration, further
highlighting the importance of noting nonverbal behavior. It is also critical to remind
ourselves that we must be exquisitely careful not to interpret cross-cultural differences in nonverbal
behavior as hints of psychopathology.
Nonverbal Indicators of Anxiety

One of the most well-known indicators of increased anxiety remains the activation of
the sympathetic nervous system, the system geared to prepare the organism for fight or
flight. During the activation of this system, a variety of physiologic adaptations occur
that can serve as hallmarks of anxiety. The heart will beat faster and blood will be shunted
away from the skin and gut to be preferentially directed towards the muscle tissue that
is being prepared for action. This shunting accounts for the paleness so frequently seen
in acutely anxious people, who look like they have seen a ghost. Saliva production
decreases, and the bowels and bladder are slower to eliminate. Breathing rate increases,
as does the production of sweat.
This last sign, increased sweating, reminds me of one of the more striking and humor-
ous examples of autonomic discharge I have encountered. A medical student was doing
one of his first physical examinations on a real patient, which can truly be an upsetting
experience, as the student frequently feels painfully inept. In this case, the patient was a
child about 9 years old, who could be generally classified under the label “brat.” As the
exam labored onward, with the worried mother looking increasingly fretful, the student
began to sweat profusely. As the student leaned over to listen to the child’s heart, a bead
of sweat fell from his forehead directly onto the child’s chest. Being a subtle kid, he
immediately looked the student in the eye and in a loud voice said, “What’s a matter
with you, you’re sweatin’ all over me!”
As if the poor student was not already stressed enough, that little proclamation did
it. He sheepishly turned to the increasingly upset mother and produced a quick-witted
white lie, “Don’t worry, I’ve got a thyroid condition.” I know this story all too well
because I was the poor panic-stricken medical student. It clearly shows the truth that the
autonomic system does not lie. With our patients, subtle signs of anxiety such as sweat-
ing, damp palms, and increased breathing rate can help us detect anxiety. If the anxiety
represents evidence of poor blending, we may be able to purposely attend to the patient’s
fears. If it represents the presence of unsettling thoughts, we may be inclined to probe
deeper.
If the sympathetic system is not presented with a chance to actually get the organism
into action soon enough, the parasympathetic system may try to counterbalance with a
discharge of its own. In these cases, one may find a sudden urge to urinate or defecate,
as people frequently feel before public performances or job interviews. If a patient begins
a session by immediately requesting the need for a restroom, this may represent a clue
to a higher anxiety level than the patient may verbally admit.
Desmond Morris believes that one type of nonverbal adaptor, which he refers to as
“displacement activities,” can be a good indicator of anxiety.51 These displacement activi-
ties are those body movements that release underlying tension. I recently watched a
businessman waiting for a meeting. As he sat in the lobby, he nervously tugged at his tie
and picked at his clothes. He then hoisted his briefcase onto his lap and meticulously
unloaded it piece by piece, after which he gingerly repacked the case, carefully feeling
each object as he delicately reassembled his “peripheral brain.”
These behaviors were accomplishing very little in the way of needed physical func-
tions, but they offered a calming effect of some sort for the businessman. Other typical
displacement activities include smoking, twirling one’s hair, picking at one’s fingers, nail-
biting, playing with rings, twitching one’s feet, tugging at the ear lobe, self-grooming
activities, tearing at paper cups, and twirling and biting pens. The list could certainly be
extended. For instance, Morris points out that serving drinks and holding them in one’s
hands at cocktail parties probably serve to decrease people’s anxiety, as they “have some-
thing to do.”52
Clinically speaking, displacement activities are worth noting during both the initial
interview and subsequent psychotherapy. Each patient seems to display a unique set of
displacement activities. Once decoded by the clinician, these activities can be fairly reli-
able indicators of patient anxiety. When suddenly increased, they may represent a more
reliable indicator than the patient’s facial expression or verbal response that an interpre-
tation was on the mark or that the patient is feeling ill-at-ease with the interviewer or
the topic.
Morris also views another sub-category of nonverbal adaptors as being suggestive of
possible underlying anxiety or fear, which he calls auto-contact behaviors. Auto-contact
behavior consists of movements involving self-touching.53 Such behaviors may consist
of grooming behaviors, defensive-covering behaviors, and self-intimacies.
Self-intimacies are defined as, “movements that provide comfort because they are
unconsciously mimed acts of being touched by someone else.”54 These self-intimacies
appear frequently during interviews. Patients may hold their own hands or sit with their
knees pulled up to their faces, arms literally hugging their own legs. In regressed patients,
one can see even more extreme forms of self-hugging as patients lay in tightly curled fetal
positions.
According to Morris, with regard to frequency, the most common self-intimacies in
order of most to least frequent are as follows: (1) the jaw support, (2) the chin support,
(3) the hair clasp, (4) the cheek support, (5) the mouth touch, and (6) the temple
support. With hair touching, there is a 3 : 1 bias in favor of women. Temple touching
demonstrates the opposite bias with a preference towards men of 2 : 1. Sometimes these
kinesthetic comforters can be tied into other sensory modalities as well. I remember one
patient who would pull her hair across her cheek. She would simultaneously gently sniff
at her hair, which she related as being very comforting. Such activity was a sure sign of
her underlying anxiety, much like a displacement activity.
In this manner, nonverbal activities such as adaptors (including displacement activi-
ties and auto-contact behaviors) may serve to alert the interviewer that the patient is
feeling pained or anxious. It can cue the interviewer that the patient may need some
verbal comforting, perhaps prompting an empathic statement. It can also alert the clinician
that powerful affective material is being approached, possibly suggesting the need for further
exploration.
It is also of interest that anxiety will sometimes display itself not through the appear-
ance of adaptors but through their conspicuous absence. When engaged in an active
conversation, most people will display a normal amount of periodic displacement activ-
ity and auto-contact. If these suddenly stop or are not present from the beginning, then
the person may be experiencing anxiety. In a sense, the person may be trying to avoid
mistakes by doing nothing.
This “still-life response” frequently appears when people are filmed or interviewed in
public. It seems to afflict interviewers even more than patients. Supervisors need to be
aware that this response may be more of an artifact than a stylistic marker of their
supervisees.
Another area of interest revolves around facial clues that the patient is visibly shaken
or on the verge of tears. I am sure the reader is well aware of the faint quiverings of the
chin and glazed quality of the eyes that frequently indicate that a patient is close to tears.
But a fact not as well publicized is the tendency for people to demonstrate extremely fine
muscle twitches across their faces when stressed. These frequently occur beside the nos-
trils and on the cheek. In people who demonstrate this tendency, these fine twitches can
be extremely accurate indicators of tension.
By way of example, I was working with a young businesswoman during an initial
interview. She had been referred to me for psychotherapy. She was attractively dressed
with a bright disposition and her speech was accompanied by a collection of animated
gestures. When asked to talk about her history, she launched into a detailed review of
her life since age 16. Of note was her striking avoidance of any events prior to age 16.
When I brought to her attention that she had avoided this earlier timeframe, she
responded that she did not know why and had not noticed it. I asked her if any aspects
of her life seemed different before the age of 16. She commented, “Not really, although
I spent more time with my father back then.” At that point a few muscle twitches
appeared by her left nostril. I commented that I had a feeling she was feeling upset, and
she burst into tears. Subsequent therapy revealed a complex and ambivalent relationship
with her father and other male figures. Throughout therapy, these faint twitches were a
sure sign of tension.
Nonverbal Hints of Deception

The issue of tension and tension release leads directly to another important aspect of
nonverbal behavior, the detection of deception. Indeed, the nonverbal clues that often
seem to accompany deceit might be less specific to deception than they are generalized
indicators that the deceiver is feeling anxious, worried, embarrassed, or frightened while
lying.
In one of the early pieces of research into the nonverbal indicators of deceit, led by
one of the true pioneers in this arena, Paul Ekman, to whose work we have already
referred, a group of nursing students were asked to participate in a study in which they
would be asked to deceive a person.55 They were told that gentle deceptions were some-
times needed in clinical work, as when comforting frightened patients. Thus the nurses
felt a need to perform well in the testing situation.
In the experiment the nurses were exposed to two different types of films. Some films
were pleasant in nature, such as an ocean scene, and other films depicted unpleasant
scenes such as a burn victim and a limb amputation. After seeing the pleasant film seg-
ments, the nurses were asked to describe their feelings to the listener. This task was obvi-
ously not problematic. But after viewing the unsettling film, in one experimental design
the nurses had to convince the listener that the gory film was pleasant and enjoyable to
watch. This task was not so easy. Indeed, it so reproduced the sensation of lying that
some nurses dropped out of the study.
All of these interactions were videotaped. Segments of these videotapes were then
shown to subjects who were asked to determine from the visual images which of the
nurses were lying. It was an ingenious experiment and represents the foundation work
upon which further research on deception proceeded.
Ekman and his colleague Friesen predicted that subjects would state that while lying
they would focus on making their faces “look natural.” This prediction proved to be true.
The deceivers did attend to their faces more, which suggested that nonverbal activities
from the neck down may provide a better lead concerning deception. Interestingly,
trained observers could pick up clues of deception from videotaped facial expressions.
These micro-expressions may represent accurate clues but are often too difficult to pick
up routinely.
In recent years, Ekman has become increasingly fascinated by the presence and impor-
tance of micro-expressions.56 He feels that many emotions, when being hidden by a
patient, are “given away” by the presence of minute movements of facial muscles fre-
quently lasting 1/15 to 1/25 of a second, which may be reflections of the person’s under-
lying concealed emotion, be that anger, sadness, or disgust. He believes that observers
can be trained to notice these micro-expressions, resulting in an enhanced ability to spot
both deceit and the presence of subtle emotions.
Ekman emphasizes that in these situations patients may be consciously withhold-
ing information or that unconscious defense mechanisms – such as repression – may
be at work. Such moments of withholding may prove to be of critical importance
when uncovering suicidal intent or moments where episodes of incest or intimate
partner violence are being hidden. In this regard, the ability to spot micro-expressions
allows a clinician to recognize that the patient may be withholding material, but it
does not necessarily indicate why. The clinician will need to further explore to deter-
mine whether the concealment is conscious deceit or the product of unconscious
processes.
At such moments, two questions suggested by Ekman may be of value: “Is there
anything more you want to say about how you are feeling?” and/or “I had the impres-
sion you were just feeling something more than what you said?”57 Ekman’s questions
are obviously also of possible value anytime the nonverbal behaviors of the patient
suggest that the patient is having a hard time sharing an emotion. For the reader inter-
ested in learning how to spot micro-expressions, Ekman has developed an innovative
training package, the micro-expression training tool (METT), that is available online
(www.ekmaninternational.com).58
As mentioned above, the body of the deceiver often has a tendency to betray its own
head, so to speak, and further research has substantiated many of the initial findings as
described in Ekman’s fascinating book, Telling Lies.59 Apparently, changes in below-the-
neck movements may be of the most practical significance for accurately detecting decep-
tion, unless one has been trained to spot and interpret micro-expressions.
Nonverbal communications (emblems) can sometimes be useful indicators of deceit.
You will recall that emblems represent nonverbal behaviors that carry a distinct meaning
within a culture, from specific messages such as “throwing the finger” to nodding a yes
or no with the head. Just as slips of the tongue may betray hidden feelings, slips of the
body via the unconscious use of emblems can occur. With the nursing students in the
above study, many felt a helpless sensation that they were not hiding their feelings well.
This feeling was sometimes inadvertently conveyed by a shrugging movement, a subtle

yet common emblem of helplessness as in “I don’t know what to think or say or do.”
When representing indicators of nonverbal leakage, emblems usually appear in parts.
Thus only one shoulder may partially rise or one palm may turn up during a shrug.
Another good indicator that an emblem represents a deceitful mannerism is the display
of the emblem in an unusual placement. An angry fist will not be raised towards an
antagonist but will quietly appear by the side of the patient.
Hand gestures, such as illustrators (used to point out or outline an object) or even
regulators (used for communicating conversational dialogue) may tend to decrease when
deceit is under way. This decrease is particularly true if the patient has not had time to
rehearse the lie and must carefully attend to what is being said. The clinician can monitor
behaviors such as those described above while exploring regions in which resistance and
deceit may be high. For example, when eliciting a drug and alcohol history from a typi-
cally active interviewee, a sudden decrease in associated hand movements may suggest
that deception is occurring.
On the other hand, nonverbal adaptors, such as displacement activities and auto-
contact seem to be one of the most powerful correlates of deception.60 Although not all
studies have confirmed this finding, a variety of comprehensive statistical summaries on
deception research, as well as some more recent studies, support the idea that such adap-
tors, including fidgeting, are correlated with deception.61–64 Several other studies have
also found supportive evidence for the idea that below-the-neck clues are best for detect-
ing deceit on a practical level.65,66
Popular literature on nonverbal behaviors has suggested that two of the most promi-
nent adaptors that signal possible deception are: (1) touching or partially covering the
mouth and (2) touching the nose.67 Touching the nose while lying has been coined the
“Pinocchio Response.” It is believed that the release of catecholamines, triggered by the
stress of lying, results in the swelling of nasal tissues followed by relief of this itch by a
quick scratch. I have not been able to find this material documented in the research
literature. On the other hand, it is interesting to note that during his Grand Jury testimony
regarding the Monica Lewinsky sex scandal, President Clinton touched his nose 26 times
when answering questions on particularly sensitive material. During questions of a more
mundane nature, the hand and nose did not meet.
Besides kinesic indicators of deception, the clinician can look for paralanguage clues
that deceit is occurring.68 For instance, a higher pitch to the voice has been associated
with deception as well as emotions such as fear. Correspondingly, lower pitches have
been associated with the observation that a subject is more relaxed and sociable. Another
possible clue to deception involves the response time latency (RTL). Deceptive subjects
were found to demonstrate a longer RTL and to give longer answers when in the act of
deceiving.
It should be kept in mind that most, if not all, of the kinesic and paralanguage clues
to deception mentioned so far represent nonverbal activities, rather than nonverbal com-
munications. Thus, it is important to remember that these behaviors are usually multiply
determined and do not in any way guarantee that the patient is being deceitful. In many
cases, they may simply indicate that the patient is feeling more anxious. Each activity
must be interpreted in the interpersonal matrix in which it was produced. The nonverbal
concept of context is critically important when interpreting nonverbal clues to deceit.
By way of example, one researcher found that an increased latency of response could
be interpreted in different fashions. If it was followed by a self-promoting comment, then
it was often interpreted as being an indication of deception. On the other hand, if the
pause was followed by a self-deprecating comment, it was often registered in the opposite
direction as evidence of a truthful remark.69
If one notices a variety of potential nonverbal indicators of deception, the following
strategy may be of value. Once the area in which deception is suspected is passed, care-
fully note the patient’s subsequent nonverbal behaviors, including adaptors and paralan-
guage clues. Then sensitively return the conversation to the area in which deceit is
suspected and look for a return of the nonverbal indicators of deceit. If done multiple
times during the interview, and the deceptive patterns continue to disappear (during
benign discussion) and re-appear (during areas in which deceit is suspected), this pattern
should certainly raise the suspicion of patient concealment.
It is probably best to conclude the discussion of cues of deception at this point. Clearly
the research is somewhat tentative, but it suggests that some changes in the baseline
behavior of the patient may provide useful hints that deception may be at hand. Caution
is certainly indicated. Peter Andersen encapsulates the state of the art well as follows:
1) no foolproof means of detecting deception through nonverbal behavior exists now or is

likely to exist in the future; 2) nonetheless, some commonalities in deceptive behavior can
aid in its detection; and 3) a complex mixture of unconscious and strategic processes
produce subtle changes in behavior during deceptive communication.70
Two practical points warrant mentioning. First, as the interview proceeds it is generally
a good idea to ascertain the baseline body movements that are typical of the patient.
Second, during sensitive inquiries, such as the elicitation of suicidal ideation and intent
(an area in which the ability to detect concealment may literally be life saving), it is
best to avoid any note taking (whether on paper or by keyboard). Note taking can mark-
edly diminish the ability of the interviewer to observe the subtle nonverbal clues that
may be the only warnings of deception. It also markedly limits the ability of the inter-
viewer to deepen engagement through the use of his or her own eye contact and other
nonverbals.
In the same sense that nonverbal activities may indicate that the patient may be deceiv-
ing the clinician, a variety of important mixed nonverbal messages may be sent to an
interviewer. These mixed messages are not necessarily deceptions. Instead, they may
represent hallmarks of patient ambivalence and confusion.
Nonverbal Correlates of Patient Ambivalence and Discordance

In order to explore this fascinating area, the work of Grinder and Bandler71 offers a well-
spring of practical and sound clinical observation. Although controversy has arisen over
their later work, their first two books provide some pioneering insights into engagement
techniques.
Their work follows naturally from the principles we have been discussing thus far. Put
simply, they state that as a person communicates a message, the message is transferred
through a variety of communication channels simultaneously. The patient’s message may
be conveyed through the content of the spoken words, the tone of voice, the rate of
speech, the amount and type of hand gesturing, the posture, and the facial expression.
These messages are termed paramessages. When all paramessages have the same meaning,
the paramessages are said to be congruent. But if some of the channels convey discordant
information, then the paramessages are said to be incongruent.
The underlying theory is simple; perhaps that is why it proves to be so powerful thera-
peutically. People who consistently communicate with an incongruent style can fre-
quently create a confusing impression. Their incongruence may make the people around
them feel ill-at-ease and uncomfortable. If the clinician can detect this self-defeating
interpersonal style, he or she may be able to help the patient modify it. In a more imme-
diate sense, incongruent paramessages may indicate underlying mixed feelings of which
the patient is unaware. Once again, the interviewer may be able to cue off this incongru-
ence, leading the patient into an exploration of the uncovered mixed feelings.
More germane to the topic of the initial interview, episodes of incongruent commu-
nication may alert the clinician to areas worthy of more immediate investigation or
perhaps regions pertinent to explore in later sessions.
I am reminded of a woman in her early 30s whom I was evaluating for possible psy-
chotherapy and/or medication use. Ms. Davis, as we shall call her, was coping with a
variety of stresses, not the least of which was the loss of her mother several months earlier.
For years she had been her mother’s caretaker and verbal whipping post. Ms. Davis was
mildly overweight with stocky legs, offset by a face embraced by a full head of black hair.
As she spoke, her conversation turned to her bitter relationship with her boyfriend, who
apparently enjoyed her sexually but found marital ceremonies not to his liking. She
commented, “I hate him, I’ll never go back to him. He’s not worth it.”
Harsh words, but one should be wary of taking them too seriously, for Ms. Davis’s
body spoke differently. The words were spoken with a tone of pained resignation, not
biting anger. They had the quality of the child-like pout, “Daddy’s not bringing home a
present from his vacation.” Not only did her voice lack indignation, but her hands inti-
mated a martyr’s role. Rather than the more typical pointing and jerking movements of
an angry accusation, they were held low towards her lap with the palms upwards. This
type of hand positioning is frequently associated with an attitude of supplication and
need.
Put more precisely, Ms. Davis was communicating with an incongruent set of parames-
sages. As Grinder and Bandler point out, all of these messages may have elements of
truth to them. In Ms. Davis’s case, she certainly did have angry feelings towards her boy-
friend, as suggested by the content of her words. But she also had extremely powerful
needs to be accepted by him; indeed, these needs bordered on a masochistic willingness
to be verbally beaten by him. Her tone of voice and hand gestures suggested her strong
need for acceptance. Her breathing rate did not increase or become more spurt-like, as
is frequently seen when someone becomes increasingly angered. This set of incongruent
messages was one of the first clues to her deeply rooted problems concerning hostile
dependence, which became central working issues in the remaining therapy. Indeed, in
this regard, her relationship with her boyfriend was no different from her relationship
with her mother.
In any given initial interview, periods of incongruent communication may occur. If
noted, they can serve as road signs that effectively guide the interviewer towards a deeper
understanding of the patient.
Nonverbal Signals During Collaborative Treatment Planning

As we have discussed in earlier chapters, during the closing phase of the initial interview,
the patient and clinician will collaboratively develop an initial treatment plan. Such
treatment planning will usually continue during the next several sessions and, indeed,
will remain an intermittent aspect of ongoing treatment, whether the treatment involves
psychotherapy, medications, or other matrix related interventions.
Positive nonverbal signs of patient interest and agreement, such as natural eye contact,
an excitement to the tone of voice, a forward lean, and positive head nodding, make it
easy to intuit when a patient is comfortable with a proposed treatment plan. The problem
arises when the patient gives a verbal positive to a treatment plan, yet does not really
want to proceed with it or has significant unstated misgivings about it. Such a situation
is easily understandable, for patients are dealing with intense pain, have not had any
time to reflect alone on what has passed during the interview, and may have appropriate
difficulties with processing information caused by the amount of information coming
their way and the newness of the therapeutic environment.
In this regard, in addition to asking the patient for his or her suggestions while col-
laboratively treatment planning, clinicians can routinely ask patients questions such as,
“How do you feel about these ideas?” The use of such questions is an excellent technique
for collaboratively treatment planning. But sometimes these questions are surprisingly
ineffective. Why? Because a patient feeling hesitant about the proposed plan of action
may feel unintended social pressure to respond positively so as to appear respectful and
cooperative, especially if they have liked the interviewer. Sometimes a clinician will pick up
on this ambivalence and follow up with, “Are you sure this is okay?” Curiously, even this
more direct question may not result in an honest answer. In fact, I have frequently seen
ambivalent patients respond even more positively at such moments, with statements
such as, “Oh yeah, this sounds like a good plan.” What gives?
I believe that patients respond in this paradoxical fashion because the clinician’s ques-
tion (“Are you sure this is okay?”) prompted further concern by the patient that they
were being perceived as being difficult or “resistant.” The overly affirmative response was
parlayed to please the clinician, a person whom the patient both likes and perceives as
a sorely needed source of help.
It is in such situations that our ability to spot discordant nonverbals may help us to
better identify patients who have concerns about the treatment plan. Put proactively,
when collaboratively treatment planning, it pays off to be on the look out for the dis-
cordant paramessages of Grinder and Bandler.
Kuhnke describes a series of discordant paramessages that may help us to recognize
hesitancy in a patient, in some instances even hostility.72 When people are feeling relaxed
and “on board” with the conversation, they often gesture fairly frequently and their
gestures frequently have open palms. As one inquires about interest in various treatment
plan options, hesitant patients may have their fingers closed over their palms, no matter
where they have placed their hands (on their lap, by the side of their legs, etc.). Some
patients will fold their hands together, in effect holding in their own tension or anxiety.
Even when listening intently, a patient who, at heart, does not like what he or she is
hearing may fold their arms or cross their ankles. There may be a subtle, or not so subtle,
leaning back in the chair. All of these movements, occurring while a patient is verbally
agreeing with a treatment plan (an example of discordant paramessages), may suggest
the patient has real doubts about the plan. It is important to uncover these doubts for
two reasons: (1) the patient might have very good reasons, being missed by the clinician,
as to why this is not a good treatment plan and (2) even if it is theoretically a good
treatment plan, as we emphasized in earlier chapters, if the patient doesn’t like it, it is
not going to work.
According to Kuhnke, three other adaptors are worth noting: (1) patients placing their
hands to their cheeks; (2) patients resting their chins on their hands; and (3) patients
placing a thumb under the chin while pointing the index finger up the side of the face.73
These three adaptors may indicate that the patient is actively contemplating what is being
said. At such moments the patient may be aware of his or her own hesitancies. Indeed,
the patient is often actively weighing the pros and cons at the time of such gestures. I
have found it to be an opportune time to ask directly about the patient’s weighing of the
options with questions such as, “What are your thoughts on the pros and cons of using
cognitive–behavioral therapy?” or “What are your thoughts on the pros and cons of trying
an antidepressant?” It can be surprising how well the strategic use of such questions,
based upon an astute observation of these three nonverbal clues, can open up commu-
nications, greatly increasing the likelihood that a truly collaborative treatment plan is
unfolding.
Nonverbal Behaviors Functioning as Social Scripts

In a similar fashion, the work of Scheflen, whom I mentioned earlier, deserves more
detailed examination, because it too focuses on the nonverbal interactions that serve as
communication scripts for people.74 Scheflen discusses the idea that humans, like other
animals, engage in certain shared behaviors that tend to escalate into specific actions.
Such actions include fighting behavior, mating behavior, and parenting behavior. Fre-
quently, certain mutually recognized behaviors serve to eliminate the need to engage in
the final actions. In this way, animals will frequently avoid actual combat by undergoing
a territorial display of sorts. Scheflen calls such escalating patterns of behavior “kinesic
reciprocals.”
Kinesic reciprocals can frequently be seen in clinical interactions. If the patient begins
the reciprocal, the clinician may inadvertently continue the process. I have certainly seen
this process occur within the realm of the “courting or mating reciprocal,” as Scheflen
refers to flirtation. Although Scheflen’s term sounds a bit dated, there is no doubt that
there is a bit of kinesic dance that occurs when two people are looking for a sustained
partner or even merely a “hook-up” in our contemporary culture.
Early in my career, I remember watching a videotape of a session of psychotherapy.
The patient was a young woman interacting with her therapist, who was a relatively young
man with about 7 years of clinical experience. The patient sat pertly forward, cigarette
hanging aesthetically from her fingers. The therapist, who was dressed casually in a sport
shirt, sat rakishly back, also with a cigarette in hand. Their voices possessed a spritely
coyness. It was unclear whether I was watching the beginning moments of a therapy
session or the opening sequences of a romantic comedy.
In any case, the therapist and his patient were engaging in the courting reciprocal.
Inadvertent participation in such reciprocals can create a variety of problems. Obviously
it can stimulate an erotic transference. Moreover, if initiated unconsciously by the thera-
pist and then reciprocated by the patient, it can lead the therapist towards the inappro-
priate perception that the patient is histrionic.
I am reminded of a talented trainee whom co-workers felt tended to be pleasantly
flirtatious and buoyant with staff. She was surprised, yet concerned, when, after several
of her initial evaluations, a male patient asked her out. On videotape the answer was
obvious. She noted, with some surprise, that she was displaying some mildly flirtatious
qualities during her clinical interviews, which she was able to quickly eliminate.
Scheflen describes the types of kinesic behaviors utilized by both sexes in the courting
reciprocal. According to Scheflen, males have a variety of kinesic actions that they take to
enhance sexual attractiveness. The male attempting to draw attention sexually will move
from any type of slumped position into a stance emphasizing his height and musculature.
Indeed, the male may unconsciously employ many of the same kinesic clues as are used
to display dominance, such as jutting the jaw slightly, sucking the belly in, raising the
shoulders, and perhaps standing more closely than normal social protocol would suggest.
The reciprocal behaviors by women are equally well known, as characterized in
popular culture as reflected in advertisements, films, and graphic novels. According to
Scheflen, a woman who is interested in attracting sexual attention may hold her head
high and at a slight angle, perhaps viewing the potential partner from the corner of her
eye with an inviting glance. The upper body will be lifted to emphasize breasts. Legs may
be crossed “around each other” so as to emphasize the calf musculature and extension
of the foot. In addition, she may intermittently present her hands with her palms up, a
highly affiliative act, in a variety of ways as when pushing back her hair, when smoking,
or when she covers her mouth while coughing.75
During flirtation, another common kinesic reciprocal commonly occurs – tentative
incursions into the intimate proxemic space of the intended partner. At one level this
simply may occur by sitting closer or occasionally leaning forward to whisper into the
ear of the other over the din of the bar. At a different level, one participant may gently
touch the other on the hand, arm, shoulder, or back. If viewed with favor, a reciprocal
touch may be shown, and the dance begins.
Other reciprocal behaviors besides the courting reciprocal can occur in an initial
interview. A striking example was provided by a video made of an initial interview for
use in supervision.
The interviewer was a young woman. Across from her, the patient, a woman just
turning 20, sat with eyes occasionally cast downwards. As the interview unfolded, the
patient produced a folded piece of paper, and she asked the clinician to read the paper
before proceeding. Her voice seemed to step meekly away from her lips. In the meantime,
the patient began fumbling with the microphone. She had correctly wrapped it around
her neck but had problems attaching it to her blouse. Noticing her problems the clinician
looked over and asked if she needed help. The patient did not look up for a moment as
she continued to fumble. Then with her head cocked downwards, she innocently glanced
upwards nodding her head “yes.” She gazed with the helpless eyes of a little girl and said
not a word. The clinician promptly leaned over and fixed the microphone.
The parenting reciprocal had emerged as naturally as if enacted between a true mother
and her child. In this brief vignette, the power of the first few minutes of the scouting
period to provide clues for further diagnostic probing is once again amply demonstrated.
This patient’s helpless style and dependent behavior suggested the possibility of some
form of character pathology. Indeed, further interviewing revealed a mixed personality
disorder with histrionic, passive-aggressive, and dependent characteristics. Apparently
this patient had perfected the art of eliciting parental responses as a method of garnering
attention.
In Section A, our focus has been on the power of the patient’s body to convey infor-
mation to the perceptive clinician. In Section B we will now explore the reverse situation,
those moments when the clinician uses his or her nonverbal knowledge and behaviors
to engage the patient.
Section B: Utilization of Nonverbal Behaviors to Engage Patients

Seating Arrangement and Proxemics
One of the exercises undertaken in our interviewing class concerns the use of seating
arrangement. Two of the trainees sit in the middle of the room on easily rolled chairs.
They are given a simple task, to situate themselves so that they feel the most comfortable
with regard to conversing with one another. In about 90% of the cases, the participants
choose a similar position. They sit roughly 4 to 5 feet apart. They are turned towards
each other but do not quite directly face one another. Instead, they are turned about a
5- to 10-degree angle off the line directly between them, both in the same direction, as
shown in Figure 8.1A. Only about 10% choose to face each other directly.
If the participants are asked to turn directly towards each other, they complain of
feeling significantly less comfortable. Some will even push their chairs back a bit. The
discomfort is related as feeling “too close,” the sensation of nonverbal immediacy is too
intense. Many of the trainees complain that the head-on position forces eye contact,
making it difficult to break eye contact without undertaking a significant head movement.
This head-on position fosters a sensation of confrontation.
On the other hand, the preferred position readily allows for good eye contact but also
makes it easy to break contact without awkwardness. In my own practice, I have certainly
found this position to be the most comfortable and the most flexible interviewing posi-
tion for me. The last part of this statement is important, because it emphasizes that the
most comfortable position may be different for each interviewer and indeed for each
interviewing dyad. Each clinician needs to discover a comfortable position, keeping in
mind that the clinician must also be willing to alter this position depending on the needs
of the patient.
Figure 8.1 A, Preferred seating angle; B, comparison of shared visual fields; C, utilization of desk.
In addition to the non-confrontational feeling provided by the position described

above, another phenomenon may be enhancing its comfortableness. From the perspec-
tive of person-centered interviewing, one of the key processes that enhances blending is
the ability of the clinician to convey a sense of seeing the world through a shared
perspective.
If one looks at the actual fields of vision available to each participant in the interview,
an important relationship readily becomes apparent. When two people are directly facing
each other, the fields of vision overlap very little. What overlap does exist lies directly
between the two participants. This situation tends to foster the sensation that “You are
over there, and I am here.” It seems to work against the sensation of “We are here
together.” On the other hand, when the two participants are turned slightly away from
each other, so that they are subtly facing the same direction, then the feeling that “We
are here, and the rest of the world is out there” naturally emerges.
Thus, in a phenomenological sense, the feeling of confrontation is decreased, while
the sense of blending is given a gentle boost, as illustrated in Figure 8.1B. It should be
noted that the directly oppositional arrangement may be preferred by some people.
Indeed, some interviewing experts recommend it,76 but I myself do not, for the reasons
provided above.
The concept of seating raises the more general issue of furniture arrangement. Some
clinicians prefer the use of two large comfortable chairs, away from their desk. Another
alternative is to utilize the desk creatively. In general, I believe a desk should not sit
between the clinician and the patient, because this places the clinician in an authoritar-
ian position, more appropriate for chief executive officers, not therapists.
However, the desk can be placed as shown in Figure 8.1C, with only a corner protrud-
ing between the clinician and the patient. If the clinician’s chair rides on wheels, the
clinician can move the chair, altering the resultant interpersonal distance either by
increasing or decreasing the amount of desk between the participants. I find that such a
desk arrangement, coupled with the use of a wheeled chair, provides me with a remark-
ably quick way of modulating the immediacy of the dyad, an ability that can pay big
benefits depending upon the immediacy needs of the patient, needs that might even
fluctuate over the course of an interview. A paranoid patient may require more distance
from the clinician, which can easily be accomplished by moving only a short way,
because the desk quickly provides a protective barrier. With a well-engaged patient, the
clinician can easily move to a point where essentially no desk intervenes. Another advan-
tage of this seating arrangement is the fact that, whether one is taking rough notes with
a clipboard or a laptop, the note-taking medium can be moved back and forth from lap
to desk unobtrusively.
The overall concept of the clinical setting warrants attention. When designing a private
office, an effort should be made to provide a comfortable and professional atmosphere.
The office represents an extension of the clinician’s persona, and the patient’s first impres-
sion in the scouting period may be significantly affected by the decor of the clinician’s
waiting area or office. Calming prints or photographs, accompanied by several diplomas
and shelves of books, provide a reassuring and pleasant environment.
Trainees are faced with limited financial resources. But three or four unframed art
posters and a few plants can be bought very reasonably, producing a sometimes-startling
change in the atmosphere of the room. There is no need for a trainee’s room to look like
a prison cell. On the contrary, part of the training experience is learning to consider the
principles behind creating an appropriate private office.
Outside the office, situations can be a bit more difficult, because the clinician faces
crowded hospital rooms and disorganized emergency rooms. It remains important in
these situations to consider the comfort of both the patient and the clinician. While
performing a consultation in a crowded hospital room, there is nothing wrong with
saying, “Before we start, would you mind if I slide your bed over, so both of us can have
more room to talk.”
This discussion of seating arrangements leads to the issue of determining an optimum
distance between the clinician and the patient, which will vary for each interviewing
dyad. There does seem to exist a small region in which the clinician’s presence respects
the patient’s sense of personal space while still allowing the movements of the clinician
to have an immediate impact on the patient. This zone of effective interpersonal space
in which the patient feels comfortable with the immediacy sensations of the interaction
may be referred to as the “responsive zone” (RZ).
If the clinician moves out of the RZ towards the patient, then the interviewer risks
frightening the patient or creating a sense of discomfort. On the other hand, if the
interviewer leaves the RZ by moving too far away from the patient, then the movements
of the clinician may have little impact on the patient. For instance, the act of gently
leaning forward towards a patient, which can enhance communication during particu-
larly sensitive moments of an interview, may have no effect if done outside the RZ.
Two examples may help clarify the importance of establishing an RZ that seems most
comfortable for each patient. First, if one intuits that a patient may be feeling paranoid,
it is useful to remember that such patients may require a larger space around them in
order to feel more comfortable. In these cases, the RZ is larger and it may be wise to
begin such interviews sitting further from the patient than one normally would sit.
Another option is to position oneself with the corner of a desk or table between yourself
and the patient, for the paranoid patient may feel safer with such a small, yet noticeable,
“protective barrier.” As the interchange proceeds the clinician may find that the distance
can be gradually decreased; hence the RZ frequently may change as the blending waxes
or wanes.
Second, one looks at the problem of accurately eliciting a formal cognitive examina-
tion in elderly patients who are seriously depressed and withdrawn. To attract and main-
tain their attention, the interviewer might need to sit considerably closer than normal.
This more intimate RZ may help decrease the likelihood of obtaining poor cognitive
results secondary to the patient’s lack of attention or interest. If a patient is not interested
in answering, then the risk of getting artificially low scores becomes very real indeed. In
such cases, the tendency to suspect a real dementia when only a pseudodementia is
present can become a true dilemma.
Another way of obtaining the withdrawn patient’s attention during the cognitive
examination is to speak more loudly, effectively moving closer without moving one’s
chair. At times it is also important to ensure attention by literally asking the patient to
look at the clinician as the questions are asked. For instance, the interviewer can gently
but firmly make statements such as, “It may help you to do well on these questions if
you watch me as I actually say the digits to you.” In the last analysis, if a withdrawn
patient is looking down at the floor as the clinician performs the cognitive mental status,
the validity of the results are certainly questionable.
The concept of increasing the validity of the cognitive examination also raises the issue
of touching patients. Touch remains one of the, if not the most, powerful of immediacy
behaviors, for it instantly places one inside the patient’s intimate zone as described by
Hall. As we saw earlier, touch is also part of the courting reciprocal. Consequently, it can
both be misinterpreted by patients easily and be harshly disengaging with paranoid or
angry patients. It must be used with caution and, in my opinion, only if necessary to
achieve a certain effect on engagement.
If you are going to touch a patient, you should get in the habit of asking yourself two
questions before proceeding: (1) What do I want to accomplish by touching this patient?
(Is it being done from the perspective of intentional interviewing or is it being done
merely by habit or from interviewer needs?) (2) Does the act of touching fit with the
patient’s needs for immediacy and the nonverbal context of this specific moment in the
interview?
On the other hand, some clinicians seem to have a block against the idea of ever
touching a patient. Although it is not frequent for me to touch a patient during an initial
interview (except for handshakes), I sometimes find touching useful and poignant. With
regard to the cognitive examination, some depressed and withdrawn patients may ignore
the clinician’s attempts to make eye contact and attend to the task at hand. In such
instances, one can touch the arm of the patient, offering comments such as, “I know it
is difficult for you to concentrate right now, but it really is important.” At such times, the
patient may glance up at the interviewer and more effective contact will have begun.
Of course, touching, a method of entering the patient’s intimate space, may also
be used at points at which the patient may benefit from some simple comforting, in
which case the clinician’s decision to touch the patient fits with the both the patient’s
sense of immediacy and the context of the interview. I am reminded of a sad, middle-
aged man whom I interviewed as he was entering the hospital. For all of his life he
had been a kind and hard-working mill worker. Unbeknown to himself he was being
exposed to an extremely toxic industrial poison. Over the years he experienced gradual
changes in his behavior, including irritability and occasional violent outbursts, which
frightened him and produced extreme guilt. Simultaneously, he underwent marked
changes in his intellectual functioning, to the point that he had problems dealing with
everyday activities. Only recently had he learned that his problems were secondary to
brain damage.
As we neared the end of the interview, he told me that he was afraid of the hospital-
ization because “people say mean things to me, they think I’m stupid. Please let me come
in, I promise I won’t hurt anybody, I promise, and I’m not that stupid.” At which point
he began to weep. It seemed only natural to reach over and grasp his arm while reassur-
ing him that I believed what he said and that we would help him make the transition
to the hospital.
Outside of the types of situations described above, touching patients is not common
during initial interviews. As mentioned earlier, touch is a powerful communication that
may carry numerous connotations, not all of which are appropriate. Patients may mis-
interpret touch as an erotic gesture or, at a minimum, as a sign of implied intimacy.
Although the clinician may intend the gesture as a sign of caring, a psychotic patient or
a patient with a histrionic personality may receive a considerably distorted message.
Indeed, if a clinician finds a routine need to touch patients during initial interviews,
it would be wise for the clinician to determine why such a need is arising. Usually it is
not from clinical considerations. Such clinicians frequently have a desire to be perceived
as “comforting angels.” Ironically, this drive to be perceived as “comforting” may get in
the way of effective care giving. Such self-exploration may also reveal flirtatious traits or
histrionic qualities in the clinician. Unchecked, these types of clinician traits can open
the door to sexual misconduct.
At this point we can turn our attention to another aspect of nonverbal behavior, which
frequently emerges if the clinician has effectively determined the appropriate RZ for the
patient. At such times, the appearance of certain nonverbal behaviors can suggest that
the blending process is proceeding well. As mentioned in Chapter 1, several verbal signs,
including an increased DOU, may indicate the presence of improved engagement. In a
similar fashion, nonverbal activities may also be used routinely to monitor the blending
process, for the spontaneous appearance of immediacy behaviors in the patient indicate
that the patient is feeling more and more comfortable, safe, and accepted by the
interviewer.
For instance, as blending increases, the patient may begin to make progressively better
eye contact, while spontaneous arm gestures and “talking with one’s hands” may increase.
Along similar lines, if a patient in a shut-down interview begins to talk more with his or
her hands, this may be a hint to pursue the present topic more fully in order to further
strengthen the engagement process. The clinician can also frequently see the patient turn
more towards him or her as blending increases. Relaxation is also shown by an asym-
metry in posture, while tense posture is frequently seen with a person who feels
threatened.77
We have been discussing the nonverbal activities that may suggest powerful levels of
blending. It is important to return to a topic approached earlier, namely, the differences
seen cross-culturally regarding eye contact, for, in a proxemic sense, eye contact can
change how close the patient feels in space from the interviewer. With regard to the
African American culture, eye contact is not considered as important in conveying atten-
tion to a listener as in some other cultures.78 Just being in the room or close to the speaker
may be considered enough to convey that attention is being given.
Direct eye contact may be considered disrespectful in certain cultures, such as with
Mexican Americans and with the Japanese. In this context, a clinician could be making
a serious error in judgment by interpreting poor eye contact with members of these
ethnic groups as an indication of rudeness, boredom, lack of assertiveness, or poor
blending.
Another process that may emerge more frequently when one has successfully found
the RZ is the surprising phenomenon of postural echoing.79 In postural echoing one finds
that two people who are communicating effectively tend to adopt similar postures and
hand gestures. At a café, two lovers may sit across from each other, both heads perched
in their hands, as they animatedly stare into each other’s eyes.
A frequent phenomenon seen in interviewing occurs when one member of the dyad
suddenly shifts position and relaxes. Simultaneously, the other person will also shift and
relax. Moreover, microanalysis of videotapes has suggested that as blending increases, the
minute movements of the interviewer and the interviewee tend to parallel each other as
if a miniature minuet were being performed. During moments of discordant interchange,
this reciprocity decreased.
At one level, these findings suggest that the appearance of postural echoing may serve
as a clue to the clinician that the blending process is on the right track. In a slightly dif-
ferent vein, the clinician can subtly match some of the patient’s postures in an effort to
actively increase blending. For example, if a male clinician is interviewing a steel worker
who is crossing his legs with his ankle over one knee, the therapist may cross his leg in
the same manner, as opposed to crossing his leg at the knees (the latter could be mis-
construed by the interviewee as “feminine”). By adopting a style similar to that of the
patient’s mini-culture, the metacommunication conveyed is that “we do certain things
similarly and we may not be as different as one might first suppose.” This discussion of
the use of postural echoing in an effort to actively engage the patient leads to a consid-
eration of other methods of nonverbally increasing the blending process.
Intentional Use of Head Nodding and Other Facilitative Techniques

As a clinician, it is worthwhile becoming consciously aware of one’s use of immediacy
behaviors, which you will recall are those nonverbal behaviors that convey warmth,
involvement, and engagement. We all enter our residencies and graduate training pro-
grams with our own habits regarding immediacy behaviors, which have generally served
us well in our everyday encounters. But in clinical work, depending upon the unique
needs of a specific patient, as well as the unique interpersonal context inherent to a clini-
cal interview, interviewers may find it useful to intentionally utilize or alter their imme-
diacy behaviors. It has been shown that counselors who demonstrate good eye contact,
smiling, and frequent gesticulation, are viewed as significantly more persuasive than
counselors who do not.80 Another commonly encountered immediacy behavior consists
of a body lean of about 20 degrees towards the patient.81
One of the most well-recognized immediacy behaviors is the simple head nod. Morris82
makes the interesting observation that the vertical head nod indicates a “yes” or “posi-
tive” response in all cultures and groups in which it has been observed, including Cau-
casians, African Americans, Balinese, Japanese, and Inuit. It has been observed in deaf
and blind individuals as well as in microcephalic people incapable of speech. He relates
that the head nod may convey different types of “yes” messages, such as the following:
The Acknowledgment Nod: “Yes, I am still listening.”

The Encouraging Nod: “Yes, how fascinating.”
The Understanding Nod: “Yes, I see what you mean.”
The Agreement Nod: “Yes, I will.”
The Factual Nod: “Yes, that is correct.”
Interviewers should make an attempt to learn the frequency with which they typically
head nod. This frequency can vary significantly among interviews. From my own obser-
vations, it appears that interviewers who are particularly adept at engaging patients tend
to head nod numerous times during any several minutes of an interview. As obvious as
the utility of the head nod may appear, I have found that approximately 20% of profes-
sionals I supervise tend to underuse it. A few barely head nod at all.
The power of the head nod became apparent to me in an unexpected fashion during
a session of psychotherapy. I had been working with a middle-aged male patient for
several months. I decided to try a brief exercise in which I would purposely stop my
typical head nodding for several minutes, in order to see what this practice would feel
like to me. To my surprise I found it difficult to do, because it had become habitual. But
more to my surprise, the patient broke off his spontaneous conversation after about 2
minutes and asked, “What’s wrong? Somehow I feel that you don’t like what I’m saying.”
This vignette emphasizes the power of nonverbal cues during clinical interaction.
Nonverbal Techniques for Engaging Guarded or Paranoid Patients

If ever there was an art to interviewing, there is an art to engaging actively paranoid
patients. In Chapter 1, when we were discussing the use of empathic statements, we
discovered that with guarded or paranoid patients, certain changes in approach could
enhance engagement. Other changes could result in a sharp decrease in engagement

known as the paranoid spiral. In particular, certain verbal approaches that were particu-
larly effective with trusting patients could be potentially disengaging with guarded
patients. For instance, paranoid patients frequently respond better to empathic state-
ments with a low valence of intuition rather than empathic statements with a high
valence of intuition, for such statements might suggest to the paranoid patient that this
clinician is “inside my head.” Some paranoid patients respond best to no empathic
statements.
Understanding these nuances in verbal interaction is important for effectively working
with paranoid patients. But over the years, I have come to realize that the use of nonverbal
behaviors probably plays an even larger role in effectively engaging patients with guarded
and paranoid process. The secret to the art seems to lie in a sound understanding of the
nonverbal concept of immediacy. In short, paranoid patients don’t want it.
As with the verbal use of empathic statements, the nonverbal use of immediacy behav-
iors can be “too much” for the typical person wrestling with paranoid process. We noted
earlier in the chapter that, much like empathic statements, immediacy behaviors can have
a valence, as manifested by their power to communicate warmth and intimacy to the
patient. Paranoid patients generally don’t want warmth and intimacy upon first meeting
a stranger. Thus, the golden principle for engaging paranoid patients is, at least in theory, a
simple one: tone down immediacy behaviors. In practice this principle can be significantly
more complex, for it often requires us to intentionally change our habitual immediacy
behaviors to a striking extent; when first being learned, this may feel quite odd to the
clinician. During my residency, it took me quite a while to get the hang of it. Let’s look
at the principle put into practice.
As mentioned earlier, from the perspective of proxemics, patients coping with para-
noia often prefer much more interpersonal distance in order to feel safe. Chairs are
consequently best set up with more distance between them. If one senses that a new
patient is displaying paranoid process, it is a cue to gently wheel ones chair back so as
to place more of the corner of the desk between oneself and the patient, thus decreasing
the patient’s feeling of immediacy and increasing the patient’s sense of safety and space.
Specific immediacy behaviors, when done too frequently, may prove disruptive to the
paranoid patient. I have heard paranoid patients comment that they have disliked fre-
quent eye contact, for what is meant to convey the attentive gaze of a “good listener”
becomes twisted into being perceived as the stark gaze of a potential persecutor. In this
context, I have found it useful to purposely break eye contact more frequently with para-
noid patients, providing them with more visual space. You may find it useful to increase
the turn of your chairs so that now the angle is about 10 to 45% off the line directly
between the patient and yourself, further decreasing oppositional gaze. It is part of the
lore of interviewing that the great interviewing innovator, Harry Stack Sullivan, who was
viewed as remarkably adept at engaging paranoid patients, would sometimes turn his
chair so that he and the patient were sitting with their chairs facing the same direction.
Even head nodding and arm gestures, both of which tend to increase a sense of imme-
diacy, which trusting patients like, can be unsettling when done too frequently with
guarded or paranoid patients. I vividly remember one patient whom I interviewed in an
emergency room. He was an intoxicated male, about 30 years old, who wore a perpetual
sneer. He challenged me frequently with not-so-subtle sniping remarks, such as, “I bet
you think you’re a good listener Doc.” And at one point he suddenly began mocking my
head nodding by aping it, with his jaw jutting outwards while repeatedly grunting out
loud “Uh huhs.” This was not one of my more rewarding interviews. While waiting for
his disposition, he later spontaneously attacked one of our safety guards.
This patient also illustrates the point that if the clinician finds a patient giving nega-
tive responses to typically engaging nonverbal behaviors, then he or she should consider
the idea that the patient may be guarded, hostile, or potentially violent.
Immediacy paralanguage must also be toned down in valence with paranoid patients.
I tend to speak fairly quickly and slightly louder than the norm in everyday life. I have
learned that it is important that I intentionally speak more softly and slowly with para-
noid patients. Thus, to make the necessary adjustments to their immediacy behaviors,
clinicians are required to become more aware of their own nonverbal behaviors, the topic
of our next section.
Clinician’s Self-Awareness of Paralanguage

Each clinician has a unique personality, much of which shows itself by how we speak.
Clinicians will vary on parameters such as tone of voice, rate of speech, and loudness
of voice. It is important for clinicians to discover their own typical way of coming across.
This knowledge is of value, because certain patients, as we just saw with paranoid
process, may respond better to different approaches. An understanding of one’s own
natural style offers the clinician the chance to modify it, if necessary, to enhance the
blending process.
With this idea in mind, it is useful for clinicians to practice exercises such as speaking
more gently and slowing down their rate of speech. If an interviewer tends to speak loudly
and quickly, a toning down of these parameters may prove more effective with a fright-
ened or guarded patient as already noted, but it may also be important in a more general
sense.
By way of example, as mentioned earlier, my own personality is somewhat upbeat,
with a mild pressure to my speech and a slightly louder voice than many people. When
beginning interviews, I purposely adjust to a calmer middle ground until I understand
the specific needs of the patient. Adjustments can then be made as deemed necessary in
either direction. In instances when I have not made this adjustment, I have certainly
come on too strongly for certain patients. In a similar light, if we are experiencing a hectic
day, it can be surprising how speeded up our speech (as well as gestures) have become
as we rush to meet the next patient in the waiting room. Armed with a self-awareness of
our paralanguage, we can catch this process and slow it down before walking into that
waiting room.
There exists another area in which tone of voice can frequently disengage a patient.
Specifically, when talking with elderly patients, clinicians often unconsciously adopt a
rather distinctive tone of voice. They talk as if they were speaking to a helpless child. This
tone of voice, which is often mildly slowed, can easily be perceived as condescending. It
is an extremely frequent phenomenon, and clinicians must guard against it carefully. It
is sometimes even done with psychotic patients and adolescents. In all these cases, the
clinician is flirting with trouble.
The Impact of Clinician Gestures and Facial Expressions on the Patient

We are generally well trained to observe the behavior of others, but the value of
observing our own gestures and facial expressions is frequently underplayed in super-
vision. As we have seen, the interview represents a dyadic process in which an under-
standing of one component depends on an understanding of the impact of the other
component. The clinician’s nonverbal activity always has the potential to significantly
alter the behavior of the patient, as we have seen in our discussion of reciprocal
behaviors.
With regard to gestures and other kinesic activities, as with paralanguage, clinicians
need to develop a sound sense of their natural nonverbal style. One exercise that helps
clinicians in developing self-awareness consists of repeatedly picturing a mirror descend-
ing during the interview itself. This imagined mirror is to drop into place between the
clinician and the patient. Such a visualization exercise rather rudely awakens clinicians
to the fact that their every move is potentially an object of scrutiny to an inquisitive
patient. As a complement to this visualization exercise, video recording provides invalu-
able objective self-observation.
The clinician should foster an awareness of those nonverbal activities that may inad-
vertently decrease blending. I am reminded of an interview that I supervised of an ado-
lescent boy. The patient sat in a pool of brooding preoccupation. He wore a worried
expression more suited to a 60-year-old man coping with an agitated depression than to
a boy beginning adolescence. Curiously, he had referred himself to the evaluation center
and did not want his mother to be contacted.
During the interview he moved about anxiously in his chair and had considerable
difficulty looking at the interviewer. He had a rounded face framed by a bowl of sandy
hair, which was neatly clipped around his ears. It was about one of these ears that the
discussion soon focused. Apparently he had the misfortune of watching a television
documentary on cancer several days earlier. Since then he had become fixated on a small
bump on his right ear, to which he gingerly pointed. He was convinced that he had
developed a malignant tumor. This gnawing obsession, which may very well have reached
delusional proportions, was nestled amidst a variety of depressive symptoms and difficult
life circumstances.
As the interview proceeded, the boy became progressively more ill-at-ease. At several
points he stopped talking, asking the interviewer, “You don’t understand, do you?” To
this, the interviewer responded in a reassuring fashion that he was trying to understand
and wanted to hear more. This type of response generally might have decreased the
tension, but in this case it seemed of no avail.
What the interviewer did not realize was the message conveyed by his own face. Each
time the boy discussed his “tumor” the clinician furrowed his brow in a not-so-subtle
fashion, forming two small vertical lines between his eyebrows. Apparently the patient
interpreted this facial gesture as a look of disbelief or condemnation. The clinician had
no conscious awareness of this particular expression, which frequently cropped up as a

habit during his interviews. It is just this type of habit that can lead to recurrent problems
with poor blending.
These habits are difficult to recognize unless the clinician is directly supervised or
video recorded. They are also sometimes hard to accept. The clinician above seemed
unimpressed with my explanation for the poor engagement until several weeks later. He
approached me sheepishly and said, “You’ll never believe what a patient just did. In the
middle of the interview he cut me off and asked me why I was frowning. My God, I must
actually do it!”
One of my own habits illustrates another category of clinician movement that can
become problematic. As I become anxious, I begin to twist my hair behind my ears. This
nonverbal activity represents what we have discussed earlier as a displacement activity.
These displacement activities can be used to monitor patient anxiety, but on the flip side,
they can be a useful self-monitor, indicating anxiety in the clinician.
During an interview, clinicians may not even be aware of the presence of their own
stress nor recognize that the intensity of their stress may be distracting them from attend-
ing effectively to the patient. But the appearance of numerous displacement activities can
alert them that such is the case.
At these points of self-awareness in the interview, it can be useful for the clinician to
explore the origins of the tension. Sometimes the interviewer may discover that they are
fretting about personal matters not related to the interview, such as problems at home
or at work. At other times, the clinician may be experiencing countertransference ten-
sions, intuitively registering patient hostility or even sensing well-hidden psychotic
process. In any case, the recognition of clinician displacement activities can provide yet
another avenue for understanding one’s internal frame of mind.
Another good reason for studying displacement activities concerns the eradication of
potentially disengaging gestures. For the most part, displacement activities are natural
and help to create a feeling of spontaneous communication. As such, there is no need
to eliminate them; indeed, they may actually foster good blending. But there exist certain
displacement gestures that are probably best eliminated. We can return to my own habit
of twisting my hair. This displacement activity has the potential to be disengaging. To
some patients it may appear effeminate, because, as mentioned earlier, women touch
their hair three times more frequently than do men. To others, it may simply be distract-
ing. In either case, it serves no purpose and is probably best discarded.
Similarly, certain categories of patients may not respond well to demonstrations of
increased anxiety in the clinician. The immediate category that comes to mind includes
patients escalating towards violence. These patients are frequently frightened that they
are about to lose control. If they see the clinician becoming progressively more tense as
well, they may become even more agitated. The same holds true for paranoid patients,
who may appear almost ludicrously hyperattentive to their environments. I remember
an older man with marked paranoid process who once asked me why I had just scratched
my head. When I said I had an itch, he did not seem particularly reassured.
Two other clinician displacement activities warrant discussion. The first activity is
smoking. Although forbidden in clinics and hospitals, some clinicians choose to smoke
in a private practice setting. I personally do not believe that clinicians should smoke
cigarettes or even the proverbial “Freudian pipe” while interviewing patients. My bias
evolves from the feeling that smoking, at the very least, represents a possible distraction
to the patient. More likely, it may actually function as an irritant. Even if one asks per-
mission from the patient, many patients who do not like smoking may find it difficult
to convey such concerns. Pipe smoking is so stereotypic of “a shrink” that it may bias
transference or simply turn some patients off.
The second displacement activity is much more of a mixed blessing, because it clearly
serves some useful purposes. I had never even viewed it as a displacement activity until
I had asked one trainee what his most common displacement activities were, and he
replied, “That’s easy, I’m constantly scribbling notes.”
A Few Notes on Note Taking

There exist many good reasons for taking detailed notes, such as making process notes
to be shared with a psychotherapy supervisor. On the other hand, I have become more
and more convinced that much of note taking in initial interviews represents a displace-
ment activity that frequently distracts both the clinician and the patient. No matter how
one views it, a clinician looking down at his or her keypad or clipboard while recording
information cannot possibly be attending to the fine nuances of a patient’s nonverbal
behavior as described in this chapter. Thus, there is a price to be paid for note taking.
Let us look at this price in more detail.
First, we should make a clear distinction between taking “rough notes” as opposed to
creating the finalized electronic health record (EHR), also sometimes called the electronic
medical record or electronic clinical record. By taking rough notes, I am describing typing
or jotting down bits of information, mostly not in complete sentences, for the primary
purpose of reminding the clinician of important information that might have been for-
gotten by the time the clinician is creating the finalized note for the EHR, which is typed,
written, or dictated after the patient leaves.
This finalized note (the EHR) is our main way of accurately communicating both
benign and critical information to future clinicians, some of which, as we shall see in
our chapter on suicide assessment, might actually save a patient’s life. In my opinion,
we owe it to our patients to produce an accurate and comprehensive permanent record.
It should also be noted that this final note will be meticulously read by opposing lawyers
in any malpractice suit. In short, the creation of the finalized electronic record requires
close to 100% attention. From both the standpoint of good care, and from the standpoint
of sound forensic documentation, I do not see how one can create such a document
during the interview itself.
In addition, and in my opinion even more importantly, I do not believe one can
effectively attend to the critically important verbal, nonverbal, and cognitive processes
necessary to effectively engage the patient, sensitively uncover a valid database, attend to
nonverbal issues, be aware of one’s own internal feelings and psychodynamics, generate
a diagnostic formulation, problem solve, and create a treatment plan while simultane-
ously typing or writing complete, polished sentences and paragraphs. Sound clinical
interviewing requires sound listening. It too requires close to 100% attention.
Also, for every second of time and attention focused upon typing the patient’s EHR
during the interview itself, that time is lost from the patient’s hour. As we have seen, the
information that can be used to rapidly and most effectively help our patients in the
initial interview is massive. In my opinion, there is no time to waste pretending that we
are well-trained transcriptionists.
Doing a sensitive interview is a human event. Creating a finalized document from the
information garnered in that interview is a mechanical one. Both processes are important.
Both processes require our best attention. Both processes require their own timeframes.
Let me summarize, I do not believe, whether typing or writing, that the finalized note
(e.g., the permanent medical/health/clinical record) should be created during the inter-
view itself. In my opinion, the only notes that should be taken during the interview itself
are rough notes, whether typed or handwritten.
With regard to rough notes, once again I am sharing a bias that some clinicians might
disagree with, I feel that rough note taking should be fairly minimized in the initial
interview as well. Whether you prefer to take your rough notes on a laptop or handwrite
them, they should be utilized to jot down hard-to-remember details such as dates, medi-
cation dosages, previous treatment histories, and family trees. By minimizing the amount
of rough note taking, a clinician can maximize his or her attention to the needs of the
patient and the complexities of the unfolding dyadic relationship – and its clinical com-
plexities – as they unfold in real time.
In particular, during the scouting phase, I believe it is much better to do little, if any,
note taking unless you are taking some demographic background. At this early stage, the
emphasis should be on actively engaging the patient. To this end, I find that patients are
more responsive to clinicians who seem more interested in them than in a keyboard or
a clipboard.
In addition, I strongly advise against any note taking (even the taking of rough notes)
when raising or exploring highly sensitive material such as suicide, incest, or domestic
violence, where it is critical to attend to any nonverbal indications that a patient may be
withholding information. During such delicate explorations, I find it expedient to place
down upon a nearby table or on the floor my means of rough note taking, whether it
be a clipboard or a laptop.
I frequently do not even begin taking rough notes until well into the interview.
When I do begin, as a sign of respect, I often say to the patient, “I’m going to take a
few notes to make sure I’m remembering everything correctly. Is that all right with
you?” Patients seem to respond very nicely to this simple sign of courtesy. This state-
ment of purpose also tends to decrease the paranoia that patients sometimes project
onto note taking, as they wonder if the clinician is madly analyzing their every thought
and action. Along these lines, I advise against any note taking when interviewing actively
paranoid patients.
How many rough notes should you take? The answer is simple – as many as you need
to accurately type up the EHR after the patient has left. This amount may vary among
clinicians. I supervised a trainee, with a “photographic memory,” who created beautiful
finalized notes but took almost no rough notes during the interview itself. The amount
of rough notes taken may even vary with a single clinician, depending upon how hectic
the clinician’s schedule. If the clinician is able to type up the finalized EHR immediately
after the interview is completed (an ideal situation), the clinician may need few rough
notes. If the day is hectic, requiring the clinician to wait till later in the day to type up
several initial intakes, then the clinician will probably need to take more rough notes
than usual.
If you choose to use your laptop to make your rough notes, remember that the fields
of your EHR should never dictate the sequencing of your questions or topics. As we saw
in Chapters 3 and 4, the goal is to flexibly structure the various regions and questions
of our interviews to meet the unique needs, concerns, and defenses of our patients. Only
then can we optimize engagement and the subsequent validity of the information gar-
nered in the interview.
One of the most effective methods of taking rough notes on a laptop – if you so
choose to do so – I was taught by a resident. She would sit with both feet on the ground
with her laptop open on her lap. She only typed rough notes, for purposes of recall, as
we have described. Consequently, she was actually typing only about 10–15% of the time during
the interview itself. Most strikingly, and cleverly, any time she stopped typing for a signifi-
cant period, she gently, yet obviously partially closed her laptop to the point where it
was clear to the patient that the clinician could not possibly see the keyboard. In addi-
tion, she would gently lean slightly forward, over the semi-closed laptop lid. The meta-
communication to the patient was immediate and powerful: “I’m not interested in taking
these notes, I’m interested in listening to you.” Furthermore, if she was not going to be
taking notes for an extended period of time, she would set the laptop on the ground or
on a desk or table to her side.
I have found that a significant number of contemporary clinicians, especially if they
are fast typists, prefer to write their rough notes on a clipboard. It gives them more flex-
ibility with how they can sit and lean during the interview and subsequently provides a
quick set of reminders with which they can rapidly type and move through the fields of
the EHR itself after the patient has left. I, myself, have found this to be preferable. But
you will need to discover for yourself which method of taking rough notes (laptop versus
clipboard) works best for you. As demonstrated above, both can be used quite effectively
in my opinion.
Nonverbal Aspects of Calming Potentially Violent Patients

Recognizing Contextual Clues of Impending Violence
Interacting with a patient who is escalating towards violence presents the clinician with
one of the most difficult of clinical situations. Although it would be nice to think that
violent interactions are rare, the facts speak otherwise. Tardiff reports that approximately
17% of psychiatric patients reporting to an emergency room are potentially violent. He
further states that roughly 40% of psychiatrists have reported being assaulted at least
once in their careers.83
Obviously, it is to the clinician’s benefit to review the various approaches that may
de-escalate an angry patient. In particular, the nonverbal characteristics of potentially
violent dyads are of considerable importance, because issues concerning proxemics,
kinesics, and paralanguage can all be of value in handling these situations. The interac-
tion with the potentially violent patient provides an excellent topic with which to close
Part 2 of this chapter, for the craft of utilizing nonverbal behavior is seldom put to a
more critical test.
I would also like to emphasize that violence is frequently a dyadic process. The clini-
cian and the patient represent a two-person system, and it is this system that becomes
violent. Clinicians may inadvertently, with their nonverbal behavior, further escalate an
already agitated patient. Fortunately, this cycle, representing a “violence reciprocal” as
per Scheflen, can frequently be broken.
To begin with, I am reminded of a curious story related by an anthropology professor
during my undergraduate education. He described an interspecies encounter in which
violence was averted by the quick thinking of a field anthropologist. This anthropologist
had been extensively studying the behaviors of a baboon troop. One day he accidentally
startled a mother baboon and her baby. Within seconds the squawkings of the alarmed
mother attracted a swarming bevy of guard males. One can assume their intent was not
of a social variety. Indeed, baboons are both intelligent and ferocious when provoked.
The appearance of an ugly white ape with a mustache and safari hat was more than ample
stimulus to prompt a display of their virility. Indeed, the baboons could have quickly
disposed of the anthropologist.
Having observed baboons demonstrating submissive behavior within the troop, he
purposely replicated their submissive gestures, which apparently involved lowering
oneself and making certain jaw movements. To his relief, the baboons grunted and
snarled but waved off their attack.
Besides being a delightful tale with which a college professor can regale wide-eyed
undergraduates, the above story has a valuable message: A group of animals were about
to interact violently. The violence was prevented by the use of specific nonverbal behav-
iors that functioned as true nonverbal communications (emblems). Like these baboons,
the human animal possesses a repertoire of nonverbal communications and nonverbal
activities that signal the intent to attack and the intent to submit.
The signals of impending attack, when recognized in a patient, can quickly alert the
clinician that something needs to be altered in the interpersonal dyad before a violence
reciprocal ensues. Through a knowledge of the signals of submission, the clinician may
alter behavior in a fashion that appears less threatening to the paranoid or intoxicated
patient. In many instances, these alterations can break the dyadic cycle of violence as
effectively as the anthropologist placating the baboon warriors. It should be kept in mind
that in rare instances, no matter what preventive actions are undertaken, violence will
erupt. The goal is not to eliminate violence but to decrease its likelihood.
Towards this endeavor, the clinician should assess whether the clinical situation indi-
cates that violence is a possibility. In the first place, diagnosis can alert the clinician to
an increased likelihood of aggression. Most psychotic patients are not violent, but psy-
chotic process as manifested in schizophrenia, bipolar disorder, paranoid disorder, and
other atypical psychoses may predispose the patient towards aggression. This is especially
true when paranoid delusions are simmering beneath the patient’s social facade. If fright-
ened, these paranoid patients may go to great extremes to protect themselves, as we
would if we shared their vision of the world. It is always important to remember that
such patients may believe that they are literally fighting for their lives.
Other types of psychosis or poor impulse control may present problems. For instance,
patients suffering from organic brain disease, as seen in frontal lobe syndromes, deliria,
and various dementias, may be predisposed towards aggression. The possibility of vio-
lence should arise in the clinician’s mind when interacting with people under the influ-
ence of various drugs, including speed, bath salts, hallucinogens, and phencyclidine
(PCP). Alcohol intoxication remains a major factor in the instigation of violence, espe-
cially in settings such as emergency departments. Because we frequently deal with alcohol
intoxication in social settings in our culture, it is easy to be lulled into underestimating
the potential for violence when dealing with an intoxicated patient. Such patients can
quickly move from jovial jesting into a fit of rage.
Diagnoses do not tell the clinician that any specific patient is about to be violent.
Most people suffering from schizophrenia are not violent, but the diagnosis does alert
the clinician to the possibility of aggression. This consideration may represent the first
step in preventing violence. In addition, the clinician may note that a patient has a history
of assaultive behavior. In such instances, the clinician is well advised to take appropriate
precautions, such as having safety officers unobtrusively nearby and aware of the
situation.
Besides diagnostic and historical factors, the clinician may be part of a situation in
which violence is more likely. If the clinician has been asked to participate in the evalu-
ation of a patient who is being committed involuntarily, then caution is always advised.
There are probably few life situations more frightening than to have one’s freedom taken
away. In this situation, patients should always be considered as potentially violent.
I remember one instance in an emergency department late at night. The patient, an
agitated woman of about 30 years of age, was being committed. Safety officers had been
called down and were appropriately nearby. The patient appeared to have calmed and
was quietly sitting with family members by her side. Everything seemed in control. The
clinician began to move away from the patient and turned her back as she headed for
the staff room. In a matter of seconds the patient was ferociously choking the clinician,
for no apparent reason. I mention this vignette because it highlights the need to think
cautiously while evaluating committed patients. It also reminds one of the old adage
that when working in an emergency department one should never turn one’s back on a
patient, an adage as true today as when it was first coined.
One other clinical situation to keep in mind arises when patients are agitated and
accompanied by family members. In such situations, the clinician should attempt to
determine quickly whether the family member is calming or upsetting the patient. In
emergency rooms, a common mistake is to not separate feuding family members until
it is too late. It is often best to separate the antagonistic family members quickly, and
have different staff members attempt to calm and understand the perspectives of both
parties.
I have strayed from the topic of nonverbal behavior. However, in a practical sense,
the first step in utilizing nonverbal behavior with violent patients consists of recogniz-
ing the violent situation in its infancy, not its adolescence. If the clinician is aware of
the potential for violence, then the following nonverbal techniques can be brought
into play.
We will first look at various nonverbal activities that can alert the clinician that vio-
lence may be incubating. Subsequently, we will look at ways to change our own behaviors
in an effort to avoid confrontation.
Nonverbal Clues of Impending Violence

The nonverbal signs of impending aggression can be loosely grouped into two categories
– early warning signs and late warning signs. Although it is extremely difficult to predict
whether a patient will engage in violence in the future, it is not particularly difficult to
tell when a patient may be headed towards immediate violence.
The early warning signs consist of behaviors that suggest emerging agitation. In the
simplest examples, one may notice the patient beginning to speak more quickly with a
subtly angry tone of voice. These paralanguage clues may be augmented by a display of
sarcastic statements or challenges, such as, “You think you’re a big shot, don’t you!”
These types of early warning signs may appear obvious, but this is exactly the reason
they warrant mentioning. As clinicians, we may inadvertently ignore these signs – in the
process unintentionally escalating the patient. This seems to occur during periods of
intense time pressure or when the clinical situation has become increasingly hectic, as
in a busy emergency department or inpatient unit. Such obstinacy can unfortunately
return as an unwanted gremlin. When these early warning signs are present, it is very
important to crystallize in one’s mind what the patient’s needs may be. If the clinician
can move with the patient’s needs, hostility will frequently decrease.
Kinesic early warning signs consist of actual evidence of agitation, such as pacing and
refusing to sit down. If patients refuse to sit, it is frequently useful to gently request
them to return to their seat. One can use phrases such as, “It might help you to relax
some if you sit over here,” or “Let’s sit down and see if we can sort some things out.”
If the patient fails to sit in response to these comments, one can quietly, yet firmly state,
“I’d like you to sit over here so we can talk.” Some clinicians might quietly add, “It’s
difficult to have to keep staring up. I think we’ll both be more comfortable if we sit.” If
these maneuvers fail, then it is probably best to let the patient walk around freely, while
recognizing that this patient may be seriously impaired with regard to impulse control.
In short, the patient may be on the way towards violence, and appropriate steps should
be taken.
If no one is aware that the clinician is alone with such a patient, it is generally best
to let someone know what is going on. It is relatively easy for a clinician to make an
excuse for leaving the room at such points. It may not be so easy 10 minutes later. Along
these lines, if the clinician is at all suspicious of possible violence, the clinician should
carry a “safety button” or know where the safety button is located in the interview room,
so that other staff can be alerted if problems arise.
Other kinesic early warning clues include rapid and jerky gesturing. Of particular note
is the action of vigorously pointing one’s finger at the clinician to “make a point.” Such
a gesture may be a harbinger of impending hostility. Increased and intense staring may
also suggest anger. Finally, the appearance of suspiciousness or other increases in psy-
chotic process, such as an increasing disorganization of thoughts and/or behaviors,
should alert the clinician to the possibility of violence.
As a person comes closer to overt violence, specific behaviors may serve as reliable
indicators that aggression is imminent. Just like the charging guard baboons with their
bared teeth, humans have evolved symbolic signs of threat.
Morris has described behaviors known as intention movements.84 These intention
movements consist of those small gestures that suggest impending actions. For instance,
when people intend to rise from a chair, they frequently lean forward grasping the arms
of the chair. This is a clear signal that they want to rise, signaling that the conversation
is about to end. The intention movements suggesting possible violence include activities
such as clenching of the fists, whitening of the knuckles while tightly grasping an inani-
mate object, and even a snarling as the lips are pulled back from the teeth. People may
not be as different from baboons as we would like to think.
Perhaps the most common intention movement of attack is the raising of a closed
fist over the head. Overhand blows delivered from this position are the most frequent
blows seen in street brawls and riots, despite the unlikelihood of hurting one’s opponent
in this manner. This behavior may be instinctive in nature, because it is frequently seen
in children who are fighting.
Morris also describes vacuum gestures. These are gestures that represent complete
violent actions, but they are not actually carried out on the enemy. Frequent vacuum
gestures include shaking the fist, assuming a boxing stance, gesturing as if strangling
the opponent, and the pounding of the fist into the opposite palm. Both intention
movements and vacuum gestures serve as late warning signals that violence is near at
hand.
It should also be noted that verbal threats or statements that one is about to strike
out often accompany the nonverbal behaviors described above. When the above late
warning signs are present, violence is a distinct possibility. At this point, an application
of nonverbal skills may help to prevent aggression.
Nonverbal Techniques for Calming a Potentially Violent Patient

Scheflen describes dominance and submission reciprocals.85 In our story of the baboons,
the anthropologist refused to participate in the dominance reciprocal. If he had, he might
very well have been killed. Instead he chose to begin the submission reciprocal, which
his would-be attackers fortunately agreed to follow. In a similar fashion, humans can
engage in either of these reciprocals.
When faced with a hostile patient, the trick is to avoid engaging in the dominance
reciprocal while utilizing some submissive behavior. One avoids the dominance recipro-
cal by not demonstrating any of the early or late warning signs of aggression. Although
this appears to make an obvious point, it is striking to watch the maladapative behavior
of clinicians when faced with an agitated patient. The fear generated by the patient’s
hostility frequently results in unconscious behaviors that may threaten the patient. The
clinician’s voice may be raised. At times, the actual movements of the clinician speed up
as the waiting area is hurriedly cleared of furniture and other patients. Even frankly
antagonistic remarks may emerge. In this respect, it is not an exaggeration to say that
sometimes clinicians actually precipitate violence.
There exist no absolute rules for interacting with a patient on the verge of violence,
but there are some principles that can help guide the clinician. In the first place, the
clinician should appear calm. The speaking voice should appear normal and unharried.
It is particularly important to avoid speaking loudly or in an authoritarian manner. With
regard to kinesics, the clinician wants to avoid an excessive display of displacement activi-
ties, which may be misinterpreted as aggressive displays. Moreover, exaggerated displace-
ment activities may create an increasing atmosphere of fear, stoking the patient’s own
fears of an impending loss of control.
Eye contact should probably be decreased, and the hands should not be raised in any
gesture that may signify an intent to attack or defend oneself. To the contrary, it can be
useful to keep the hands low, by the side, and with palms upwards when gesturing.
Upwardly open palms are a submissive signal to many primates including humans.
Unfortunately, probably related to nervousness and fear, some clinicians will place their
hands behind their backs (a soothing auto-contact behavior), a gesture that may raise
fears in the patient that a weapon is being hidden. With regard to posture, one can pur-
posely stoop one’s shoulders slightly in an effort to appear smaller, because humans,
when about to attack, frequently raise their shoulders and chests in a slightly gorilla-like
display. In this regard, I have found it to be very valuable to bend my knees slightly, so
as to decrease my height, when near a potentially violent patient. Similarly, it is probably
also wise to remain in front of the patient, because an approach from behind or from
the side may startle an agitated patient.
One of the most important principles concerns an issue mentioned earlier when dis-
cussing proxemics. At least one study has suggested that potentially violent patients may
have significantly altered buffer zones.86 Specifically, they will feel that their intimate
body space is being invaded at distances that are much greater than for most people.
These patients may feel that the interviewer is “in my face” while standing a full 6 feet
away. In general, the agitated patient needs more room and interpersonal space. This can
be a tough principle to remember, because some good-hearted clinicians feel a desire to
calm the angry patient by touching them. This desire usually goes away after a few unfor-
tunate encounters with feet or fists.
If these principles are followed, accompanied by an intelligent use of safety officers
and medication as needed, many violent encounters can be avoided in emergency
rooms, on inpatient units, and in other settings. With regard to avoiding dangerous
situations, another point warrants mentioning. When sitting in an emergency depart-
ment examination room with a patient whom one does not know, it is probably wise
to arrange the chairs so that the clinician is closer to the doorway, while not obstruct-
ing the patient’s pathway to the doorway. With this arrangement one can always get
away if the patient becomes threatening or produces a weapon. It is naive to think
that these situations do not arise, especially in emergency departments. To pretend that
they do not probably represents a defensive denial that prevents the clinician from
fully thinking about these situations in a manner that could help prevent them in the
first place.
In conclusion, nonverbal processes are core elements of human communication
during violent interactions. A sound knowledge of these processes can help the clinician
to calm an angry or frightened patient. Helping patients to regain a sense of internal

control remains one of the fine points of the art of interviewing. It also increases the
chances that the clinician will be around to practice his or her art.
PART 3: BOLD NEW FRONTIERS – THE NONVERBAL IMPACT OF

TECHNOLOGY, THE WEB, AND MOBILE CONNECTEDNESS ON INTERVIEWING
It is both remarkable and exciting to be addressing a topic that did not even exist as a
topic when I wrote the last edition of this book. As the new century was approaching,
the web was powerfully establishing itself, but it essentially had no connection to clinical
interviewing. How times have changed.
The web is bringing many new opportunities and channels for communicating clini-
cally, some of which will hopefully allow us to both transform and save lives. In my role
as a member of the Standards and Training Committee for Lifeline (the national orga-
nization in charge of certifying and training crisis line staff), it has been my privilege to
see some of these dynamic developments. These developments are occurring because the
web offers certain characteristics that traditional face-to-face (and even traditional tele-
phone crisis) intervention does not offer.
For instance, one of the great attractions of the web is anonymity.87 There is no way
of recognizing the voice, let alone the face, of a person with whom we are chatting online;
neither is it possible to be “tracked down” by such a person in the real world. For some
patients who are contemplating suicide, this anonymity is appealing. For them, it is easier
and more comfortable to contact a nonprofessional support system, or even a crisis line
professional, by using the web. This anonymity creates a sensation of safety. This sense
of safety may foster an enhanced sharing of sensitive, intimate, or dangerous material. It
may have also been the deciding factor that led an ambivalent patient to make contact
in the first place. In addition, the geographic anonymity that prevents the police from
easily being contacted by a crisis clinician to do an active intervention on an imminently
dangerous caller is actually appealing to some callers in whom a fear of such an interven-
tion is intense.
In addition, chatting, texting, and instant messaging are second nature to the genera-
tion that grew up using the web, many of whom are the readers of this book. Conse-
quently, both with veterans and with college students, suicide crisis centers have been
developed that are completely web-based. Whether it is the result of anonymity, second
nature, or both, it is hoped that potentially suicidal patients who might never have gone
to an emergency room, nor called a telephone crisis line, will make contact via these new
web-based centers. It is then hoped that a skilled web-based clinician can subsequently convince
the more potentially suicidal patients to seek out a face-to-face interview (college counseling
center, emergency department after hours, etc.), where a more effective risk assessment can be
accomplished. I think that many lives may be saved as a result.
All of these crisis contacts are initial interviews of a sort, yet they have a common
factor not seen in the interviewing situations described thus far in this book – a scarcity
of nonverbal interaction. One wonders what impact this might have and how our
understanding of these nonverbal deficits might help us perform these “interviews” more
effectively. Indeed, most readers of this book will be involved in clinical interviews in
which there is minimal nonverbal communication, including handling our own patients’
crisis calls, covering by phone the crises of the patients of our colleagues who are on
vacation or ill, and performing tele-video interviews, psychotherapy sessions, and
medication checks on patients living in isolated rural areas in whatever country we
might live.
In order to most effectively use the advantages of any new technology, we must be
familiar and open to the idea that there may be disadvantages and limitations to that
very same technology. This is a chapter that explores some of these limitations, in the
hope that we will better be able to tap the many promising advantages of online and
mobile connectedness, as well as other communication advances such as improved
teleconferencing.
Interactive Audio-Visual Technology (IATV) and the “Phantom

Presence Effect”
The ability to communicate with people remotely, in real time, both visually and aurally,
is a reality made possible only by recent technological advances. It was the stuff of Star
Trek only 40 years ago. At first, such communications were created via traditional video-
conferencing. Today, it is being revolutionized by the web, through Skype and similar
platforms. With the advent of apps that can create IATV for smart phones and other
devices, it will undoubtedly become commonplace in the very near future.
IATV offers us the chance to provide sound clinical assessments for patients who might
not otherwise be able to reach help. With the use of IATV, we have entered the world of
telepsychiatry and telecounseling as performed via computer link-up. Ofer Zur summa-
rizes some of these circumstances nicely:
IATV offers tremendous advantages for working with those who are in remote areas with
limited access to in-person services; those who are home-bound (e.g., those with agorapho-
bia or a physical disability); those in the LGBT community, who are reluctant to discuss
their concerns with local psychotherapists or counselors; those in jails and prisons, where
mobility of prisoners and access to care are surmountable problems; and those who need
professional services outside usual business hours. Indeed, for some individuals in-person
treatment may not be a possibility due to personal, physical, psychological, financial, or
cultural issues, and IATV may be a viable treatment option for them … Then there are
people who simply prefer the distance and control of the setting that is provided by video
technologies in comparison to in-person meetings.88
In order to more effectively utilize IATV, it is important to realize that although it allows
for more nonverbal communication than telephone work or purely verbal electronic
communication (as with e-mail, texting, and chat rooms), it is still limited in scope, as
anyone can attest who “attends” an all-day lecture series by videoconferencing. Such
educational formats often seem dull and very long, even when watching a talented
speaker. Although such dullness provides a wonderful opportunity for texting friends,
playing web games, checking e-mail, sending an Instagram or two, or catching up on the
writing of progress notes, one is stuck with the question of “Why this dullness”? Why is
watching a talented speaker much less enjoyable when participating by videoconferenc-
ing as opposed to attending the training?
I believe that by revisiting the concept of immediacy we will find our answer. Although
the positive feelings of immediacy are partially communicated by factors easily seen by
the use of videoconferencing (facial expressions, head nodding, and gestures), much of
immediacy appears to be related to something else. Part of the “something else” is the
role of proxemics, and for proxemic factors to be felt, there must be a palpable presence
of “the other” in the same room. There is no such presence in videoconferencing or other
forms of IATV, such as skyping. Let us examine this phenomenon in more detail.
With IATV, many of the nonverbal indicators of immediacy, such as facial expressions
and gesturing, are clearly visually present. Consequently, it is surprisingly easy for us, as
clinicians, to be lulled into the perception that we are a real presence to the patient in
the room. But we are not. Our “presence” is merely an image, not a concrete reality.
Patients do not feel our presence in the room as they would in a face-to-face interview.
We are a mere image – a talking head of sorts. To the patient, we are a phantom presence
and vice versa.
Our lack of real presence has many powerful nonverbal implications that can limit
the quality of the assessment process. This lack of the sensation of the presence of another
person in the room, and its resulting problems with creating immediacy, is a phenom-
enon I like to call the “phantom presence effect.” Because of this phantom presence
effect, the ramifications on our ability to create an engaging sense of immediacy will
impact not only our proxemic interactions with the patient but key kinesic interactions
as well.
We have seen earlier in this chapter that people adjust interpersonal distance while
communicating. People (and cultures) can be keenly aware of changes in interpersonal
distance. When doing interviews using IATV, clinicians must be aware of two facts: (1)
The interviewer will not have any of the nonverbal proxemic clues to blending that are
normally provided by the patient’s spontaneous use of space as engagement either
improves (patient tends to move closer or leans forward) or deteriorates (patient is expe-
riencing disagreement, anger, guardedness, or paranoia, resulting in moving away or
“keeping at a distance” from the interviewer). (2) Similarly, the interviewer will not have
the ability to impact on the patient by his or her use of interpersonal distance (moving
closer to a patient during a particularly sensitive or painful moment or “yielding” to an
angry patient by moving away).
Another powerful variable in immediacy that is hampered significantly by the phantom
presence effect is the ability to make eye contact effectively. Once again, we lose clues to
blending and engagement because of this decrement. As with proxemics, we also lose
the ability to have an impact on the patient through our own intentional use of eye
contact.
Even at surprising distances, eye contact and interaction are important creators of the
feeling of immediacy and listener interest. When providing training events, whether
nationally or internationally, I have learned that making eye contact with the members
of my audience can significantly impact on their engagement. I can read both their inter-
est level and their “buy-in” to what I am saying (some participants return good eye
contact and supplement it with head nodding and even a smile, others look blandly on
or stare). In addition, these immediacy behaviors also show that the audience member
is keenly aware of my presence and of the possibility that I will personally interact with
them by engaging them with eye contact. Such an expectation of contact on the audience
member is literally “felt,” as evidenced by the fact that some participants will quickly
look away and not return my eye contact. When I pick up on the uncomfortableness of
such an audience member, communicated by his or her nonverbal cues, I know to avoid
such eye contact for the rest of the talk with that particular participant, thus shaping the
use of my eye contact to the unique needs of the audience member.
I mention this non-clinical setting to highlight the importance of eye contact in
engagement and the ability to perceive whether or not someone agrees with you. If I can
have an impact on an audience member at a distance of 50 feet, imagine the power of
eye contact when interviewing at a distance of 5 feet or when trying to recognize the
degree of wariness in an actively paranoid patient. Much, although not all, of this is lost
in IATV interviewing. It also suggests that during the collaborative treatment planning
undertaken in the closing phase, an IATV clinician may be missing some of the important
nonverbal indicators of the patient’s agreement or disagreement.
Considering the great limitations to the effectiveness of eye contact when using plat-
forms such as Skype to undertake interviews, one will want to maximize whatever
remains of the impact on the patient via eye contact. Elisa Rambo offers a useful insight
in this regard. She points out that we tend to naturally look patients in the eye intermit-
tently throughout an interview, “but if you peer straight at your patient’s eyes on the
computer screen, from her perspective you then appear to gaze downwards. Looking
upward, into the camera, seems more like eye contact from her end.”89 Rambo further
suggests reminding oneself to look straight at the computer’s camera at least every 10
seconds or so.
Our discussion of the nuances of a decrease in eye contact suggest that something
even more intriguing may be at work in the generation of the phantom presence effect
itself. This generating factor is a matrix phenomenon, impacting both participants in
the interview. The phantom presence effect may be caused not only by changes in both
parties’ abilities to read and impact on each other, but by fundamental changes in how
intensely each individual is attending and preparing to respond to the environment –
the activation level of each person. The degree to which a person is spontaneously
interested in an environment probably impacts on how easily engaged the person may
be with parts of the environment, such as a clinician. Let us look at this idea in more
detail.
As we have already discovered, to effectively gain a feeling of immediacy, there is a
pre-requisite: a person must be aware that another human being is in the room. Once
this awareness occurs, it is my belief that biological and psychological processes that help
an organism to “be alert” and to “remain alert” are probably triggered. They are triggered
to monitor the safeness of the environment and to allow the organism to take appropri-
ate action if threatened by the other presence.
Thus a major psychological component and pre-requisite of powerful immediacy is
the unconscious and conscious awareness that the other person may “try to interact with
me at any moment.” Likewise, the person may become aware that the other individual
in their environment may force them to interact by speaking to them, moving closer, or
touching. All of these factors unite to create a more alert organism, whether it be the
presence of a sales assistant in a shop or a patient sitting in our office. This perceived
potential for face-to-face speakers to cause interaction (making eye contact with an audi-
ence member or spontaneously asking a question to a specific audience member) may
help to explain why live talks are often more interesting than videoconferences – imme-
diacy (hence alertness) is activated by the very potential for uninvited interaction by the
speaker.
As clinicians, we must remember that this powerful precursor of immediacy – the
activation of an alerted state caused by the recognition by the patient of the actual pres-
ence of another person in the room – is not available when communicating via IATV.
This activated alertness, and resulting readiness to interact, can be an important part of
the engagement process. With some patients, its absence may negatively impact the
engagement process, placing an increased emphasis upon the content of what we are
saying (such as an increased need for empathic statements) to generate the same level
of engagement we would have achieved in a face-to-face interview.
Curiously, yet logically, if one thinks about it, we may discover that IATV is preferred
by some patients (perhaps those patients with intense social anxiety or with paranoid
process), for the exact same reason that makes engagement more challenging – the less-
ening of immediacy – because they don’t like the sensation of immediacy. To their great
relief, the feeling of immediacy will be significantly decreased by IATV. There is no way
that a clinician many miles away can “touch me or do bad things to me.”
Another important possible limitation with IATV interviewing is the question of intu-
ition. We do not know exactly what allows us to be intuitive, a skill of particular impor-
tance in many aspects of clinical interviewing, from recognizing when to use an empathic
statement to recognizing acute suicidal intent. Most likely many factors contribute in an
interactive fashion, some of which we have already alluded to earlier in the book. I per-
sonally feel that our own sense of immediacy, while interviewing, plays a significant role.
Consequently, when undertaking an interview via IATV, it is important for the clinician
to recognize that his or her intuitive abilities may be compromised, a realization that
can have important ramifications when assessing for suicide or trying to spot patient
deceit.
Closing on a minor, yet still significant, point, it is important to recognize the effects
of the decreased size of the patient’s image in most IATV interviews. The limited size of
IATV images (sometimes as small as the screen of a smart phone) can significantly
hamper our ability to see or recognize the visually available nonverbal behaviors of our
patient, such as the patient’s facial expressions, head nods, and gestures (many of which
may be off-screen).
Interviewing on the Telephone

We will now visit a more traditional technology. Telephone work has some advantages.
Once again, the relative anonymity (more than IATV but less than text-based web com-
munication) and the geographic distance from the clinician (with a resulting decrease
in immediacy) are appealing to some patients. In certain instances these factors probably
foster an increased sharing, the so-called “bartender effect” in which people tend to open
up to total strangers. But overall, telephone work is difficult.
In contrast to IATV, telephones more radically diminish nonverbal behaviors. Indeed,
all nonverbal behaviors are absent except for paralanguage cues. The ramifications
are significant and well acknowledged by anyone performing telephone intakes or
handling crisis calls. In this brief section we will examine two difficulties in this type
of work.
Problems Assessing Patients on the Phone

Off the bat, all of the problems in assessment described for IATV interviews are equally
present in telephone interventions. Indeed, problems with understanding the patient’s
sense of engagement and immediacy are further heightened, for nonverbal clues to
immediacy (such as facial expression, eye contact, head nodding, body lean, and gestur-
ing) have vanished. In the absence of these nonverbal clues, clinicians need to recognize
that their clinical intuitions on highly sensitive assessments such as determining suicidal
intent, dangerousness to others, presence of deceit, and genuine interest in follow-up
may be impaired. This impairment does not mean we should avoid tapping our intu-
itions on these topics; it simply means we should trust them less, once tapped.
Confronted with such difficult clinical challenges, when we are on the phone, we must
make our clinical formulations of suicide risk with an increased reliance on analytically
processing the information we have garnered. If something does not add up, it is impor-
tant to continue the call and try to uncover any missing information that might help, as
opposed to intuitively thinking, “Well, I think he sounds okay.” If one is bothered by the
situation, one needs to find out why. This is true in all suicide assessments, including
face-to-face ones, but one could argue it is even more true in telephone work, where the
lack of nonverbals may hinder our intuition.
Paralanguage becomes critically important in telephone work. You will recall that it
includes elements such as tone of voice, loudness of voice, pitch of voice, rhythm and
fluency of speech. One of the most important skills, especially if taking a call from a
patient in crisis, is learning to purposely get a feel for the caller’s paralanguage traits early
in the interview, especially when they seem to be talking openly and freely. This familiar-
ity with the caller’s typical speech characteristics is important, for they may change when
the caller is hiding material that is sensitive, such as incest, domestic violence, drinking
and drugging behaviors, and suicidal thoughts, behaviors, and intent.
It has also been suggested that problems with speech and language, such as more
errors in speech, repeating words and phrases, and taking longer to respond (increased
RTL) appear to be indicators of both anxiety and deceit.90 Good telephone clinicians
learn to listen carefully for such changes in the patient’s speech.
In addition, hesitancies and silences are almost always useful to note, keeping in
mind that they are nonverbal activities that may be multiply determined. A silence
before answering a question could be caused by something benign (as with a patient
carefully thinking through an answer or perhaps being caught off-guard by a question)
to something more troublesome (as when the silence indicates disengagement, hesi-
tancy to share sensitive material, or deceit). At such moments one can gently ask, if
the alliance seems reasonable, “You seemed to hesitate a bit before answering that
question, what was going through your mind?” When timed well, the answers can be
quite revealing.
A brief note on training is in order. To acquire a good handle on assessing the paralan-
guage clues of patients, I believe it is useful to do role-playing exercises that are done
back-to-back. Such back-to-back role-playing better simulates the real world of clinical
practice when interacting with the patient over the phone.
Problems Engaging Patients on the Phone

The loss of all nonverbals except paralanguage poses some unique challenges when we
are performing phone assessments. The first thing to remember is that the patient is also
limited in his or her ability to read our nonverbals. Thus, the patient may place a remark-
ably high importance to our paralanguage, such as our tone of voice and speed of speech.
Clinicians must become aware of these parameters in their normal interviewing style
through supervision, input from fellow trainees, and observation. I think it is very useful
to not only be video recorded but to also be audiotaped (or to turn away from a video
while listening only to ones voice). If a clinician discovers that his or her tone of voice
or speech rate occasionally communicates haste, terseness, disinterest, or a judgmental
attitude (when heard in isolation from kinesic and proxemic cues) it is well worth noting.
In everyday face-to-face practice, a clinician’s potentially disengaging paralanguage
traits may be nicely counterbalanced contextually by other immediacy behaviors, such
as smiling warmly, head nodding, and naturalistic gesturing. But when this same clini-
cian interviews over the phone, all of these counterbalances will be missing. Only his or
her paralanguage characteristics will remain. The patient’s nonverbal impressions of the
interviewer will be made solely on how the interviewer sounds. If you have a terse voice, then
you will probably be viewed as a terse person over a phone. If you speak quickly, you
may be viewed as busy or pushy; and so it is for the other paralanguage traits. Naturally,
when on the phone one wants to learn to speak in a naturalistic, engaging fashion,
attempting to convey a quiet warmth and a genuine concern.
I have come across some clinicians who were very talented at engaging patients in
face-to-face interviews, being greatly surprised that they were not perceived as warm on
the phone. These trainees possessed great visual immediacy behaviors that powerfully
facilitated engagement in a face-to-face context. But their paralanguage traits were merely
run-of-the-mill with regard to communicating warmth and empathy. Once spotted in
supervision, I have seen such trainees make significant improvements in their paralan-
guage skills.
In addition, it is important to realize that when we are on the phone, our verbal com-
municators of empathy can be put to good use. Empathic statements, as well as “empathic
grunting” and facilitative phrases (such as “Go on” and “Uh-huh”) can, and should, be
intentionally increased.
In closing on this topic, there is one caveat to be aware of: humor is great on the
phone, but use it carefully. There are many visual nonverbal behaviors that cue people
that a statement is to be taken humorously. These visual cues are totally absent over the
phone. I do not recommend the use of humor by phone with angry, disengaged, or para-
noid patients. In addition, with many people, sarcasm and “kidding comments” may be
misinterpreted over the phone, for we communicate that they were meant in jest primar-
ily by visual cues made immediately after such comments. A patient previously unknown
to the interviewer may not find such a comment to be funny. Even a more familiar patient
can misinterpret such comments when stripped of their visual envelopes.
The Ultimate Nonverbal Challenge: Interviews Done by Chatting, Instant

Messaging, and Texting
As stated earlier, it is hoped that programs such as internet-based crisis chat rooms may
save many lives by offering people who might not otherwise seek help the opportunity
to reach out, because they feel more familiar and/or more comfortable with the anonym-
ity of online communication. Initial responses to such programs with college students
and vets appear to be promising in this regard.
While developing such programs, it is important to keep in mind that we are enter-
ing uncharted territory that will undoubtedly hold surprises, many of which are related
to nonverbal behaviors, or the lack thereof. With chat, instant messaging, texting, and
e-mailing, the last vestiges of nonverbal interaction fall by the wayside. Even paralan-
guage cues are absent. All natural nonverbal clues that are used to determine the
patient’s engagement, emotions, level of anxiety and agitation, and clinical state are
suddenly gone. In the non-clinical world of everyday web communication, an attempt
to compensate for the loss of nonverbal interaction has given rise to emoticons and
contextual acronyms (e.g., LOL), but they prove to be painfully inadequate in this
arena.
There is no doubt in my mind that an interviewer’s abilities to rapidly understand
and read patients is hampered by this great loss in nonverbal behavior. In addition, even
more dramatically than we saw with IATV and telephone interviewing, the interviewer
must cautiously assess the accuracy of his or her intuition.
In addition, there is no ability for clinicians to use their own nonverbal behaviors to
impact their patients. Kinesic immediacy behaviors, such as head nodding, eye contact,
and gesturing are unavailable for use in engaging the patient and building a sense of
safety. Powerful proxemic behaviors, such as leaning forward and moving closer, are now
empty shells. The clinician’s ability to modulate tone of voice and pace of speech are
also of no utility.
Keeping in mind that research has shown that roughly 60 to 65% of social meaning
is communicated by nonverbals, a lack of nonverbal interaction between patient and
clinician can leave interviewers feeling distinctly ill-at-ease. This unpleasant disquietude,
created when a clinician is stripped of the use of nonverbal interaction, I like to call the
“naked communication effect.” Normally, we clothe all of our everyday words with non-
verbal communications and activities. Their sudden absence can be surprisingly unset-
tling. As one might logically suspect, when the interviewer is performing complex
assessments that carry critical ramifications (such as suicide assessments), the naked
communication effect can be truly unnerving to some clinicians.
Moreover, novel stresses that one might not as easily have anticipated can be experi-
enced by clinicians who are performing such delicate tasks via chat programs. For
instance, useful hesitancies in vocal speech and silence, often indicators of patient affect,
anxiety, and even deceit are absent, which further amplifies the naked communication
effect. But curiously, a new form of “silence” is causing problems.
When chatting online or instant messaging, people don’t always answer questions
immediately. They can wait minutes, hours, or simply not answer the clinician’s question
at all by signing off. One can imagine the potential stress of such delays on a clinician.
Picture a patient who has communicated to an interviewer that he has pills in his hand.
Imagine the psychological strain on the interviewer if the patient did not respond for an
hour in response to the following question, “Are you thinking of overdosing right now,
are you okay?”
The tendency of some patients to not answer immediately when chatting or texting
is creating another unexpected clinical challenge, never before encountered. In traditional
telephone crisis work, clinicians stick with the caller until the call is completed and then
handle the next crisis call. In chat room crisis work, because some patients may demon-
strate many delays before answering, many interviewers must learn to handle multiple
assessments simultaneously. If one or more of the “calls” is particularly “dicey” with
regard to risk, this need for the interviewer to multiprocess can be quite stressful. It is
not everybody’s cup of tea.
It should also be kept in mind that the patient’s slowness in responding may indicate
that the patient is also multitasking. The patient may even be chatting or texting with
someone else while being assessed for suicide by the clinician. They can even be asking
a friend or friends what they think of the interviewer’s responses and suggestions (e.g.,
“This guy thinks I should go to the emergency room for assessment, what do you
think?”). It is truly a new world of interviewing.
One benefit for web interviewers, and it may prove to be a very significant one, is the
ability to engage in ongoing contact, via phone or web, with a supervisor during a dif-
ficult call. This supervision can even be enhanced by the fact that complex exchanges, or
ambiguous statements, occurring earlier in the intervention can be referenced immedi-
ately with total accuracy, for they can be pulled up on screen or downloaded.
I believe that research in this arena, which is desperately needed, will skyrocket in the
years to come. Some excellent research has already begun to shed some useful light. With
regard to instant messaging, Zhou has shown that liars tend to pause more briefly than
truth tellers. In addition, they tend to spontaneously correct their text less frequently.91
Andersen suggests that these results may not merely reflect unconscious processes. They
might be the result of conscious manipulation by the sender. The deceitful sender might
assume that long pauses or numerous corrections could be perceived as evidence of lying.
Consequently the sender intentionally decreases both.92
In the final analysis, it is hoped that for those patients presenting with difficult suicide
assessments, the web-based interviewer will be able to persuade the patient to meet with
a clinician face-to-face. In the presence of a caring and skilled interviewer, an even more
effective assessment can then be undertaken, enhanced by the richness of communica-
tions provided by the nonverbal behaviors of both participants.
As we wrap up this section, the interested reader can find some excellent resources
regarding the use of the web as an interviewing medium. A variety of articles are insight-
ful,93–99 and the chapter by John and Rita Sommers-Flanagan is a rich resource for further
practical tips.100
CONCLUSION
In this chapter we have reviewed the basic principles of proxemics, kinesics, and paralan-
guage. It can readily be seen that these processes are at the very root of effective com-
munication. As such integral parts of human interaction, they remain pivotal in the
creation of a successful interview. I can think of no better way to close our chapter than
with a statement by Richard Frankel, the noted researcher on the patient–physician
relationship. It captures the essence of our chapter admirably: “Most physicians in train-
ing spend at least the early part of their careers interacting with their books. The book
doesn’t care what facial expression you have when you are reading it, but patients care
a lot.”101
In Part I of this book we have reviewed many of the basic principles of both verbal
and nonverbal behaviors as they apply to the initial interview. We are now ready, in Part
II, to explore the various mental disorders and symptoms that cause the intense suffering
of the patients seeking our help. We will learn how to better understand these symptoms
and what they mean to both our patients and those who love them. From the painful
world of depression and bipolar disorders to the puzzling and frightening world of psy-
chosis, we will hunt for better ways to interview our patients so that they can share their
pain and their symptoms more easily. Such an exploration will quickly move us into
some of the most complex and fascinating aspects of clinical interviewing.
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CHAPTER 9
Mood Disorders: How to Sensitively
Arrive at a Differential Diagnosis
I wander thro’ each charter’d street,

Near where the charter’d Thames does flow
And mark in every face I meet
Marks of weakness, marks of woe.
William Blake
London1
INTRODUCTION
In the early 1800s as Blake wandered the drab lanes of London, his eyes met the face of
depression at every corner. Depression stalked among merchants, seamen, and prostitutes
alike, because depression impolitely ignored the proper boundaries of social class. Today,
whether on Fifth Avenue in New York or at a community mental health center in rural
Nebraska, mental health professionals encounter faces strongly reminiscent of those that
William Blake described centuries ago. As in Blake’s time, depression masquerades in
many costumes and clinical presentations.
As an illustration of this diversity, I remember working with a woman of about 40,
who had been a successful interior designer. In the midst of a severe economic downturn,
she found herself jobless. Her confidence and self-esteem were affronted with each
passing day. Her belief in herself insidiously weakened as if she were an invalid who
decided that there was no hope. Anxiety attacks punctuated her daily routine. Despite
her pain she continued her frantic job search, terrified by each job interview. Her days
became compacted cells of anxiety neatly delineated by bars of self-doubt.
How different this woman’s presentation appears when contrasted with a strikingly
white-haired woman I met in North Carolina. Although only 50 years old, this woman’s
face was branded by thick wrinkles. She had been extremely dependent on her father, a
caricature of “Daddy’s little girl.” Following his death 4 months earlier, she had felt as if
her skin had emptied. She was no longer whole. The sight of his face could not comfort
her. His touch could not reassure her. She was brought into the hospital on an involun-
tary commitment. According to the police she had been found wandering a local
338 The interview and psychopathology: from differential diagnosis to understanding
cemetery with a butcher knife in hand. She related that her father’s voice was pleading
with her to join him.
These people were obviously experiencing life very differently, yet both were suffering
from depressive symptoms. I highlight this diversity of presentation to emphasize that
depression, as well as bipolar disorder and other disturbances in mood, are not “things.”
They are constantly evolving processes. Being processes, mood disorders become a way
of living. They are unique for each individual and create damaging effects throughout
the wings of each individual’s matrix.
Nevertheless, there are many similarities in the presentations of mood disorders that
enable the clinician to recognize them despite atypical patterns. This dual capacity of
mood disorders to appear both foreign and familiar provides the interviewer with the
first inkling that sensitively uncovering mood disorders requires many levels of
understanding.
As we have already noted, gifted intentional interviewers integrate the process of dif-
ferential diagnosis with the continuous art of understanding, incessantly searching for
the person beneath the diagnosis. Only when a patient feels the intensity of his or her
clinician’s drive for such an understanding is it likely that the clinician’s help will be
accepted, whether it exists in the form of psychotherapy, medication, or other interven-
tions within the patient’s matrix.
To this end, in this chapter we will explore interviewing tips and strategies that will
allow us to more deftly and sensitively perform a differential diagnosis regarding mood
disorders. At the same time it will provide a sound introduction to the psychopathology
and symptoms of these disorders.
In addition, by learning how to sensitively explore depressive and manic symptoms,
you will be learning interviewing principles and diagnostic strategies that you can gen-
eralize to the differential diagnosis of other major psychiatric disorders (such as anxiety
disorders, substance abuse disorders, eating disorders, and trauma disorders, which are
not included in this book due to size limitations). Indeed, in the video modules at the
end of this chapter, you will have an opportunity, if you so choose, to not only watch
me utilize the interviewing techniques described in this chapter for exploring a major
depressive disorder, but to also watch me utilize the same interviewing techniques to
explore other disorders not addressed in this text (such as panic disorder and adult
attention-deficit disorder).
This chapter on differential diagnosis will also provide us with yet another bonus of
sorts, for as we explore the nuances of the psychopathology and the differential diagnosis
of mood disorders, our explorations will bring us face-to-face with several complex
everyday interviewing tasks (such as delineating an accurate history of the presenting
disorder, taking a past psychiatric history, and uncovering a family history) that are of
practical use in all initial assessments. We will also get a chance to address important
cross-cultural issues inherent in the understanding of the differential diagnosis of mood
disorders.
But before we can begin our exploration of differential diagnosis in this chapter, it is
important that we first examine a topic that will be critical for our understanding of all
of the diagnostic entities discussed, not only in this chapter but in the rest of Part II of
Mood disorders: how to sensitively arrive at a differential diagnosis 339
this book. Specifically, we need to briefly address the principles of how diagnostic systems
are designed, for how they are designed can create limitations in how effectively you and
I can use them.
To understand these practical and clinical limitations – and the design elements that
created them – we must focus our attention on some of the principles and terminologies
that describe diagnostic design itself. I must admit that when I first encountered these
concepts and terms (such as face validity, inter-rater reliability, categorical versus dimen-
sional design) I found them to be somewhat abstract and off-putting. My goal in the
following few pages is to create a quite different initial experience for you. I want to
provide you with a simple, brief, easily understood, and enjoyable introduction to these
pivotal concepts – an introduction that was not available to me. At the same time, I hope
to do so with the appropriate level of sophistication that befits a well-trained mental
health professional.
In the last analysis, our ability to do differential diagnosis sensitively and effectively
will be directly related to the sophistication that we possess regarding the limitations of
whatever diagnostic system we have chosen to utilize. A diagnostic system employed
without a knowledge of its limitations is a diagnostic system that has the potential to do
harm. By the end of the next few pages, I believe we will have the sophisticated knowl-
edge that we need to avoid this trap. We will then be able to effectively use differential
diagnosis to help kick-start the healing process.
DIAGNOSTIC SYSTEMS: THERE HAS NEVER BEEN A PERFECT ONE AND

THERE NEVER WILL BE
The human brain craves understanding. It cannot understand without simplifying, that
is, without reducing things to a common element. However, all simplifications are arbitrary
and lead us to drift insensibly away from reality.
Lecomte du Nouy
Biologist, and author of Human Destiny
The Nature of the Dilemma for Front-Line Clinicians

Validity Versus Reliability
At its simplest, the “validity” of a diagnostic system is its ability to describe accurately
the person or phenomenon it is delineating. Designers of diagnostic systems feel that
highly valid systems are often the most useful in helping patients, for such diagnostic
systems accurately capture the symptoms and problems that a patient is experiencing.
Such an understanding can provide a sound framework for collaborative treatment plan-
ning and intervention.
At first glance, one would think that it would be best to always design a diagnostic
system that is maximally valid. But there is a catch. Diagnostic systems that are extremely
valid are not necessarily easy to use or even capable of being effectively employed in the
real world of clinical practice, because they may require too much time to perform or be
so complex as to hinder their acceptance by clinicians.
From this practical perspective, it is essential that a diagnostic system be constructed
in such a fashion that different interviewers who interview the same patient will arrive
at the same diagnosis, and in a timely fashion, a characteristic called inter-rater “reli-
ability.” Without reliability, a diagnostic system is essentially useless in a clinical setting.
Without reliability, a single patient could be given radically different diagnoses by dif-
ferent clinicians, either because the clinicians were confused by the too-numerous criteria
or were not able to explore the criteria within the tight time constraints of everyday
practice. Furthermore, with such difficulties in terms of definitions and diagnoses, clini-
cians could not effectively communicate with one another and research would also grind
to a halt.
An ideal diagnostic system would exhibit extremely high validity and extremely high
reliability, while simultaneously being easily completed in an initial interview and easy
to learn. The problem lies in the fact that the requirements for validity and reliability are
often conflicting and require different approaches. Specifically, they often demand an
intentional change in interviewing technique.
Consequently, all diagnostic systems experience a tension between these two desirable
traits. The more reliable a system, often the harder it is for it to be valid, and vice versa.
An old metaphor may be helpful here: You don’t want to miss the forest for the trees.
To use this analogy, the tension in designing diagnostic systems is often between gaining
accuracy on all the trees (validity) versus simply and quickly identifying the overall nature
of the forest (reliability). Truth be told, both are very important, yet neither can be com-
pletely maximized in any given diagnostic system.
Thus, whether one is using the DSM-5 (or a future variant) or the ICD-10 (or upcom-
ing ICD-11), one is never using a perfect tool. But the designers of both of these systems
have done their best to arrive at a compromise that can help guide collaborative treat-
ment planning with the goal of relieving the greatest amount of pain in our patients in
the fastest way possible.
Construct Validity, Face Validity, and Descriptive Essence

Validity, itself, is comprised of subtypes. For instance “construct validity” defines whether
a diagnostic system appears to be constructed upon previously delineated clinical/design
principles that are viewed as being useful by experts and clinicians and logically follow
one from the other. A system with high construct validity should adhere to the best evi-
dence base available at the time of development.
“Face validity” describes the degree to which a diagnostic system, or a specific diag-
nosis within a system, appears “on the face of it” to make sense. Do the diagnostic catego-
ries and their criteria fit with how patients with these disorders actually present in the
real world of clinical experience?
It is to a special aspect of face validity that I want to now draw our attention, for it
has direct ramifications as to whether a diagnostic system will be of immediate use to
us during the interview itself. This aspect is a concept I call “descriptive essence.” A diag-
nosis will have high descriptive essence if:
1. As a clinician reviews the diagnostic criteria, the key characteristics of the diagnosis
that delineate it from other diagnoses are immediately apparent. (In less technical
terms: Do the real-life hallmarks of this disorder jump out at the reader as the diag-
nostic criteria are scanned?)
2. When an interviewer reads or hears the name of the disorder, the diagnostic label
clearly suggests the essence of the disorder. (In less technical terms: Does this diag-
nostic tag seem to resonate with the symptoms of a typical patient presenting with
this disorder?)
From a practical standpoint – and so from the viewpoint of an everyday clinician –

descriptive essence is of immense importance. There are a great number of diagnoses
and diagnostic criteria in both the DSM-5 and the ICD-10. It is critical that they are as
easy to remember as possible. If the criteria seem to fit the fashion in which a clinician
pictures people presenting with the diagnosis in question (the diagnosis possesses high
descriptive essence), then it is much easier for the interviewer to remember what
questions to ask.
Categorical Diagnostic Systems Versus Dimensional Diagnostic Systems

Categorical Diagnostic Systems
In a categorical diagnostic system, the items, phenomena, or behaviors to be classified
are placed into discrete categories as one might expect from the name. Thus, the resulting
disorders are qualitatively different from one another. In the DSM-5, for example, a
patient’s behaviors and experiences are ultimately classified into discrete diagnostic cat-
egories (such as Schizophrenia Spectrum and Other Psychotic Disorders, Bipolar and
Related Disorders, Depressive Disorders, Anxiety Disorders, and Personality Disorders).
Each diagnosis within a categorical system contains a set of criteria or an overall cluster
of attributes that must be present for the diagnosis to be made. For instance, in the DSM-5
there are nine criteria for satisfying the diagnosis of a major depressive disorder (such as
depressed mood, loss of interest or pleasure, and insomnia) of which five or more of the
symptoms must be present for the diagnosis to be made.
Generally speaking, with a categorical system, if it is well designed the criteria have
excellent descriptive essence, making them relatively easy to remember. Because the cri-
teria are specific and easily recalled, the diagnoses can frequently be made relatively
quickly. In addition, the more specific the criteria, the easier it is for different clinicians
to arrive at the same diagnosis when interviewing the same patient. Thus, categorical
diagnostic systems tend to have relatively high reliability, ease of use, and practicality in
everyday clinical situations. If designed well, they will also show good validity. On the
down side, it can be hard to design them well, and it is the validity that suffers.
Dimensional Diagnostic Systems

In contrast, dimensional diagnostic systems view phenomena, symptoms, and experiences
as not being easily placed into discrete, unrelated categories. Dimensional systems take
into account the difficulty of fitting shifting processes such as symptoms and behaviors
– that do not have discrete borders – into tightly delineated diagnostic labels (as might
occur in a categorical diagnostic system) and that doing so is inherently artificial in nature.
From this perspective, the complexity of a human behavior, personality, and psychopa-
thology cannot be accurately portrayed by fitting it into a box of characteristics that are
present or not present. Instead, it is more accurate (increased validity) to look at all of the
individual behaviors, symptoms, and traits of a person, ascertain which characteristics are
present, and subsequently determine how intense and frequent the characteristics may be.
Dimensional systems even speculate that characteristics may vary over time and situation.
In a purely dimensional system, it is not so much that a person has (meets the cri-
teria for having) such and such a symptom, experience, or trait, it is more that people
vary on how much they display symptoms, experiences, and traits that are shared by
most, if not all, people but not to the same degree. Thus, from the perspective of a classic
dimensional system, all people can show anger, but this can range from appropriate
anger to inappropriate rage and aggression as seen in an episode of dysphoric mania.
Dimensional systems often require an interviewer to survey a large number of experi-
ences, behaviors, symptoms, and traits in great detail. Often these characteristics are ranked
by number (or a severity level) as to how problematic they might be. Generally speaking,
the more experiences, behaviors, symptoms, and traits a dimensional system delineates,
the more accurate the resulting picture of the person will be (increased validity).
In my opinion, there is no doubt that a well-designed dimensional diagnostic system
can result in a highly accurate portrait of a patient, more accurate than a comparable
categorical diagnostic system can produce. There is also no doubt that, depending upon
the number of characteristics a clinician is expected to explore and the extent to which
the interviewer is expected to explore them, a dimensional system can be unwieldy and
impractical.
A Pivotal Step Forward in the DSM-5

The DSM-5 remains a diagnostic system that is primarily categorical in nature for
ease of use, but it is a system that has added important dimensional qualities. The addi-
tion of these dimensional qualities, in my opinion, is one of the most significant
advances of the DSM-5 from its predecessor, the DSM-IV-TR. In essence, the DSM-5 has
maintained the ease of use of a categorical system and yet has increased validity through
the use of judicious dimensional criteria. The DSM-5 even offers an alternative, hybrid
categorical/dimensional system (which emphasizes dimensionality) for delineating per-
sonality disorders that can be officially used in everyday practice if the clinician prefers
a more dimensional approach to personality differential diagnosis.
Dimensional diagnostic characteristics allow one to paint a more individualized
picture of a given patient’s experiences that better captures both the pain of the patient
and the immediate impact of the symptoms on the patient and his or her functioning.
The DSM-5 has accomplished this advance by expanding the “specifiers” that one can
add to any specific diagnosis.
For instance, experienced clinicians know all too well that some people afflicted with
obsessive–compulsive disorder (OCD) can develop obsessions that truly reach psychotic
proportions (i.e., the patient is absolutely convinced that they have dangerous germs all
over his or her hands and will die if hand washing is not done). This is, indeed, a very
different individual to a patient with OCD who feels his or her fear of germs is not
normal and wishes that he or she could stop the incessant hand washing for it is not
necessary. In the DSM-IV-TR there was no way to paint this description accurately; in the
DSM-5 the clinician can note whether the patient has one of three levels of insight: (1)
good or fair, (2) poor, or (3) absent or delusional in nature. Naturally, the presence or
absence of insight may have significant implications for both treatment and, equally
important, methods for securing the patient’s interest in that treatment.
With regard to mood disorders, many specifiers can be utilized. It is beyond the scope
of this book to review these in detail, but I urge the reader to become familiar with them,
for they can help one to more accurately uncover the phenomena being experienced by
the patient and communicate that distress more accurately to fellow clinicians.
By way of example, in the DSM-5, Depressive Disorders have the following specifiers:
(1) with anxious distress (including a severity dimension from mild to severe), (2) with
mixed features (allows one to include manic symptoms being concurrently experienced
by the patient), (3) melancholic features, (4) atypical features, (5) psychotic features, (6)
the presence of catatonia, (7) with peripartum onset (if the symptoms emerge during
pregnancy or 4 weeks postpartum), (8) seasonal patterns, (9) the presence of remissions,
and (10) severity (from mild to severe). In my opinion, the added dimensionality of the
DSM-5 has given it an even higher “descriptive essence” than previous DSM systems.
Throughout the chapters on differential diagnosis in Part II of this book, the role of
dimensionality will be addressed in those aspects where it can help us to provide better
care through better diagnostic acumen. We will soon see that it can play a critical role
in achieving a better understanding, recognition, and treatment of bipolar disorder in
particular for, I assure you, not all people who have manic episodes experience them in
the same fashion.
FIRST STEPS IN THE DIFFERENTIAL DIAGNOSIS OF MOOD DISORDERS

For the sake of discussion, let us assume that the material described in the following
clinical presentations has been elicited after roughly the first 40 minutes of an initial
interview. As the reader reviews this material, two points will become obvious: (1) all of
these people are in significant psychological pain, and (2) all of them appear depressed.
The next question facing the clinician is whether all of these people should be diagnosed
as having a true major depressive disorder or some other mood disorder such as bipolar
disorder or persistent depressive disorder (dysthymia). The following clinical illustrations
will focus on the various lines of questioning that an interviewer might use to sort out
this sometimes-difficult differential diagnosis.
In the first place, in order to diagnose accurately the clinician needs to be thoroughly
familiar with the basic criteria of DSM-5. This familiarization does not mean that the
clinician should obsessively memorize hundreds of criteria. On the contrary, this suggests
a working knowledge of what material is necessary to clarify the major diagnoses. This
diagnostic familiarization allows the clinician to focus on the art of eliciting the neces-
sary material while successfully engaging the interviewee. The establishment of a sound
therapeutic alliance, as usual, remains of paramount importance.
The diagnostic criteria for two of the most common depressive mood disorders in the
DSM-5 are reviewed below.2,3 Later in the chapter we will be addressing DSM-5 criteria
for other common mood disorders, such as bipolar I disorder, bipolar II disorder, and
cyclothymic disorder. The DSM-5 defines major depressive disorder and persistent depres-
sive disorder as shown below.
DSM-5 DIAGNOSTIC CRITERIA FOR MAJOR DEPRESSIVE DISORDER

A. Five (or more) of the following symptoms have been present during the same 2-week period and
represent a change from previous functioning; at least one of the symptoms is either (1) depressed
mood or (2) loss of interest or pleasure.
Note: Do not include symptoms that are clearly attributable to another medical condition.
1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g.,
feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In
children and adolescents, can be irritable mood.)
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly
every day (as indicated by either subjective account or observation).
3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body
weight in a month), or decrease or increase in appetite nearly every day. (Note: In children
consider failure to make expected weight gain.)
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective
feelings of restlessness or being slowed down).
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly
every day (either by subjective account or as observed by others).
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective
account or as observed by others).
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific
plan, or a suicide attempt or a specific plan for committing suicide.
B. The symptoms cause clinically significant distress or impairment in social, occupational, or other
important areas of functioning.
C. The episode is not attributable to the physiological effects of a substance or to another medical
condition.
Note: Criteria A–C represent a major depressive episode.

Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster,
a serious medical illness or disability) may include the feelings of intense sadness, rumination about the
loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive
episode. Although such symptoms may be understandable or considered appropriate to the loss, the
presence of a major depressive episode in addition to the normal response to a significant loss should
also be carefully considered. This decision inevitably requires the exercise of clinical judgment based on
the individual’s history and the cultural norms for the expression of distress in the context of loss.
D. The occurrence of the major depressive episode is not better explained by schizoaffective disorder,
schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified
schizophrenia spectrum and other psychotic disorders.
E. There has never been a manic episode or a hypomanic episode.
Note: This exclusion does not apply if all of the manic-like or hypomanic-like episodes are substance-
induced or are attributable to the physiological effects of another medical condition.
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright
©2013). American Psychiatric Association. All Rights Reserved.
DSM-5 DIAGNOSTIC CRITERIA FOR PERSISTENT DEPRESSIVE

DISORDER (DYSTHYMIA)
This disorder represents a consolidation of DSM-IV-defined chronic major depressive disorder and
dysthymic disorder.
A. Depressed mood for most of the day, for more days than not, as indicated by either subjective
account or observation by others, for at least 2 years.
Note: In children and adolescents, mood can be irritable and duration must be at least 1 year.
B. Presence, while depressed, of two (or more) of the following:
1. Poor appetite or overeating.
2. Insomnia or hypersomnia.
3. Low energy or fatigue.
4. Low self-esteem.
5. Poor concentration or difficulty making decisions.
6. Feelings of hopelessness.
C. During the 2-year period (1 year for children or adolescents) of the disturbance, the individual has
never been without the symptoms in Criteria A and B for more than 2 months at a time.
D. Criteria for a major depressive disorder may be continuously present for 2 years.
E. There has never been a manic episode or a hypomanic episode, and criteria have never been met
for cyclothymic disorder.
F. The disturbance is not better explained by a persistent schizoaffective disorder, schizophrenia, delusional
disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.
G. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse,
a medication) or another medical condition (e.g., hypothyroidism).
H. The symptoms cause clinically significant distress or impairment in social, occupational, or other
important areas of functioning.
Note: Because the criteria for a major depressive episode include four symptoms that are absent from
the symptom list for persistent depressive disorder (dysthymia), a very limited number of individuals will
have depressive symptoms that have persisted longer than 2 years but will not meet criteria for
persistent depressive disorder. If full criteria for a major depressive episode have been met at some
point during the current episode of illness, they should be given a diagnosis of major depressive
disorder. Otherwise, a diagnosis of other specified depressive disorder or unspecified depressive
disorder is warranted.
For the novice clinician, after reviewing the above criteria, the first step is to ensure that
one can readily recall them during the interview itself, a task that can appear a bit daunt-
ing at first glance. Cary Gross at Massachusetts General Hospital coined a mnemonic for
easily remembering the symptoms of depression, which was popularized by Danny
Carlat in his outstanding primer on clinical interviewing.4 The mnemonic is based upon
a well-known Latin abbreviation (“SIG”) found on all prescription pads for medication
(prescribers write how the medication is to be taken, as with once a day or twice a day
directly after the Latin word “SIG”). The idea is that the mnemonic represents a “prescrip-
tion” for recalling the symptoms of depression. The mnemonic is as follows – SIG: Energy
CAPSules. I find that for many prescribing clinicians, the acronym is easy to remember
because of their familiarity with this abbreviation. Interestingly, for many non-prescribing
clinicians it is equally easy to remember for the exact opposite reason, its oddness. See
what you think. Each letter represents one of the classic symptoms of a major depression
as follows:
Sleep disorder (either increased or decreased)

Interest deficit (anhedonia)
Guilt (worthlessness, hopelessness, regret)
Energy deficit
Concentration deficit
Appetite disorder (either decreased or increased)
Psychomotor retardation or agitation
Suicidality
Let us now proceed to our clinical presentations, for no one can better teach the nuances
of depression and bipolar disorder than the people experiencing their destructive power.
Note that, as in the rest of this book, all patient names are fictitious.
Clinical Presentations and Discussions

Clinical Presentation #1: Mr. Evans
Mr. Evans is a 61-year-old White single man who retired from a prestigious administra-
tive job at the police department 1 year ago. He is accompanied by his fiancée. With her
help he hopes to open a bar in the next 6 months if they can get a liquor license. Mr.
Evans is well groomed and dressed in a simple flannel work shirt and corduroy trousers.
He appears very sad and relates, “It seems strange, but I can’t really cry.” He speaks softly
and slowly, taking a while before answering questions as if the act of thought required
immense effort. On occasion, he tries to manage a smile. His eyes study the floor, seldom
meeting the eyes of the interviewer. His fiancée chimes in, “Nothing cheers him up. Lord
knows, I try. But nothing.” Mr. Evans complains of severe depression, of not being able
to enjoy anything, sleep disturbance, loss of appetite and libido, and severe loss of energy.
In the past 3 weeks he had held a loaded revolver to his head on several occasions. He
spontaneously reports seeing no future. Before she left the room, his fiancée, although
obviously concerned, appeared to be somewhat irritated and commented to the inter-
viewer. “He just won’t help himself no matter how much I try to help him. Now I’ve got
to meet with the Liquor Control Board agent alone next week.”
Discussion of Mr. Evans

The Painful World of Anhedonia: Its Role in Diagnosis
Major depressive disorders are common. In any given year in the United States about
7% of the population will meet the criteria for a major depressive disorder. Generally
speaking, beginning in adolescence, females experience a 1.5- to 3-fold higher rate of
depression. Interestingly, there is also a marked increase in prevalence in adolescence
and young adulthood, with 18–29 year olds having a threefold higher rate of major
depressive disorder compared to individuals 60 years and older.5 It is a disorder not to
be taken lightly, for up to 15% of patients with this disorder die by suicide.6
Mr. Evans demonstrates many of the classic symptoms of a major depression. In the
first place, Mr. Evans states clearly that he has a persistently depressed mood, thus fulfill-
ing one of the first two symptoms of criterion A needed for a diagnosis of major depres-
sion in the DSM-5. It is important to note that one does not need to feel “depressed” to fulfill
criterion A, because one needs the presence of either Symptom A-1 or Symptom A-2 for making
a diagnosis of a major depressive disorder.
You will recall that Symptom A-2 reads “Markedly diminished interest or pleasure in
all, or almost all, activities most of the day, nearly every day.” Symptom A-2 is essentially
an undeclared definition of anhedonia. The word “anhedonia” is a derivative of the Greek
word “hēdonē,” referring to pleasure, as also seen in the English word “hedonism.” In
anhedonia, one demonstrates a decreased ability to experience or to anticipate pleasure
or to develop interest. This alteration in the experience of pleasure is a common symptom
of depression warranting a careful search in the initial interview.
One of the ways in which to sensitively explore anhedonia is to discover first what
types of activities the interviewee enjoys in general, as we saw in our discussion of the
“wellness triad” from Chapter 6. Questions such as the following may be fruitful for
setting up such an exploration:
a. “What kinds of things do you like to do when you’re away from work?”
b. “In the past, have you generally enjoyed your work?”
c. “Do you have any types of hobbies or sports you enjoy?”
d. “Do you enjoy reading or watching TV?”
e. “Do you like surfing the web, looking at YouTube or online gaming or shopping?”
f. “How much time do you spend on social media like Facebook or Twitter?”
g. “In the past, have you enjoyed socializing?”
Often I will spend considerable time exploring these interests further, because they can
provide important insights to the clinician about the person’s viewpoints and psychologi-
cal integration, as seen, for instance, in the following:
Clin.: Do you enjoy reading or listening to music?

Pt.: I used to enjoy reading quite a bit … sort of odd stuff … (tiny smile) … like St.
Augustine, Thomas Aquinas, and other theological books.
Clin.: Sounds like pretty heavy reading?
Pt.: Yeah, it is. But I used to enjoy it. (pause) … I used to be fairly religious … used to
be (said with a trailing off of the voice).
From this dialogue it appears that religious themes may be important issues for this
patient, perhaps contributing to his depressive anxiety or perhaps offering potential
resources for healing. This questioning has not only laid the groundwork for the explora-
tion of possible anhedonia, but it has also served the dual function of gathering pertinent
intrapsychic material about the spiritual wing of the patient’s matrix, while further engag-
ing the patient. At this point one may continue the search for anhedonia with questions
referring to the groundwork laid above.
a. “Over the past several weeks have you felt like doing these activities?”
b. “Do you find it as enjoyable to do these things as you used to or has there been a
change?”
c. “Have you been feeling interested in your hobbies over the past several weeks?”
At times, interpersonal questions can uncover anhedonic complaints, as evidenced by

the following:
Clin.: You mentioned your grandchildren. Do you have a good time when you’re around
them now?
Pt.: (sigh) Sort of … Don’t get me wrong, I love my grandchildren, but I just can’t seem
to enjoy anything anymore, even them.
Uncovering the Neurovegetative Symptoms of Depression

What Are the Neurovegetative Symptoms of Depression?
Mr. Evans appears to be suffering from many of the neurovegetative symptoms of depres-
sion. Although it is difficult to find a standard definition of neurovegetative symptoms,
I view them as symptoms suggesting that basic regulatory physiology has been disturbed.
With such a definition in mind, in addition to anhedonia, the neurovegetative symptoms
can be listed as follows: change in appetite, change in weight, sleep disturbance, change
in energy, change in libido, altered concentration, and retarded or agitated motor activity.
Although not always labeled as neurovegetative symptoms, other common physiologic
correlates of depression exist including constipation, dry mouth, and cold extremities.
The neurovegetative symptoms are classic hallmarks of a major depressive disorder,
fulfilling many of the symptoms in Criterion A for this disorder in the DSM-5. If they
are not elicited spontaneously, they should always be actively sought. When done prop-
erly, such questioning powerfully engages the interviewee. It shows the interviewee two
reassuring characteristics: (1) that the interviewer is interested in the individual as a
person whose depression affects every aspect of his or her life, and (2) that the interviewer
is knowledgeable, as witnessed by the fact that the questions seem right on the mark.
Tips for Exploring Early Morning Awakening and Other Sleep Disturbances
Sleep disturbance warrants a thorough discussion. Part of the lore of psychiatry has been
that people suffering from major depressions often display early morning awakening.
The exact frequency of this phenomenon is not entirely clear, although there is good
evidence that both feeling worse in the morning and early morning awakening are fre-
quently present in depressive episodes. As we shall see later, in one type of severe depres-
sion, melancholic depression, both of these symptoms are quite common and quite
severe.
However, in my experience, early morning awakening of a milder, yet still disturbing
nature, is common in major depressive disorders of even a mild to moderate severity.
The symptom of early morning awakening often has a distinctive phenomenology.
It is not just that patients awaken earlier than they would like. It is that patients feel
as if they are abruptly awakened by a steady stream of unpleasant worries. They find it
extremely hard to shake these frets. Once one fret is gone, a new one appears. The worries
are often accompanied by a growing feeling that the prospective problems of the day are
insurmountable. It is very difficult to fall back to sleep, despite staying in bed. One of
my patients, a physician, elegantly captured the pain as follows:
It’s literally one worry after another. Frankly, the sensation is almost more like fear than
worry. You just know you can’t cope with everything you’re supposed to do that day. It’s
simply overwhelming (patient tears up). You just lay there and toss and turn. You absolutely
do not want to get up, because then you know that you have to start the day. On the other
hand, you’re miserable lying there in the bed (he pauses). What a horrible feeling, what
a mess. I wouldn’t wish it on anyone. And, you know, the really funny thing about it is
that it usually gets better as the morning goes on once I get up. I don’t know why I just
don’t make myself get out of the bed because there is no way I’m going to get back
to sleep.
I have found the following questions to be useful in spotting early morning

awakening:
“Do you find yourself sort of jolted out of your sleep in the mornings by worries and
frets, and you can’t get back to sleep?”
“Do you find yourself waking up earlier than you want to and your mind is filled with
worries and you just dread getting up, you just don’t feel you can face the day?”
Another curious, but logical, aspect of early morning awakening is the patient’s frequent
puzzlement that when they went to sleep they were feeling better. It feels as if the worries
somehow worsened during their sleep.
Other aspects of the patient’s sleep cycle are worthy of careful exploration for a variety
of reasons. Thorough questioning conveys to the patient that the interviewer is sensitively
interested in the day-to-day disturbances of the patient’s life caused by the depression.
Furthermore, sleep disturbances can also provide early clues to other diagnostic possibili-
ties. For instance, sleep continuity disturbances (e.g., waking up during the night) are
common not only in depression, but also in psychosis, drug and alcohol abuse, and in
the elderly. Difficulty falling asleep can also be seen in a variety of disturbances, includ-
ing depression, mania, anxiety disorders, substance use disorders, adjustment disorders,
and various psychotic processes.
Besides decreased sleep, one should also search for evidence of increased sleep or a
tendency for daytime sleeping. A reversed diurnal pattern of sleep, whereby the patient
sleeps during the day and remains awake at night, can be seen in entities such as depres-
sion, bipolar disorder, and schizophrenia. By eliciting a detailed sleep history, one may
also stumble upon an unsuspected primary sleep disturbance such as sleep apnea, nar-
colepsy, or nocturnal myoclonus.
Sensitively Asking Patients About Libido

With regard to anhedonia, mention should also be made concerning the investiga-
tion of libido. At times interviewers feel shy about asking about libido. Seldom
should this present a problem in engaging a patient if approached appropriately. In
the first place, the topic should be broached smoothly while in a natural context.
For example, if the clinician has been discussing the neurovegetative symptoms at
length one might ask:
“It sounds like your depression has really upset your system. Do you think it has also
affected your sexual drive?”
Alternatively, if the patient has been talking at length about the disruption of a romantic
relationship by depressive symptoms one might query:
“From what you are saying, it sounds as if your depression has been causing a lot of
tension between you and your husband. Do you think it has also affected your sexual
relationship?”
I would like to add several points about questions concerning libido. I have found many
patients relieved to know that decreased libido is a common feature of depression. Con-
sequently, after asking about libido, I might add, “I ask about sexual drive because basic
drives such as appetite and sexual desire are commonly decreased by depression.” To
such a statement, patients sometimes respond with sentiments such as “Thank God. I
thought my loss of desire was just another one of my failures.”
Another important issue is the tone of voice. If interviewers ask their questions
matter-of-factly, without hesitation, it greatly decreases the risk that the patient will
feel put off. In a different light, if the patient does react unusually strongly, then one
may have incidentally learned something about the patient’s views on sex, their body,
or on what is proper for them to disclose. Such information is grist for the mill in
later sessions.
As a final note, some people confuse sexual drive with actual intercourse. It sometimes
helps to clarify this issue with remarks such as “By sexual drive, I mean your interest in
having sex, not whether you are actually having it or not.” If this point is not clarified,
a patient who is not dating or in an intimate relationship may quickly state that libido
is absent, “since I’m not seeing anyone,” when in actuality a strong libido may be
present.
Gracefully Weaving the Neurovegetative Symptoms Into the Interview
Questions dealing with the neurovegetative symptoms should seldom be asked in a
checklist fashion with statements such as, “I need to ask a few questions now,” or “Let
me just go over a few things here.” Instead, as we saw demonstrated in Video Module
2.1 and will view again in Video Module 9.1, they should be imperceptibly woven into
the fabric of the conversation with appropriately spaced empathic statements – what we
referred to in Chapter 4 as a “blended expansion” – as shown below:
Pt.: I don’t know how to keep coping with all this strain, what with my hours at work
decreasing and now my wife on my back.
Clin.: You’re going through some tough times (empathic statement). Is this affecting your
sleep at all?
Pt.: Oh my God, yes. I can’t sleep at all.
Clin.: Tell me more about it.
Pt.: I’m waking up a couple of times a night. I just toss and turn thinking about Janet
and whether she’ll leave me. I don’t know why she stays, except I think she needs
the money.
Clin.: Sounds miserable (empathic statement). How many times do you think you
actually wake up?
Pt.: Maybe two or three, it’s pretty bad. Sometimes I have a hard time getting back to
sleep. I feel horrible in the morning, not rested at all.
Clin.: Roughly what time are you waking up in the morning?
Pt.: Around 5:00 A.M.
Clin.: Do you wake up naturally or are you sort of jolted out of your sleep by worries?
Pt.: Oh no, I feel horrible. I can’t get back to sleep no matter how hard I try. I just lay
there worrying. It ruins the whole rest of my day.
Clin.: What do you worry about?
Pt.: Oh, basically the job. My boss is really fed up with me. And he probably has a right
to be. I suppose that’s why he cut my hours. (pauses) … I guess I’m worried he’s
going to fire me. And then I worry about my marriage, my kids, money, you
name it.
Clin.: That’s a lot of worries. (said gently)
Pt.: It is. (patient smiles sheepishly) Trust me. It is.
Clin.: It sounds like the mornings are really a rough time for you. Are you having any
problems falling asleep too?
Pt.: Not really, and I never really have. Oh, maybe a little bit years ago, but not much
even now, just a little.
Clin.: Roughly how long does it take you to fall asleep?
Pt.: Maybe 10, 20 minutes.
Clin.: Well, it sounds like your sleep has been pretty disturbed. I’m wondering whether all
the loss of sleep has affected your energy at all?
Pt.: None. Everything is an effort. Just getting up is an effort. Trying to cut the grass is
like trying to swim the English Channel. I have no energy, no desire to do anything.
Clin.: What about your golf or your Kindle, you said you liked to read a lot?
Pt.: Sometimes I get a little satisfaction, but I really just don’t enjoy them anymore. I
haven’t golfed in 4 weeks, and I used to golf three times a week. When I was a
young man, I golfed five times a week. I haven’t picked up my Kindle in months.
Clin.: That must be an upsetting feeling, not wanting to do anything. (empathic
exploration)
Pt.: Yes it is (pause) … everybody just thinks I’m lazy … who knows. (through his
empathic exploration the interviewer has uncovered a pocket of guilt)
Clin.: It’s not uncommon for people with depression to lose their interest in things, it’s
not that you’re lazy. It’s really quite common in depression. (interviewer adeptly
assuages the patient’s guilt) Sometimes it even affects their appetite. Have you
noticed any change in your appetite?
Pt.: As a matter of fact, food doesn’t taste very good. I only eat two meals a day, and
sometimes I don’t even eat at all.
Clin.: Have you lost any weight?
Pt.: A little, I think.
Clin.: Are your clothes getting too big or loose?
Pt.: Actually, they are. I probably lost at least 10 lbs.
Clin.: Over how long a time did it take to lose that weight?
Pt.: Oh, about 2 months.
Clin.: So your appetite has decreased, your energy is low, and your interest in things has
decreased. What about your concentration? [and so on]
In summary, anhedonia and the other neurovegetative symptoms are critical areas to
explore when considering any mood syndrome such as a major depressive disorder or
persistent depressive disorder (dysthymia). Furthermore, by asking such questions, one
can gain a vivid picture of what depression feels like for the interviewee. To the inter-
viewee, the interviewer will appear to be one step closer to understanding.
The Concept of Melancholia

When we look back at the presentation of Mr. Evans, his anhedonia and neurovegetative
symptoms appear to be particularly severe. Indeed, he fits a dimensional specifier in the
DSM-5 called “with melancholic features.”7 Melancholia is a particularly severe variant
of depression that is more frequently seen in an older population. In order to fulfill the
criteria for melancholia the patient must be experiencing a loss of pleasure in all, or
almost all, activities and/or doesn’t feel much better, even temporarily, when something
good happens, as was reflected by the comment of Mr. Evans’ wife that, “Nothing cheers
him up. Lord knows, I try. But nothing.”
In addition, to warrant the specifier “melancholic” the patient must also have at least
three out of six of the specific symptoms described below, the first of which relates to a
distinctively unpleasant type of depressed mood. This phenomenologically distinct mood
is often experienced as a profound sense of despondency, often to the point of despair.
Sometimes it presents slightly differently, primarily being characterized by either a marked

moroseness or a so-called “empty mood.”
This “empty mood” consists of an overwhelming sense of no connection with life.
Patients have described this to me as if they have “no mood,” or make statements such
as, “I care about nothing.” It is as if the person were an abandoned house, empty of
dreams, activity, or light. It can be quite difficult to get the attention of a person experi-
encing these periods of empty mood. During the interview, you may find the patient
looking listlessly ahead or downward, almost as if you were not in the room. In many
respects, to the patient, you are not.
The other five criteria symptoms for a melancholic depression include a depression
that is worse in the morning, severe early morning awakening (at least 2 hours before
usual awakening), marked psychomotor agitation or retardation, significant anorexia or
weight loss, and excessive or inappropriate guilt. As mentioned earlier, the tendency for
the depression to be decidedly worse in the morning and the presence of a severe form
of early morning awakening often go hand-in-hand.
Anxiety: Another Important Dimensional Specifier

Although in older diagnostic systems, anxiety symptoms and depressive symptoms were
viewed almost as separate types of phenomena that clustered into two distinct categories
of disorder – mood disorders and anxiety disorders – it has become apparent that there
is much overlap. Indeed, from a phenomenological viewpoint it could be argued that
some so-called depressive symptoms, such as motor agitation and early morning awaken-
ing, are experienced by patients as more of an anxious than depressive process. In any
case, many people with depression experience anxiety and vice versa.
Whenever one explores depression, it is particularly important, in my opinion, to
carefully screen for anxiety. As Jan Fawcett has repeatedly shown in his research, and
explicitly warned in his writings, the presence of intense anxiety in depressive states
should alert the clinician to the potential for suicide.8–10 Moreover, patients who are
experiencing prolonged and/or intense anxiety coupled with impulsivity – as might
appear when manic qualities are also a part of the depressive soup, or as seen in a mixed
bipolar disorder – can be particularly prone to suicide. Fawcett emphasizes that the pres-
ence of actual panic attacks can significantly raise the risk of suicide.
Once again, the dimensional quality of the DSM-5 gently nudges clinicians to attend
to important aspects of clinical care, in this case, the risk of suicide and the role of anxiety
in its manifestation in patients presenting with a primary mood disorder. In the DSM-5,
the clinician’s rating of the dimensional factor of anxiety in a depressed patient (from
mild to severe) is not merely a diagnostic nicety; it is a sensitive probe towards a better
estimate of suicide risk.
The Role of Substance Abuse in the Differential Diagnoses of Depression

The information from the first 30 minutes of Mr. Evans’ interview highlights another
important issue. He relates that he hopes to open a bar with his fiancée. Further ques-
tioning revealed that Mr. Evans had had moderate problems with drinking in the past,
including evidence of both dependence and significant social dysfunction. He has not
been drinking for over 1 year. Drinking, drug abuse, and depression often go hand-in-
hand. Drinking itself can actually be an organic cause of depression. A variety of pieces
of research have indicated strong associations linking alcohol misuse with both depres-
sive and anxious symptoms and disorders.11
In most cases, these depressive symptoms clear after detoxification. But depressive
symptoms can continue up to 2 months after detoxification, with sleep disturbances
lasting as long as 6 months. Consequently, from an assessment perspective, when heavy
drinking is reported in an initial interview, the validity of the diagnosis of a major depres-
sive disorder is somewhat suspect and may best be viewed as a tentative diagnosis or a
rule-out diagnosis. Many clinicians would wait to see if the depressive symptoms remained
robust and present for some weeks after detoxification and sustained abstinence,
before considering the diagnosis of depression confirmed. In actuality, depressive symp-
toms triggered by the alcohol abuse can actually remain for many months after
detoxification.
As opposed to being caused by the drinking, the depression may precede the drinking
or coincide. In a sense, these patients may be self-medicating with either alcohol or drugs
as opposed to antidepressants. A true major depression is more likely if there is clear-cut
evidence of depressive symptoms before the onset of sustained drinking. In any case, no
survey of depressive symptoms is complete until a thorough drug and alcohol history
has been taken, both of current and past use.
Important Data Points When Taking a Past Psychiatric History

Mr. Evans’ case underscores another important point. Past psychiatric history may be very
valuable. In particular, the following material should be actively elicited:
a. Any past psychiatric diagnoses (if the patient is depressed, carefully search for a past
history of depression, mania, or hypomania).
b. Previous hospitalizations (names and dates of hospitalizations).
c. Previous outpatient treatment (including names of mental health professionals).
d. Previous medications (names, dosages, and length of time on medications). I also
often ask if the patient liked the drugs, or if he or she experienced side effects.
e. Previous psychotherapy (name of clinician and when). I often ask the patient’s
opinion of the psychotherapy, as well as a brief description of what he or she did in
therapy.
f. Any history of electroconvulsive therapy (ECT).
g. Current psychotherapies (current medications will be elicited in the medical history).
h. Past use of alternative medicine interventions (St. John’s wort, acupuncture, medita-
tion) and light therapy.
i. Periods of time when the patient feels that he or she could have benefited from
mental health care but did not seek it.
As we have noted before, time limits are tough in contemporary clinical practice. You
will often not be able to cover all of these past history points in the initial interview.
Instead, as time permits, the clinician will cover those that seem most important to this
particular patient’s history. Any past history that is missed can easily be garnered in the
next interview or by the clinician to whom the patient is being referred as an outpatient
or to inpatient staff.
Mr. Evans has provided an excellent gateway for understanding many of the elements
involved in making a differential diagnosis where a major depressive disorder is present.
He presents with many of the classic symptoms of a major depressive disorder, indeed,
with melancholic features.
In our next chapter we will explore in even more detail the complex phenomenology
of depression. We will see how an understanding of this phenomenology will lead us to
an array of sophisticated interviewing techniques for uncovering depression and engaging
those depressed patients and their families.
But we are not quite done with Mr. Evans, for our diagnostic impression is about to
be challenged. If we stop here, it seems that we are at risk of falling into a common and
easily sprung diagnostic trap. At this point, let us look at some further, revealing dialogue
with Mr. Evans.
Clin.: Mr. Evans, you’ve been explaining how very depressed you feel. I’m wondering if
there has been a time in your life, even in high school or college or as a young
man, or any time for that matter, when you felt just the opposite?
Pt.: I’m not sure I know what you mean.
Clin.: Well, has there ever been several days or even weeks when you felt really super
energized, didn’t feel a need for sleep, and just felt ready to take on the world. It
might have even happened right after you were feeling depressed and might have
seemed puzzling to you?
Pt.: (very faint smile) Hmm, yeah, I had some problems once, I was really on
the go.
Clin.: Tell me a little about that time.
Pt.: I was working real hard and suddenly it all became so easy, at least I thought it was
easy. It was when I first had become a police officer. I was really excited about my
career. I was really jacked up. It seemed like I just didn’t need sleep. I went for days
with only a couple of hours of sleep. I was like the Energizer Bunny.
Clin.: Did you start to speak rapidly or did any of your friends remark that you were
talking too fast?
Pt.: Yeah. The other officers began calling me motor-mouth. At first I thought that was
kinda funny. (pauses) … God, it all seems so foreign to me now. I’d give my right
arm for one-tenth of that energy right now.
Clin.: Certainly it would be nice for you to have some of that energy now, but do you
think that you might have had too much energy back then?
Pt.: Oh yeah, things got crazy back then.
Pt.: Well I didn’t really know what I was doing. I couldn’t get anything done well. Oh, I
started plenty of stuff, but I didn’t finish anything.
Clin.: Did you start to do anything you were embarrassed about, like spending too much
money or giving your money away?
Pt.: Oh yeah, yeah. I did. I wanted to help everybody. I wanted to help the prisoners.
That’s why I tried to let a couple of them go (pause) … and that’s when the Chief
called me in and told me I needed a rest, and they put me in a hospital.
Clin.: So things got so upsetting you needed a hospital?
Pt.: Oh yeah.
Clin.: What hospital was that?
Pt.: St. Anthony’s. It was a tolerable place.
Clin.: Have you ever had any other episodes like that one?
Pt.: Yeah, one other time but just for a couple of days. I didn’t think anything of it.
Spotting Bipolar I Disorder: Traps and Nuances

The above dialogue strongly suggests that Mr. Evans is not suffering from merely an
episode of major depressive disorder. Indeed, he is probably best viewed as having
bipolar I disorder in a depressed phase. In the United States, patients have been reported
as having a 12-month prevalence rate of bipolar I disorder of about 0.6%,12 with a life-
time risk of dying by suicide at least 15 times that of the general population.13
This patient illustrates one of the easiest traps to fall into when interviewing a severely
depressed patient. As both the interviewer and the interviewee become empathically
absorbed by the depressive symptoms, contextual clues suggesting mania do not appear.
Without such clues, the interviewer may forget to ask about current or past manic behav-
ior. The depressed patient may be too preoccupied with depressive thought content, as
was the case with Mr. Evans, to spontaneously bring up a manic history unless prompted
to do so. Consequently, one should always inquire about manic symptoms with every
patient. The DSM-5 criteria for mania and hypomania are as follows.14
DSM-5 DIAGNOSTIC CRITERIA FOR MANIA AND HYPOMANIA

MANIC EPISODE
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, and
abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and
present most of the day, nearly every day (or any duration if hospitalization is necessary).
B. During the period of mood disturbance and increased energy or activity, three (or more) of the
following symptoms have persisted (four if the mood is only irritable) are present to a significant
degree and represent a noticeable change from usual behavior:
1. Inflated self-esteem or grandiosity.
2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
3. More talkative than usual or pressure to keep talking.
4. Flight of ideas or subjective experience that thoughts are racing.
5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli) as
reported or observed.
6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor
agitation (i.e., purposeless non-goal-directed activity).
7. Excessive involvement in pleasurable activities that have a high potential for painful consequences
(e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business
investments).
MANIC EPISODE—Cont’d
C. The mood disturbance is sufficiently severe to cause marked impairment in social or occupational
functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic
features.
D. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a
medication, other treatment) or to another medical condition.
Note: A full manic episode that emerges during antidepressant treatment (e.g., medication,
electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that
treatment is sufficient evidence for a manic episode and, therefore, a bipolar I diagnosis.
Note: Criteria A–D constitute a manic episode. At least one lifetime manic episode is required for the
diagnosis of bipolar I disorder.
HYPOMANIC EPISODE
A. A distinct period of abnormality and persistently elevated, expansive, or irritable mood and
abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and
present most of the day, nearly every day.
B. During the period of mood disturbance and increased energy and activity, three (or more) of the
following symptoms (four if the mood is only irritable) have persisted, represent a noticeable change
from usual behavior, and have been present to a significant degree:
2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
3. More talkative than usual or pressure to keep talking.
4. Flight of ideas or subjective experience that thoughts are racing.
5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli) as
reported or observed.
6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor
agitation.
7. Excessive involvement in pleasurable activities that have a high potential for painful consequences
(e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business
investments).
C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the
individual when not symptomatic.
D. The disturbance in mood and the change in functioning are observable by others.
E. The episode is not severe enough to cause marked impairment in social or occupational functioning
or to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic.
F. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a
medication, other treatment) or to another medical condition.
Note: A full hypomanic episode that emerges during antidepressant treatment (e.g., medication,
electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that
treatment is sufficient evidence for a hypomanic episode diagnosis. However, caution is indicated so
that one or two symptoms (particularly increased irritability, edginess, or agitation following
antidepressant use) are not taken as sufficient for diagnosis of a hypomanic episode, nor necessarily
indicative of a bipolar diathesis.
Note: Criteria A–F constitute a hypomanic episode. Hypomanic episodes are common in bipolar I
disorder but are not required for the diagnosis of bipolar I disorder.
Bipolar I Disorder
Over the years, several different types of bipolar disorder have been delineated. The classic
form of bipolar disorder, which Mr. Evans would prove to be suffering from, is now called
“type I” in the DSM-515 and consists of one or more major depressive episodes with at
least one full-blown manic episode at some point in the history or a patient who presents
solely with a single episode of mania (such patients generally will subsequently show
depressive episodes, and a lifetime course consisting only of manic episodes is a relative
rarity).
In bipolar I disorder, the mean age of onset for the first manic, hypomanic, or depres-
sive episode is around 18 years of age. But earlier-aged adolescents (and some children)
may show manic symptoms.16 Mania can first appear after age 50 as well. (Late-appearing
manias should alert the clinician to hunt for disease states related to structural damage
to the brain, as with frontal lobe tumors or degenerative processes such as neurocognitive
disorders [NCDs] that happen to impact more on behavior, personality, and language
– as opposed to the memory deficits that hallmark the more classic presentation of NCDs
such as dementias.) Manic episodes tend to come on fairly abruptly, usually over the
course of days and can be quite startling and “unexplainable” to both the patient and
family members.
I have found, though, that if the patient and family members are questioned carefully,
they often describe early warning signs, sometimes unique to a specific patient, of
impending mania. These signs may appear over the course of weeks. These early warning
signs, if present, can prove to be invaluable in preventing relapse.
I remember a family interview in which I asked everybody in the room if they could
think of anything else that warned them that their dad was heading for a manic break.
There was a pause. One of the older sons piped up, “Oh yeah,” shaking his head from
side to side with an almost resigned sense of the inevitable, saying, “That hat with the
little Swiss feather. It’s a fedora, and, Dad,” turning towards his dad, “when you pull that
damn hat out of the closet, I book tickets for a quick vacation, because you’re gonna be
a wild man within 2 weeks.” The entire family burst into laughter, including the patient.
The “positive fedora sign” would prove to be an invaluable early harbinger of an impend-
ing manic episode with Dad.
Manic episodes tend to last for several weeks to several months, although some
patients may tend to show significant partial symptoms between episodes. Compared to
depressive episodes, they tend to be of shorter duration and, as was the case with onset,
they tend to end more abruptly. Roughly 60% of manic episodes immediately precede
a major depressive episode.17 Many patients will show a characteristic style to these
switches that can serve as a “fingerprint,” helping the patient, family members, and clini-
cians to better predict upcoming episodes and hopefully prevent them.
Classic Euphoric Mania

In the prototypic manic episode, the patient seems to exhibit the opposite symptom
picture from depression, with an elated (euphoric) mood, a grandiose sense of skill and
mission, extremely high energy, and little need for sleep (often sleeping only a couple
of hours per night and sometimes going for days with next to no sleep). Manic patients
are also often hypersexual as well. Indeed, in a euphoric mania the patient’s presentation
almost seems to resemble a carbon opposite of the neurovegetative symptoms found in
withdrawn depression.
Manic patients often exhibit striking changes in speech. They generally demonstrate
a fast, pressured, and loud speech, throughout which they often crack jokes and speak
on a plethora of barely related topics (thus appearing easily distracted). The term “flight
of ideas” – seen as one of the manic criteria in the DSM-5 – refers to a style of speech
originating from these manic tendencies. In flight of ideas, the speech is greatly speeded
up (as are the patient’s thought processes) and although a logical connection between
thoughts is generally maintained, the connection is at times tenuous. The flow of the speech
abruptly shifts from topic to topic, not infrequently triggered by external stimuli, plays
on words, or humor.18 In severe manifestations, the associations are so weak and so fast
that the patient’s language may appear to be disorganized and incoherent.
When I was writing this section on mania, I had one of the most remarkable synchro-
nous events of my life. In a strange way it would prove to be of immediate value to us
in our discussion of mania. I often write in the library of a local college and was stepping
out of a study room for a break. At the time of the break, I was trying to decide what
patient I wanted to describe in the chapter to illustrate a euphoric mania.
As I opened the door, I was abruptly confronted by a man who had his hand raised
as if he was about to knock on the door. He appeared to be in his late 50s, with a rather
wildly arranged patch of grey hair sprouting from his balding head. Without my saying
anything, he immediately proclaimed, “I just did 15,000 jumping jacks in 30 minutes.
It’s a world record. I’m heading for Ripley’s.” Needless to say, I found this greeting a bit
odd. But, things were about to get a good deal odder.
As I stepped into the hallway, I saw that Mr. Matthews, as we shall call him, looked
a bit winded and was dressed in worn clothes inadequate for the wintry weather. I saw
before me a man who was jubilantly pleasant and spoke with great speed and excitement
about his recent exploits, of which there were many.
He stood uncomfortably close to me, and as I would gently step away to increase our
interpersonal distance, he followed, maintaining his inappropriate closeness. In addition,
he had an intense affect with very direct and unyielding eye contact. I must admit that
despite the uncomfortableness of our interpersonal spacing, he was rather fun to engage,
not unlike encountering Santa Claus on speed.
He gestured with enthusiasm as he commented, “You know, I walked around the
Grand Canyon backwards.” At which point he proceeded to do his best imitation of a
Michael Jackson moonwalk. He quickly added, “I can do a hundred backhand push-ups
in a row, want to see?” Before I could say no, he was on the ground doing a perfect set
of six backhanded push-ups (I might add, a physical feat that is quite hard to do at any
age).
An unwary student stumbled upon us, who Mr. Matthews immediately engaged with;
“Hey, you know me, everybody knows me, I give talks at schools all over the country, a
greatly admired athlete with college students, right? Frank Lloyd Wright, get it? I build
buildings, the best in the business. Watch me as I fall into the waters. Get it? Right?” Mr.
Matthews smiled and began laughing. At which point the student dully nodded yes and
glanced anxiously at me. For those unfamiliar with Frank Lloyd Wright, he was a highly
innovative architect, who happened to build a residence in Western Pennsylvania called
“Falling Waters.” One cannot find a much better example of a flight of ideas.
Mr. Matthews was demonstrating a classic euphoric manic presentation. His presenta-
tion highlights several points not delineated as DSM-5 diagnostic criteria per se, but they
are subtle phenomenological symptoms and behaviors frequently seen in euphoric
manias.
People experiencing a euphoric mania often show disruptions in the acceptable non-
verbal rules for conversation, ranging from proxemic to paralanguage abnormalities.
They frequently create a profound (and uncomfortable) increase in the sensation of
immediacy (see Chapter 8, page 286) caused by their invasion of personal space. This
uncomfortable immediacy sensation is exacerbated by the loudness of their voices and
the directness of their eye contact. It is sometimes further accentuated by an unpleasant
body odor, for during a manic fury, bathing quickly drops to a low rank on the patient’s
daily “to do” list.
As the above exchange involving Mr. Matthews demonstrates, patients coping with
euphoric mania sometimes assume a false familiarity, abruptly engaging bystanders in
conversation in which they assume the bystander already possesses information as if they
had previously conversed. They often also display what I like to call a “demonstration
propensity,” as was aptly displayed by Mr. Matthews with both his moonwalking abilities
and his ability to perform backhanded push-ups.
With someone whose mania is as advanced as Mr. Matthews, it is easy to spot a mania.
But with much earlier manias, these same propensities may show themselves in muted
forms that, if recognized by a savvy clinician, can lead to the early detection of a hypo-
manic or manic episode with resulting interventions that can prevent a tremendous
amount of pain. Early intervention with mania can dramatically decrease its impact and
ferocity, and may also lessen the number of medications and the sizes of the doses
required to reverse the mania.
Before leaving the topic of spotting a euphoric mania, I want to mention a point that
at first can appear to be paradoxical. All is not necessarily “rosy” inside the mind of a
person displaying a euphoric mania. Besides showing an irritability that can also be seen
in depressed patients, those experiencing a euphoric mania often display a peculiarity of
affect called “affective lability.” A patient experiencing affective lability can move from
laughter to tears remarkably easily and sometimes back again in a matter of moments.
In addition, euphoric manic patients can become remarkably impulsive, a characteristic
of mania that often results in a darker side to the manic break (far from euphoric in
nature), including substance abuse, car wrecks, and both violence and suicide.
It is this violent unpredictability that I most want to emphasize to the reader. It is
important to realize that even in so-called “euphoric” manias, elements of anger and
irritability may lie just below the surface. A state of euphoric mania, as described above
with Mr. Matthews, can transform quickly into an angry and hostile state, sometimes
prompted by the patient responding to limit setting or an attempt to structure the inter-
view itself. Indeed, when I tried to re-direct Mr. Matthews, saying “Why don’t you and I
move downstairs to the lobby,” he turned on me angrily, snapping “Don’t push me
buddy. I’m talking to this student right now.” He then smiled and continued rambling
away to the student.
Especially in an emergency department or on an inpatient unit, be on the alert when
interviewing patients with a “happy mania.” Be particularly on-guard if the patient is
pacing and seems intent on getting his or her way. I have seen such patients turn hostile,
and even violent, in a matter of seconds. We will also soon see that manias are often not
purely “euphoric,” but can come in all forms of mixtures and disguises. But first, Mr.
Matthews brings to light another common aspect of manic presentations.
Psychotic Process in Mania

Mr. Matthews also raises one final point regarding bipolar disorder, albeit an important
one. His grandiose statements appeared to be delusional in nature. If I had performed a
clinical interview pressing him on his insight, I suspect I would have found that they
were truly delusional in nature. About 60% of patients with bipolar disorder will show
some psychotic symptoms, such as delusions or hallucinations, over their lifetime.
As illustrated by Mr. Matthews, most manic delusions consist of mood-congruent
themes such as religious destinies (“I am the Christ”) or special powers (as with 15,000
jumping jacks in 30 minutes). The term “mood-congruent” means that the patient’s
delusional or hallucinatory content seems to fit their immediate mood in a logical sense.
Thus mood-congruent delusions in a depressed patient tend to be of a depressed nature
(such as guilty concerns, death, self-loathing, etc.). Mood-congruent psychotic process
during a manic episode suggests themes of grandiosity, remarkable powers, identifying
as an extraordinary historical or religious figure (such as the Christ or Allah). In contrast,
when patients have mood-incongruent psychotic process, the hallucinations and delu-
sions do not fit the mood or are unrelated to the patient’s mood state, and are possibly
bizarre or paranoid in nature.
Mendelson nicely summarizes bipolar psychotic process, adding that about 30 to 40%
of manic patients will have mood-incongruent delusions such as being controlled by
others. Interestingly, about 25% of patients with bipolar disorder will experience psy-
chotic process during their depressions, a fact often missed by clinicians. This rate is
more than four times more frequent than the rate of psychotic process in unipolar
depression.19
Other psychotic processes, such as auditory hallucinations, are common, especially in
mania. Although relatively infrequent, patients have been known to self-mutilate (enu-
cleate their eyes, mutilate their genitalia) or even kill themselves or others in response
to command hallucinations during a manic episode. We will study how to effectively
uncover such dangerous ideation in our chapters on psychosis. At this point let us return
to Mr. Evans.
The Importance of Family Members and Collaborative Sources When Delineating Mania
A subsequent telephone interview with Mr. Evans’ quite elderly mother revealed that he
had demonstrated many of these classic features in his manic episode, which, in reality,
occurred more than 30 years ago. He had been working, as he said, on a police force,
but in a very small rural town in Pennsylvania. Over the course of several days he began
talking very rapidly. His patrol partner became progressively worried about him, as he
regaled him with news of his latest project. He was writing a three-book series on “How
Police Officers Need to Be Nicer to People.” He had not bathed for over a week and also
reported that sleep was for “lower forms of life.”
His mother related that both at home and in the police station he was talking con-
stantly and was a veritable one-man comic monologue. His mother commented dryly,
“He thought he was hysterically funny. He wasn’t.” When asked about hypomanic epi-
sodes in the past she commented, “I am very proud of him and he has done some
wonderful things as a police officer over his life, helped a lot of people; but he was always
my most unique child. I used to call him, my little nutball.” She also mentioned that
when he experienced his one actual manic episode, he had seemed to have problems
thinking straight. When asked what this meant, she described him as having problems
concentrating and remembering things.
There is one other detail from the interview with Mr. Evans’ mother that provides an
important lesson for any clinician. At one point she commented, “Did he tell you that
he pulled a knife on his dad during that manic break. It’s something we didn’t tell the
police department about.” Here was a salient point that Mr. Evans had not shared with
me during the interview, nor was his fiancée aware of it.
This telephone interview with Mr. Evans’ mother highlights several important clini-
cal points. People will often downplay past episodes of mania. I believe it is natural
to do so. Mr. Evans had gone on to have an outstanding career in the police force.
Being in an extremely small town, the police chief eventually decided to overlook
Mr. Evans’ brief manic interlude, eventually allowing him back on the force. It would
have been uncomfortable for Mr. Evans, during our interview, to think back on the
embarrassing behaviors that were present during his manic episode, especially any
violent behaviors. On a conscious level, the behaviors caused by a manic process are
often embarrassing (or guilt producing) for patients. To protect the patient from such
memories, on an unconscious level, defense mechanisms such as rationalization,
repression, and denial may bury the details of a manic episode deep into the uncon-
scious of the patient. Consequently, it is common for past manic episodes to be
“sealed over.”
In the light of this, it is often important, if one uncovers a hint of history suggesting
some hypomanic or manic symptoms in an initial assessment, to interview family
members and other collaborative sources that might provide a more accurate picture of
the severity of the manic symptoms, as was the case with Mr. Evans’ mother. Also keep
in mind that both patients and family members often do not spontaneously report
hypomanic episodes unless the interviewer specifically asks about them, for the hypo-
manic symptoms seem so inconsequential compared to the manic or depressed
symptoms.
Cognitive Deficits in Mania

Comments by Mr. Evans’ mom on his “problems thinking straight” remind us that there
is considerable evidence that patients with manias, as well as with depressions, may have
specific cognitive deficits not caused simply because they are “wound-up” and having
difficulty with attention. The manic process may actually cause cognitive dysfunction.20–22
This cognitive dysfunction may persist even when the patients are euthymic (a term
indicating normal mood where there is no evidence of depression or mania).23,24
If manic patients become seriously sleep deprived, as well as dehydrated and
physically exhausted by a manic overdrive that may stretch for weeks, they can present
with a delirium accompanied by all of the cognitive dysfunction typical of a deliri-
ous state. On very rare occasions, serious cognitive dysfunction and frank confusion
can occur as a typical part of a person’s manic presentation. I have seen this only
one time in my career. It was with a college student with extremely rapid cycling
(multiple switches per day). In this patient, both his girlfriend and his parents related
that in the hour before his manic episodes, he would sometimes appear slightly
confused or cognitively impaired. For instance, one time he seemed confused about
how to drive home and was manic half an hour later. In such instances it is impor-
tant to rule out a seizure disorder, such as partial complex seizures, that could mimic
such a presentation, although this patient proved to be seizure free and responded
well to lithium.
Differential Diagnosis on Mr. Evans and Summary of Key Interviewing Tips

With regard to Mr. Evans, a summary of his diagnostic formulation seems in order. There
was no evidence of a personality disorder upon further interviewing. Concerning any
physical disorders, Mr. Evans complained of chronic and painful osteoarthritis in his
knees.
Although there is no multiaxial system in the DSM-5, it is a diagnostic system that
strongly urges the interviewer to always explore for personality dysfunction and the pres-
ence of medical conditions. Consequently, as I mentioned earlier in the book, I find it
useful to indicate the presence or absence of these disorders, almost as if Axis II and Axis
III from the DSM-IV-TR still existed. By doing so, I remind myself of the importance of
always searching for personality dysfunction and for the presence of medical disorders
with every patient. This documentation in the electronic health record (EHR) also indi-
cates to future readers of the EHR whether or not the interviewer carefully looked for
these disorders. If one carefully looked for a personality disorder and found none, if one
does not document this fact clearly in the EHR, as in “none found,” the reader of the
document will have no idea if the previous clinician even looked for personality
dysfunction.
Mr. Evans’ formulation might appear as follows:
General Psychiatric Disorders:

Bipolar I disorder, major depressive episode (with melancholia)
Alcohol use disorder (in remission)
Personality Disorders:
None found
Medical Disorders:
Chronic osteoarthritis
Before leaving the discussion of Mr. Evans, some key differential diagnostic points are
worth reiterating.
1. A major depressive episode may present without the reporting of a depressed mood.
Instead the patient will be experiencing a markedly diminished interest in pleasure
in all, or almost all, activities most of the day, nearly every day (anhedonia).
2. Early morning awakening has quite distinctive qualities that can help the interviewer
spot it, while simultaneously engaging the patient more effectively. Severe early
morning awakening is common in melancholic depressions.
3. Neurovegetative symptoms should be artfully woven into the fabric of the interview
via blended expansions and should not be used in a checklist fashion.
4. Alcohol and drug abuse are commonly associated with depression. What may appear
as a major depressive episode may actually be primarily related to alcohol or street
drugs.
5. When patients present with depression, especially a severe episode, it is easy for the
interviewer to forget to ask about manic or hypomanic symptoms, yet it is imperative
to do so.
6. Past manic and hypomanic episodes may not be spontaneously reported and should
always be elicited.
7. It is both natural and common for patients to “seal over” past manic symptoms
because they are embarrassed by them or unconscious defense mechanisms have
hidden them. In such instances, family members may provide more accurate
information.
8. Do not be lulled by the pleasant interactions of a person with a euphoric mania.
People experiencing the euphoria of mania can quickly become irritated and angry,
at which point the interviewer should be on the lookout for potential violence.
Clinical Presentation #2: Danny Ramirez

Danny is an 18-year-old high school senior, a second generation Latino, whose dad is
the principal of the local middle school. Danny has always been an excellent student
and is active in community service. Of his many accomplishments, he is proudest of his
being part of an environmental group that helped to revitalize a park area for the inner
city, a project that received note in the official record of the House of Representatives
in his home state. Throughout his life he has always enjoyed people and has been fas-
cinated by various aspects of life, from a boyhood crush on Shakira to computer pro-
gramming as an adolescent (although he still thinks Shakira is hot). At 8 years old, he
developed severe OCD. His mother commented, “He’s always been a really intense kid,
I just wish he didn’t take things so seriously.” For many years he experienced what were
believed to be reactive depressive symptoms in relation to the great difficulties caused
by his OCD. But in high school, the depressive symptoms became much more striking.
His angst became so great that his therapist became concerned about suicide. He cried
frequently, reported problems concentrating and getting to sleep. Appetite was mildly
decreased and mood reported as, “I’m always depressed. Life is shit.” In addition, he
was very irritable and bitterly angry at the world. His personality became much “darker”
throughout high school, with three episodes of superficially cutting his wrists. Despite
a very good relationship with his parents, he could become hostile and dramatic with
them. One time when asked about having just scratched his wrists by his parents, Danny
startled his parents by yelling loudly and angrily, “I just wanted to see my blood, I’m
in so much pain!” The above information has just been elicited by a psychiatric consul-
tant at the request of Danny’s therapist (who feels he should be started on an
antidepressant).
Discussion of Danny Ramirez

Bipolar I Disorder, Mixed Presentation
History Repeats Itself: An Evolving Diagnosis
Before discussing Danny’s presentation, it is useful to review, from a historical perspec-
tive, a type of bipolar disorder we have not yet encountered – a mixed bipolar presen-
tation. Historically, it is interesting to note that according to the DSM-IV-TR, to meet
the criteria for a mixed bipolar disorder a patient needed to exhibit, for at least a
week’s duration, the required diagnostic criteria for both a mania and a depression
simultaneously.
The first time I encountered this phenomenon, I was stunned by its apparent oddness.
The patient, an X-ray technician, was in his mid-30s. He had a scraggly beard and a pair
of wild eyes. He could barely sit still. He kept leaning forward as if about ready to bolt
from his chair. His speech was extremely rapid and pressured with a tangential quality,
suggesting mania. Yet the content of his speech was markedly depressive, with guilty
ruminations, self-derogatory exclamations, and suicidal ideation. Within a split second
his eyes would fill with tears, but just as quickly his face would transform into laughter.
Such incongruities of behavior, affect, and thought content should alert the interviewer
to a possible mixed state. According to the DSM-IV-TR, during a mixed presentation
individuals often experience rapidly alternating moods (sadness, irritability, euphoria).
Such patients can also experience agitation, irritability, anger, insomnia and appetite
dysregulation, and may show psychotic and/or suicidal thinking.25
All of these traits are, indeed, characteristic of mixed bipolar states. But the DSM-IV-
TR had a major problem with regard to its criteria requirements for a mixed bipolar
disorder: It was the fact that its supposedly “prototypic picture” or “common presenta-
tion” of a mixed bipolar disorder was neither prototypic nor common. Although patients
certainly can present with episodes in which they simultaneously demonstrate the criteria
meeting both a depressive episode and a manic episode, in my entire career, I have only
ever seen one patient who met the criteria for both simultaneously – our X-ray technician,
above.
However, partial mixed states, in which patients show mixtures of depressive and
manic symptoms in varying numbers and combinations, appear to be relatively common
presentations.26–30 Indeed, Goodwin and Redfield, in a recent edition of their classic text
on bipolar disorder, state that research data suggests that, “… using broader criteria for
mixed states, incorporating the clinical concept of dysphoric mania and perhaps also
agitated depression, in patients with bipolar disorder, would result in more than 50% of
episodes in bipolar disorder being diagnosed as mixed states.”31
In this regard, the ubiquitous nature of mixed bipolar states suggests that the depic-
tion of depression and mania as being polar opposites may not be as clear-cut as was
once thought. Indeed, mania and depression may not represent opposite categorical
entities. Instead, they may be better conceptualized as being part of a continuum.
The concept of mixed bipolar states receives support not only from recent research
findings, but also from a most curious source – the past. In fact, it is probably inaccurate
to state that modern psychiatry is discovering mixed bipolar states. In actuality, modern
psychiatry, as suggested by Goodwin and Redfield, as well as others, is more accurately
described as re-discovering the concept of mixed bipolar states.
In the late 1800s and early 1900s, these states were well defined by European psychia-
trists, who were interested in both phenomenology and descriptive psychopathology.
Emil Kraepelin, one of the greatest of the descriptive psychiatrists, devoted an entire
chapter to mixed bipolar states in his Lectures on Clinical Psychiatry,32 and he talks of
“depressive or anxious mania” and “excited depressions” in his book Manic-Depressive
Insanity and Paranoia.33 Indeed, in 1899, Kraepelin viewed mixed states as the most
common type of presentation of bipolar illness and carefully delineated six distinctive
mixed states.34 And Kraepelin was far from alone.
The great Eugen Bleuler, who for 25 years was a professor at the University of Zurich
and Director of the famed Cantonial Hospital at Burghölzli, found that mixed states can
present as unique, stable, and particularly destructive conditions.35 His observations on
the tendency of mixed bipolar states to have more severe presentations has been proven
to be remarkably on the mark by more recent research. As early as 1882, Wilhelm
Griesinger, writing from the University of Berlin, described a specific mixed state – “mel-
ancholia with destructive tendencies” – that, as we shall soon see, seems to capture the
very essence of what is now sometimes called a dysphoric mania.36
The concept of mixed bipolar states is not merely a fascinating novelty of modern
research or a quaint finding of distant phenomenological inquiry, it has major impli-
cations for contemporary intervention and healing. Patients that are showing a mixed
bipolar presentation, who are quite depressed but also have several manic symptoms
(but not enough to meet the criteria for a full mania – as would have been neces-
sary for the diagnosis of a mixed bipolar disorder in the DSM-IV-TR system), are
in my opinion fairly common. In the DSM-IV-TR, their bipolarity would often have
been unrecognized, and they would have been misdiagnosed as having agitated
depressions.
Consequently, I suspect that in the past several decades, many of these patients who
might have benefited from mood stabilizers (such as lithium or Depakote) did not
receive them. Moreover, many of them may have worsened when given antidepressants
(as this can sometimes unleash manic symptoms, as we shall discuss later in this
chapter), some with devastating results. It was up to the DSM-5 contributors to change
the fashion in which clinicians conceptualized bipolar process so that these errors in
treatment could be avoided. It was the concept of dimensionality that once again proved
to be the key.
A Practical Solution From the DSM-5

In contrast to the DSM-IV-TR, the DSM-5 does not make it necessary to meet the criteria
for both a mania and a depressive episode simultaneously in order to make the diagnosis
of a mixed bipolar disorder. Keeping in mind recent research findings, as well as recog-
nizing the value of historical descriptive psychopathology, the designers of the DSM-5
have created a system that allows one to more accurately describe and recognize people
coping with mixed bipolar states. You will notice in the following DSM-5 descriptions
that once a patient has met the criteria for either a depressive episode or a mania, he or
she only needs three criteria of the opposite state in order to be viewed as having a mixed
state. This flexibility is much more in tune with the reality of mixed presentations, hope-
fully allowing clinicians to make better treatment decisions.37
DSM-5 DIAGNOSTIC CRITERIA FOR MANIC OR HYPOMANIC EPISODE,

WITH MIXED FEATURES
A. Full criteria are met for a manic episode or hypomanic episode, and at least three of the following
symptoms are present during the majority of days of the current or most recent episode of mania or
hypomania:
1. Prominent dysphoria or depressed mood as indicated by either subjective report (e.g., feels sad
or empty) or observation made by others (e.g., appears tearful).
2. Diminished interest or pleasure in all, or almost all, activities (as indicated by either subjective
account or observation made by others).
3. Psychomotor retardation nearly every day (observable by others; not merely subjective feelings of
being slowed down).
4. Fatigue or loss of energy.
5. Feelings of worthlessness or excessive or inappropriate guilt (not merely self-reproach or guilt
about being sick).
6. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific
plan, or a suicide attempt or a specific plan for committing suicide.
B. Mixed symptoms are observable by others and represent a change from the person’s usual
behavior.
C. For individuals whose symptoms meet full episode criteria for both mania and depression
simultaneously, the diagnosis should be manic episode, with mixed features, due to the marked
impairment and clinical severity of full mania.
D. The mixed symptoms are not attributable to the physiological effects of a substance (e.g., a drug of
abuse, a medication, other treatment).
DSM-5 DIAGNOSTIC CRITERIA FOR DEPRESSIVE EPISODE, WITH

MIXED FEATURES
A. Full criteria are met for a major depressive episode, and at least three of the following manic/hypomanic
symptoms are present during the majority of days of the current or most recent episode of depression:
1. Elevated, expansive mood.
Continued
DSM-5 DIAGNOSTIC CRITERIA FOR DEPRESSIVE EPISODE, WITH

MIXED FEATURES—Cont’d
3.
More talkative than usual or pressure to keep talking.
4.
Flight of ideas or subjective experience that thoughts are racing.
5.
Increase in energy or goal-directed activity (either socially, at work or school, or sexually).
6.
Increased or excessive involvement in activities that have a high potential for painful
consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish
business investments).
7. Decreased need for sleep (feeling rested despite sleeping less than usual; to be contrasted with
insomnia).
B. Mixed symptoms are observable by others and represent a change from the person’s usual
behavior.
C. For individuals whose symptoms meet full episode criteria for both mania and depression
simultaneously, the diagnosis should be manic episode, with mixed features.
D. The mixed symptoms are not attributable to the physiological effects of a substance (e.g., a drug of
abuse, a medication, or other treatment).
Note: Mixed features associated with a major depressive episode have been found to be a significant
risk factor for the development of bipolar I or bipolar II disorder. As a result, it is clinically useful to note
the presence of this specifier for treatment planning and monitoring of response to treatment.
Note that when making these diagnoses, the DSM-5 also allows you to add the dimen-
sion of anxiety as a specifier. I believe this added dimensional flexibility of the DSM-5
is important, for many mixed bipolar states, in my opinion, also have significant anxiety
components. Using the specifiers for mixed states and anxious distress, clinicians can
often paint a more valid picture of the patient’s unique combination of symptoms when
experiencing mixed bipolar process. There are as many types of mixed bipolar states as
there are combinations of these depressive, manic, and anxious symptoms. Armed with
a diagnostic system (the DSM-5) that allows one to recognize the unique qualities of
each person’s experience of bipolarity, we can now take a more careful look at Danny’s
presentation.
“Dysphoric Mania”: One Type of Mixed Bipolar Disorder
Differentiating a Dysphoric Mania From an Agitated Depression
Danny’s presentation is instructive for several reasons. As diagnostic systems such as the
DSM-5 evolve and are implemented, it is hoped that the improved degree of understand-
ing provided by the dimensional qualities of the system may allow us to uncover new
categories of illness that can be more quickly spotted. In a paradoxical sense, dimensional
systems sometimes help to ferret out hidden categorical entities. Danny may well repre-
sent one of these advances.
For years there has been debate as to whether or not one of the mixed bipolar states
may be common enough (and demonstrate enough consistency of symptom pattern) to
warrant a separate sub-category within the diagnosis of mixed bipolar disorder, in a
similar sense that we now can specify some major depressive disorders as being “melan-
cholic” in nature. As noted previously, early phenomenologists seemed to be aware of a
style of mania that seemed to be in contrast to “euphoric mania.” This type of mixed
state seems to fit fairly closely to what in today’s literature is sometimes referred to as a
“dysphoric mania.”
The issue remains debated. I personally agree with authors such as Strakowski and
colleagues that one must be careful in creating new categories until appropriate research
has been undertaken to show their validity, reliability, and usefulness.38 But it is my hope
that the dimensional advances of the DSM-5 will allow us to eventually clarify the issue.
Danny may very well represent this particular type of mixed bipolar state.
Dysphoric mania is a state that I believe will eventually prove to have validity as a
specifier, and I also believe it has potentially major therapeutic implications when uncov-
ered during an interview. It is worth spending some time understanding its nuances and
its implications for clinical interviewing.
If you will recall, Danny was 18 years old. He was presenting with a severe depression
that was of concern to his therapist because of the risk of suicide. The therapist, who was
quite skilled and had been seeing Danny for his depression and his OCD for several
years, was hoping that Danny might be prescribed an antidepressant. The therapist felt
that Danny had been given an adequate trial of psychotherapy (with a good therapeutic
alliance) but it had not resulted in adequate relief. Indeed, the depression was intensify-
ing and serious suicidal ideation was being expressed. Danny’s therapist had commented
to the consultant that, “Danny’s pain is palpable when he is in my office. In fact, it’s so
intense it scares me. This kid is really hurting. I am worried he will kill himself.” You
will also recall that Danny had become somewhat dramatic in his behaviors, with several
instances of self-cutting and comments to his parents like, “I just wanted to see my own
blood!”
With a patient like Danny, who is clearly seriously depressed, one diagnosis that can
be confused with a mixed bipolar state, such as a dysphoric mania, is an agitated depres-
sion (people with agitated depressions often report their thoughts to be racing and show
marked pacing and irritability). Off the bat, one factor that helps with this differentiation
is the simple fact that agitated depressions are more common in the elderly and signifi-
cantly less common in adolescents and young adults.
Moreover, I believe that future phenomenological research will show that there are
subtle, yet significant, differences in how the depression feels to patients experiencing
a dysphoric manic state in contrast to patients experiencing an agitated depression.
Agitated depressions often manifest with a striking overlay of anxiety and fretting.
Whether the patient is worrying about mundane concerns, such as finances, business
affairs or illnesses (common in the agitated depressions of the elderly), or more unusual
material bordering upon, or moving into, the psychotic realm, as with delusional fears
of disease and death, many people with agitated depressions appear to be overwhelmed
by their worries. The result is an unpleasant sensation of helplessness. Consequently they
often appear to be lost in a wave of agitated disorganization, almost paralyzed by their
fears.
Patients experiencing dysphoric manias also have a high degree of anxiety. But, in
contrast to people experiencing an agitated depression, I have found that individuals
with dysphoric manias do not tend to feel, or look, as overwhelmed or helpless. Instead,
they often report a sense of being driven to do something, almost anything, to fix their
problems. Rather than presenting as helpless, they appear driven to action. Curiously, they
are overwhelmed, not by their anxieties, but by their need to take action on their anxieties. I
find this to be a distinctive sensation in manias, including mixed states such as dysphoric
manias. Careful interviewing will uncover that it is reflected both in an intensity to the
patient’s affect and in the intensity with which the patient describes his or her need to
act. It is one of the reasons that manic patients can quickly turn angry if they perceive
that their needs are being thwarted by a clinician, even over something as apparently
unimportant as the need to have a smoke.
As we will see with Danny, this compelling drive to act sometimes feels foreign to the
patient (as if an unfamiliar part of themselves is pushing them to act). This manic sense
of being driven by their urges can also be reflected in the suicidal ideation of these
patients. For example, Danny commented later in his interview, “I don’t really want to
kill myself, but sometimes I almost feel like I have to, like something inside me is pushing
me to do it.” This sense of being driven to act on urges, from gambling and frantic buying
to suicide and violence towards others, is typical of manic states including mixed states
such as dysphoric manias; and I have personally found it to be atypical of agitated
depressions.
If a clinician suspects the presence of a dysphoric mania, the following three questions
can be of use in no particular order:
1. “Do you have any ideas of how to solve your problems?” (Although a patient with a
dysphoric mania may not have decided upon the solution, they often have quite
specific ideas for a possible plan or plans of action. People coping with agitated
depressions often appear befuddled and/or irritated by this question.)
2. “Do you feel like you need to do something about this problem and you need to do
something now?”
3. “Are you feeling sort of driven to do something to solve this problem, almost like
you’re going to need to do something about it even if you don’t feel it’s smart to
do so?”
I have chosen Danny as our illustration of a specific type of presentation for a mixed
bipolar state (dysphoric mania), because I feel that dysphoric manias are frequently
missed in late adolescents and young adults, where they appear to be more common. In
my opinion, missing this diagnosis can result in great and unnecessary pain. The ques-
tion is: why are they so easily missed?
One of the reasons these dysphoric manias are misdiagnosed as agitated depressions
is that some clinicians are unfamiliar with mixed presentations, an unfamiliarity
re-enforced by the use of the DSM-IV-TR (which had an extremely narrow view of mixed
bipolar states, as discussed earlier). Moreover, the intensity and vocalization by the
patients of their depressive pain, as we will see below, is extremely striking. The patients
will often spontaneously make comments to the clinician such as, “I’m extremely
depressed. I’m depressed all the time. I hate life.” Because the pain of their depression
is so palpable, it is easy for the clinician to think of nothing but depression as a diagnostic
possibility.
Another reason that these states can be easily missed is the fact that most of the classic
manic symptoms may not be present, and those that are present tend to be of the dys-
phoric type, as opposed to the more classic picture of a manic patient appearing euphoric
and grandiose. Danny’s presentation reflects this potentially confusing picture. It is a
camouflage of a sort, in which the mania fades into the depressive overlay, and it can
lead even an experienced clinician to miss the presence of a mixed bipolar state. Let’s see
it at play with Danny.
Danny was experiencing his thoughts as being intensely speeded up at times and
pressured, as is typical with a mania; but, curiously, according to both his therapist and
his parents, Danny only infrequently showed rapid or pressured speech and it was of a
mild nature. Phenomenologically, I have found that patients with dysphoric manias tend
to find their internal pressure of thought (often filled with disturbing and dark images)
to be unpleasant. Indeed, they often feel an intense desire to get away from it somehow.
In contrast, I have found people experiencing an euphoric mania to frequently find their
accelerated thinking to be exciting and creative. They feel no need to stop it and often
make comments such as, “My thinking has never been so clear!”
Danny also did not move particularly quickly, nor was he prone to pacing (both of
which, if present, might prompt a clinician to look for mania). He showed no flight of
ideas, distractibility, excessive involvement in pleasurable activities (although he had a
mild hypersexuality), or inflated self-esteem or grandiosity (as we saw in the euphoric
mania exhibited by Mr. Matthews regarding his moonwalk around the Grand Canyon).
Indeed, Danny was pessimistic of his future prospects.
He also reported a mild, but significant, tendency to stay up later than normal for
him. At its most extreme, his parents once saw him doing pull-ups outside on a tree limb
because he lacked a pull-up bar in the house. Not particularly odd until one hears the
fact that it was being done at midnight! Thus Danny showed evidence of manic overdrive
but he did not show the progressive tendency to stay up later and later, as is commonly
seen in classic manias. At no point did he show any euphoria or increased happiness.
The question is, Are there symptoms that could tip-off an interviewer to look for a mixed
bipolar disorder in a patient who presents primarily complaining of severe depressive
angst as was the case with Danny?
Three Practical Tips for Spotting a Dysphoric Mania. Let’s take a look at three phe-
nomenological factors that might prompt a clinician to more aggressively search for a
dysphoric mania despite a depressive camouflage: (1) the prominent presence of anger,
(2) the intensity of the patient’s depressive angst, and (3) a discordance between the
severity of patient’s angst and the relative mildness of the patient’s neurovegetative
symptoms.
Regarding our first tip, one thing that the consulting psychiatrist noted quickly from
the history, supported by both Danny and his parents, was the striking amount of anger
Danny was experiencing. It was broad-based in nature, ranging from feelings of betrayal
with friends to contempt for the world at large in response to current events. He had
always socialized well with people and had maintained good friendships, but throughout
high school his friendships, both male and female, were intense affairs with stormy
moments. He had always been extremely conscientious (an “A” student, with great
conduct) and had experienced a good relationship with his parents, sharing many of his
thoughts and pains. As with his attitude towards his friends, his attitude towards his
parents had become dismissive and contentious. The intensity of the anger felt during a
dysphoric mania can be quite frightening and, indeed, these patients can be prone to
both planned and impulsive violence.
The following questions may be of help here:
1. “Tell me a little bit more about your anger and who you are angry at?”
2. “How often in a day do you feel irritated or angered by the things people do?” (During
a dysphoric manic episode, patients often feel irritated or angry for much of the day,
with this angry overtone being more prominent to them than their depressive feelings.)
3. “Do you think the world is fair?” (They can look aghast at how stupid this question
is, for, to them, it is obvious that the world is not fair and you may hear a diatribe
making this point.)
There is one other aspect of the anger that patients with dysphoric manias experience to
which I would like to draw your attention. For a moment, let us return to the historically
rich clinical literature of descriptive psychiatry and phenomenology. In this regard, the
words of Wilhelm Griesinger, written in 1882, can provide insights that remain remark-
ably useful for us in our everyday clinical work over 130 years later.39 Griesinger, in
describing a condition that he called “melancholia with destructive tendencies” – which
today I think we would diagnose as a dysphoric mania – elegantly captures the patient’s
brooding anger, which can be pregnant with violence towards self or others:
In melancholia this emotional state of uneasiness, of anxiety, and especially of mental

suffering, give rise to certain impulses … which always assume a negative, gloomy, hostile
and destructive character. The negative ideas and feelings … may be directed either against
the individual himself, against other persons, or finally against inanimate objects.
When further describing the emergence of the patient’s anger and hostility, I believe
Griesinger captures a particularly useful phenomenological quality that characterizes the
anger experienced by patients during a dysphoric mania:
In such cases we often see developed a feeling of bitter animosity towards the world, which
becomes to such individuals perfectly hateful, gloomy, and fearful; and there frequently
arise the impulses to commit these indeterminate acts, by which the individual thinks to
repay the world, in some splendid crime, for all these griefs and imaginary evils, as well
as all those painful impressions, the cause of which he is ever seeking, not in himself, but
in the outer world.
I believe that Griesinger is describing the type of rage that can explode behaviorally into
violence towards loved ones or mass shootings in a Colorado movie theater or on a
college campus. Note well that the predominant focus of the patient with a dysphoric
mania on thoughts directed towards the outer world (as well as a desire to interact with
that outer world) is, in my opinion, generally different to patients suffering from an
agitated unipolar depression. Although there can definitely be anger and intermittent focus
on the outer world in unipolar depression, typically the principal focus is more consistently
inwards upon oneself, upon topics such as one’s inadequacies, feeling overwhelmed, feeling
guilt, somatic preoccupations, and withdrawal from the harshness of the world, even
when feeling agitated.
This distinction, which can be readily apparent by merely recognizing the amount of
time your patient spends talking angrily about specific people, the culture at large, and
various “wrongs in the world,” can be a useful indicator that the interviewer is sitting with
an adolescent or young adult experiencing a dysphoric mania not an agitated depression.
Such was the case with Danny, where the angry darkness of his worldview revealed itself
in the consultant’s interview, and was verified as being “really striking” by Danny’s thera-
pist. “This kid is a great kid. I’ve known him for several years, but something is really wrong
here. I mean really wrong.” At one point, Danny told the interviewer, “The world’s a hor-
rible place. It disgusts me. There’s no reason for anyone to really go on living is there?”
With a patient like Danny, it can be productive to explore the patient’s predilections
on the web as well as his or her fantasies, for the patient’s dark preoccupations often will
reveal themselves. Questions such as the following may be of use:
1. “What types websites do you like to go to?” (Be on the lookout for websites focused
upon anger at the culture, violence, and suicide.)
2. “How often do you have images of violence?”
3. “Do you ever picture yourself doing something violent?”
If psychosis ensues, the risk of danger to self and others suggests that an increased search
for dangerous ideation is in order. Psychotic self-mutilation as a freestanding phenom-
enon, or in response to command hallucinations, can occur. Fortunately, at this point,
Danny did not show thoughts of violence or evidence of psychotic process despite his
dark musings.
Let us now move to our second tip for spotting a dysphoric mania – the intensity of
the patient’s depressive angst. If you will recall, Danny’s psychotherapist had commented
to the consultant, “Danny’s pain is palpable when he is in my office. In fact, it’s so intense
it scares me. This kid is really hurting. I am worried he will kill himself.” I have found
that with people experiencing mixed bipolar states that fit the mold of a dysphoric mania,
the intensity of the manic process seems to be translated into a particularly severe angst
that possesses an almost bitter tone to it.
Note well that this intensely painful brooding angst presents as a persistent mood state,
not solely as an intermittent rage response triggered by interpersonal affronts – this latter
trait being commonly seen in people coping with borderline personality disorders (as
we will see in Chapters 14 and 15). Patients with dysphoric manias may have an inter-
personal reactivity as seen in some personality disorders, but it tends to be imbedded
within this persistently dark mood. The intensity of the angst of these patients can
increase their suicidal potential significantly. Coupled with the impulsivity of the under-
lying manic drive, the risk of suicide, in my opinion, can be high.
Let us wrap up our three tips on spotting dysphoric manias by looking at an often-
missed third clue that a dysphoric mania may be present. I have found that the severity
of the patient’s reported psychological pain is frequently not matched by the severity of
their neurovegetative symptoms. One would imagine that a person whose depression
was causing this amount of angst (often accompanied by suicidal ideation) would also
demonstrate equally severe neurovegetative symptoms. As we see with Danny, this is not
always the case. His neurovegetative symptoms, although problematic, are not striking
in nature. His appetite is mildly impaired. Energy and concentration were reported as
fine, and there was a relatively mild difficulty falling asleep and no early morning
awakening.
I suspect that the classic neurovegetative symptoms as seen in a unipolar depression
are being overturned by manic energies and drives. Keep an eye out for such a discordance
between the severity of a patient’s depressive angst and the severity of their neurovegeta-
tive symptoms. I believe that it often points towards the fact that a patient is not just
depressed. They may have a mixed bipolar state, specifically, a dysphoric mania.
Interestingly, some evidence exists that the depressions seen in bipolar disorder, in a
general sense, may have a tendency to show some features not typical of classic unipolar
depression. One study showed that bipolar depressions had an increased tendency to
show atypical depressive symptoms, including mood reactivity (think of Danny’s stormy
relationships), overeating, oversleeping, and excessive fatigue.40 In younger patients there
is also a tendency for a higher percentage of “mixed” presentations, as we have been
describing,41 as well as an increase in depressive psychotic features.42 There is considerable
evidence that people experiencing mixed bipolar disorders have a significantly higher
rate of suicide.43–45
It is time to wrap up our discussion of dysphoric manias. As phenomenological and
empirical research unfolds using the now available dimensional qualities of the DSM-5,
my hunch is that the sub-category of “dysphoric mania” will prove to be both valid and
reliable. The term also has very high “descriptive essence” (the words capture the core of
the syndrome effectively). I believe its therapeutic usefulness is high, and that these
dimensional/phenomenological characteristics should be aggressively sought by clini-
cians, even if a specific category does not emerge as a unique diagnostic entity. Evidence
suggests that patients who are experiencing a dysphoric mania frequently respond well
to mood stabilizers. Many will respond poorly to antidepressants alone, and in some
cases antidepressants will unleash the underlying manic rage even further.
Historical Tip-Offs That Raise the Suspicion of Mixed Bipolar States in General
Although we have been focusing upon a possible specific subtype of mixed bipolar dis-
order – dysphoric mania – it is important to remember that patients may experience
many different types of mixed processes, including those in which euphoric symptoms
are common. Whatever the type of mixed presentation, there are two historical factors
that may also point towards a mixed bipolar process in a patient who presents with
depression.
Look carefully at the patient’s family history. It may have both bipolar I and bipolar
II disorders (which we will be exploring presently), sometimes in surprising numbers.
Patients with mixed bipolar disorder may also be more likely to show a positive family
history for depression, anxiety disorders, and alcohol and substance disorders. Danny’s
family history was loaded with depression, alcohol dependence, and anxiety disorders.
His paternal grandfather was adopted and nothing was known of the paternal family
history from that point. (It could have been filled with bipolar disorder, but no one
knows.)
The second historical factor that may raise suspicions of the presence of a mixed
bipolar state is the discovery, when taking a psychiatric history, of other bipolar processes
earlier in the patient’s life, such as bipolar II disorder and substance/medication-induced
bipolar and related disorder. Both of these can also present as mixed states. These disor-
ders are so important that they deserve a closer examination. Before we do this, however,
there is one differential diagnostic error that we should make sure we are not making.
Over-Diagnosing Bipolar Disorder: A Serious Diagnostic Error

Thus far, we have examined the importance of not missing bipolar process (which can
be seen across age groups from childhood throughout adolescence and adulthood). We
have particularly focused upon mixed states (including dysphoric manias), which can be
easily missed. The consequences of missing these bipolar states are potentially serious.
There is a flip side to this coin, the consequences of which are also serious: it is the
mislabeling of patients, especially children, adolescents, and young adults, as having
bipolar disorder when they do not. The result of this misdiagnosis by clinicians is patients
being placed on mood stabilizers, and sometimes antipsychotics, in the absence of symp-
toms for which these medications are helpful. Consequently, these patients are taking
medications that can be of no value, yet have potentially serious side effects. This problem
is so important that the DSM-5 has attempted to minimize its occurrence by addressing
it directly. Let’s see how.
The problem manifests when young patients display marked behavioral problems
involving angry outbursts and disruptive behaviors. Such problems may manifest at
home, at school, during recreational time, or all three. In truth, some of these adolescents
may be experiencing normal responses to severe stresses such as bullying or violence at
home. Many are dealing with disorders such as attention-deficit/hyperactivity disorder
(ADHD) or an oppositional defiant disorder. Others may be dealing with a depressive
equivalent.
The term “depressive equivalent” was coined to acknowledge a well known observa-
tion that children and adolescents, possibly as a result of differences in maturation of
the brain when compared to adults, sometimes display depression less through depressed
mood and classic neurovegetative symptoms and more through anger and disruptive
outbursts. In any case, whether the behaviors are normal responses to stress, examples
of ADHD or oppositional defiant disorder or a depressive equivalent, these patients
should not be diagnosed as having bipolar disorder and, consequently, be exposed to
medications they do not need and that may prove to be harmful.
In direct response to this problem, the DSM-5 created a category of mood disorder
that can help clinicians to spot children and adolescents who are displaying angry out-
bursts as part of a depressive equivalent. This mood disturbance is called “disruptive
mood dysregulation disorder.”46 The interested reader should learn about the details
and presentation of this disorder in the DSM-5. Although this book is not a textbook
concerning child and adolescent disorders, suffice it to say that disruptive mood dysregu-
lation disorder cannot be made if the phenomenological criteria for a manic or hypo-
manic episode are present or if the disruptive behavior occurs only during an episode of
major depressive disorder.
It is hoped that this new category will decrease the likelihood that clinicians will
misdiagnose children and adolescents as having bipolar disorder when they don’t, for
the term bipolar disorder is explicitly reserved in the DSM-5 for episodic presentations
of bipolar symptoms. As we have seen, an understanding of the phenomenology of
depression, mania, and mixed bipolar disorder, together with the birth of this new diag-
nostic category, should allow clinicians, in my opinion, to more easily make this dif-
ferential diagnosis. By reducing the rate at which children and adolescents are
misdiagnosed as having bipolar disorder, the DSM-5 will have done a great service by
preventing the unnecessary use of inappropriate medications.
Bipolar II Disorder
According to DSM-5 criteria, a diagnosis of bipolar II disorder is met when a patient has
one or more depressive episodes with at least one hypomanic episode. Some authors
refer to this spectrum of disorders (including hypomanic variations of substance/
medication-induced bipolar disorder, described below) as “soft bipolarity” and argue,
rightly so, that spotting these disorders has major implications for treatment.47 Bipolar
II disorder is surprisingly common, with a lifetime prevalence rate of 1 to 2%. In patients
suffering with recurrent major depressive disorder, it has been estimated that 25 to 50%
have features of hypomania.48
DSM-5 criteria specify that hypomania presents as bursts of low-grade manic-like
symptoms that last for at least four consecutive days.49 The patient may experience an inflated
sense of self-importance or increased energy with less need to sleep; and/or the patient
may feel more talkative and unusually social (perhaps having an increased sex drive as
well). The patient’s thoughts may seem to be racing, and there may be a significant
increase in his or her irritability. These changes will be distinctly noticeable to those who
know the patient well.
What separates these hypomanic symptoms from manic symptoms is not their char-
acteristics, it is their disruptive severity and their duration. In hypomania, the “manic”
symptoms are not severe enough to cause marked impairment in social or occupational
functioning, nor are they severe enough to necessitate a hospitalization. In addition, the
presence of any psychotic process rules out hypomania and requires a diagnosis of mania.
Moreover, in true mania the symptoms must be present for at least a week.
Sometimes patients feel pretty good during milder hypomanic periods and relate to
their interviewers that they are more productive, witty, and creative, which is sometimes
true. Indeed, if we could all be programmed to have a consistent very low-grade hypo-
mania without the irritability, the world might be a better place. It would certainly be a
happier one.
However, the problem is that these episodes are often more disruptive and unpleasant
than they are valuable. During the hypomanic episodes, patients often report feeling
scattered, unproductive, and bothered by an unsettling sensation that “I am just not
myself.” They may be more likely to do things impulsively (e.g., initiate inappropriate
drinking binges or regretted sexual liaisons). Because such episodes are an indication of
an underlying instability of mood regulation in the brain, they can frequently transform
into a depressed mood, which is sometimes severe. Unfortunately, a significant percent-
age of these patients go on to develop a full-blown bipolar I disorder.
As we saw with mixed bipolar disorder, this diagnosis is evolving. Daniel Smith argued
convincingly, in my opinion, that the DSM-IV-TR diagnosis was too rigid, for many
patients have hypomanic episodes lasting only 1 or 2 days, as opposed to the 4 days
demanded by the DSM-IV-TR.50 I feel that I have seen hypomanic bursts appear multiple
times in a single day in some patients. It is interesting to note that the ICD-10, when
describing rapid cycling in bipolar disorder, recognizes that mood shifts may occur in
the course of a single day or two. I believe that the new dimensional qualities of the
DSM-5 will eventually result in research that clarifies the frequency with which both
manic and hypomanic bursts can occur (although keep in mind that currently the DSM-5
demands a minimum of 4 days of relatively consistent symptoms to be present in order
to make the diagnosis of hypomania).
In addition to the more typical euphoric manic symptoms typical of the DSM-5 cri-
teria for hypomania, keep an eye out for the presence of consistent dysphoric symptoms,
for I have seen hypomanic bursts that consist primarily or solely of the dysphoric quali-
ties of a mania. Look out for bursts of the following dysphoric symptoms: a preoccupa-
tion with violent and dark images; agitation; difficulty falling asleep; irritability; anger;
an unpleasant racing of thoughts; a destructive impulsivity to gamble, drink, attempt
suicide or violence; and an unpleasant sense of psychological angst and darkness.
With any person who presents with depression, it is important to look for episodes
of hypomania suggestive of bipolar II disorder. The use of a mood stabilizer in these
patients can sometimes significantly improve the quality of their lives. Although not
proven, there is speculation that the addition of a mood stabilizer, such as lithium, in
those patients who would have naturally evolved into having bipolar I disorder, might
prevent them from experiencing this potentially catastrophic evolution. In addition,
antidepressants used alone are commonly considered to be counter-indicated in these
patients, for they may unleash further hypomanic bursts and/or a full-blown manic
episode.
In my opinion, the diagnosis of bipolar II disorder is frequently missed. Every clini-
cian should be on the lookout for it. As we have seen, it is a diagnosis that can be
uncovered rather easily in the initial interview if the clinician asks questions that address
it. If made, it is a diagnosis that can transform, and perhaps even save, a patient’s life.
Let’s take a look at two screening questions that might help us to spot hypomania. Once
again, from a clinical standpoint, I aggressively search for hypomanic bursts that may
occur more briefly than appearing for 4 solid days as required by the current DSM-5
criteria.
After exploring depression with a patient, I find the following question to be a nice
one for uncovering euphoric hypomanic episodes:
“Do you have periods of time, even just for hours or a couple of days or weeks, where
you suddenly and unexpectedly feel unusually happy, super-energized, ready to ‘take
on the world’ and you can’t explain why, it feels almost odd to you?”
This screening question covers several of the more common symptoms when experienc-
ing a euphoric hypomanic episode. It is made even more effective (and less likely to yield
false positives) by the phrasing, “… and you can’t explain why, it feels almost odd to
you?” This part of the question stems from a sophisticated understanding of the people
beneath the diagnoses of hypomania. It acknowledges a common response of these
patients towards their symptoms (not just the presence of the symptom). This phenom-
enological understanding can help us to avoid mislabeling someone as having a hypo-
mania when, in reality, they are experiencing normal feelings of “being on top of things”
or “having a great day.”
Many, although not all, people who are truly experiencing hypomanic symptoms are
genuinely puzzled by their own mood shifts. The puzzlement is particularly acute if they
have been feeling depressed and then suddenly and unexpectedly feel hypomanic,
without any positive change in their environment or the interpersonal wing of their
matrix that could explain it. If a patient admits to hypomanic symptoms, and to puzzle-
ment in reaction to their presence, it increases the likelihood that the symptoms are valid
and problematic enough to warrant the diagnosis of hypomania.
After asking the above question, the interviewer can use the question below as a
follow-up screening for dysphoric hypomanic episodes:
“Do you have periods of time, even just for hours or a couple of days or weeks, where
you suddenly, and unexpectedly, find your thoughts really speeded up on you, in an
unpleasant rush that you feel you really can’t control, and your thoughts are sort of
angry and life just seems darker and you can’t explain why you suddenly feel so bad, the
dark shift in mood feels almost odd to you?”
Substance/Medication-Induced Bipolar and Related Disorder

As just mentioned, some patients only develop hypomanic or manic symptoms when
given an antidepressant. It is important to realize that medications other than antidepres-
sants (or other psychotropic medications) have been shown to occasionally unleash
manic-like symptoms and/or suicidal ideation and/or violent ideation. Although defini-
tive research is ongoing, offending agents may include amantadine (used to treat Parkin-
son’s disease), isotretinoin (used to treat severe acne), varenicline (used to stop smoking),
and steroids (used to treat a variety of illnesses and as an adjunctive agent by athletes and
body builders). As one would expect, a variety of street drugs can induce bipolar process
including stimulants, phencyclidine (PCP), and bath salts.51 In addition, complementary
and alternative medicines (such as St. John’s wort), ECT, and light therapy can also trigger
hypomanic or manic symptoms. In the DSM-5, one would record these diagnoses as
“Substance/Medication-Induced Bipolar and Related Disorder with manic features”
(noting what substance or treatment triggered the mania). In clinical and research litera-
ture, this syndrome has often been referred to in the past as bipolar type III disorder.
Shortly after the offending medication or intervention (antidepressant, St. John’s wort,
light therapy) is removed, most patients lose all manic or hypomanic symptoms and
return to their baseline moods. However, if the hypomanic or manic symptoms still
persist 1 month after the suspected triggering agent has been discontinued, then the
diagnosis is switched to bipolar I disorder or bipolar II disorder.
As one follows the progress of patients who have met the criteria for substance/
medication-induced bipolar and related disorder over the ensuing years, a small percent-
age will go on to develop bipolar type II disorder. Some of these will subsequently
develop bipolar I disorder. A very small percentage will skip bipolar II disorder and
directly develop bipolar I disorder. It is unclear whether the releasing agent simply
speeded up a disease progression that would have unfolded at a later date without any
use of an antidepressant or other agent, or whether, in some instances, it triggered a
bipolar process in someone who would not otherwise have developed these disorders.
In either case, it is likely, in my opinion, that the patient was genetically predisposed to
bipolar process.
Either situation is a disturbing one. Consequently, I feel it is critical to aggressively
hunt for hypomanic process and a family history of bipolar process in all patients pre-
senting with depression before starting any antidepressant agent. When patients report
current hypomanic symptoms or relate a history suggesting hypomanic process in the
past, if clinically feasible, some clinicians prefer the use of psychotherapy alone. If it fails,
then such clinicians might consider adding an antidepressant after the patient has been
prophylactically loaded with a mood stabilizer such as lithium or Depakote. It is interest-
ing to note that even one of the mood stabilizers, lamotrigine (which has antidepressant
effects), has been documented to trigger or exacerbate suicidal ideation.52
Varying therapeutic approaches and debate as to how to best proceed with a depressed
patient reporting a past history of hypomania go far beyond the scope of this book. I
urge readers to seek out the appropriate literature on these complicated situations. Nev-
ertheless, it is safe to say in a book on clinical interviewing that one should question for
hypomanic or manic symptoms, past or present, with all patients presenting with
depressed symptoms. Their presence can have major implications on how to proceed
therapeutically and in a safe fashion.
We now come full cycle, back to Danny Ramirez. When the consultant asked the
parents the following question, “With Danny’s history of OCD early in his childhood
and his repeated problems with depression, I would think he’s been tried on numerous
antidepressants. How has that gone for him? Have they helped at all?” Before he was
even done with the question, the parent’s glanced over at each other, shook their heads,
and said, “Oh God.”
At the age of 8, Danny’s OCD erupted with a vengeance. (Note that there appears to
be an even higher rate of OCD and other serious anxiety disorders in patients with
bipolar disorder when compared to unipolar depressions, which already have a high
frequency of co-morbidity with anxiety disorders.) Because of the severity of Danny’s
pain, an antidepressant was started, hoping that he would also eventually respond to
cognitive–behavioral therapy (CBT). The antidepressant provided quick and remarkable
help, with a 90% remission within 3 weeks, much to Danny’s relief.
But within 5–6 weeks, Danny developed agitation, sleep problems, and “an attitude.”
Up until the use of the antidepressant, Danny had been the type of a kid who has a big
superego, is pleasant with adults and siblings, receives excellent grades, and demonstrates
great deportment at school. About 2 months after initiating antidepressant therapy,

Danny began to talk back to his parents. He became highly oppositional, requiring mul-
tiple time-outs throughout the day. He had numerous angry outbursts, with several out-
of-character episodes of screaming and swearing at his parents. The change in behavior
was topped off by a bizarre incident of pulling out a kitchen knife and threatening to
kill the family dog, a dog that Danny that had always loved. His parents told the con-
sultant, “It was really amazing. It was like he had a totally different personality. It was
sort of like he was Sybil or something.”
He was promptly pulled off the antidepressant. All oppositional behavioral problems
disappeared within 2 weeks; unfortunately, so did the relief from his OCD. His OCD
returned with a crippling vengeance. Danny did not engage well in his CBT, despite really
liking his therapist. Consequently, over the next 2 years various attempts were made to
use different antidepressants at very low doses. Every single attempt resulted in dysphoric
manic symptoms, highlighted by one frightening brief episode of paranoid psychosis. In
short, Danny was a textbook illustration of person who, in the DSM-5 system, we would
diagnose as having a history of a substance/medication-induced bipolar and related
disorder.
Recognizing Suicidal Ideation Unleashed During Partial Manic Responses to a Medication

During episodes when dysphoric manic symptoms are partially or fully unleashed by
medications or other treatment modalities, some patients can develop thoughts of self-
mutilation and/or suicide (violent ideation has also been reported). Whether you are
functioning as a consultant who is performing a one-time initial interview, engaged in
ongoing psychotherapy with a patient who has been placed on an antidepressant by a
prescribing colleague, or you yourself have prescribed the medication, several features of
the patient’s suicidal ideation, in my opinion, suggest that it may be related to an
unleashing phenomenon (as opposed to the natural development of suicidal ideation
in a patient whose depression is worsening).
Be suspicious that a worsening of your patient’s depression is not the cause of the
patient’s emerging suicidal ideation when: (1) the suicidal ideation is unexpected and
inconsistent with the patient’s past suicidal ideation; (2) the patient reports the ideation
as feeling very different from past suicidal ideation; (3) the ideation has a peculiar feeling
of intensity and impulsiveness that has never been present before, and the ideation
appears to be erupting with other co-existing phenomena characteristic of a dysphoric
mania, such as agitation (ranging from pacing to a striking increase in nervous displace-
ment activities such as finger picking, hair twirling, and foot twitching), angry outbursts,
racing thoughts experienced as unpleasant, marked problems falling asleep, and intense
psychological angst.
One of my psychotherapy patients, in her late 20s, provides an excellent illustration
of this process. She had been doing reasonably well, but had had only a partial response
to her antidepressant at a fairly high dose. I increased her antidepressant to an even
higher dose to see if we could get a more robust response. Within about 10 days, although
no new stresses had occurred in her life, she developed an acutely agitated state with
extreme irritability, very low stress tolerance, and tearful episodes with mood lability. She
reported, “I’ve been screaming at my kids and husband. It’s like I’m a different person.
It’s so strange. I don’t know what to do. I just don’t know what to do.” To her surprise
she had also developed suicidal ideation of an intensity and quality that had frightened
her. She stressed repeatedly in our session, “You have to understand, I don’t want to die.”
She reported that the morning of the day I saw her she had become particularly
wound-up. While in her bathroom, she suddenly had the urge to electrocute herself by
thrusting her hair dryer into the bathtub. She had never had such thoughts before. She
reported feeling compelled by it, although in her heart she didn’t want to die. It scared
her, and she aggressively threw the hair dryer into the bedroom. When I asked whether
the suicidal ideation felt the same as in the past, she quickly responded, “No. This was
very different. It just came on so abruptly. It was very intense. And it felt different than
anything I’ve ever felt before. It really frightened me.”
Keep in mind that only 10 days earlier she had been doing fairly well (with about a
60% remission in her symptoms and no agitation or suicidal ideation whatsoever). Her
last suicidal ideation, overdosing, had occurred over 8 years ago and was mild in nature.
In my office, she appeared distraught and cried intermittently with her feet twitching
rapidly whenever she crossed her legs. In short, she was “beside herself.” Within 2 days
of markedly decreasing the antidepressant, she felt “almost back to normal,” with no
suicidal ideation. By the fifth day she was fine. Her suicidal ideation never returned.
Cyclothymic Disorder and Rapid Cycling

Let me wrap up by describing two final diagnostic considerations that Danny’s presenta-
tion brings to mind, for they may have potential ramifications for treatment in other
patients. In a cyclothymic disorder, as defined by the DSM-5, over a 2-year timeframe an
adult patient will experience intermittent and frequent bouts of low-grade depression
and hypomania, neither of which reaches the proportions of a full-grade depressive
episode or manic episode. During this 2-year timeframe, any combination of the depres-
sive or hypomanic symptoms must be present for at least 50% of the time and no period
of time in excess of 2 months can be symptom free.53 Although clearly less disruptive
than true bipolar disorder, cyclothymic disorder is painful, problematic, and puzzling to
those people experiencing it. There is also a 15 to 50% chance that a person with cyclo-
thymic disorder will eventually develop bipolar I disorder or bipolar II disorder.54 If the
clinician discovers cyclothymic disorder, he or she might be able to change a patient’s
life in a very positive fashion by prescribing a mood-stabilizing agent, as well as utilizing
psychotherapy.
It should also be noted that the specifier “rapid cycling” can be added to either a
diagnosis of bipolar I disorder or bipolar II disorder. To apply this specifier, the patient
must have shown four or more mood episodes, in any combination, within 12 months.
Whether these episodes are depressive, manic, or hypomanic, they must be demarcated
by either a full period of remission between episodes or by an immediate switch into an
episode of opposite polarity.55 Rapid cycling characterizes roughly 10 to 20% of people
presenting with bipolar disorder. Interestingly, bipolar disorder in general is fairly equally
distributed between the sexes, whereas rapid cycling bipolar disorder is more common
in women. On a practical level, the presence of rapid cycling can be associated with a
poorer prognosis, and it often requires more complicated combinations of medications

to achieve sustained remission.
Differential Diagnosis on Danny Ramirez and Summary of Key Interviewing Tips

The consultant that was seeing Danny at age 18 felt that Danny had been currently mis-
diagnosed as having a major depression. He felt that Danny’s symptoms were better
characterized as a mixed bipolar disorder with dysphoric features. He also felt antidepres-
sants were counter-indicated (unless used after a sound trial of a mood stabilizer first).
He recommended the initiation of lithium.
His expectation was that the dysphoric characteristics of Danny’s condition would
improve markedly, including a disappearance of the angry, acting-out behaviors that
could be mistaken for budding personality dysfunction, such as screaming “I just wanted
to see my blood.” He predicted that some true depressive symptoms would remain. He
recommended that these be addressed by continued psychotherapy, hopefully without a
need to add an antidepressant. He also felt that once the dysphoric manic symptoms
were relieved by lithium, the psychotherapy would progress much more effectively (a
healing matrix effect as described in Chapter 7).
The consultant also felt that if untreated with a mood stabilizer, Danny ran a high
risk of developing severe manic symptoms, including psychotic process. His predictions
proved to be right on the mark.
A brief trial of lithium was undertaken with excellent results. But Danny felt he did
not have a bipolar disorder. Unfortunately, several subsequent psychiatrists concurred,
telling his parents that Danny most likely had a personality disorder. Lithium fell by the
wayside.
During his third year at college, as predicted by the original consultant, Danny
experienced a ferocious psychotic manic episode, replete with command hallucinations
to enucleate his eyes and a bevy of demonic delusions. At that time, he was diagnosed
as having bipolar I disorder, mixed (with dysphoric manic symptoms). It required over
5 months to bring the mania into remission. Fortunately, because of the outstanding
care he subsequently received and his own sophisticated understanding of how to
effectively utilize his medications, 4 years after his manic episode Danny remained
symptom free. He had completed college, become fully employed and had found a
steady girlfriend.
Let us return to our original consultant’s interview to see how Danny’s differential
diagnosis would be formulated today using DSM-5 criteria. It also serves as a refreshing
reminder of how a well-trained clinician, in a single 50-minute interview, may arrive at
a more valid, useful, and accurate diagnosis than clinicians who have seen the patient
on a regular basis.
Danny’s original presentation is consistent with a dysphoric mania. He clearly is
reporting a severe depressive mood that has resulted in a marked decrease in his func-
tioning both at home and at school, as well as interpersonally (the severity of his dys-
function would immediately eliminate hypomania as a diagnosis). It is persistent in
nature, and severe enough, to generate significant suicidal ideation and intent. It has
many of the identifying characteristics of a dysphoric mania including: an overlay of

anger and hostility, a deep angst highlighted by a dark and gloomy worldview, and a
surprising discordance between his relatively mild neurovegetative symptoms and the
intensity of his depressive angst. He is plagued with racing thoughts, agitated anxiety,
dark and foreboding images, problems falling asleep because of agitation, and an intense
desire to do something to release his pain (including several episodes of self-cutting).
All of this symptomatology is highlighted by a well-documented history in childhood of
several medication-induced hypomanic and manic episodes (one of which included
psychotic process).
Truth be told, it’s tough to easily fit Danny’s presentation into the DSM-5 system as
it now stands for two reasons. (1) The DSM-5, despite its innovative dimensionality, in
my opinion, still maintains a too restrictive criteria set for the diagnosis of a mixed
bipolar disorder. In order to make this diagnosis, the patient must fulfill the criteria for
either a major depressive episode or a manic episode – Danny does neither, yet he clearly
is afflicted with a major mood disorder. (2) The DSM-5 tends to emphasize euphoric
manic symptoms and lists few dysphoric manic symptoms in its criteria for mania or
hypomania.
For such situations, the DSM-5 has a reasonable solution, although, in my opinion, it
lacks descriptive essence. In any case, you could probably use the diagnosis of other speci-
fied bipolar and related disorder. Of course, after his future psychotic episode in college,
the DSM-5 diagnosis would have become bipolar I disorder, manic (mixed episode with
depressed and anxious symptoms) with mood-incongruent psychotic features.
During his consultation, after collaboratively interviewing Danny’s parents and having
already spoken with Danny’s therapist, no evidence of marked personality dysfunction
was present. Indeed, Danny had been viewed as a pleasant and high-functioning indi-
vidual, although a bit rigid and intense. Concerning medical issues, Danny had been
evaluated medically on several occasions and deemed to be physically fit. Because of the
severity of his symptoms, the consultant was recommending a more aggressive work-up,
perhaps including a computed tomography (CT) scan and electroencephalogram (EEG).
In any case Danny’s differential diagnosis at the end of the consultant’s initial interview
would be as follows if we were using DSM-5 criteria:

Other specified bipolar and related disorder (“dysphoric mania”; patient does not meet
criteria for either a major depressive disorder or a manic episode)
Obsessive–compulsive disorder (with good insight)
Rule out bipolar and related disorder due to another medical condition
None
Medical Disorders:
Rule out medical causes of bipolar disorder such as tumors, epilepsy
I believe that future research – made possible by the added dimensionality of the DSM-5
– will eventually substantiate the importance of dysphoric manic symptoms as well as
their common appearance in mixed bipolar states. Indeed, it is my personal belief that
future revisions of the DSM-5 may very well include a set of specifiers for dysphoric mania
exactly as it has a set of specifiers for a melancholic depressive disorder.
Such an addition will serve to remind clinicians to look for this specific symptom
cluster, the presence of which can significantly impact treatment planning. In addition,
the term bipolar I disorder (mixed, dysphoric mania) captures the descriptive essence of
Danny’s complex and painful inner world distinctly and with a minimum of words.
Let us review the wealth of diagnostic interviewing points that Danny’s presentation
illustrates:
1. Some patients present with a curious mix of depressed symptoms and manic symp-
toms simultaneously (or that are cycling so fast that they appear to be merged).
2. Mixed presentations may be more common in late adolescents and young adults,
where they are easily misdiagnosed as major depressions with irritability and/or
agitation.
3. Mixed states, especially in this younger age group, may present primarily with dys-
phoric manic symptoms including: an intensely depressive angst, racing thoughts
experienced as distinctly unpleasant, irritability, anger, a dark moodiness, stormy
relationships, impulses for self-cutting and other self-damaging behaviors, suicidal
ideation or violent ideation, and feeling intensely driven to get relief from their dark
and racing thoughts and/or to “right” what is wrong with the world or the people
in their world.
4. In the initial interview (as well as within ongoing sessions), be sure to monitor the
potential for violent behaviors such as self-cutting, suicide, and violence towards
others.
5. Three symptom characteristics may point towards the presence of a dysphoric
mania in a patient complaining of depression: (1) persistent anger as a major
presenting symptom, (2) intense psychological angst, and (3) intensity of a patient’s
psychological angst being markedly more intense than their neurovegetative
symptoms.
6. Two historical markers can also suggest the possibility that a patient is suffering
from a classic bipolar disorder (or perhaps from one of the other types of mixed bipolar
states): (1) a positive family history for bipolar I disorder, bipolar II disorder,
substance/medication-induced bipolar disorder, or cyclothymic disorder, (2) the
patient has a personal past psychiatric history of bipolar II disorder, substance/
medication-induced bipolar disorder, or a cyclothymic disorder.
7. Patients experiencing dysphoric manias may have a predilection to develop psy-
chotic process.
8. The patient’s dysphoric manic symptoms (especially angry outbursts, dark moodi-
ness, stormy relationships, impulsive self-cutting and suicidal ideation and behav-
iors) can be easily mislabeled as evidence of personality dysfunction, resulting in
an inappropriate personality diagnosis such as borderline personality disorder.
9. If you see behavioral characteristics suggesting diagnoses such as borderline person-

ality disorder and histrionic personality disorder, be sure to carefully interview for
evidence of mixed bipolar disorders of a dysphoric nature.
10. Be on the lookout for the opposite error (diagnosing patients with borderline per-
sonality disorder as having bipolar disorder, although some patients may have
both).
11. Also be on the lookout for the similar error of misdiagnosing a child or adolescent
with hyperactive ADHD, oppositional disorder, or a conduct disorder as having
bipolar disorder. Keep in mind the diagnosis of disruptive mood dysregulation
disorder.
12. Bipolar II disorder is diagnosed when the patient has at least one major depressive
episode with one or more hypomanic episodes (with none of the hypomanic epi-
sodes reaching the full criteria for a manic episode).
13. Substance/medication-induced bipolar disorder is diagnosed when a patient only
has hypomanic or manic episodes while taking a traditional medication (such as an
antidepressant), a complementary alternative medicine (such as St. John’s wort), or
other non-pharmacologic interventions such as light therapy or ECT.
14. Before starting any patient on an antidepressant agent, carefully search for the following
during the interview: (1) current symptoms or signs of hypomania (remember that
hypomanic symptoms may be subtle and under-reported unless directly asked
about), (2) a history of past hypomanic or manic symptoms, and (3) a family history
of bipolar process, including relatives with hypomanic histories (often untreated,
with families viewing them as “just sort of nutty” or as having a “motor mouth”).
15. Medication/treatment-induced hypomanic or manic episodes can include impulsive
suicidal ideation/behaviors or violent ideation/behaviors.
16. Suicidal thoughts and impulses triggered by a partial or full mania being unleashed
by a medication or street drug may have different phenomenological characteristics
than the typical suicidal ideation experienced by the patient during his or her previ-
ous or current depressive episodes. Such phenomenological differences may help
the interviewer to distinguish suicidal ideation caused by the patient’s underlying
depression as opposed to suicidal ideation caused by a manic burst triggered by a
medication or street drug.
17. Listen carefully to family members’ opinions on symptoms, responses to medica-
tions, and diagnostic impressions. They can be invaluable.
Clinical Presentation #3: Mr. Whitstone

Mr. Whitstone was admitted to a general hospital for evaluation of bizarre behavior
described by his family as paranoid. He is a distinguished-appearing 62-year-old White
man who has been a prominent businessman. At the time of the interview, he is refusing
all hospital care, including intravenous lines and medication. The interviewer has been
called in as an emergency consultant. During the interview Mr. Whitstone appears
guarded, thoroughly grilling the interviewer about his training and his purpose. Outside
of his suspiciousness, Mr. Whitstone is cooperative. During the first 10 minutes of the
interview he appears tense, complaining, “I’m really having trouble with my thinking. I
can’t concentrate anymore. But they don’t understand.” When asked whether he feels
depressed, he answers, “No, I don’t feel particularly depressed.” He reports problems
with appetite and sleep. But of all his concerns, he is most upset about his business
company, since he feels “Someone in the company, and I’m not quite sure who, is out
to get me. I’m pretty sure my life is in danger.” He has not returned to work since his
triple bypass heart surgery in January, 6 months earlier. He is alert and oriented times
three with a stable level of consciousness. Three members of his family are at his bedside
when the interviewer first enters the room.
Discussion of Mr. Whitstone

Patient Hesitancies to Admit to Depression and How to Transform Them
Mr. Whitstone had had heart surgery 6 months earlier. Currently he was refusing all
medical help. One of the curious facets of Mr. Whitstone’s presentation remains the fact
that when asked directly about depression he stated, “No, I don’t feel particularly
depressed.” Further questioning suggested differently. Since his bypass surgery in January,
he had been experiencing many neurovegetative symptoms of depression, including dif-
ficulty falling asleep, sleep continuity disturbance, loss of appetite, weight loss, poor
concentration, and anhedonia. Collaborative information from his wife and children
pointed towards depression. They felt that he appeared withdrawn, sad, and not himself.
Mr. Whitstone appeared to be depressed, and yet he denied it. Such a denial of depres-
sion is common. Donald Klein estimates that approximately 30% of people fulfilling the
criteria of major depression will deny being depressed.56
When first asking about depression I have found the following series of questions to
be useful in determining whether depressed mood may be present:
a. “How would you describe your mood over the past several weeks?”
b. “Tell me a little bit about how you’ve been feeling recently.”
c. “Would you say that you’ve been feeling depressed?”
If the patient denies depression, the interviewer can switch to a different word than
“depressed,” which, for whatever reason, the patient may identify with more, such as:
a. “Have you been feeling sad at all?”

b. “Have you been feeling unhappy?”
It is not uncommon for a person suffering from depression to deny depression while
admitting to sadness. Another useful question for uncovering depressed mood remains,
“When was the last time you felt like crying?” The phrasing of this question automatically
conveys that the interviewer feels it is both common and acceptable to cry, and is an
example of one of our validity techniques (gentle assumption) from Chapter 5. Certain
patients, especially males, feel hesitant to admit tearfulness. This question helps to skirt
this resistance by asking only when they felt like crying. Such sensitive phrasing allows
the self-conscious patient many avenues for saving face. The direct question, “Have you
been crying?” may yield false negatives, since it does not offer any avenues for the patient
except denial or admission of tearfulness.
Finally, if the patient denies both depression and sadness (Mr. Whitstone actually
vigorously denied both), the following questions may unearth material suggesting
depressed mood:
a. “Have you been feeling yourself recently?” or

b. “Have you been feeling up to par over the past several weeks?”
Cross-Cultural Issues in Recognizing Depression

Throughout the book we have emphasized the importance of understanding cultural and
ethnic considerations during the initial interview. Such issues remain important in dif-
ferential diagnosis as well. Sometimes cross-cultural differences can be the cause for
missing the presence of a major depressive episode, for depression may be experienced
or labeled differently depending upon the patient’s culture.
For instance, in the Latino/a population, depression is likely to be associated with
“bad nerves,” and clinicians may be able to more effectively elicit depressive symptoms
with questions such as, “When you are really stressed, do you sometimes experience
‘nervios’ or trouble with your nerves?” In addition, as seen with many cultures, in the
Latino/a culture there can be a tendency to experience depression via somatic complaints
such as headaches (sometimes called “brain aches”). Indeed, the syndrome of nervios
encompasses a broad range of symptoms besides classic depressive symptoms including,
trembling, tingling sensations, and mareos (dizziness with occasional vertigo-like quali-
ties). Thus nervios can span a variety of DSM-5 diagnoses from depression and anxiety
disorders to dissociative disorders and even psychosis.57 In any case, the term “nervios”
is an excellent gateway for uncovering depression and depressive equivalents in the
Latino/a culture.
It is also worth noting that the rapid onset of “ataque de nervios” can meet the criteria
for a panic attack, which demonstrate a considerable co-morbidity with major depressive
disorders as described in the DSM-5. It is important for interviewers to realize that the
symptoms of a panic attack may vary from culture to culture, even in cultures/ethnic
groups that are stereotypically viewed as being loosely related cultural/ethnic entities
such as Latino/a, Hispanic, Dominicano, Cuban, etc. (all of which may have distinctive
differences in cultural heritage, customs, and beliefs, as well as being composed of various
races and racial mixtures).
For instance, ataques de nervios in Puerto Rican and Dominican patients may be
characterized by the appearance of abrupt trembling, uncontrollable crying and/or
screaming, aggressive or suicidal behavior, and depersonalization/derealization symp-
toms.58 An interviewer unaware of these common cultural manifestations of a panic
attack in these patients may mislabel a Puerto Rican or Dominican patient – who is
simply having a typical panic attack of the variety seen in their cultural matrix – as being
histrionic or troubled by aggressive propensities.
In a metaphorical sense, this somatic tendency sometimes carries over into the label
chosen for depression, as seen in Middle Eastern cultures where a depressive episode
might be described as having “problems of the heart.” In the Hopi nation the same
episode would be described as being heartbroken. In Chinese and Asian cultures, a
patient may be more comfortable complaining of being weak, tired, or feeling
“imbalanced.”59
As was the case with Danny, Mr. Whitstone’s presentation also emphasizes the critical
importance of sources of information other than the patient. A hallmark of shrewd
interviewers remains the ability to know when their interview was inadequate. In the
case of Mr. Whitstone, both his wife and other family members felt that he had been
pervasively depressed for at least 2 months.
Problems With Concentration and Cognitive Functioning in Depression

When questioned whether he had been feeling up to par recently, Mr. Whitstone pen-
sively yet openly discussed his concerns over inadequacy and his fears about his
thinking:
Clin.: In what ways haven’t you felt yourself?

Pt.: My concentration is shot. It’s been very upsetting, let me tell you. I’m a fairly
intelligent man, I’ve gone far. But about a month ago, I called my secretary to
dictate a memo. I had to hang up, because I couldn’t do it. (Mr. Whitstone was
dismally moving his head from side to side.) It took me 2 days to write that memo
(pause). I could normally do it in 20 minutes.
Other useful questions concerning cognitive processes include:
a. “Have you noticed if your thinking appears to have speeded up [hypomania, mania,
mixed bipolar states, agitated depression] or slowed down [melancholic or withdrawn
depression]?”
b. “Are you finding it more difficult to make decisions recently?”
c. “Do you find yourself feeling frustrated when you are trying to make a decision?”
d. “Does it ever seem like your thoughts are getting disconnected or confused?”
e. “Has it been difficult for you to hold a train of thought?”
f. “Are you finding it difficult to read or to follow people as they talk?”
We will examine the important role of the cognitive exam in further delineating the extent
of a patient’s cognitive dysfunction as well as its role in uncovering dementias masquer-
ading as depressions and depressions masquerading as dementias (pseudodementia), in
more detail later.
Spotting Atypical Depression

With Mr. Whitstone we have seen that a seriously depressed person may not always
complain of depression. Another cause for diagnostic confusion is the presence of an
atypical depression. Not all people with depressions present with classic neurovegetative
symptoms, and in such cases the DSM-5 allows one to specify that the depression is
“atypical” in nature.
I place the word atypical in quotes because these depressions are hardly atypical in
nature. Estimates in both community and clinical settings indicate that 15.7 to 36.6%
of depressions meet the criteria for atypical depression. As we saw earlier, these atypical
features are seen even more frequently (in up to 50%) with bipolar type II depression
and in dysthymia.60 Some features, such as mood reactivity, also remind one of the
“depressive” states seen in mixed bipolar process, and, indeed, atypical depressions are
more common in bipolar I disorder, especially mixed presentations.
Spotting atypical depressions has distinct clinical implications. Their presence cues
the clinician to thoroughly hunt for evidence of bipolar process, which, if present, may
caution against the use of antidepressants without first covering the patient with a mood
stabilizer or perhaps indicate only a psychotherapeutic intervention if possible. Even if
hypomanic symptoms are not present, it reminds both the clinician and the patient to
be particularly on the lookout for an unexpected unleashing of manic symptoms once
an antidepressant is instituted, in which case the antidepressant can be promptly discon-
tinued, hopefully before major manic symptoms have been precipitated. In addition,
there is evidence that if a patient solely has an atypical depression (without bipolar
process), and the patient’s depression is not responding to medications such as selective
serotonin reuptake inhibitors or tricyclics, they might preferentially respond to mono-
amine oxidase inhibitors61 and/or cognitive psychotherapy.
So what do these atypical depressions look like? In the DSM-5, in order to be viewed
as having an atypical depression, the patient must first meet the criteria for a major
depressive disorder while simultaneously presenting with a phenomenon known as
“mood reactivity.” In addition, the patient must demonstrate two out of four secondary
symptoms.
Let us first look at the concept of mood reactivity. In a classic depression, the patient’s
depressive symptoms, although somewhat fluctuating in intensity over time, are persis-
tently present over time and don’t respond much to environmental triggers. Thus, when
anhedonia is present, a classically depressed patient will not suddenly respond with an
uplift in mood and/or interest when an otherwise enjoyable activity for that patient
presents itself (e.g., the chance to see a favorite movie) or respond positively and with
animation to a compliment from a friend or employer. In contrast, patients with mood
reactivity have the capacity to feel at least 50% better and can even become transiently
euthymic (experience normal mood) when encountering positive events.62,63 It has been
noted that some of these patients can maintain a good mood for hours, or longer, if the
positive re-enforcer continues (e.g., a weekend getaway with a new romantic interest).64
It should be noted that some authors feel, and perhaps this will be reflected in future
diagnostic systems, that the symptom of mood reactivity is not always present in atypical
depressions and should not be viewed as necessary for making the diagnosis.65
In the DSM-5, once the patient demonstrates mood reactivity, in order to be viewed
as having an atypical depression, two of the following four symptoms must be present:
(1) significant weight gain or increase in appetite, (2) hypersomnia, (3) leaden paralysis,
and (4) a long-standing pattern of interpersonal rejection sensitivity that results in
significant social or occupational impairment. Of these symptoms, rejection sensitivity

seems to be the most common, as seen in a study of 332 patients of whom 71% reported
rejection sensitivity, 47% hyperphagia, 47% leaden paralysis, and 35% oversleeping.66
Let us look at these symptoms in more detail. Rejection sensitivity is unique among
them, for it represents a personality trait, which is lifelong in nature and is seen both during
the depression and between episodes of the depression. It can be exacerbated during the
depressive episodes themselves. This diagnostic marker is one of the rare instances in
the DSM-5 where a non-personality disorder includes a stable personality trait as one
of its criteria. It is not surprising then to see that patients with atypical depressions have
a higher rate of personality disorders such as histrionic, borderline, and narcissistic
disorders.
The rejection sensitivity displays itself as an unpredictable and rapid negative response
to both hostile and non-hostile interpersonal comments and/or interactions. Patients
with atypical depressions tend to “take things in the wrong way” whether responding to
conversation, comments in a chat room, a text message, or a tweet. Rejection, hurt,
embarrassment, and anger may occur in response to relatively innocuous comments or
behaviors. The result is a backlog of employment problems, broken friendships, stormy
romances, and sometimes a maladaptive seeking of drugs and alcohol for solace. One
can imagine that this entire array of behaviors can be further fueled by the patient’s mood
reactivity. It is important to remember that not all patients with atypical depressions have rejec-
tion sensitivity.
In addition, people with atypical depressions frequently find that during an episode
of depression they find themselves with an increased appetite and/or a significant weight
gain over the course of the episode. Note that this increase in appetite contrasts rather
sharply with the more typical decrease in appetite found in more classic major depressive
episodes.
Hypersomnia is sometimes present, including feelings of needing to sleep during the
day and being just too tired to work, although the patient may feel suddenly more perky
if pleasant activities are available (a type of energy reactivity akin to mood reactivity). To
meet the criteria, the patient must show either a total of 10 hours of sleep per day (includ-
ing nighttime sleep and daytime naps) or at least 2 hours more of sleep per day than the
patient shows normally when not depressed.67
Perhaps the oddest of the symptoms is the sensation of “leaden paralysis.” The term,
in my opinion, is a poor one for it has nothing to do with feelings that a limb is para-
lyzed. Instead it refers to an unpleasant feeling of heaviness in the arms or legs (I have
found it to be more common in the legs), creating the “leaden” sensation of the symp-
tom’s name. I find that patients may describe their legs as feeling weak, rubbery, or “just
not right.” Patients sometimes report being frightened by the sensation in a medical
sense. Indeed, if present, it is important to make sure, especially in older patients, that
this sensation is not being misattributed to depression when it is, in actuality, a symptom
of peripheral arterial disease.
In closing our discussion on atypical depression, one should be aware that both
classic depressions and atypical depressions may also show a tendency, especially in a
primary care clinic, to present with pain or other somatic complaints. In such patients,
if the interviewer vigorously pursues classic neurovegetative symptoms or looks for

symptoms of an atypical depression, he or she will often uncover one lurking below the
surface.
Many mental health providers will find themselves, at some point in their careers,
working in a primary care setting, where it is important not to miss such depressions as
well as other disorders that present with pain or somatization. During the course of a
single year, about 10–12% of all adults in the United States will present to a primary
care clinician during a timeframe in which they are suffering from a major psychiatric
disorder. Disturbingly, more than 50% of these individuals will have two or more psy-
chiatric disorders.68
In addition, roughly 50% of all people who die by suicide have been seen by a primary
care clinician within 1 month of the suicide, with 1 in 5 of these patients having seen a
primary care clinician within 1 week of their suicide.69 It is not an exaggeration to say that
the use of the types of skilled interviewing techniques that we will study and see dem-
onstrated on video in our chapter on suicide assessment (Chapter 17) may represent one
of the major hopes for lowering the suicide rate in the United States and
internationally.
Psychotic Process in Depression

In our discussions of Mr. Evans and Danny, we noted that psychotic process is a relatively
common phenomenon in bipolar disorder, especially during manic and mixed states,
but also in the depressed phase of the disorder. Mr. Whitstone serves to remind us that
psychosis can arise in unipolar depression as well, especially in agitated major depres-
sions and in the elderly. As discussed earlier, the DSM-5 refers to such psychotic material
as either mood-congruent or mood-incongruent. In a unipolar depression, the mood-
congruent material frequently concerns itself with depressive ideation or themes of decay
that would seem to be natural in a depressed individual. According to the DSM-5, such
themes include personal inadequacy, guilt, disease, poverty, nihilism, or deserved punish-
ment. Mood-incongruent delusions or hallucinations do not revolve about the above
themes. They are more bizarre or peculiar and include phenomena such as paranoid
delusions, demon possession, thought insertion, delusions of control, and other themes
not necessarily related to depressive ideation. Mr. Whitstone’s paranoia would fulfill the
criteria for mood-incongruent psychotic features.
Ruling Out Non-Psychiatric Biological Causes of Depression

Finally, I have saved perhaps the most important point for last. When confronted with
a mood disorder presentation, one should always “think organic.” Further investigation
revealed that Mr. Whitstone had qualities suggestive of delirium, including auditory hal-
lucinations, rapid fluctuations in affect, and a few periods of a fluctuating level of con-
sciousness according to the nursing notes. Besides the standard clues hinting at an
organic state, Mr. Whitstone’s history was suggestive of an organic etiology for several
reasons: (1) He had not seemed normal since his bypass surgery; (2) he had been on
anticoagulants, raising the possibility of emboli (blood clots) having been previously
dislodged from his heart and passed to his brain or of a hemorrhage in his brain related
to his anticoagulants; and (3) he was significantly dehydrated.
In relation to organic precipitants of depression, it is important to stress the need for
asking questions about both over-the-counter medications and prescription medications.
A brief list of medications that commonly affect mood includes cimetidine, propranolol,
methyldopa, reserpine, amantadine, steroids, birth control pills, and opiates. Even thia-
zide diuretics can cause depression by altering electrolyte balance.70 Be on the lookout
for depressions triggered by the use of prescribed synthetic opioids, such as OxyContin
and Percocet. The abuse of these drugs is of epidemic proportions in the United States.
They are currently one of the leading causes of death/suicide by overdose.
When considering an organic cause of depression besides medications and intra-
cranial disease, one should keep in mind extracranial diseases such as hypothyroidism,
hyperparathyroidism, lupus, hepatitis, and carcinoma. Pancreatic carcinoma is notorious
for initially presenting with depressive complaints. Looked at more systematically, Ander-
son71 has separated the organic causes of depression into six categories, including:
1. Drugs and poisons

2. Metabolic and endocrine disturbances
3. Infectious diseases
4. Degenerative diseases such as multiple sclerosis
5. Neoplasm
6. Miscellaneous conditions such as chronic pyelonephritis or Meniere’s disease
It is well beyond the scope of this chapter to discuss a thorough differential of the organic
causes of depression, but I heartily urge the reader to review this material.
Naturally, even the best clinician will sometimes miss organic causes of depression
despite a search for them. This failure is to be expected. But in the last analysis, there is
no excuse for not having thought of looking for an organic cause of depression. In par-
ticular, one situation presents itself in which I unfortunately find it very easy to forget
about possible organic factors.
This situation arises when the patient presents complaining of a significant life stress
such as unemployment, housing problems, divorce, or a death in the family. In such
instances it is easy to assume psychological causality, but this assumption can be patently
misleading. Simply because a person has ample reason to be depressed does not mean
that his or her depression does not also have a concurrent organic cause. Quite to the
contrary, physical and psychological disabilities often go hand-in-hand. For instance,
Schmale has reported a high incidence of separation events preceding the onset of
medical illnesses.72
The clinician should think holistically, checking for both psychological and physi-
ologic roots of depression. One can often be fooled by what appears obvious. On
the one hand, apparent adjustment reactions may be hiding something more ominous
biologically. On the other hand, the obvious endogenous depression may actually
be triggered or sustained by some not-so-obvious psychological factor or family
dynamic.
Differential Diagnosis on Mr. Whitstone and Summary of Key Interviewing Tips

In closing the discussion of Mr. Whitstone, let me diagnostically summarize his situation
at the end of the initial interview.

Psychotic disorder due to another medical condition, condition unknown (provisional
diagnosis)
Rule out delirium
Rule out major depressive disorder (with mood-incongruent psychotic features, para-
noid delusions)
Possible paranoid or compulsive traits (derived from data elicited from the family)
Medical Disorders:
Significant dehydration
Status post-bypass cardiac surgery
Rule out embolism to brain or hemorrhage
By way of follow up, a rigorous organic evaluation, including delirium/dementia chem-

istry screen, EEG, CT scan of head, lumbar puncture, and echocardiogram (checking for
clots in the heart which could have embolized to the brain) revealed no abnormalities.
Moreover, once Mr. Whitstone was rehydrated he continued to be symptomatic. Appar-
ently he was most likely suffering from a major depressive disorder with mood-
incongruent psychotic features, although there may have been some brief periods of mild
delirium, possibly secondary to dehydration, as well.
At this point I would like to summarize the major issues underscored by Mr. Whit-
stone’s interview:
1. People suffering from depression often deny that they are depressed.
2. Specific questions should be asked in an effort to uncover dysphoric mood not readily
described by the patient.
3. Become familiar with varying presentations of depressive disorders across cultures.
(Also keep in mind that patients may vary on how likely they are to share depressive
symptoms related to the degree of stigmatization associated with depression within
their culture.)
4. Atypical depression often presents with mood reactivity accompanied by symptoms
such as increased appetite, hypersomnia, “leadenness” of the limbs, and rejection
sensitivity.
5. Outside information from family and significant others may be needed to delineate
the diagnosis.
6. Even mood-incongruent psychotic features such as paranoia or thought insertion can
occur during severe depressive episodes.
7. It is imperative to ask questions and to order appropriate lab work that can help to
rule out possible organic causes of depression.
Clinical Presentation #4: Ms. Wilkins

Ms. Wilkins enters the outpatient office with hesitant steps. Her patterned blue dress is
faded and wrinkled. She is a 26-year-old White single woman who reports, “I feel hor-
rible. I am so very depressed. Last night I was thinking of maybe (pause, tearfulness) …
killing myself.” She reports numerous neurovegetative symptoms of depression such as
sleep disturbance, decreased energy, decreased libido, and increased appetite. She reports,
“I’ve been depressed for years.” She truly appears very sad. As the interview proceeds, the
interviewer feels a deepening desire to help as well as an increasing concern. There is
also an angry quality to Ms. Wilkins as she relates, “My best friend is really a bitch. I
can’t believe I trusted her.” Ms. Wilkins denies concrete suicidal or homicidal ideation
at the time of the interview, stating, “I’m feeling in control now.” She wishes to have
both medication and psychotherapy.
Discussion of Ms. Wilkins

Despite her sad affect, further questioning revealed some intriguing differences when
comparing Ms. Wilkins with our three previous individuals:
Pt.: I’m really feeling horrible. My whole world is collapsing. I don’t know who to trust.
Clin.: How long have you been feeling this way?
Pt.: Years, for years. I can’t think of a time when my life went smoothly. It’s all a big
mess.
Clin.: When you say “for years” do you mean your depression never lifts?
Pt.: Well, not really, I mean, I have my good days. Even a bad apple has its good parts
… so … sometimes I feel fine.
Clin.: When looking back over the past several weeks, did you have some of those good
days?
Pt.: Oh, I actually had a couple of good days last week, right before the big blow-up
with Janet, but I knew Janet would blow it.
Clin.: Tell me how you felt on those days.
Pt.: Fine. In fact, I was having a great day on Friday until Janet had to open her big fat
mouth.
Clin.: You say you’ve been feeling depressed for years, but it sounds like your mood
changes a lot. Have you ever had a period of at least 2 weeks where for the entire 2
weeks you felt down and depressed?
Pt.: That’s a little hard to answer. I haven’t felt that way for a long time … back home
though, yeah, back home I was about 19, I was depressed for almost 4 months straight.
Clin.: Tell me more about it.
The Need to Determine the Persistence of Depressive Symptoms and How to Do It

From this dialogue it becomes apparent that Ms. Wilkins is probably not currently expe-
riencing a sustained depressive episode. She would later describe a history of intermittent,
low-grade depressive symptoms for many years, meeting the criteria for having a
persistent depressive disorder (dysthymia, refer to page 345 for DSM-5 criteria). Without
a sustained alteration in mood or marked anhedonia lasting for 2 weeks, she will not
fulfill criteria for a major depressive disorder. On the other hand, she appears to have
undergone a 4-month major depression in her teens. Further interviewing revealed that
this episode was accompanied by persistent neurovegetative symptoms. She currently
notes some fluctuating neurovegetative symptoms, including some difficulty falling asleep,
increased appetite, and low energy. From her history she appears to have had a major
depression at age 19, which is currently in remission. This previous depression had
responded to paroxetine successfully.
The above dialogue emphasizes two points: (1) A detailed history of the present dis-
order should be carefully elicited. In this exploration, the interviewer pays particular
attention to both the time course and the duration of the symptoms. The foundation of
a good diagnostic interview remains a good history of the presenting disorder. (2) One
should rigorously evaluate whether the depressive symptoms are sustained or whether
they fluctuate towards normal. Many people whose depressed feelings come and go will
describe their symptoms as unrelenting unless questioned carefully, perhaps related to
the fact that depressive feelings often tend to be experienced as intolerable, thus over-
shadowing the moments of normal mood. The DSM-5 criteria, for a major depressive
episode, require that the depressive symptoms need to have each been present nearly every day
for a period of at least 2 weeks. Consequently, if the interviewer uncovers a significant
fluctuation of symptoms, then he or she must look elsewhere than a major depressive
disorder for a diagnosis.
Incidentally, I have found that statements such as, “I’ve been depressed for years,” are,
curiously enough, often indications that a classic major depressive disorder is not present.
When questioned in more detail, such people often do not describe a sustained depres-
sion. Instead, they relate histories of depressive symptoms that fluctuate in response to
environmental rewards or pleasures, as is commonly seen in some personality disorders,
with a dysthymic disorder, in substance abuse, and in some atypical depressions. The
following questions may be of value concerning the exploration of mood fluctuation:
a. “Do you find that your mood can shift during a single day?”
b. “Would you describe yourself as a moody person?”
c. “When you are feeling down, do you ever find that a friend or ‘something to do’ can
perk you up quickly?”
If the patient answers “yes,” then the interviewer, using behavioral incidents, asks the
person to describe some examples of such experiences. Another very useful question for
determining whether a depression is persistent or not is:
“Some people tell me that, when they are depressed, their symptoms stay with them day
after day. Others tell me that their symptoms come and go almost like a roller-coaster.
Where on that continuum would you place yourself?”
As mentioned earlier, the lack of sustained depressive symptoms suggests other diagnoses
such as dysthymia, cyclothymic disorder, certain personality disorders, or drug abuse or
atypical depressions.
Red Herrings: Disorders That Mimic Major Depressions

In contrast to Danny, Ms. Wilkins presents the opposite diagnostic trap – misdiagnosing
a patient who actually has a personality disorder as solely having a major depressive
disorder. Missing a personality disorder, especially severe disorders such as borderline
personality disorder, can have major ramifications for a patient including: missed oppor-
tunities to use effective psychotherapies (such as dialectical behavioral therapy), inap-
propriate triage to inexperienced clinicians, the development of dangerous dependencies
on the therapist, exposure to unnecessary medications, and lack of appropriate attention
to suicide potential.
Upon further interviewing during her initial assessment, Ms. Wilkins described a long
history of angry outbursts (e.g., throwing a hammer through a window), severe loneli-
ness, intense feelings of boredom and emptiness, confusion over homosexual versus
heterosexual relationships, and a series of overdoses. She also described a lengthy history
of self-cutting her wrists and of burning her fingertips. These non-lethal self-injurious
behaviors could occur in the middle of a series of days when she was feeling good, the
behaviors occurring abruptly after a perceived interpersonal stress.
Later in the interview, Ms. Wilkins would provide further information suggesting that
her problematic behaviors were long-standing, persistent, and not caused by substances
or other disorders such as mania. She denied any history of bipolar process in her family
and she had no history of unleashed manic symptoms upon use of antidepressants. She
met the criteria for a diagnosis of borderline personality disorder. In addition, the inter-
viewer sensitively uncovered a history of sexual abuse as a child, a situation that we shall
see in our chapter on personality disorders is not uncommon with people presenting
with a borderline personality disorder.
Her presentation emphasizes the following simple but easily forgotten principle: No
matter how severely depressed a person looks, the diagnosis is not always that of a major
depressive disorder. In fact, when it comes to looking severely upset, individuals with
borderline personality disorder have a knack for such a dramatic presentation. With this
in mind, when the interviewee complains of sadness or depression, the following diag-
noses should be considered in addition to a major depression or a bipolar disorder:
a. Persistent depressive disorder (dysthymia)

b. Cyclothymic disorder
c. Borderline personality disorder
d. Other personality disorders such as the histrionic personality, narcissistic personality,
avoidant personality, dependent personality, or obsessive–compulsive personality
e. Alcohol or drug abuse
f. Adjustment disorders with depressed mood
g. Medical etiologies of depression such as hypothyroidism
h. V-codes such as marital problems or housing and economic problems (normal depres-
sive responses to situational stresses)
Far from being a complete differential, this list represents the common entities that are
often misdiagnosed as major depressive episodes. In contrast to a major depressive
episode, these entities tend to show significant fluctuation in both mood and symptom-
atology. To mislabel these disorders as a major depressive disorder can lead to serious
errors in triage or medication prescription, as mentioned earlier. To further illustrate the
point, it could be a fatal mistake to prematurely prescribe antidepressants for Ms. Wilkins,
subsequent to having mistakenly diagnosed her as having a major depressive disorder.
Indeed, Ms. Wilkin’s psychiatric trail is littered with empty bottles signifying her suicidal
gestures by overdosing.
Tips for Delineating an Accurate History of the Presenting Disorder

Delineating the history of the presenting disorder and determining the consistency of
the symptoms are not tasks as easily accomplished as one might think. The process is
greatly complicated by a variety of factors, including: (1) patient difficulties with memory,
(2) unconscious distortion of the facts by the patient, (3) conscious or histrionic distor-
tions by the patient, and (4) misunderstandings by the patient of the questions asked.
These problems are compounded when the clinician becomes lost in the facts and has
no general approach to eliciting the history of the presenting disorder.
Consequently, it is worth spending some time examining some approaches to gather-
ing a valid history of the present disorder for the classic psychiatric diagnoses unrelated
to personality dysfunction. This history can be broken down into three contiguous
phases: the early phase, the mid-phase, and the recent phase of the disorder (the 2
months directly preceding the interview). All three phases are important, but because of
the time constraints facing the intake clinician, an emphasis should be placed, in my
opinion, on the early phase and the recent phase.
The early phase may provide critical diagnostic information, because it allows the
clinician to see the natural unfolding of the pathologic process. A patient may present
with striking hallucinations while also reporting depressive feelings. If the patient has a
major depression, then the early phase will generally demonstrate the appearance of
marked depressed symptoms first, followed by psychotic symptoms. However, as we shall
see in Chapter 11 on the differential diagnosis of psychotic disorders, the patient with
schizophrenia (although the patient may have mild prodromal depressive symptoms)
will generally demonstrate psychotic symptoms and agitation first, with more severe
depressive symptoms appearing later. Unless the clinician asks the patient or collabora-
tive sources such as parents and other family members for this information, it can easily
remain buried in the history. It is also during the history of the early phase that the
interviewer has the opportunity to hear about the symptoms of the disorder without the
distorting impact of medications.
A careful delineation of the recent history is an absolute necessity, because it provides
the information needed to determine the patient’s immediate level of functioning and
the present diagnostic reality of the patient. As noted above, this immediate diagnostic
picture can be confusing if the patient is currently taking medications, because the
patient’s symptom picture may be incomplete, since partial remission may be present.
As obvious as this point may seem, it is surprisingly easy in a busy clinic setting to be
trapped into thinking that a patient is not experiencing a major depressive episode when,
in actuality, it is hiding beneath the facade created by partial treatment. In such
circumstances, it is important to explore the symptom picture at the time directly preced-
ing the use of medications.
With the understanding that it may be valuable to emphasize the early phase and the
recent phase, two rather different approaches can be utilized when eliciting the history
of the presenting disorder. Both are effective. Clinicians must determine which seems
best suited to their style and the needs of the specific patient.
In the first technique, as the patient discusses the history of the presenting disorder,
an effort is made to quickly direct the patient to the early phase of the illness. The history
is then taken chronologically from past to present, with less emphasis upon the middle
phase. Stressors and responses to stressors are frequently elicited as the history naturally
unfolds. The strength of this approach is the detailed and well-ordered history that
results. The weakness is the fact that because patient histories are frequently both complex,
and fascinating, the clinician can easily spend too much time on the early and middle
phase, coming away with a hazier picture of the immediate problems and current
presentation.
A brief piece of dialogue will demonstrate two important features concerning the
delineation of the onset of the disorder.
Clin.: When did this depression first begin for you?

Pt.: Uh … a couple weeks after Thanksgiving … yeah, after Thanksgiving everything
began to fall apart.
Clin.: Think carefully, in the months before Thanksgiving were you feeling totally normal
or were you already feeling not quite yourself? (time-related anchor question)
Pt.: Huh … actually I had been feeling somewhat depressed shortly after Patty, my
daughter, went away to college.
Clin.: What were the first symptoms you noticed?
Pt.: I felt tearful at times and unusually tired … yes, yes, I remember being struck at
how little I wanted to get out of bed in the morning. But I’m not really certain
when that feeling began … no, now that I think of it, that might have happened
much later, I’m just not certain (looking frustrated).
Clin.: It’s hard to remember details like this and you’re doing an excellent job. Let’s focus
upon Thanksgiving. Did you have a hard time getting out of bed then?
Pt.: Oh yes, that I do remember. I didn’t want to clean the house either or even cook
the turkey.
Clin.: What was your appetite like over Thanksgiving?
Pt.: Very poor.
As illustrated in the preceding dialogue, when first asked to date the onset of their dis-
order, patients frequently give an inaccurately late date, because it is easiest to remember
when they began to feel really bad, usually a point several weeks or months after the
onset of the illness. Consequently, they should be gently pushed by asking a second time,
as shown in the example. Another useful method of increasing the validity of the data,
as illustrated in the above dialogue, is to use a validity technique we described in Chapter
5 called the “time-related anchor question,” delineated by Danny Carlat. Time-related
anchor questions prime the memory of the patient by using specific holidays or personal
events that can function as a trigger for increasing memory production.73
The second approach for eliciting the history of the present disorder consists of focus-
ing the patient upon the recent and current phase of the illness first. The clinician then
skips to the early phase and delineates the remainder of the history chronologically, with
less emphasis upon the middle phase. This method provides the clinician with a sound
understanding of current symptoms, stresses, and level of functioning, ensuring that these
critical areas do not get short shrift because of time constraints. Patients also frequently
like talking about recent symptoms first. Generally, this method also provides the early
generation of a good diagnostic differential, which can help guide the subsequent ques-
tioning concerning the earlier phases of the history of the presenting disorder.
When delineating the recent history, it is often useful to frame the time period with
comments such as, “Let’s look for a moment at just the last 2 weeks. All of the following
questions deal only with the last 2 weeks. During that time how has your energy been?”
Because the patient has been coping with large amounts of psychological pain and
confusion, even with the above framing, it is easy for that person to eventually begin
discussing earlier symptoms without letting the clinician know that this is the case.
Consequently, it is useful to remind the patient several times of the timeframe with
statements such as, “Once again, just looking at the past 2 weeks, what has your sleep
been like?”
Let us now return to the presentation of Ms. Wilkins, because her history provides
several more practical interviewing points.
Ruling Out Peripartum Depressions, Grief, Adjustment Disorders, and V-Codes

Pay particular attention to mood disturbances in the months directly after a patient has
given birth. The tremendous hormonal shifts associated with pregnancy, birthing, and
breastfeeding can trigger mood disturbances. Ms. Wilkins was neither pregnant nor post-
partum, effectively ruling out this diagnosis.
Sometimes women who develop postpartum mood disorders may have had signifi-
cant mood disturbances during the pregnancy itself. It is also important to note that
a true postpartum depression is strikingly more severe than the normal moodiness
(postpartum blues) seen in many women following birth. Postpartum depressive epi-
sodes can evolve into bipolar disorders and mixed states, including psychotic process,
as we shall discuss in Chapter 11. It is important in these postpartum psychotic states
to ask questions that can sort out whether there may exist some danger to the newborn
(as with a belief the child is demon possessed or the patient is experiencing command
hallucinations to hurt the child). Whether the depressive episode begins prepartum or
postpartum, in the DSM-5 these major depressive disorders are indicated by adding
the specifier “with peripartum onset.”74
With further questioning, Ms. Wilkins denied the recent death of any close friends or
family. This point is mentioned because her initial symptoms would have been consistent
with an uncomplicated bereavement. In addition to the natural depressive responses
accompanying grief, it is not uncommon for a full major depressive episode to occur
during the acute phase of grief. If it does – or if the patient demonstrates severe depres-
sive symptoms not typical of his or her culture – one should consider adding the diag-
nosis of major depressive disorder.75
On the other hand, if the bereavement lasts too long a time and/or begins to persis-
tently intensify over the months following the death, then the diagnosis of a major
depressive disorder should be made instead of an uncomplicated bereavement. Also
clinicians can use their phenomenological understanding to help differentiate normal
grief from the development of a pathologic depressive episode.
In normal grief, the depressive symptoms are less persistent and consistent than in a
major depressive episode. Indeed, in normal grief it is common to see wave-like “pangs
of grief” as the person is reminded of the deceased. In a similar fashion, in normal grief
the neurovegetative symptoms may not be as severe or persistent in nature. Guilty cogni-
tions are more commonly seen in true major depressive episodes when they assume a
generalized feeling of being inadequate, worthless, or weak. In contrast, if guilty rumina-
tions appear in normal grief, they tend to be specific towards letting down the deceased,
as with not visiting enough, not getting a chance to say good-bye, or not telling the
deceased how much he or she was loved.
An uncomplicated bereavement is one of the many “V-codes” in the DSM-5 system
(close to a hundred such codes are enumerated). A V-code is a situation or life stressor
that the clinician feels is playing a significant part in the person’s current difficulties and
warrants attention from the clinician. It is important to remember that V-codes are not mental
disorders. V-codes are, in essence, reminders to subsequent clinicians of various aspects
of the person’s matrix where intervention may be valuable. They can include factors such
as current marital problems, spouse or partner abuse, problems at work, financial or
housing problems, as well as quite specific situations such as deployment to a war zone
for a soldier or the spouse of a soldier.76
The diagnosis of adjustment disorder specified with depressed mood describes those
occurrences in which there is a clear-cut psychosocial stressor within 3 months of the
depression. These disorders are viewed as exceeding normal response by either the
distress being markedly out of proportion to the experienced stressor and/or there is
significant impairment in social, occupational, or other areas of functioning. But even
if there is a clear-cut stressor within the specified timeframe, if the criteria for a major
depressive episode are fulfilled, then the diagnosis of adjustment disorder is no longer
applicable and should be dropped, and the diagnosis of major depressive disorder
should be made. Note that adjustment disorders can be classified with various speci-
fiers, such as depressed mood, anxiety, conduct disturbance, or admixture of such
symptoms.77
Differential Diagnosis on Ms. Wilkins and Summary of Key Interviewing Tips

Note that Ms. Wilkins seems to clearly have had a true major depressive episode about
8 years earlier, which raises the possibility that she could, theoretically, be currently start-
ing into a second or recurrent episode, although her symptoms are not yet persistent
enough to meet such a disorder. In addition, she reports some phenomena, such as mood
reactivity, interpersonal rejection sensitivity, and an increased appetite, that are consistent
with an atypical depression (a type of depression seen with some regularity in people
fitting the criteria for a borderline personality disorder and some other personality
diagnoses). Ms. Wilkins diagnostic summary, after her initial interview, would be as
follows:

Persistent depressive disorder (dysthymia)
Personal past history of childhood sexual abuse (one of the V-Codes, included in the
differential diagnosis to ensure that appropriate attention is given to this factor in
treatment)
Rule out major depressive disorder, recurrent
Rule out major depressive disorder, recurrent, with atypical features
Borderline personality (principal diagnosis)
Medical Disorders:
None
Notice that if a personality disorder is the main presenting problem (often becoming the
focus of care) or the reason for a hospital admission, it can be useful to identify it as the
“principal diagnosis.”
By way of summary, Ms. Wilkins’ presentation illustrates the following points:
1. A careful history of the presenting disorder is the foundation of the diagnostic com-
ponent of an initial interview.
2. The duration of the depressive mood should be thoroughly discussed. To fulfill a
major depressive disorder it must last at least 2 weeks in length with little fluctuation
in symptoms.
3. Many other diagnoses may present with depression. In particular, one should be
careful to check for a borderline personality disorder, dysthymia, drug or alcohol
abuse, an adjustment disorder, or a V-code.
4. The clinician should develop a well thought-out approach to the history of the pre-
senting disorder. Otherwise, it is easy to become lost in the database.
5. Patients frequently date the onset of their illness later than it was in reality. Once a
date is given, ask the patient to carefully consider whether he or she had felt com-
pletely normal in the month or two before that date.
6. One can prime the patient’s memory by referring to holidays or to special events in
the patient’s life (the use of a time-related anchor question).
7. When gathering the recent history, it is useful to frame the time period for the patient
and intermittently remind him or her of the timeframe being discussed.
8. Uncomplicated bereavement (a V-code) may simultaneously fulfill the criteria for a
major depressive episode. If this occurs, the process is still labeled an uncomplicated
bereavement and the diagnosis of a major depression is added as a concurrent
disorder.
Clinical Presentation #5: Mr. Collier

Mr. Collier and his wife presented at the psychiatric emergency room. Mr. Collier is a
26-year-old White man who is casually but nicely dressed. He has dark brown hair and
a strong jaw. His voice is rich with a vigorous, almost aggressive, tone. He answers quickly
with authority. While he interacts with his wife, the interviewer finds it easy to picture
Mr. Collier giving his wife “the third degree.” Mr. Collier complains bitterly of severe
depression “ever since I was a teenager.” He continues, “I remind myself of my father.”
He reports a tendency to sleep during the day and frequently feels tired. On the other
hand, he reports that his energy can be pretty good if he has something to do that he
likes doing. Along these lines, he reports a robust appetite and sex drive. In fact, he reports
that, “I still enjoy life a fair amount. I love getting out with my buddies and there is
nothing better than Super Bowl Sunday!” He complains of intermittently “feeling sort
of worthless and lazy.” He is definitely upset that he has been sharp with his kids. A day
before their emergency room visit he slapped his 5-year-old daughter, Jackie, on the face.
This incident frightened him and prompted the emergency room visit. He occasionally
has fleeting suicidal ideation, remarking, “If I had to, I guess I’d jump in front of a car
or bus … you know, to make sure my wife gets the insurance.” He denies current suicidal
ideation. He states, “I’m the problem here. Help me and you’ll help my family.”
Discussion of Mr. Collier

In some respects, Mr. Collier’s interview sounds reminiscent of Ms. Wilkins’ presentation.
Further questioning revealed that, like Ms. Wilkins, his mood tends to fluctuate. He
would not meet the criteria for a major depressive disorder for he has not had a recent
period of pervasively depressed mood lasting for 2 weeks or more. He denies any manic
or hypomanic symptoms other than chronic irritability.
Questions pertaining to the history of his present disorder revealed that he had felt
intermittently depressed for over 10 years. He had had no periods of good mood lasting
consistently longer than a month or two. Mr. Collier did not relate further symptoms
consistent with a borderline personality or any other personality disorder, although he
displayed, and his wife supported, that he had some mildly narcissistic traits. The above
information, once again, suggests a diagnosis of dysthymia, a relatively common psychi-
atric syndrome. There is substantial research evidence that dysthymia can respond well
to antidepressant medication, as well as psychotherapy, suggesting both modalities as a
potential tool for intervention.78
Dysthymia (also called persistent depressive disorder – see DSM-5 criteria on page
345) often presents, as it did with Mr. Collier, with a low-grade depressive mood (and
two or more common depressive symptoms) being present most days over a minimum
of a 2-year timespan. If the patient, at any point, meets the criteria for a major depressive
disorder, it is added as a concurrent diagnosis.
Techniques for Eliciting a Family History

Mr. Collier’s comment that “I remind myself of my father,” warrants further follow-up.
This statement may be the first indication that mood disorders run in his family. Research
has shown genetic predispositions for many psychiatric disorders are common, ranging
from severe processes such as psychotic depression and bipolar disorder to much milder
processes such as dysthymia.
For instance, the heritability of bipolar disorder has been estimated to be about 60%
to 80% in genetic studies of the concordance of the disorder in monozygotic (same egg)
twins.79 In a similar fashion, patients with major depressive disorders show a higher
prevalence of relatives with major depressive disorders and depressive personalities.
Other studies have suggested some genetic correlation between mood disorders and
alcoholism. For instance, in a well-known study – the Collaborative Study on the Genet-
ics of Alcoholism (COGA) – Nurnberger and associates found that alcoholism and
depression do, indeed, tend to run in families, with evidence that some of this concur-
rence may be related to genetic factors.80
An accurate family history can help patients in several ways. Sometimes, the presence
of a specific disorder in the family history (such as bipolar disorder) can alert the clini-
cian to more carefully hunt for similar symptoms in the patient that might have been
overlooked in the earlier interviewing. The presence of processes such as psychosis or a
strong history of suicide in the family may prompt the interviewer to seek more careful
follow-up or recommend hospitalization to the patient (if one is “on the fence” as to
whether or not hospitalization might be useful for observation or more intensive treat-
ment). In addition, if one uncovers the same psychiatric disorders in family members as
with the patient, it is useful to ask, “Do you know if your dad (or whomever is being
discussed) responded well to any medications?” Excellent response in a family member
can be an indicator that the patient may have a positive response to that specific medica-
tion. Finally, as we have already seen, the presence of bipolar process in family members
(or the unleashing of a manic process after the use of an antidepressant in a family
member) should alert us to be careful with the use of antidepressants in the patient.
Difficulties in Taking a Family History and How to Transform Them

Despite its importance, elaborating a valid family history in the first 50 minutes is no
easy task. A variety of variables can get in the way, including: (1) the patient’s lack of
information about his family history; (2) the patient’s decreased concentration and other
cognitive impairments decreasing the accuracy of his statements; (3) the patient’s protec-
tion of other family members; (4) the patient’s culture disapproves of sharing informa-
tion on psychiatric disorders; and (5) the interviewer’s ineffective exploration of the
patient’s family history. This last variable is the only one over which we have direct
control.
Frequently, vague questions such as “Does anyone in your family have a mental
illness?” can often lead to blanket negatives. The interviewee may have no idea that the
interviewer is including blood relatives such as aunts, uncles, or cousins in such a ques-
tion. Along the same lines, the interviewee may have no idea that the interviewer is
including alcoholism as a mental disorder. To anticipate these problems, it may be of
value to help the patient understand the reason for obtaining a family history. Such an
approach also “focuses” patients, increasing their willingness to jog their memories. Just
one of many lead-ins is illustrated below with a patient we shall call Carl:
Clin.: Carl, you mentioned earlier that you sometimes remind yourself of your father. In
what ways is this true?
Pt.: Hmm … Well, my father often seemed upset to me as a kid. He got irritable and
would yell at us, all of us, even Annie, the baby. He just seemed troubled.
Clin.: Do you think he was depressed?
Pt.: Yeah, I do.
Clin.: Had he ever received help from a therapist or psychiatrist?
Pt.: Oh, no! He would never do that. He didn’t believe in that sort of thing; even so, I
think he needed help.
Clin.: While we are talking about your father’s depression, I would like to touch upon
other family members. Sometimes we can gain clues from psychiatric problems in
relatives that may give us better ideas of how to help you.
Following such an introduction to the topic, the clinician can proceed to discuss each
member of Carl’s nuclear family, inquiring specifically about drinking, schizophrenia,
and other affective disorders. With regard to more distant family members, it is important
to state whom you are interested in.
Clin.: The rest of these questions concern any of your blood relatives, including
grandparents, aunts, uncles, and cousins. Have any of your father’s blood relatives
had depression or schizophrenia? (repeat these questions later for the other side of
the family)
Pt.: Well, I’m not really sure. I had an aunt who was sort of crazy.
Pt.: They put her away for a while because she had a nervous breakdown.
The preceding exchange illustrates several points. First, one needs to be careful with
technical words like “schizophrenia” or “bipolar disorder.” Many patients do not know
what these terms mean and will consequently deny their presence. A brief definition may
help clarify the issue. Second, it can be of use to ask the question, “Has anybody in your
family been hospitalized or institutionalized for a mental disorder?” People may remem-
ber a concrete hospitalization concerning a distant relative much easier than a nebulous
process like depression. Third, terms such as “bad nerves” or “nervous breakdown” are
common labels for serious disorders such as schizophrenia, bipolar disorder, or an agi-
tated depression. Such terms warrant further inquiry.
Another important question is simple and to the point, “Has anybody in your family
ever tried to kill themselves or actually did kill themselves?” Surprisingly, after having
denied any serious psychiatric illnesses in their family, interviewees will suddenly recall
a suicide following this question.
This phenomenon parallels the finding that subsequent interviewing will often reveal
positive family history that went undetected in the initial interview. In a similar way, it
is remarkable how interviewing family members of the patient regarding a history of
familial mental disorders pulls forth some surprises. If possible, questioning family
members, in addition to the patient, about mental illness and suicide in the family tree
is a good habit to cultivate.
Cross-Cultural Sensitivity When Taking a Family History

As one would expect, cross-cultural differences can impact on the eliciting of a family
history of psychiatric disorders. Generally speaking, there is a hesitancy in all cultures to
relay personal information about psychiatric disorders in family members. In some cul-
tures, this hesitancy is particularly strong. As an example, individuals from Asian cultures
may experience relatively extreme stigmatization concerning mental illness. To admit to
mental illness in oneself or one’s family members may, essentially, be a cultural taboo.
In this regard, clinicians may need to be sensitive and employ subtlety in the phrasing
of potentially disengaging questions about the presence of mental illness in family
members.
When asking about past family psychiatric history with an Asian patient, it can be of
use to avoid asking direct questions such as, “Does anyone in your family have a mental
illness?” or “Anyone in your family with psychiatric problems?” Michael Cheng81 suggests
that with Asians and Asian Americans it is sometimes best to proceed with questions
that cue directly off the symptoms of the patient himself or herself, focusing more upon
phenomenology or stress, such as:
1. “Has anyone in your family ever had similar difficulties as yourself?”

2. “Has anyone in your family had mood problems like the ones you’ve been having?”
3. “Has anyone been feeling anxious like you’ve been feeling?”
4. “Has anyone in your family been particularly stressed, like you’ve been recently?” (If
the answer is yes, the clinician can ask whether the family member has been having
similar symptoms.)
Even the term “nervous breakdown” may sound less stigmatizing to an Asian American
than “psychiatric illness.” If there appears to be confusion over the less direct questions
above, one can ask, “Has anyone in your family, perhaps related to stress, had a nervous
breakdown?” These questions are often of use with almost any patient who is particularly
afraid of stigmatization, no matter what his or her cultural background.
Another potential problem arises if the interviewer is unaware that a particular culture
may use a different word than “depression” for a depressive equivalent. We saw this
problem earlier with the word “nervios” often being used instead of depression (or other
psychiatric disorders). Consequently, when inquiring about a psychiatric family history
with a Latino/a patient (or his or her family members), it can be useful to ask, “Have
there been any of your family members who, when very stressed, developed nervios?” It
should also be kept in mind that many cultures will express depressive equivalents with
somatic symptoms, particularly true in Asian and Hispanic cultures. It is also quite strik-
ing in some refugee populations.82
A final impediment to uncovering a valid family history occurs when the interviewer
is unaware that there are specific major mental disorders unique to the patient’s culture
that are not present in the culture of the interviewer, as we shall examine in Chapter 12.
Obviously, when taking a family history, the interviewer may need to ask directly about
such culture-specific disorders in order to hear about them. A subtle variation occurs
when a similar disorder exists to a DSM-5 disorder, but it might not be viewed as being
“psychiatric” in nature in the patient’s culture, hence not shared with the interviewer
when questioning about a family history of psychiatric disorders.
A nice example of this process can be found when interviewing a patient or refugee
from Vietnam. In Vietnamese culture, there is a syndrome called trung gio.83 The syn-
drome has many of the symptoms of a panic attack as defined in the DSM-5. Interestingly,
these attacks are viewed as being literally caused by the wind. Anticipation of such attacks
on a windy day can even result in what might be called agoraphobic tendencies in the
DSM-5. Our point, regarding family history, is that such attacks might not be conveyed
by the patient as being present because they are not necessarily viewed as being a mental
disorder. Instead, they are viewed as being caused by the movements of the wind. In
hunting for a family history of panic disorder with a Vietnamese patient, after asking
directly about panic attacks, the interviewer might add, “Have any of your family members
tended to have problems with trung gio and feel very frightened and upset when they go
out in the wind?”
Family History as a Reflection of Family Dynamics

Before leaving the issue of family history, I would like to add one final point. The family
history may provide more information than just that relating to genetic inheritance of
mental illnesses. The tone of voice and the manner in which the patient talks about
family members may provide subtle clues concerning family relations themselves. At
times, it pays to take a brief excursion into interpersonal and dynamic issues during this
part of the interview, as illustrated below.
Clin.: Do you feel your brother had problems with depression or drugs?
Pt.: Him (said with an astonished and sarcastic tone)! No. He’s lily white. He’s never
had any problems.
Clin.: You sound almost surprised by my question.
Pt.: Oh, it’s just that he has always been everybody’s favorite.
Clin.: How have you noticed that?
Pt.: He always made better grades. Report card day was a real pain in the ass for me. I
used to …
In this example, “family history” has taken on a richer meaning.
Differential Diagnosis on Mr. Collier and Summary of Key Interviewing Tips

Before looking at Mr. Collier’s diagnostic summary, three points should be made. First,
with regard to medical problems, Mr. Collier related having bronchitis secondary to
smoking. Second, on an interpersonal level, further interviewing indicated significant
marital distress. Couples therapy was recommended. This disruption on the intimate
wing of Mr. Collier’s matrix would prove to be a core issue with regard to Mr. Collier’s
depression. Third, the physical slapping of his child demanded much more careful
inquiry during the initial interview. Both parents related this action as a one-time inci-
dent. Mr. Collier’s diagnostic summary is as follows:

Persistent depressive disorder (dysthymia)
(with early onset and moderately severe)
Relationship distress with spouse or intimate other (V-code)
Encounter for mental health services for perpetrator of parental child abuse
(V-code)
No disorder but may have narcissistic traits
Medical Disorders:
Chronic bronchitis secondary to smoking
Note that when using the V-code regarding child abuse, it is critical that you explain in detail
in the body of your EHR the exact abuse and your estimate of its severity. This V-code can have
powerful legal ramifications. In this case, after extensive interviewing, if the clinician
believed in the truthfulness of the reporting by Mr. Collier and his wife, he would state
that the physical abuse appeared to be limited to one example of slapping. A wise inter-
viewer would return to this topic in later sessions to see if more abuse was relayed upon
further engagement with Mr. and Mrs. Collier.
Also, after completing this initial interview, I would also advise that the clinician
should consult with a superior to determine whether an interview with the child was
indicated. During this consultation, a decision could be made as to whether any
further requirements existed for reporting to appropriate protective agencies (various
states may have differing laws and regulations governing such reporting of potential
abuse).
In conclusion Mr. Collier’s presentation emphasizes several points:
1. Individuals with persistent depressive disorder (dysthymia) commonly experience

psychological symptoms of depression as well as some neurovegetative symptoms,
but neither their psychological symptoms nor their neurovegetative symptoms persist
in a sustained manner for over 2 weeks, unless a major depressive disorder is concur-
rently present. Also note that if a major depressive disorder does not go into a full
remission within 2 years, the diagnosis of a persistent depressive disorder should be
added.
2. The depressive symptoms of a dysthymia can often rapidly shift towards normal if
there is something “fun” to do, similar to the mood reactivity seen in atypical
depressions.
3. A detailed family history should be an integral component of all comprehensive
initial assessments.
4. Blanket questions such as “Does anybody in your family have a mental illness?” will
often yield false negatives.
5. Patients may not view alcohol dependence or drug dependence as mental illnesses,
and you should clearly mention them specifically.
6. Some patients will need you to explain potentially confusing terms, such as schizo-
phrenia or bipolar disorder in everyday language, or they will simply deny their pres-
ence in the family history.
7. Consider carefully cross-cultural differences when taking a family history.
8. A family history occasionally provides a nice take-off point for exploring family
dynamics.
The above five case discussions are not intended to be an exhaustive review of the diag-
nostic subtleties associated with mood disorders. Instead, I have attempted to present a
sound, and hopefully exciting, introduction to the process of differential diagnosis
during an initial interview. My goal has been to show some of the practical interviewing
strategies and techniques for arriving at a DSM-5 diagnosis, while simultaneously showing
how an accurate uncovering of these diagnoses can have profoundly useful ramifications
for our patients’ healing.
I believe it is an opportune time for us to look at some video material. In Video
Module 9.1 below, I will demonstrate the expansion of the diagnosis of a major depres-
sive disorder exactly as described in this chapter. In addition, as mentioned earlier, the
interviewing principles delineated in this chapter on mood disorders are equally appli-
cable to most of the major psychiatric disorders. Thus they can serve as models from
which you can generalize to the expansion of these other disorders.
Consequently, in our optional second video, Video Module 9.2, I thought it might be
fun for the interested reader to have a chance to see both didactic material and subse-
quent interviewing demonstrations in which I illustrate expansions on three disorders
that you will commonly encounter in your clinical practice: panic disorder, generalized
anxiety disorder, and adult attention-deficit disorder. Our optional second video package
allows us to look at didactics and interview segments that cannot be covered in our book
due to space limitations. It’s a bonus of sorts. I hope you find this additional material
to be both useful and enjoyable.
VIDEO MODULE 9.1

Title: Sensitively Uncovering the Symptoms of Major Depressive Disorder
Contents: Contains both expanded didactics and annotated interview excerpts demonstrating the
diagnostic expansion of a major depressive episode.
Important note to the reader: After viewing Video Module 9.1, you can proceed directly with the
text below OR you may view optional Video Module 9.2.
VIDEO MODULE 9.2

Title: Sensitively Exploring the Diagnostic Criteria for Other Psychiatric Disorders such as Panic
Disorder, Generalized Anxiety Disorder, and Adult Attention-Deficit Disorder
Contents: This video module contains three sequentially unfolding learning segments. Each
segment contains didactic material and an interview demonstration of how to effectively expand
the diagnostic region of the three disorders indicated in the title of the module.
In our next chapter, we will move past the art of differential diagnosis and begin to
explore how depressive symptoms are uniquely experienced by our patients and those
who love them. We will see how depression impacts and resonates throughout the matrix
of each patient who enters our offices. From the perspective of person-centered interview-
ing, the art of differential diagnosis is always performed hand-in-hand with the art of
understanding the person beneath the diagnosis. We will now turn our attention to this
equally important second art.
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CHAPTER 10
Interviewing Techniques for
Understanding the Person Beneath
the Mood Disorder
When the low heavy sky weighs like a lid

Upon the spirit aching for the light,
And all the wide horizon’s line is hid
By a black day sadder than any night; …
When like grim prison bars stretch down the thin,
Straight, rigid pillars of the endless rain,
And the dumb throngs of infamous spiders spin
Their meshes in the cavern of the brain, …
Charles Baudelaire
Spleen1
INTRODUCTION
In this chapter, we will search for a more sophisticated understanding of how a mood
disorder is experienced by a patient in each wing of the patient’s matrix as first described
in Chapter 7 on treatment planning. For the sake of conciseness we will collapse the
matrix into the following five wings: biological, psychological, dyadic, familial/societal,
and worldview (as reflected in the patient’s spirituality and framework for meaning). We
will begin with the very smallest system of interaction – biological – and move outwards
through progressively larger systems. We will see how these disorders create damage, and
trigger core pains, throughout the wings of the patient’s matrix from biological and psy-
chological disruptions to the damage done to the patient’s family, friends, workplace,
spirituality, and worldview.
Because there is no time to explore all of the mood disorders, we will focus, specifi-
cally, upon the symptoms of depression, using depressive symptoms as a prototype
through which we might better understand these damaging matrix effects in other mood
disorders, indeed, in all psychiatric disorders. We will see how each depressive symptom
is experienced uniquely by the person beneath the diagnosis, for every depression is a
unique one.
I also believe that in order to effectively uncover psychiatric symptoms, it is critical to

understand how patients experience these symptoms personally, in a phenomenological
sense. As we shall soon see, this empathic familiarity on the part of the interviewer, if
present, is quickly recognized by patients, resulting in a markedly more pronounced
sense of safety. From the clinician’s questioning, it becomes clear to the patient that this
interviewer has seen these symptoms before, often many times, and respects their com-
plexity and nuance.
The more an interviewer understands the concepts explored in this chapter, the more
open the interviewer will be to the subtle clues suggesting depression in an initial
encounter, thus decreasing the likelihood that a depressive state will be missed or its
severity underestimated. Simultaneously, this understanding helps the clinician to better
phrase his or her questions in a fashion that empathically resonates with the patient,
enabling the patient to share the intimate details of their pain more readily, including
suicidal ideation and the other harsh realities left in a depression’s wake. From this
understanding, interviewers enhance their sensitivity, their clinical acumen, and their
ultimate engagement with patients. The interview is, at once, both more human and
more clarifying.
At another level, our more sophisticated understanding of the human matrix will
emphasize the sometimes-overlooked fact that interviewers – whether they want to or
not – will, by their very presence, become a subsystem touched by the patient’s depres-
sion. The interviewer will both affect and be affected by the depressive processes being
explored. Awareness of this fact can lead to important insights in intervention. Blindness
to this fact can lead to short-sighted conclusions and misplaced interventions. With these
ideas in mind, our exploration begins. At its conclusion, hopefully we will have a truer
understanding of what it is like to be at a place where:
… all the wide horizon’s line is hid
By a black day sadder than any night.
THE PAIN BENEATH DEPRESSION

Fields of Interaction
The Biological Wing of the Matrix
As one enters the room occupied by a person experiencing depression, the physiologic
ravages of the process are often disturbingly apparent. In a severely depressed person the
initial glance may reveal unkempt hair, ragged or mismatched clothes, dirty nails, untied
shoes, and a vacant look to the eyes. More striking may be the slowness of movement
and the person’s lack of responsiveness. It may take a few seconds or longer for the
depressed person to acknowledge the interviewer, if such acknowledgment occurs at all.
In a similar manner, more subtle decrements in responsiveness may be the first clues of
Interviewing techniques for understanding the person beneath the mood disorder 415
a milder depressive state. Thus, the interview begins with the first look, before any words
are uttered.
The slowness of movement probably parallels the disquieting sensation of heaviness
often reported by depressed people. Depression, as Baudelaire suggested with his line,
“When the low heavy sky weighs like a lid …”, often feels like a heavy shawl weighing
down upon the patient’s shoulders. As noted in the last chapter, the arms and limbs of
the patient may feel weighted down, a sensation called “leaden paralysis” in the DSM-5.
This abnormal sensation may be related to the powerfully intense sense of inertia that
can accompany depression. It becomes distressing for the depressed person to initiate
movement; it seems so much easier to simply rest. A young woman with a depressive
disorder vividly describes this phenomenon:
It is so strange. Depression is exhausting in a physical sense. You know, most people have
chores they have to do just to keep their lives going. And if the chores are waiting for you,
and you sit there and look at them, they just seem overwhelming. And I could easily sit
for 2 hours in a chair just looking at some clothes I left on the bedroom floor and not be
able to motivate myself to pick them up. My body just feels heavy, as if it wouldn’t want
to respond unless I absolutely forced it to … Hmm … You know it is actually almost as
if your brain lost half of its ability to control your body in the sense that even making a
decision to pick something up required so much energy that you don’t want to make it.
You feel like it couldn’t possibly be worth it. I just want to vegetate.
This sensitive excerpt brings up another important point with the opening comment, “It
is so strange.” Depressed patients, at times, present a peculiar dichotomy in the manner
in which they cognitively and affectively experience their profound condition. On a
cognitive level, they often feel they are the root of their problem, their speech becoming
an entangled web of self-recrimination and belittlement. They cognitively experience
their depression as being actively caused by their own flaws. Simultaneously, they emo-
tionally experience the depression as coming on them or over them from an outside
source. In a sense, they feel invaded and violated. They feel they are the passive recipients
of a phenomenon that they do not understand or control. This incipient “loss of control”
presents a terrifying threat to their sense of ideal self. Jaspers, with a single word, captures
the pith of this process when he describes depressed patients as experiencing a physical
and emotional “ossification.”2
At present, the etiologic meaning of such radical changes in movement and body
perception in the patient’s biological wing remains unclear. Such changes may represent
a variety of damaging inter-wing matrix effects: psychological defenses to withdraw the
patient from painful external circumstances, social indicators that the person needs help,
cultural attempts to withdraw a malfunctioning person from a potentially dangerous
environment, or spiritual angst revealing itself as the need to withdraw from a meaning-
less world. Or they may be caused by a direct intra-wing matrix effect being the direct
results of a primary biochemical imbalance. Any combination of the preceding factors
is possible. No matter what the etiology of these phenomena, they create frightening
experiences for anyone suffering from a depression. In essence, even patients’ bodies
become strangers to them – one more step toward their intense sense of isolation.
The other neurovegetative symptoms also represent an array of biological markers of
depression. Baseline energy withers. Appetite and libido dry up as if parched by the
intensity of the process. These feelings of altered functioning can become immensely
disturbing to patients, sometimes being perceived as further evidence of their personal
failure. With these phenomena in mind, questions such as the following may add depth
to the interview:
a. “What has your body felt like to you recently?”

b. “What does it feel like to you to have lost your energy and drive?”
c. “You mention that you have lost your energy, your appetite, and your ability to sleep.
How have all these changes made you feel about yourself?”
As well as allowing patients the chance to ventilate, these questions emphasize that the
interviewer is interested in them as unique people whose depression they alone can
explain.
Before leaving the biological field, I would like to briefly describe some of the biologic
ramifications of an agitated depression. Here too there exists a peculiar dichotomy, as
described by an elderly male patient in response to a question about losing energy, “I
don’t know exactly what you mean, but yeah, I’ve got energy all over the place, driving
me constantly, but no, I don’t have any sustained energy to do anything.” The result in
an agitated depression is often an inability to begin tasks, the patient being disabled by
the frenzy of his or her own agitation.
Note the difference between the disorganized energy seen in an agitated depressive
episode when compared to the organized energy frequently seen in a patient experienc-
ing a dysphoric mania as described in the last chapter. Although the patient with a
dysphoric mania may not successfully complete many tasks, they are compelled to try
them and initially may approach them with a remarkably well-organized drive. As
opposed to the almost frantic inertia seen in a patient suffering from an agitated depres-
sion, a patient with a dysphoric mania may develop and initiate surprisingly intricate
and well-developed plans of action with regards to self-harm, suicide, and violence to
others.
Returning to depression, in an agitated depressive state there exists a nagging need to
move. The energy is unbridled and disobedient. Consequently, the body tends to assume
an incessant display of “bad nerves.” Hands wring each other in a frenzy of confusion.
Fingers pick at the body or pluck the clothes. Sitting becomes an act of will power. From
deep inside the legs there erupts a need to move. Pacing becomes a necessary method of
release as natural as breathing. Especially when the patient is experiencing a depressive
episode marked by melancholia, this agitated state may appear worse in the morning.
In the interview it can be revealing to ask, “What part of the day seems worse to you?”
It is important to remind oneself that a relatively calm patient interviewed at 4:00 P.M.
may have looked remarkably more agitated at 8:00 A.M. Depression nags the body with
an intermittent voice.
The Psychological Wing of the Matrix

Depression has a calling card. This calling card consists of a distinct set of changes that
occur within the mind of those experiencing the depression. Not all depressed people
experience these feelings, but many do in one combination or another. Four broad areas
are touched by depression and will be the focus of this discussion: (1) perception of the
world, (2) cognitive processes, (3) thought content, and (4) psychodynamic defenses.
An understanding of the above processes can increase the ability of the interviewer to
recognize the subtle clues of depression and can increase empathic abilities, as well.
1. Depressive Changes in How the World Is Perceived

Concerning the perception of the world, depression alters both the sense of time and
the size of the world actively engaged. In a person experiencing a severe major depressive
episode, the concept of current or future change frequently appears conspicuously absent.
A mantle of flatness suffocates spontaneity. Moment-by-moment existence seems void
of any chance of alteration. Without this feeling of possible change, time passes arro-
gantly slowly. In a literal sense, time passes painfully.
Such a state of psychic monotony can have a curious effect on the interviewee’s per-
ception of the future. In effect, if change does not exist, then the future is essentially
meaningless. All days are merely replicas. Our sense of the future is partially dependent
upon our sense that the future may be different. To the depressed interviewee, the future
is draped in a radically bland light. This perception may be one reason why depressed
people often appear unmotivated. Without a perceived future why should they attempt
change? This phenomenon has been described by the phenomenologist Eugene
Minkowski as a “blocking of the future.”3
The second alteration in world perception does not involve time. It revolves about
space. The “active world” of the depressed person undergoes a profound alteration. By
“active world” I refer to that part of a person’s environment that he or she remains inter-
ested in engaging. In depression, the active world shrinks. The patient’s sense of space
gradually vanishes creating a “cataract of the mind.” This shrinking of the active world
can powerfully short circuit environmental reinforcement and reward. The depressed
person becomes a behavioral isolate. The woman quoted before elegantly depicts this
process.
I’m so focused inward … When I feel depressed it is such a great pain, and I am paying
so much attention to it trying to control it, that I walk down the street and really don’t
see much at all … I screen out other people because I don’t want to interact with others
… I probably miss a lot. Even in the sense that I can walk down the street where I work
and there can be roses blooming. And if I am really depressed, I don’t even see them. And
I love roses. Whereas, if I am feeling better, even despite the smell of the buses running
around, I will still smell the roses. And I will admire them …
It can come as quite a shock to the interviewer to realize that the interviewer may not
be a feature of the interviewee’s active world. To engage such patients, the clinician needs
to enter their world as best as possible. Consequently, the interview with a severely
depressed patient may require a change in style. At times, the clinician must be more
active while also accepting, with patience, the interviewee’s difficulty in responding.
The Window Shade Response
In an even more striking example of the patient’s need to consciously shut out the world,
there is a specific sensation that sometimes plays a role in the shrinking of the patient’s
world. To me, the phenomenon appears to be fairly unique to withdrawn depressive
states, and it is not reported by patients with agitated depressions or anxiety disorders.
I have found it to be a surprisingly reliable marker of the presence of a moderate to severe
depressive episode.
It is a phenomenon perhaps related to the well-documented tendency of depressed
patients to withdraw to their beds for much of the day. When patients seek out their
beds, if they sleep, it is a fitful sleep at best. In point of fact, I find that they are seldom
returning to their beds primarily to sleep. Instead, they are returning to their beds because
they can shut their eyes while in their beds, for it is the natural place in our culture where
it is acceptable to shut one’s eyes. With the closing of their eyes, they have effectively
shut out the stresses of their world. The result is a desperately needed and immediate
sense of relief. Sometimes severely depressed patients will actually draw their bed sheets
over their head, an action often paralleled beforehand by the pulling down of the
window shades so as to darken the room and further isolate themselves from the outside
world.
And here we can see the connection with the uniquely depressive phenomenon that
I hinted at above. Specifically, patients coping with depression not infrequently feel a
need to shut their eyes, even while standing or walking about. It is as if the depressed
patient is escaping the world by pulling down the ultimate window shade – their own
eyes. Sometimes this need to shut the eyes is almost overpowering.
This “window shade response” was poignantly described by a particularly articulate
lawyer, who first introduced me to the phenomenon. I have since found it to be common
in moderate to severely depressed patients. He described it as follows. Note that he too,
as with the patient above, emphasizes the “overwhelming” sensation experienced when
depressed:
Sometimes the world is so overwhelming to me. It is mind-boggling how overwhelming

the simplest of things is … I don’t want to see or talk to anyone. It is almost painful, and
yet it sounds so silly. I’ll tell you another thing that is really interesting, it’s almost weird.
When I’m depressed, I will find myself almost compelled to shut my eyes.
It is so odd. It is not a desire to rest or sleep, it’s not sleepiness. I just want to shut every-
thing out. As soon as I shut my eyes, I feel some relief. And I just don’t want to open them
and face the world again … It really feels like I’m driven to do it, because the relief feels
so good … It can come over me, and that’s exactly what it feels like, like the urge to shut
my eyes is somehow coming over me, almost against my will, almost any time when I’m
really depressed.
During this last depression, I forced myself to keep up with my morning walks before work,
which I’m really proud I did. It was tough to do, but I’m glad I did it. But here’s the
strange thing. I’d be walking on the old dirt road up behind my house through a beautiful
woodland and I would feel compelled to close my eyes while I was walking. And I did! I
would do it for several paces intermittently. I didn’t even want to see the woods around
me. I didn’t want to see anything. It’s hard to believe that several hours later, I’d be in
court trying to do my best for my client. If they only knew what I looked like just 3 hours
earlier.
To uncover the “window shade response” I have found the following question to be
useful:
“When you’re really depressed, do you sometimes have an intense desire to just shut
your eyes? It seems almost odd to you how strongly you want to shut your eyes, to
just shut the world out?”
I think you will find the presence of the window shade response to be a surprisingly
reliable marker of a moderate to severe depressive state in the interviewee. As I noted
above, in my experience, it does not appear to be present in patients experiencing a pure
anxiety disorder such as a generalized anxiety disorder or obsessive–compulsive disorder.
In addition, it is very engaging to inquire about the phenomenon, for depressed patients
are often surprised that you are familiar with the sensation.
2. Cognitive Changes Caused by Depression

Changes in the Flow of Thought and Ideational Caging
A second broad area of alteration concerns changes in the cognitive processes of the
depressed person. In a melancholic depression, the thought process slows, as if the stream
of thought were frozen by an unexpected drop in temperature. In contrast, in an agitated
depression thought races, as if the same stream had sustained a turbulent boil. In both
cases, the thought process becomes disjointed. Concentration becomes annoyingly
elusive.
Besides these alterations in the speed and flow of thought, depression creates an ide-
ational caging. The term “caging” suggests that the mind becomes trapped within a small
network of limiting themes. Such depressive rumination can lock the depressed person
into worries about the past, the present, or the future. Once within the cage, the depressed
patient has great difficulty attending to new and perhaps therapeutic influences. In the
interview, caging may demonstrate itself as a frustrating tendency for the patient to return
to a specific topic. Or, alternatively, the patient may repeatedly ask the same question,
despite the interviewer’s reasonable reassurances.
Such caging can seriously block an interview. One method of trying to circumvent it
consists of attempting to acknowledge it while simultaneously refocusing the patient, as
illustrated below. This strategy may look familiar, for it is one of the strategies that we
examined in Chapter 3 for effectively transforming “wandering interviews.” In this inter-
view, the clinician had done an excellent and sensitive job of providing the patient a
chance to ventilate and describe her financial concerns. When an effort was made to learn
more about her depressive symptoms, the patient would not move on.
Clin.: Mrs. Jones, can you tell me a little bit about the effect of all these troubles on your
sleep?
Pt.: Sleep, can’t sleep … (pause) can’t sleep because of the bills. I just know we won’t
be able to pay the bills. Oh God, my children, we’ll be ruined.
Clin.: No question about it, the money situation needs to be addressed. I’m also trying to
figure out more about your depression too, it’s also a big problem for you right
now. It might be even making it harder to fix the money situation. The reason I’m
trying to learn more about your sleep is that it will help me to understand more
about your depression and what type of medications might help you the most,
that’s why I’m asking you about it. For instance, how long has it been taking you to
fall asleep?
Pt.: I don’t know, all I think about are the bills. I know that somehow I’m to blame.
What will we do? What will we do! Somebody has got to help.
Clin.: Mrs. Jones, I know it can be really hard to not talk about your financial concerns,
and we’ll spend a lot more time doing so later; but, you know, in order to help
you, I think I need to learn more about what your depression has done to you and
what it feels like to you. To help us stay focused, I’m going to ask you some
important questions, and if we get sidetracked I will pull us back to the question. It
will help us figure out which of your symptoms we can help you with as fast as
possible. Once again think carefully, how long is it taking you to fall asleep? (the
preceding is said with a calm but firmer tone)
Pt.: It’s bad, real bad, maybe 2 or 3 hours; I just can’t fall asleep. My nerves are shot.
Clin.: Can you stay asleep or do you keep waking up?
Pt.: Stay asleep! I wish. God knows. I can’t ever get a good night’s sleep. Ever. Ever.
With proper timing, such an intervention may open a cage. At other times, the caging of
the patient will not yield despite the interviewer’s best intentions.
Cognitive Distortions as Conceptualized by Aaron Beck
Aaron Beck, one of the founders of cognitive psychotherapy, has delineated many specific
cognitive impairments in depression. Beck has pointed out that depressed patients may
over-generalize, with statements such as “Everything has fallen apart” or “No one cares
about me.” They can exaggerate, in essence creating the proverbial mountain out of a
molehill with a statement such as, “My boss Mr. Henry looked angry. He’s dissatisfied
with me. I’m sure it is only a matter of time until I’m fired.”
They also have a tendency to ignore the positive. For instance, a businesswoman con-
fused me with the following statement, which illustrates this principle: “It’s the best
Christmas season we’ve ever had. We’re really selling books all over the place. But I set
myself a remarkably high quota. If we don’t meet it, I will have failed miserably as a
manager.”
Beck has also described a trio of distortions – the cognitive triad – that frequently
appears in depression: (1) negative view of the world, (2) negative concept of the self,
and (3) a negative appraisal of the future.4
First Distortion in Beck’s Triad: Negative View of the World

This negative view of the world is partially generated by the tendency of the depressed
patient to continually validate his or her depression. The patient speaks as if he or she
had placed a negative filter over his or her eyes, as witnessed by the following taped
comments:
When I’m really depressed every negative, every unpleasant thing that I could possibly
think of that might be happening to another person like someone being hit by a car or
someone getting cancer or a dog being injured will trigger personal fear and worry that
the world is bad. And so the depression has no justification to ever lift because everything
about life is horrible. It’s all just proof that depression is reality just looking itself in the
face …
Second Distortion in Beck’s Triad: Negative Self-Concept

With regard to negative self-concept, the tendency to assume self-blame may be a major
contributing factor. I do not think I have ever seen this quality as strikingly portrayed as
in The Bob Newhart Show, a show whose re-runs are still quite popular with mental health
professionals. In this show, Newhart plays a psychologist with a client named Mr. Herd
who epitomizes the self-blamer. A typical exchange might be as follows:
Dr. Newhart: (after entering the office) I can’t believe it, I left my wallet at home.
Mr. Herd: I did it … You were worried about me and forgot your wallet over me … I’m
sorry, I’m really sorry. I won’t let it happen again.
Although funny in the Newhart show, the process of self-blame stands as a vicious cogni-
tive trap. In a sense, it may represent a milder variant of the much more ominous
symptom known as delusional guilt.
Third Distortion in Beck’s Triad: Negative View of the Future
Another jarring twist in cognitive process comes to mind at this point. Depressed patients
sometimes exhibit a trait that I prefer to call “an immunity to logic,” which can be very
frustrating to the family, therapist, or initial interviewer. Facts are simply irrelevant. This
immunity to logic, which is just one example of the processes that can lead to a negative
view of the future, was brilliantly depicted by Minkowski, while at the same time illus-
trating the blocking of the future mentioned earlier. Minkowski spent several months
living with a man experiencing a psychotic depression. The following excerpt refers to
Minkowski’s vain efforts to convince his apartment-mate that he would not be horribly
mutilated and subsequently executed:
From the first day of my life with the patient, my attention was drawn to the following
point. When I arrived, he stated that his execution would certainly take place that night;
in his terror, unable to sleep, he also kept me awake all that night. I comforted myself
with the thought that, come the morning, he would see that all his fears had been in vain.
However, the same scene was repeated the next day and the next, until after 3 or 4 days
I had given up hope, whereas his attitude had not budged one iota. What had happened?
It was simply that I, as a normal human being, had rapidly drawn from the observed facts
my conclusions about the future. He, on the other hand, had let the same facts go by him,
totally unable to draw any profit from them for relating himself to the same future. I now
knew that he would continue to go on, day after day, swearing that he was to be tortured
to death that night, and so he did, giving no thought to the present or the past. Our
thinking is essentially empirical; we are interested in facts only in so far as we can use
them as basis for planning the future. This carry-over from past and present into the future
was completely lacking in him; he did not show the slightest tendency to generalize or to
arrive at any empirical rules.5
Although this is a description of a psychotically depressed man, a similar, albeit milder,

process commonly accompanies non-psychotic depression.
All of these disturbances in cognitive process may be encountered by the initial inter-
viewer. By training themselves to listen for such abnormalities, interviewers may increase
their ability to detect depression. For instance, people with atypical depressions, or
somatic presentations of depression, may initially betray their underlying depression by
the use of such pathologic processes. Of course, the presence of such processes in a less
severely disturbed patient may also alert the interviewer to the possible use of cognitive
psychotherapy as a future treatment modality. At this juncture, I would like to turn atten-
tion to the third major psychological area affected by depression, thought content itself.
3. Alterations in Thought Content Found in Depression

The distinction between cognitive process and cognitive content is sometimes a blurred
one, but I would like to focus briefly on four content themes: loneliness, self-loathing,
helplessness, and hopelessness. These factors blend with one another, reinforcing their
mutual perpetuation.
Depressive Loneliness
The loneliness of the depressed person can become practically insurmountable. As shown
earlier, processes such as caging and the shrinking of the active world separate the
depressed patient from friends, family, and even the clinician. Their loneliness reaches
such an intensity that it may begin to assume a qualitative difference from the more
common loneliness encountered in daily living. Put differently, they are not only lonely
– they feel that they are alone.
The loneliness assumes an irrefutable realization that they are isolated, somehow cut
off permanently from others. Such isolation does indeed diminish social reinforcement
and therapeutic intervention. Thomas Joiner has emphasized that acutely suicidal patients
may feel intense loneliness even when surrounded by caring loved ones. Indeed, the
existence of loved ones is sometimes cruelly twisted by depressive process into a guilt-
ridden sense that one is a burden to others, a cognition further increasing the draw
towards suicide in depression as seen below.6,7
Depressive Guilt and Self-Loathing
Combined with this alienation from others, depressed patients may also experience a
profound alienation from, and hatred of, themselves, accompanied by intense guilt.
Such a self-loathing only intensifies their feeling of loneliness, because they are repulsed
by their own company. To the guilt-laden patient, it seems as if he or she lacks any
real existence or purpose at all except for his or her pain. As described above, these
feelings can shift imperceptibly into the potentially lethal thought that “I am truly a
burden to those I love.” It is a thought that Joiner feels can be one of the most reli-
able of interpersonal harbingers of a suicide attempt. Sometimes guilt-laden thoughts
may emerge in the interview in a more oblique fashion as in, “Don’t bother with me.
Talk with someone you can help.” The initial interviewer needs to probe beneath such
comments, hunting for the more dangerous logic that “others would be better off if I
were dead.”
Carlat suggests the following types of questions for helping patients share even subtle
feelings of guilt8:
“Have you felt especially critical of yourself lately?”

“Do you feel that you are essentially a good person, or do you have doubts?”
Depressive Helplessness
From their social isolation and their repugnance toward themselves, feelings of helpless-
ness emerge naturally. This profound sense of helplessness can contribute to the inertia
that effectively prevents therapeutic encounters. Phrased succinctly, depressed patients
wonder “Why bother?” The interviewer can easily estimate the role of this factor by
simply asking, “Have you been feeling helpless?” A more sophisticated gauge may emerge
with the question, “At this time, what kinds of ways of getting help do you see for your-
self?” A blank negative or dismal shake of the head in response to this question should
alert the interviewer to the potential seriousness of the depression.
Depressive Hopelessness
Finally, all of the above depressive themes may lead to hopelessness. Beck has demon-
strated that hopelessness represents a more specific and sensitive predictor of suicide
potential than depressive mood itself.9 As such, the interviewer can begin to measure the
degree of hopelessness with an indirect question, such as “What do you see for yourself
in the future?” and/or follow up more directly with, “Are you feeling hopeless?”
4. Psychodynamic Defenses and Their Role in Depression

I have found the discussion by MacKinnon, Michels, and Buckley in the 2nd edition of
their book, The Psychiatric Interview in Clinical Practice,10 to be particularly illuminating
in this area. I shall summarize some of their points, focusing on those defenses that can
most easily confuse the interviewer.
As we noted earlier in our discussion of Mr. Whitstone in Chapter 9, some people
have trouble admitting depression into their cognitive awareness. They tend to verbally
deny depression. In fact, they may be truly unaware that they are depressed. Such an
ironic state may be the result of psychodynamic defenses such as denial and repression.
Despite these defenses, careful questioning will often uncover the depression by eliciting
neurovegetative symptoms or evidence of depressive cognitive functioning such as caging
or generalization. Other common defenses include isolation and rationalization. The

patient may isolate all his or her depressive rumination onto one symptom complex.
The patient may simultaneously deny depression, as illustrated by “I’ve got no real prob-
lems other than the fact that I can’t sleep at night and I’ve got daily headaches.”
The patient’s anger can provide the interviewer with the first glimpse of the depressive
phenomenon. Analytic theorists such as Abraham and Freud have stressed the idea that
depression may represent anger turned inward.11 This anger may originate from a variety
of situations, including perceived abandonment, rejection, frustration, direct or indirect
attacks on oneself, or feelings of betrayal or injustice.
In line with this thinking, anger often pierces the sadness of the person experiencing
an agitated depression. Thus a patient who quickly verbally attacks the interviewer may
be betraying his or her depression to that very same interviewer. I have even been sur-
prised to see anger unexpectedly shooting through the apathy of the supposed “melan-
cholic depression,” as evidenced by vicious diatribes against past doctors or relatives. As
we have already seen, anger also routinely disrupts the existence of people displaying
borderline personality disorders, dysthymia, atypical depressions, and mixed bipolar
states.
Anger and depression can form a damaging, self-enhancing feedback loop, as follows.
The patient lashes out at a close friend. From this angry display, the patient develops
guilt for having such inappropriate feelings. This guilt triggers further depression. As the
depression deepens, the patient becomes increasingly irritable. Soon enough, the patient
lashes out again, thus completing and fueling the cycle.
A third confusing clinical picture resulting from psychodynamic defenses involves
the defense of projection, with resultant paranoia. MacKinnon emphasizes that depres-
sion and paranoia may alternate with each other. The person’s intense self-incrimination
can become too painful. Deflection of this pain occurs through projection. Instead of
hating himself or herself, the person finds that “other people hate me,” or “others want
to punish me.” This last statement sometimes demonstrates the projection of suicidal
ideation outwards. The need to consider paranoia as a defense against depression
dramatically demonstrates itself in the following vignette provided by one of my
colleagues.
Apparently he had consulted on a patient who presented as psychotically paranoid
in a medical hospital. This patient denied all suicidal ideation; furthermore, he related
few neurovegetative symptoms. Transfer to the psychiatric hospital was recommended in
the morning. The patient was checked throughout the night but was not placed on a
one-to-one observation. During a period of non-surveillance, the patient quickly and
efficiently hanged himself. Little more need be said.
A final dynamic mechanism that can easily fool the interviewer exhibits itself in the
process of pseudo-hypomanic defenses against depression. One needs to be wary of
anybody who appears “too happy” while describing numerous unsettling stressors. If
watched carefully, the surprisingly buoyant person may betray sadness by a minute quiv-
ering of the chin or a hesitancy to the voice. At these moments, a quiet statement such
as, “You know, as you are talking you seem sort of sad to me” may open a floodgate of
tears.
The Dyadic Wing of the Matrix

When two people interact, a dyadic system is born. Depression often first shows
itself through its impact on the flow of communication and affection within this
dyadic system. In this sense, depression exists as an interpersonal phenomenon,
seldom, if ever, restricted to the world of a single individual. Perhaps the following
description by a patient will illustrate the power of depression to alter the inter-
personal field:
It makes it harder to interact with people. It decreases your motivation for talking … first
of all because you are so acutely aware of how depressed you are that you are convinced
that other people are going to recognize it immediately, and it is very embarrassing to
think that. So it makes you feel as if any interaction with other people will make you feel
as if you will need to put on a front. It requires a lot of energy to do that. And that makes
you very tired. It is sort of a circular motion … you see how much energy it will take to
relate so you avoid doing it. I have even noticed that if I enter a store or see a Burger
King and I want coffee I tend to speak softer and not really smile like I normally do.
When I am depressed I want to limit the interaction as much as possible so I don’t smile
and I don’t really look at them. I just want to get it over with and get away …
This excerpt illustrates several subtle facets of interpersonal disruption. At one level,
the depressed person feels withdrawn and consequently attempts to decrease interac-
tion. This decrease in interaction robs the depressed person of the chance to gain
positive reinforcement from others, as mentioned earlier. But, perhaps more impor-
tantly, depression decreases the quality of the remaining interactions. The decreased
smiling, the decreased spontaneity, and the curtness of interaction displayed by the
patient can be perceived by others as coolness or aloofness. Once perceived in this
manner, people may treat the depressed person with increased reserve. For instance,
an employee behind the counter at a fast food chain may snap at the person, thus
further creating a hostile environment. This generates a self-fulfilling prophecy in
which the patient creates a hostile world, a world lacking rewards for interactions
with others.
This destructive cycle can be one of the forerunners of the learned helplessness some-
times seen in depression and postulated by Seligman as an etiology of depression.12
Seligman discovered that if you experimentally expose an animal, such as a dog, to ines-
capable aversive stimuli, the dog will eventually stop attempting escape. The animal
appears to give up. It does not attempt to find new ways of coping. Once this learned
helplessness has occurred, exploration ceases. With the cessation of exploration, the
chance for new learning and positive reinforcement vanishes. In a sense, the helplessness
has ensured its own survival. A very similar process may occur in humans, perhaps made
even more damaging by the uncanny ability of the human to cognitively reframe such
interactions into self-derogatory beliefs such as, “Obviously, nobody likes me,” or “I don’t
even know why I bother.”
The interviewer can search for evidence of interpersonal dysfunction and learned
helplessness with questions such as the following:
a. “Do you find yourself going out as frequently as you used to?”
b. “Tell me what it is like for you when you are around people at work?”
c. “When you talk with people what kinds of feelings do you have, like if you meet a
friend on the street?”
d. “How do people seem to be treating you?”
e. “Do you find yourself easily irritated or ‘flying off the handle’ recently?”
f. “Does it require much energy to be around people such as your friends?”
g. “Are you spending the same amount of time on social media?”
The Impact of the Patient’s Depression on the Interviewer

At this point one of the more fascinating elements of interviewing presents itself. I am
referring to the fact that not only are the friends and family of the patient affected by
the patient’s depression, but also the interviewer cannot escape the process. It benefits
clinicians to periodically look within themselves at their own emotional responses. In
the first place, such intuitive responses may be the tip-off that one has encountered a
depression or a depressive equivalent. In the second place, negative feelings generated in
the interviewer can seriously damage engagement. The interviewer may inadvertently
distance the interviewee by tone of voice or nonverbal cue. Put differently, the interviewer
needs to adjust to the needs of the patient in a continuous, adaptive creativity. To accom-
plish this process, interviewers must be aware of the impact of patients on themselves
and vice versa.
There exist several emotions commonly felt by interviewers besides generally acknowl-
edged reactions such as sympathy, empathy, or a desire to help. For instance, the depressed
patient’s slowness of movement and speech, caging, and hesitancy to answer questions
can create a sense of frustration in the interviewer. Questions may have to be asked
repeatedly. Answers may be vague. The interview may loom as a long and tedious process.
Such feelings of frustration may be useful indicators that the clinician should be on
the lookout diagnostically for a major depressive episode while being wary of
countertransference.
In a similar fashion, the patient’s depressive manner of interaction may create anger
in the interviewer as well as frustration. At times, interviewers may subsequently feel guilt
because they suddenly catch themselves being “non-caring.” This resultant guilt may
provide the initial clue to a diagnosis of depression. This guilt also provides the inter-
viewer with a vivid, experiential glimpse into the world of family members and friends
who interact with a depressed patient on a daily basis. Occasionally, the first suggestion
that one has encountered an atypical depression may be a growing sense of unexpected
sadness within the interviewer.
A final feeling that an interviewer may experience while interviewing a depressed
patient arises from both the withdrawal of the patient and the shrinking of the patient’s
active world. In short, as the patient introverts, the interviewer may feel ineffectual or
out of touch. Such feelings are to be expected. They do not necessarily suggest that the
interview is going poorly.
The preceding interactions emphasize the need for interviewers to adjust both their
pace and their expectations. The interview with the depressed patient requires both a
calm and a calming style. Indeed, any suggestions of haste or irritation may be interpreted
in a highly disengaging fashion by the depressed patient. A frustrated interviewer may
be perceived as, “Just like everyone else, you find me irritating.” Such an interaction
hardly sets an ideal platform for a therapeutic alliance.
How a Clinician’s Behaviors Can Submerge a Depression From View

So far I have been describing the impact of the patient on the therapist, generating feel-
ings such as sadness, annoyance, or guilt. Flipping the coin, one finds that the therapist
can unwittingly affect the patient’s presentation. With regard to depression, this phenom-
enon occurs most frequently with atypical depression, dysthymia (persistent depressive
disorder), and in depressions accompanying a personality disorder.
People with these disorders are often highly responsive to their immediate surround-
ings. A patient with dysthymia or with a histrionic personality can sometimes be cheered
up deceptively rapidly if the patient feels that someone is showing an interest, an example
of the “mood reactivity” described in Chapter 9. Therefore, an overly warm or extroverted
interviewer can unknowingly shift the patient’s affect. To such an interviewer, the pre-
sentation of the patient may not seem very sad or depressed. Such an initial impression
might mislead the interviewer into downplaying the significance of the depressive
complaints.
It should also be remembered that “happy people” are often very annoying to depressed
people, being perceived as incapable of understanding how miserable they feel. The
interviewer best approaches the patient from the calming middle ground of gentle
warmth and interested listening.
Effectively Addressing Tearfulness

While interviewing depressed patients, the clinician will undoubtedly encounter tearful
patients. The first time a patient cries in an interview, it is generally comforting to allow
the patient to cry for a brief period. If the patient is on the brink of tears, statements
such as, “You seem sad right now,” or as MacKinnon and Michels13 suggest, “Are you
trying not to cry?” may be very helpful. Said with a soft tone, they will offer the patient
a chance to ventilate, thus decreasing a sense of discomfort. Many patients feel embar-
rassed or vulnerable at such moments. I generally address this unstated issue with a
statement such as, “It’s all right to cry. We all cry at times. It’s our body’s way of telling
us we are hurting; (after a brief pause) maybe you can tell me a little more about what
is hurting you.”
After allowing the patient some time to ventilate, I generally will ask, “Would you like
a tissue?” while simultaneously offering one in my outstretched hand. Such an interac-
tion has many metacommunications. The clinician is conveying an acceptance of crying
as a normal aspect of sadness. Simultaneously, respect is given to the patient’s current
needs. Rather than just giving the patient a tissue, the clinician asks if one is needed. By
the process of asking, the clinician conveys confidence that the patient is still in control,
fully capable of making decisions.
During the tearfulness and as it subsides, the interviewer has an ideal chance to learn
about the core pains of the patient. Tearfulness tends to decrease the use of defenses. At
such a point, pertinent and startling information may emerge. If the clinician had pre-
vented the tearfulness by cutting it off abruptly or by changing topics, then valuable
information might have been lost.
Of course, at times, one might find a patient whose uncontrollable crying prevents
progress. To further the interview, statements said reassuringly but firmly such as the
following may be effective, “Mr. Jones this is obviously very upsetting and would be to
anybody. Take a moment to collect yourself. It’s important for us to talk more about
what is bothering you.”
But, generally speaking, interviewers tend to prematurely shut down crying, perhaps
because it is disturbing to feel another person’s pain. Another emotion may also con-
tribute to this premature shut-down, for the patient’s tearfulness can make the interviewer
feel awkwardly helpless. On a deeper level, it remains important for interviewers to
understand their spontaneous feelings when someone cries. In this regard, part of the
interviewer’s basic training should be a search for answers to questions such as the
following:
a. What do I feel when someone cries?

b. Do I ever perceive crying people as weak or ineffectual?
c. How often do I cry and how do I feel about myself when I do?
d. Have I ever seen my parents, family, or friends cry, and how did I feel then?
By exploring such questions, the interviewer decreases the risk that countertransference
issues will adversely affect the ability to deal with a crying patient. In the last analysis,
many a powerful therapeutic alliance has been forged by a clinician’s calming and mature
response to a patient’s first tears.
The Familial and Societal Wing of the Matrix

In an immediately practical sense, it is important to interview family members, for they
may provide invaluable information regarding the patient’s history. Sometimes patients
may be so withdrawn or their cognitive abilities so impaired that they have trouble pro-
viding reliable information. In this situation, family members may provide valid infor-
mation regarding the patient’s symptoms and the situational and interpersonal
circumstances that may be triggering or impacting upon the patient’s depression.
Additionally, family members are potentially illuminating sources for collaborative
treatment planning, as well providers of information on what interventions have been
either useful, damaging, or unproductive in past care. To not invite family input or to
ignore it once given is not only foolish, but it will often antagonize the family members
(and rightly so), who are living with the patient and who must cope with the patient’s
symptoms on a daily basis once leaving the interviewer’s office.
On a more complex level, sometimes depression seems to possess a life of its own,
independent of the person labeled as depressed. It is within the family that this phe-
nomenon comes most vividly to mind. To understand a patient’s depression in an initial
interview fully, one must understand its contextual role in the family and within the
culture that is shaping that family.
Family interaction may be the primary root of the depression, as in a hateful sibling
rivalry or incest. At other times, the depression may have its roots in a biochemical
process yet damaging matrix effects will reverberate throughout the family. A case in point
would be a spouse laid off from work secondary to a severe endogenous depression.
Surely, all members of the family will feel the pains of this depressive process, almost as
if the biochemical imbalance were in their own neurochemistry. Finally, family pathology
may feed a depression already caused by another wing of the patient’s matrix, such as
the biochemical or psychological system. For instance, an abusive spouse may re-enforce
a depressed patient’s guilt by making denigrating comments such as, “You’re letting
everybody down, especially the kids, you’re truly worthless.”
Cultural biases can also impact on how a depression reverberates throughout the
members of a family. In Asian cultures, a family member’s depression may be viewed as
a bad reflection upon the entire family, in which case added shame and guilt may fall
upon the patient struggling with the depression. Such cross-cultural influences may also
make it harder for a clinician, when interviewing an Asian American, to hear the truth
about a patient’s degree of disability from family members for there may be covert cul-
tural pressures to keep this quiet.
An Illustration of the Insidious Impact of Depression on a Family

I will accent this topic by describing an interview that I supervised in person. The inter-
viewer was talking with the identified patient, whom I shall refer to as Mrs. Ella Thomas.
The husband and son of Mrs. Thomas were also present in the same room. Mrs. Thomas
was a gray-haired woman with angry eyes that seemed resentful of all 70 of her years.
She fidgeted and cried throughout the interview. At times she would suddenly change
topics, whining out such statements to her husband as, “You’ve got to help me, Leonard!
I can’t go on. The pain! The pain!” She complained about the hospital and warned that,
“I had better get my sleeping pills or I’ll leave.”
As the interview proceeded, an atmosphere of increasing tension pervaded the room.
Her husband had refused to have a chair brought for himself. Consequently, he stood
throughout the interview, stationed reservedly behind his wife. As the interview pro-
gressed, he tightly rolled his lips upon each other, while his arms closed over his chest.
Mrs. Thomas’ son sat down, his body turned sideways to his mother. He occasionally
tossed a glance at her when his eyes were not staring at his shoes or the floor. Later in
the interview, with an angry tone plucking each word, the son challenged the clinician,
“Why can’t she have those meds?” I felt a growing sense of discomfort inside me. The
poor interviewer was nervously breaking eye contact with Mrs. Thomas, while he sheep-
ishly performed a mental status.
I can safely say that no one in that room was comfortable. That room represented a
classic reflection of the impact of depression on a family system and even on the hospital
system itself. Diagnostically, Mrs. Thomas had an agitated major depressive disorder. In
reality, this entire family was experiencing a depressive episode. But it did not stop at the
boundary of her age-spotted skin. Depression is often reflected in the actions and words
of family members. Her husband and son demonstrated the frustration and anger often
generated in those who love the patient. These people experience a sense of helplessness,
fearing that nothing will change, despite their best efforts. Not personally experiencing
the patient’s anhedonia and loss of energy, they cannot understand why the patient does
not help himself or herself. They also find their own daily activities continuously inter-
rupted by the complaints and actions of the depressed person. If the initial interviewer
has the opportunity to meet family members, sometimes their statements and nonverbal
messages may be the first clue that depression is the diagnosis.
Addressing the Pain of Family Members

The interviewer should keep in mind that family members who are desperately trying to
help their loved one may need support themselves. The problem is not “just Ella’s
problem.” Our mission includes helping to relieve the pain of family members as they
deal with the devastation that depression has brought to their worlds. Occasionally,
secondary to such frustration, family members will develop a major depressive episode
of their own. In a sense, like a virus, the depression will have replicated itself. If one
senses that an accompanying family member appears to be depressed, it can be comfort-
ing and rewarding to interview them alone briefly, to see how they are coping. I find that
the following question, asked gently, can be a powerful doorway into the family mem-
ber’s pain:
“I can see that you are providing great support for your mother during her depression
but I’m wondering who is providing you with support?”
I have seen family members burst into tears following such a question as they simply
answer, “No one.”
Occasionally, you will need to inquire about suicidal thought in a family member. It is not
uncommon to help family members to connect with appropriate mental health follow-up
for themselves if necessary.
In the last analysis, it is difficult to over-estimate the pain generated in family members
by watching their loved one suffer. The angst of seeing a child or spouse suffer from a
mental disorder while feeling helpless to relieve his or her pain is, quite frankly, beyond
words. I can vouch for this pain, for I have felt it myself.
One of our greatest gifts as clinicians is to take the time to help relieve the suffering
of those family members who love the patients for whom we are providing care for ill-
nesses ranging from depression to bipolar disorder and schizophrenia. In this regard, be
sure to checkout the wonderful article, “Practical Interview Strategies for Building an
Alliance with the Families of Patients Who have Severe Mental illness” by Murray-
Swank,14 (complete article available in Appendix IV).
Uncovering Potentially Damaging Family Impacts on the Patient

As illustrated above, the pent-up frustration and anger of family members may be
expressed not only towards the patient but also towards the interviewer. Unfortunately,
as described earlier in the section on dyadic process, the negative feelings generated by
Mrs. Thomas may backfire upon her, creating a hostile environment even within the
hospital.
From a very different perspective, depressions sometimes play a curious role in a

family, for the family system may in some way need Mrs. Thomas’ depression as a sta-
bilizing force, as theorists such as Bowen or Minuchin have discussed.15 Family members
with low self-esteem may find a boost in self-worth as they embrace the role of a care-
taker “who is the only person who is really helping Mom.” Or an adult child who always
felt “put-down” by a parent might find it exhilarating to be one-up on that parent and
in charge of care. At an unconscious level, these family members “may not want Mom
to get better,” potentially undercutting treatment recommendations made in the closing
phase of the interview. All of these points emphasize the need for the interviewer to
carefully explore the family dynamics in order to understand the depression.
Within the individual interview, family tensions may be spontaneously brought up
by the patient. At other times, questioning may be needed to illuminate the issues. Ques-
tions such as the following represent some good jumping off points:
a. “Who in your family seems to understand your depression and who doesn’t?”
b. “Who in your family are you concerned about right now?” (The answer may uncover
a family member who is having trouble coping with the patient’s depressive state.)
c. “How do you think your family members view your depression?”
d. “What kinds of suggestions have your family members been making to you about
how to feel better?”
e. “Have you been feeling any pressure from anyone in your family to get better?”
f. “Has anyone in your family told you that you ‘just need to pick yourself up by the
bootstraps’?”
g. “Has anyone in your family said something to you like, ‘I’m sick of you being
depressed all the time.’”
h. “What kind of pressures has your spouse been coping with recently?”
i. “Do you think your spouse views you as a problem?”
Questions such as the above must be asked in sensitive fashion with the clinician always
being aware of their impact on the patient. When used effectively, they will often yield
valuable information about the “psychodynamics” of the family. They may elicit inter-
personal tensions between specific family members, where more direct questioning
might have elicited denial.
For instance, when answering the question about pressures on the spouse, the patient
may relate feelings of guilt for being a burden, feelings of anger towards the spouse for
perceived neglect, disgust at the spouse’s over-attention to work or other family members,
or he or she may seem detached and uninterested in the spouse. From such a question,
one may also learn valuable information about situational stressors in the family system
as well.
The Impact of Depression on Societal and Cultural Systems

Larger systems other than the family may experience damaging matrix effects from the
patient’s depression. On a direct level, impact of the depression will be seen in systems
such as the job environment, church groups, social organizations, and social media
such as Facebook, Instagram, and Twitter, where the patient’s participation may
plummet.
From a different perspective, such systems may act as major stressors triggering the
depression in the first place. Conversely, they may act as important supports, helping to
buffer the patient from their depression. Society itself can be an integral system involved
in depression. Careful questioning might reveal that the husband of Mrs. Thomas had
been forced to retire secondary to economic layoffs. Or perhaps her family had recently
relocated because of increasing taxes in their former state. Likewise, the hospitalization
of patients such as Mrs. Thomas may ultimately affect the Medicaid and Medicare systems
or the Affordable Care Act. The societal cost in treating depression, and in lost productiv-
ity in the workplace, is estimated in the billions of dollars per year, a striking example
of a damaging matrix effect.
Cultural Impacts on the Patient’s Depression

In the same sense that depression impacts on the patient’s family and cultures, cultures
impact on how depressions are perceived and the degree with which they are stigmatized.
Indeed, if a patient’s culture strongly disparages depression, and perhaps suicidal think-
ing as well, the culture can strikingly increase depressive guilt and shame. Here we see a
stigmatizing viewpoint, housed within the cultural wing of the patient, causing inter-
wing damage on the patient’s psychological response to his or her own depressive symp-
toms. We have already seen how cultural stigma might limit the accuracy of information
provided by family members by compelling them to downplay the severity of the their
loved one’s symptoms.
If one is unfamiliar with the cultural beliefs of an interviewee regarding depression,
the interviewer should not be hesitant to ask about them. The very act of asking can help
the patient to share serious depressive symptoms, perhaps even suicidal ideation more
readily. It does not matter if one is a Muslim clinician trained in Pakistan who is inter-
viewing a Christian White American or vice versa, questions such as the following can
be useful:
1. “You know, I’m not entirely certain how depression is viewed in the West. Back in
the States, do people tend to talk about depression openly or do they hush it up?”
2. “I’m curious about how your family and friends view depression?”
3. “Help me to get a better understanding of how Christianity views suicide, for instance
is it viewed as a sin and could one get to heaven if one had killed oneself?”
The answers to such questions can be quite revealing. They may prove to be the
gateway to an engaging and potentially life-saving discussion. No matter how you
mark it, cultures shape depressive episodes. Conversely, depression leaves its mark
throughout all the interlocking wings of the patient’s matrix. The sensitive interviewer
understands these inter-relationships and attempts to make a reconnaissance of each
system during the initial and subsequent interviews. Through this diligent search, the
puzzle of depression may become clearer and avenues of therapeutic intervention more
apparent. As we’ve just seen in our review of the cultural ramifications of depression,
spirituality itself can partially shape depression. It is time to explore this impact in
more detail.
The Wing of the Matrix Encompassing Worldview and Spirituality

As we have emphasized repeatedly throughout our book, one should attempt to under-
stand how patients view their symptoms, their problems, their life, and their beliefs.
Such views represent the patient’s worldview or framework for meaning as described in
Chapter 7.
In an initial interview, one will seldom have the time to explore this framework in
depth as it relates to the patient’s depression, but even a few minutes of discussion may
provide clues for engagement or for future therapeutic discussion. Such questioning may
also further foster an understanding of the person beneath the depression, as well as
providing hints as to possible causes of the patient’s depression. Failure to have evolved
a framework for meaning or a sudden breakdown in a pre-existing framework can func-
tion as triggers or perpetuators of the patient’s depression, representing an existential
crisis.
To investigate these areas of existential framework, several regions of information may
be of value. At times, demographic questions concerning religious background may act
as springboards for further inquiry. Significant information may present itself following
questions such as, “What role does religion play, if any, in your life?” If asked with a
nonjudgmental tone, I have found that people generally respond naturally and specifi-
cally. Very quickly, the interviewer will register the role of religious doubt or ambivalence
in the current crisis. In Chapter 20 devoted to advanced strategies for exploring cross-
cultural issues and diversity, we will examine in detail various interviewing techniques
for exploring religious beliefs and spiritual perspectives, which play such a pivotal role
in the cultural matrix of our patients and ourselves.
Religion/spirituality is not the only axis upon which a framework for meaning is built.
Other areas include family, job, community, charities, patriotism, and subcultures such
as those associated with sports and hip hop music. Ignorance of these factors can result
in markedly disrupted engagement. Moreover, as we saw earlier in Chapters 6 and 7,
these systems can have a very powerful influence on whether the patient will follow up
with treatment recommendations. Consequently, it remains critical for the initial inter-
viewer to understand these factors, as illustrated below:
Clin.: What kinds of things do you like to do in your spare time?

Pt.: When I felt better, I used to love to sing.
Clin.: Oh … (with an increased interest in tone of voice) What kinds of music did you
like to sing?
Pt.: All types, but I really loved gospel music. What a beautiful way to bring God to
people … I think if you put all of your trust in God, He will help you. Man is not
the answer. Man provides artificial answers.
Clin.: Have you been praying recently in an attempt to gain some guidance?
Pt.: Yes I have. Every day. It helps, but I wonder if maybe I ask for too much. Perhaps I
am to blame.
This vignette provides a wealth of information for the clinician. In the first place, religion
obviously plays a major role in this person’s life. The interviewer may want to further
examine the possible therapeutic supports that religion could provide, such as meetings
with a pastoral counselor, minister, or choral church activities. However, it is possible
that religion may be feeding some guilty ruminations that are part of the depressive
process itself. Perhaps even more important, the clinician has some clues concerning
where engagement could go wrong. In particular, the patient’s statement, “Man is not
the answer. Man provides artificial answers,” serves as an alert to the clinician. Specifi-
cally, the patient may find treatment modalities such as psychotherapy or medication as
clearly “artificial answers.” Premature reference in the interview to such treatments could
easily rupture engagement. The clinician will need to proceed cautiously, trying to gently
find out what this particular patient wants in the way of help.
It is beyond the scope of this chapter to discuss the numerous ramifications that the
search for meaning may play in depression. I refer the reader to authors such as Frankl,16
Yalom,17 Josephson and Peteet,18,19 and Cloninger,20 who address these issues in the detail
they deserve. In closing, I am reminded of another example in which understanding the
patient’s framework for meaning helped in the initial interview of a patient with depres-
sive complaints. I had been asked to see this patient as a psychiatric consultant on a
medical ward.
Mr. Kulp (as I shall refer to him) was a 55-year-old man with alcoholism suffering
from moderately severe Parkinson’s disease (a progressive form of muscular rigidity). He
had been admitted with suicidal ideation following a drunken spree. He had many
stressors, not the least of which was a markedly battered self-image created by the stiffen-
ing of his body from his Parkinson’s disease. Mr. Kulp had always prided himself on
being an energetic breadwinner for his family. He viewed himself as a tough Marine.
This latter affiliation surfaced when I asked him if he liked to read. He mentioned
that he loved to read, pointing to his books. When I asked if I could see them, he enthu-
siastically showed them to me. All of them concerned Marines and various war heroes,
which led to a discussion of his former Marine days, including his boot camp experiences.
At the time, I did not know exactly what to make of this information. Later its usefulness
would become apparent.
By way of understatement, Mr. Kulp did not respond positively to my recommenda-
tions that he needed to enter a local alcohol rehabilitation center. As the discussion
proceeded, I felt that he would decide against entering the program. He balked, stating
that it would be too big of a time commitment and too tough. At which point I made
a comment to the effect, “Well Mr. Kulp, I guess you’re right. It’s a tough commitment,
but not your first. It’s sort of like boot camp was a tough commitment. But you needed
boot camp. It made a good soldier of you. Maybe you and your family need this
program.” This statement appeared to affect Mr. Kulp. He eventually decided to enter the
rehabilitation program. Perhaps he would have entered anyway, but the understanding
of his framework for meaning certainly seemed to help. Suddenly the rehabilitation
program was not viewed as a foreign entity; it was akin to his familiar and respected boot
camp. Mr. Kulp had been given a chance to be a soldier again.
REFERENCES
1. Baudelaire C. The flowers of evil. Franklin Center, PA: The Franklin Library; 1977. p. 123.
2. Jaspers K. Symptom complexes of abnormal affective states. In: General psychopathology. Manchester, UK: Manchester
University Press; 1963. p. 598 [Original work published 1923].
3. Minkowski E. Findings in a case of ‘schizophrenic’ depression. In: May R, editor. Existence. New York, NY: A
Touchstone Book; 1958. p. 133.
4. Beck AT. Cognitive therapy and the emotional disorders. New York, NY: The American Library; 1976. p. 105.
5. Minkowski E. 1958. p. 132.
6. Joiner T. Why people die by suicide. Cambridge, MA: Harvard University Press; 2005.
7. Joiner TE, Van Orden KA, Witte TK, Rudd MD. The interpersonal theory of suicide: guidance for working with suicidal
clients. Washington, DC: American Psychological Association; 2009. p. 57.
8. Carlat D. The psychiatric interview. 3rd ed. Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins; 2012. p.
168.
9. Beck AT, Kovacs M, Weissman A. Hopelessness and suicidal behavior. JAMA 1975;234:1146–9.
10. MacKinnon RA, Michels R, Buckley PJ. The psychiatric interview in clinical practice. 2nd ed. Washington, DC:
American Psychiatric Publishing, Inc.; 2006. p. 229–80.
11. Akiskal H, McKinney W. Research in depression. In: Guggenheim F, Nadelson C, editors. Major psychiatric disorders:
overview and selected readings. New York, NY: Elsevier Science Publishing Co.; 1982. p. 73.
12. Akiskal H, McKinney W. 1982. p. 74.
13. MacKinnon RA, Michels R, Buckley JR. 2006. p. 256.
14. Murray-Swank A, Dixon LB, Stewart B. Practical strategies for building an alliance with the families of patients who
have severe mental illness. Psychiatr Clin North Am 2007;30(2):167–80.
15. Gurman AS, Kniskern DP, editors. Handbook of family therapy. New York, NY: Brunner/Mazel Publisher; 1981.
16. Frankl VW. The doctor and the soul. New York, NY: Vintage Books; 1973.
17. Yalom I. Existential psychotherapy. New York, NY: Basic Books; 1980.
18. Josephson AM, Peteet JR. Handbook of spirituality and worldview in clinical practice. Washington, DC: American
Psychiatric Publishing, Inc.; 2004.
19. Peteet JR. Putting suffering into perspective: implications of the patient’s worldview. J Psychother Pract Res
2001;10:187–92.
20. Cloninger CR. Feeling good: the science of well-being. Oxford, UK: Oxford University Press; 2004.
CHAPTER 11
Psychotic Disorders: How to
Sensitively Arrive at a
Differential Diagnosis
And then a Plank in Reason, broke,

And I dropped down, and down –
and hit a World, at every plunge,
And finished knowing – then – …
Emily Dickinson
INTRODUCTION
One wonders what the world is like when a plank in reason splinters, as Emily Dickinson
describes the slip into psychotic process. The more we, as clinicians, can develop a feeling
for this world, the easier it is to uncover subtle psychotic states. As intuitive understand-
ing increases, it also becomes easier to understand the needs of the patient, an under-
standing that leads directly into a more compassionate, person-centered interview.
To begin our exploration, we will turn to Gérard De Nerval, a poet of extreme talent,
who had the misfortune of falling through a plank in reason sometime during the middle
of the Victorian Era. De Nerval was a gifted Symbolist poet, who was also a world traveler
and a man deeply interested in philosophy. He was blessed with a child-like awe of
nature. In 1841 he experienced his first psychotic break. Some 14 years later, psychotic
process would lead him on a cold winter night to an iron gate bordering an alley near
the Boulevard St-Michel. There, the following morning, he was found hanging from a
railing with his neck fatally embraced by an apron string.1
On the morning after his suicide, fragments of a work entitled Le Rêve et la Vie were
found in his pocket. It is this piece that provides us with our first glimpse into the world
of psychosis:
First of all I imagined that the persons collected in the garden (of the madhouse) all had
some influence on the stars, and that the one who always walked round and round in a
circle regulated the course of the sun. An old man, who was brought there at certain hours
of the day, and who made knots as he consulted his watch, seemed to me to be charged
with the notation of the course of the hours …
I attributed a mystical signification to the conversations of the warders and of my com-

panions. It seemed to me that they were the representatives for all the races of the earth,
and that we had undertaken between us to re-arrange the course of the stars, and to give
a wider development to the system. An error, in my opinion, had crept into the general
combination of numbers, and thence came all the ills of humanity. …
I seemed to myself a hero living under the very eyes of the gods; everything in nature
assumed new aspects, and secret voices came to me from the plants, the trees, animals,
the meanest insects, to warn and to encourage me. The words of my companions had
mysterious messages, the sense of which I alone understood.2
In some respects, it is De Nerval’s last statement that provides one of the most telling
clues as to the nature of psychotic process. As psychotic process becomes more intense,
the patient’s world becomes progressively more unique to the patient, receding further
from the experience of the world as witnessed by others. In this sense, psychosis can be
defined in simple terms as a breakdown of perceptual, cognitive, or rationalizing func-
tions of the mind to the point that the individual experiences reality very differently than
other people within the same culture.
De Nerval’s world became filled with a maelstrom of curious and disturbing sensa-
tions. His words sensitively depict a variety of classic symptoms of psychosis, including
delusions, ideas of reference, and hallucinations. It also demonstrates the fact that some
aspects of psychotic process may be exciting and even beautiful. But – and this is an
important “but” – psychosis is almost invariably ultimately accompanied by an intensely
painful collection of fears. The patient senses impending catastrophe. For instance, De
Nerval states, “An error, in my opinion, had crept into the general combination of
numbers, and thence came all the ills of humanity.” Such paranoid perception can create
a tremendous sense of urgency and responsibility in those experiencing psychotic process.
Perhaps for De Nerval, it was the realization that he could not correct this heinous error
in the universe that led him to believe that his life should be ended because he had failed
both God and humanity.
There are many aspects of psychotic process that, to my mind, demarcate it from the
innovative workings of eccentric and/or creative men and women, whose thought is
clearly at variance with the worldview of most people but is not a psychotic process.
Creative thinking may bear a resemblance to psychotic process, but it is not identical to
it. We shall see that it is not so much the content of the psychotic thinking that is patho-
logic, but more the way in which the thinking occurs that marks the process as
psychotic.
THE DIFFERENTIAL DIAGNOSIS OF PSYCHOTIC STATES

Now that we have arrived at a working definition of psychosis, an important point needs
to be emphasized. The word “psychosis” is not a diagnosis. Psychosis is a syndrome that
can result from any number of psychiatric disorders delineated in the DSM-5. As we have
Psychotic disorders: how to sensitively arrive at a differential diagnosis 439
already seen, mood disorders such as major depressive disorder and bipolar disorder can
present with psychotic symptoms. It is never enough to simply state that the patient
appears to be psychotic, because one must proceed to determine what diagnostic entity
is causing the psychotic process. With some disorders such as schizophrenia and psy-
chotic bipolar disorder, timely recognition can lead to early intervention, lower doses of
antipsychotic medications, and an untold reduction in the patient’s severity and duration
of suffering. Other disorders that can sometimes feature psychosis such as deliria and
central nervous system infections, can prove to be acutely life threatening, requiring
immediate diagnostic recognition. In this chapter we will look at the interviewing tech-
niques and strategies that will allow us to spot these diagnostic distinctions in a sensitive,
rapid, and accurate fashion.
To accomplish this task, we will look at seven clinical vignettes that illustrate the
diversity of possible disorders that can present with psychotic symptoms. Once again,
the emphasis will be upon a discussion of both the symptoms experienced by the patients
and the practical interviewing techniques that allow us to more sensitively and effectively
uncover these symptoms. In the process we will explore the interface between interview-
ing and the delicate art of differential diagnosis.
Before proceeding with this clinical material, it may be of value to review the DSM-5
criteria for schizophrenia, because schizophrenia may very well represent the classic
example of a psychotic illness. One of the main goals in the approach to any psychotic
patient remains the determination of whether or not schizophrenia is present. To this
end the DSM-5 criteria are as follows3:
DSM-5 DIAGNOSTIC CRITERIA FOR SCHIZOPHRENIA

SCHIZOPHRENIA
DIAGNOSTIC CRITERIA 295.90 (F20.9)
A. Two (or more) of the following, each present for a significant portion of time during a 1-month period
(or less if successfully treated). At least one of these must be (1), (2), or (3):
1. Delusions.
2. Hallucinations.
3. Disorganized speech (e.g., frequent derailment or incoherence).
4. Grossly disorganized or catatonic behavior.
5. Negative symptoms (i.e., diminished emotional expression or avolition).
B. For a significant portion of the time since the onset of the disturbance, level of functioning in one or
more major areas, such as work, interpersonal relations, or self-care, is markedly below the level
achieved prior to the onset (or when the onset is in childhood or adolescence, there is failure to
achieve expected level of interpersonal, academic, or occupational functioning).
C. Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include
at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase
symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or
residual periods, the signs of the disturbance may be manifested by only negative symptoms or by
two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual
perceptual experiences).
D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled
out because either (1) no major depressive or manic episodes have occurred concurrently with the
active-phase symptoms, or (2) if mood episodes have occurred during active-phase symptoms, they
have been present for a minority of the total duration of the active and residual periods of the illness.
E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse,
a medication) or another medical condition.
F. If there is a history of autism spectrum disorder or a communication disorder of childhood onset, the
additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in
addition to the other required symptoms of schizophrenia, are also present for at least 1 month (or
less if successfully treated).
Specify if:
The following course specifiers are only to be used after a 1-year duration of the disorder and if
they are not in contradiction to the diagnostic course criteria.
First episode, currently in acute episode: first manifestation of the disorder meeting the defining
diagnostic symptom and time criteria. An acute episode is a time period in which the symptom
criteria are fulfilled.
First episode, currently in partial remission: Partial remission is a period of time during which an
improvement after a previous episode is maintained and in which the defining criteria of the
disorder are only partially fulfilled.
First episode, currently in remission: Full remission is a period of time after a previous episode
during which no disorder-specific symptoms are present.
Multiple episodes, currently in acute episode: multiple episodes may be determined after a
minimum of two episodes (i.e., after a first episode, a remission, and a minimum of one relapse).
Multiple episodes, currently in partial remission.
Multiple episodes, currently in full remission.
Continuous: Symptoms fulfilling the diagnostic symptom criteria of the disorder are remaining for
the majority of the illness course, with subthreshold symptom periods being very brief relative to
the overall course.
Unspecified.
Specify if:
With catatonia (refer to the criteria for catatonia associated with another mental disorder, pp.
119–120, for definition).
Coding note: Use additional code 293.89 (F06.1) catatonia associated with schizophrenia to
indicate the presence of the comorbid catatonia.
Specify current severity:
Severity is rated by a quantitative assessment of the primary symptoms of psychosis including
delusions, hallucinations, disorganized speech, abnormal psychomotor behavior, and negative
symptoms. Each of these symptoms may be rated for its current severity (most severe in the last
7 days) on a 5-point scale ranging from 0 (not present) to 4 (present and severe). (See Clinician-
Rated Dimensions of Psychosis Symptom Severity in the chapter “Assessment Measures”).
Note: Diagnosis of schizophrenia can be made without using this severity specifier.
It should be noted that there also exists a diagnosis, schizophreniform disorder, that is
applied when a patient meets Criterion A of schizophrenia (as well as having ruled out
depressive disorder with psychosis, bipolar disorder, and schizoaffective disorder) but
the symptoms do not last for 6 months nor necessarily result in a marked decline in
functioning. In the schizophreniform disorder, the symptoms (including prodromal,
active, and residual phases) must last at least 1 month but less than 6 months. Many
patients who have received this diagnosis provisionally will eventually receive the diag-
nosis of schizophrenia if their symptoms last longer than 6 months and significant
impairment in functioning begins to appear.
For psychotic presentations of an even shorter duration, the DSM-5 delineates the
diagnosis of brief psychotic disorder. This diagnosis is used when the patient has one (or
more) of the following symptoms, with at least one of the symptoms being in the first
three listed: (1) delusions, (2) hallucinations, (3) disorganized speech, and (4) grossly
disorganized or catatonic behavior. The timeframe is at least 1 day but less than 1 month,
with the patient eventually having a full return to his or her previous level of functioning.
If the psychotic episode is triggered by a specific stressor, this stressor should be specified.
Such psychotic episodes are often called brief reactive psychoses in the clinical literature.
To begin our discussion, let us meet some people who have had the misfortune of
falling through a plank in reason. As with Chapter 9, where we examined the differential
diagnosis of mood disorders, it is assumed, for the sake of discussion, that the following
clinical material was obtained during an initial assessment interview unless otherwise
noted.
Clinical Presentations and Discussions

Clinical Presentation #1: Mr. Williams
Mr. Williams presents to the emergency department (ED) accompanied by three police
officers. His behavior has not put the officers in particularly good moods. As one officer
states, “This guy is wacko. Every once in a while he tries to bolt, as if something was after
him.” The officer has no idea what the “thing” is that appears so disturbing to Mr. Wil-
liams. In the interview, Mr. Williams presents as a 33-year-old male who initially appears
relatively calm despite the beads of perspiration on his forehead. He is just finishing
supper from his dinner tray and is neatly wiping his mouth with a napkin. His pants are
torn and soiled; obviously, they are not strangers to the harshness of street life. He
appears oriented to person, place, and time. As he begins to talk, he becomes more ani-
mated, displaying tangential speech with occasional glimpses of derailment (also known
as a loosening of associations in the clinical literature). He also appears to be increasingly
more distracted as evidenced by his having trouble focusing on the interviewer’s ques-
tions. He denies any recent drinking or drug use, but his story is vague, concerned pri-
marily with the appearance of some creature that has been following him. Suddenly, in
the middle of the interview, his eyes widen as he stares down at his feet. He cannot attend
to the interview because his attention is riveted to the floor. He begins kicking at some
invisible object and angrily looks at the clinician, yelling, “Get rid of that thing!”
Discussion of Mr. Williams

Phenomenology of Visual Hallucinations and Illusions: Their Diagnostic Implications
While with the police, Mr. Williams had appeared to be responding to visual hallucina-
tions, a process that reappeared during the interview itself. And here is the first clue
to the diagnostic entity causing his immediate psychosis: The presence of visual
hallucinations should alert the clinician to the possibility that a general medical condi-
tion may be causing the disorder. Schizophrenia can cause visual hallucinations but
auditory hallucinations are significantly more frequent. However, general medical causes
of psychosis (e.g., substance abuse and withdrawal, endocrine disorders, infections,
toxins, and seizures) frequently present with extremely vivid visual hallucinations, with
or without auditory hallucinations.
Fish has suggested that the quality of the visual hallucination may tend to vary
depending on whether schizophrenia or a general medical process is present,4 but no
specific characteristics clearly differentiate them. Nevertheless, some characteristics seem
to be more common in each category and may provide clues to etiology.
Visual hallucinations in patients whose psychosis is caused by a general medical con-
dition, as seen with delirium, tend to vary from the classic psychoses by preferentially
occurring at night, by being briefer in duration, and by being more frequently perceived
as moving. They may also have little personal significance to the patient. For example, a
patient with schizophrenia may hallucinate about a recently deceased relative, whereas
the delirious patient may see snakes.5
With patients for whom the psychosis is caused by drugs or other general medical
conditions, the hallucinations may appear more frequently and more vividly when the
patient is in a darkened room or has his or her eyes shut. This is not the case with people
with schizophrenia, who tend to see their hallucinations with eyes open or who experi-
ence little difference whether the eyes are open or closed.6,7 In this sense, it is of value
to ask patients, “When you see your hallucinations, what happens if you close your eyes?”
With a hospitalized patient it is of value to check with the nursing staff concerning
whether the patient is hallucinating more at night.
With people suffering from schizophrenia, visual hallucinations seldom occur by
themselves. They usually present with auditory hallucinations or hallucinations from
some other sensory modality.8 Also of interest to the interviewer is the fact that
schizophrenic hallucinations are frequently superimposed on an otherwise normal-
appearing environment or may even appear with the surrounding environment absent.
In hallucinogenic drug-induced psychoses, the entire environment frequently seems
distorted with numerous illusions and hallucinations.9 In a similar vein, the visual
hallucinations of schizophrenia tend to appear suddenly, without preceding visual
illusions or less formed visual hallucinations; whereas visual hallucinations caused
by a general medical condition, as seen in delirium, tend to have a prodrome of
visual illusions, simple geometric figures, and alterations of color, size, shape, and
movement.9
Patients with schizophrenia tend to see concrete things such as faces, body parts, or
complete figures, as opposed to geometric patterns or poorly formed images. On the
other hand, once patients whose psychosis is caused by a general medical condition begin
seeing concrete images, it has been my experience that the images frequently appear
extremely real to the patients. The delirious patient may look on with terror, pointing
towards the hallucination, eyeing it warily, or moving away from it as it appears to
approach. Occasionally the patient’s affective response may be pleasurable, as experi-
enced with hallucinations of miniature people, so-called Lilliputian hallucinations,
sometimes seen in the early stages of delirium tremens (DTs) and other medically related
states.10
In Mr. William’s case, the interviewer asked him if he could point more closely to the
creature in question. Mr. Williams hesitantly obliged by cautiously moving his hand
towards the open space in front of his feet. Abruptly he halted, “I ain’t getting no closer!”
It became even more apparent that the hallucination was vivid and quite realistic. At
times, these types of hallucinations can create a peculiar sensation in the interviewer,
because the actions of the patient, like the movements of a mime, create the feeling that
one ought to be seeing something.
Sometimes the terms “hallucination” and “illusion” are confused. Mr. Williams pres-
ents with a true hallucination, for with hallucinations the perceptual image arises from
an open space and is not triggered by an environmental stimulus. Whatever Mr. Williams
is seeing, he is seeing it in the open space in front of his feet, not triggered by any object
in the room itself. In contrast, with an illusion, the image is triggered by some actual
object or stimulus. For instance, one patient vividly described watching the face of a man
standing beside him on the bus. He saw the man’s face begin to twist in a grotesque
fashion and saw his eyeballs shatter and begin to bleed. This experience represents a
visual illusion and also emphasizes that such illusions may be as striking and terrifying
as true hallucinations.
Recognizing Psychotic Process Induced by Alcohol Withdrawal

We have seen that the appearance of vivid visual hallucinations ought to arouse suspicion
that an organic agent may be at work. Mr. Williams presents with one of the more typical
organic causes of psychosis that the initial interviewer must constantly keep in mind
– abuse and withdrawal from alcohol, street drugs, or medications. It is important to
realize that there exist two different manners in which drugs may precipitate a psychosis:
by acute intoxication or by withdrawal. First, let us look at the issue of withdrawal,
because Mr. Williams is suffering from a substance withdrawal delirium caused by an
abrupt discontinuation of his drinking. Such a delirium is traditionally called delirium
tremens – DTs.
It is beyond the scope of this book to provide a thorough review of drug abuse, and
the reader should study this topic elsewhere in detail. However, there are some basic facts
with which all assessment clinicians should be familiar, for psychoses triggered by sub-
stance abuse can be life threatening in nature, whether presenting in a clinical environ-
ment where they are encountered frequently (emergency department, inpatient unit,
community mental health center) or one where they are seen much less often, yet, nev-
ertheless, can present (college counseling center or private practitioner’s office). They are
also one of the most common causes of psychotic process. All initial interviewers need
to be familiar with their symptomatic presentation and physical signs.
With regard to withdrawal states, alcohol and sedative/hypnotic drugs are the most
likely to cause psychotic features. They are also the most likely to result in death if not
recognized and treated. Withdrawal from these drugs is significantly more dangerous
than withdrawal from drugs such as heroin or amphetamines. Some estimates of the
mortality rate of patients with definite DTs from alcohol, who have been hospitalized,
have been as high as 15%, although with good management this number should be
markedly lower.11
As people begin to withdraw from alcohol and sedative hypnotics, they generally
move from mild symptoms of withdrawal towards progressively more severe states such
as DTs. As withdrawal occurs, patients frequently experience sleep disturbances, nausea,
anxiety, over-alertness, tremulousness, and a peculiar intensification of their sensory
modalities. Delirium tremens, itself, often persists about 5 to 10 days, with 62% of epi-
sodes resolving in 5 days or less.12
Even if patients such as Mr. Williams deny recent alcohol abuse, they may willingly
admit to withdrawal symptoms if asked matter-of-factly and without the suggestion that
they have “a personal problem.” In this regard, questions such as the following may be
useful:
a. “Since you stopped drinking, have you been noticing any problems with your sleep,
because many people use alcohol to help with their sleep and without it, they have
problems falling asleep?”
b. “Have you been feeling edgy over the past couple of days, you know, just can’t seem
to relax?”
c. “Over the past couple of days, have you been feeling sick in your stomach?”
d. “Recently, have you found yourself to be more edgy, you know, being startled by
noises or upset by people moving or talking loudly near you?”
To develop DTs, the patient must have used alcohol heavily for a long period of time,
minimally imbibing 4 to 5 pints of wine, or 7 to 8 pints of beer, or 1 pint of “hard”
liquor every day for several months. It does not typically occur under the age of 30,
although it clearly can, and it usually requires consistent use of large amounts of alcohol
for several years,13 most often appearing after a decade or so of abuse. This chronic use
of alcohol sets up a complex set of compensatory physiologic changes in autonomic body
regulation. When the alcohol is abruptly stopped, these compensatory changes go
unchecked, resulting in such abnormalities as increased pulse, increased temperature,
normal or elevated blood pressure, rapid breathing, muscle twitching, and sweating. As
the syndrome becomes more serious, the patient may become so tremulous that walking
appears to be difficult.14
While interviewing the psychotic patient, the clinician should do a quick survey to
see if any of these physiologic signs of withdrawal are present. With Mr. Williams, he
was noted to appear sweaty. The clinician also knew that his pulse rate was elevated
at 100, with a mild increase in temperature. This emphasizes an important point. In
general, a patient presenting with an acute psychosis should have his or her vital signs taken
before the clinical interview, thus alerting the clinician that an acute organic process may be
at work.
Mr. Williams proceeded to become more agitated, claiming that some kind of bug
was crawling on him and that some “wires are running around on the floor. They’re
shocking the hell out of me, man!” It is not uncommon for people with DTs to halluci-
nate about small animals, and sometimes large objects such as trains or the proverbial
pink elephant. Tactile hallucinations or illusions such as mice or lice crawling on the
skin also occur, as seen with Mr. Williams.14
The clinician astutely cut this interview short, proceeding rapidly with a physical
examination and appropriate medical management, which raises another important
point. These patients need prompt medical attention. If one is not a physician, then one
must immediately arrange to have such a patient seen by one. An appointment for “later
in the day or tomorrow” is inadequate and potentially dangerous.
Before leaving the topic of DTs, a few more points are worth mentioning. Seizures
(“rum fits”) sometimes precede DTs, usually occurring during the first 2 days after the
cessation of drinking. More than one in three patients who have withdrawal seizures will
go on to develop DTs. DTs usually begin 24 to 72 hours after the cessation of drinking
but can appear much later, even as long as 7 or more days later.14 While performing an
initial assessment on a psychotic patient in the hospital, a few issues are worth
considering.
During their hospital stay, some patients may have a temporary alcohol or drug source,
such as a friend, who eventually stops bringing them drugs. In these cases, DTs may not
appear until much longer into the patient’s hospitalization. Keep in mind that even
patients with a higher income may purposely lie about alcohol consumption and may
consequently develop withdrawal problems only as the hospitalization proceeds. Curi-
ously, surgery may delay the appearance of DTs as well. All these facts considered, clinicians
should be alert to the possibility of drug withdrawal in any patient who develops a psychosis at
any time during a hospital stay, especially if the patient’s vital signs are abnormally elevated.
Recognizing Psychotic Process Induced by Street Drugs

Violently psychotic patients, frequently brought in by the police, serve as a bridge to the
next topic, patients who are acutely intoxicated by a psychosis-producing agent. The list
of offending agents is extensive and includes common agents such as methamphetamine,
lysergic acid diethylamide (LSD) and other hallucinogens, marijuana, cocaine, crack, and
phencyclidine (PCP). For a concise and practical discussion, the reader is referred to
specialized texts, such as Goldfrank’s classic article on PCP and outstanding general
textbooks such as the recent work of Fischer and Harrison.15,16
By way of example, I will briefly describe some of the more typical aspects of a patient
intoxicated on PCP, a drug originally developed in the 1950s as an anesthetic-analgesic
agent. These patients frequently present as markedly psychotic, although they can present
without any psychotic features. In addition, they can be extremely violent. In this regard,
any violent patient should alert the clinician to the possibility of PCP abuse. Even at low
doses this drug can produce the “three As” of PCP use: analgesia, amnesia, and ataxia
(problems with gait). The analgesia can result in self-mutilatory behaviors such as eye
gouging. If use of PCP is even remotely suspected, the initial interviewer should have
safety officers informed and immediately available during the interview.
On a behavioral level, the psychotic features of these patients may be quite bizarre,
such as running naked in public or crawling around on all fours like an animal.
They may develop paranoia, disorientation, auditory hallucinations, and visual
hallucinations.
The physical examination may provide important clues, such as the various types of
nystagmus (abnormal eye jerks) and hypertension, reported as occurring in 57% of these
patients.17 These patients generally show miosis (smaller than normal pupils) but may
also present with mydriasis (larger than normal pupils), especially if they also ingested
an anticholinergic agent. Increased muscle tone and increased salivation are also common.
Rather than presenting as agitated, these patients may present lethargically or in a coma
if they have ingested high doses of the drug.
At the time of writing this chapter, a new, still-legal drug was hitting the streets. It can
create psychotic states similar to PCP, but is more common than PCP. It is known as
“bath salts” and, in actuality, is not a single agent but is often a concoction of chemicals
that are sought for their psychedelic effect. Unfortunately, wildly psychotic states can
result – ranging from public nudity to extreme violence. One rare, but particularly bizarre,
behavior associated with bath salts has been cannibalism, as seen in a young man under
the influence of bath salts, who was found naked, eating the flesh off of a homeless man’s
face on a street in Miami. Another newer class of drugs that can also trigger psychotic
states has been the synthetic cannabinoids, referred to by various street names including
“spice.”
One cannot leave the topic of street-drug induced psychosis without addressing meth-
amphetamine in more detail. The rise of illicit meth labs has been striking – so com-
monplace, in fact, that it has been the subject of a popular television series; Breaking Bad
is based on the exploits of a former high school teacher turned master of meth produc-
tion. Chronic use of methamphetamine can create a psychotic state that appears remark-
ably like paranoid schizophrenia or a mixed bipolar disorder such as a dysphoric mania
with psychosis. The two most common psychiatric symptoms with meth use are persecu-
tory delusions and auditory hallucinations.18 Even when patients stop the use of the drug,
psychotic symptoms can persist.19,20 Other persistent symptoms, despite continued absti-
nence, can include cognitive impairment, social instability, and an increase in lifetime
suicide attempts.21 For the initial interviewer, any patient presenting in an agitated state
(often accompanied by severe problems sleeping), anger, paranoia, and auditory hallu-
cinations should be considered as a potential methamphetamine user with appropriate
drug screens ordered, even when street drug use is adamantly denied.
Returning in a more general sense to psychosis as precipitated by drugs, a few more
points are worth noting. The rapid appearance of a full-blown psychosis in a matter of
hours should make the clinician very suspicious of a drug-induced psychosis, as might
be seen with LSD, PCP, or bath salts. Processes such as schizophrenia tend to develop
more slowly over days, weeks, or months. Some patients may not know that they have
been given a drug; it may have been slipped to them or sprinkled on a joint. In this
regard, it is always worthwhile checking with friends who may know more about the
actual circumstances surrounding the drug ingestion. One should always be on the
lookout for two possibilities when faced with drug-intoxicated, psychotic patients:
1. Is the patient actually under the influence of more than one street drug?
2. Is it possibly a medication rather than a street drug that is precipitating the psychosis
in this patient?
Recognizing Medication-Induced Psychosis

I am reminded of a young woman with a chronic history of paranoid schizophrenia. She
had been doing very well in the hospital and was consequently sent home on a pass.
Within a few hours of returning from her pass, she began to appear agitated and reported
feeling apprehensive. In another 30 minutes she became grossly psychotic and reported
that small dragons were chasing her. Indeed, she was seen racing down the hall as if
pursued by a bevy of such monsters. The physical examination revealed dilated and
poorly responsive pupils, a dry mouth, and an elevated pulse. It was discovered that she
had taken “a few extra” Cogentin (benztropine mesylate) tablets while at her apartment.
Cogentin is a prescribed anticholinergic agent that helps to alleviate some of the side
effects of antipsychotic medications such as a Parkinsonian syndrome.
If taken in excess, these anticholinergic agents can quickly precipitate a delirium, as
was the case with this patient. Elderly patients appear to be particularly susceptible to
such anticholinergic deliria. It is therefore important to inquire about both prescription
and non-prescription medications. Keep in mind that specific medications may have a
mild anticholinergic effect, but when given together these medications may have an
additive effect strong enough to precipitate a delirium, especially in the elderly.
Classes of medications that may have anticholinergic properties include some over-
the-counter hypnotics and “cold medicines,” certain antidepressants, some antipsychot-
ics, certain antiparkinsonian medications, some medications for peptic ulcer disease, and
even antihistamines.22 The clinician must always carefully elicit a medication history from
both the patient and the patient’s family.
At the time of the writing of this third edition, the class of medications known as the
semisynthetic opioids, such as oxycodone and OxyContin (its time-released prepara-
tion), as well as hydrocodone (Vicodin, Hycodan and, in combination with acetamino-
phen, Percocet) have achieved an epidemic prevalence in the United States. They have
also led to a striking increase in the subsequent use of heroin and a sharp rise in heroin
overdoses and deaths. OxyContin (because of the particularly high concentration of
oxycodone in each tablet for it is a time-released medication) has become a major drug
of abuse. Some of the common street names for oxycodone are: ox, oxy, kicker, cotton,
hillbilly heroin, 40 and 80. I mention them here for a specific reason. In general, these
substances are not highly associated with the production of acute psychotic symptoms,23
but because of this recent upsurge in their use, clinicians should keep them in mind as
etiologic agents when patients are presenting with psychotic features and substance use
is suspected.
These medications at high doses have been reported to cause vivid and terrifying visual
hallucinations. If a patient presents with vivid visual hallucinations in a clinic or emer-
gency department setting, abuse of these agents should be considered. Also, be on the
lookout for these agents as the cause of psychotic process, including vivid visual hallu-
cinations, in any post-operative or pain patient. Sometimes with post-operative patients,
the hallucinations do not appear for days after the patient’s discharge from the hospital,
until after they have returned home, much to the shock of both the patient and his or
her family members. These psychotic presentations often have accompanying agitation
and intense anxiety.
In concluding our discussion of medication-induced psychosis, the clinician should

also keep in mind one other broad category of agents that could precipitate a medication-
induced psychosis, namely, herbs and other natural agents. A naturally occurring source
of anticholinergic agents is a family of plants known as the Solanaceae. Such an innocu-
ous sounding name actually houses a variety of not so innocuous plants, including Atropa
belladonna (commonly called deadly nightshade), jimsonweed, mandrake, and henbane.24
Historically, ointments and potions made from such agents may have resulted in the
psychotic states that, at least partially, functioned as the source of the wild phenomena
reported by the witches of the Middle Ages, such as flying through the night sky to a
Sabbat. In the present, it remains important to consider the ingestion of herbs and other
“natural foods” while evaluating an unexplained acute onset of psychosis.
Effectively Interviewing and Collaborating With Law Enforcement Officers

Thus far, the material gained from the actual interview with Mr. Williams has been the
focus of discussion. However, in addition, one of the most important interviews to
perform when a patient is brought to the emergency department by the police is with
the officers, and there is an art to this process. The first trick is training oneself to take
the time to perform this interview. Both the police and the clinician are frequently
harried, but nevertheless this interview can provide invaluable information.
In particular, one wants to establish the following: (1) What were the circumstances
in which the patient was found? (2) Is the patient a known alcohol or drug abuser? (3)
Do the officers know the patient’s family and has the family been contacted? (4) Did the
patient appear disoriented or demonstrate any signs of psychosis? (5) Has the patient
appeared drowsy or been unconscious? and (6) Has the patient been in a fight involving
a possible head blow?
Actively psychotic patients, especially paranoid patients, can be surprisingly violent,
especially if they perceive, from a paranoid perspective, that they are fighting for their
lives. I believe it is important initially to inquire as to whether an officer may have been
injured while bringing the patient under control. This inquiry is both medically impor-
tant and builds sound collaborative relationships among law enforcement officers and
emergency department staff.
As with any type of professional, a particular police officer may be talented or not so
talented in their work. In this regard, officers vary on their understanding and effective
handling of psychiatric patients. Since the last edition of this book, law enforcement
agencies, coupled with concerned patients, family members, and mental health profes-
sionals, have developed several outstanding programs for training law enforcement offi-
cers to be particularly effective and compassionate with patients coping with mental
illness. I believe all initial interviewers should be aware of such efforts and tap them, if
possible, in building healthy collaborative relationships with police departments, whether
the interviewer works in an emergency department, on a crisis team, or at a college
counseling center. Two such innovative programs are the Crisis Intervention Team
Memphis Model – CIT – (http://cit.memphis.edu/) and the Connecticut Alliance to
Benefit Law Enforcement – CABLE – (www.cableweb.org).
Considering the difficulties of subduing a person experiencing an agitated psychotic

process, it is expedient to discover how the patient was subdued, including whether or
not a Taser was used. The clinician should also determine whether an officer delivered a
head blow, either justly or unjustly. Uncovering a history of a physical confrontation can
help alert the clinician to the possibility of a subdural hematoma or an intracranial bleed
as the source of the psychosis, especially in older patients who have been struck. It may
also help the clinician understand and perhaps decrease the patient’s fear that more
violence may follow.
A sensitive interviewer approaches these topics in a manner that places the officers at
ease. It is important to remember that most officers resort to violence only when abso-
lutely necessary. Angry countertransference feelings directed towards the police can only
get in the way of gaining valid information from them. The following type of approach
may be useful:
Clin.: It really looks like you had your hands full tonight.
Police: You can say that again, this guy’s really out of it. It took three of us to get him
down.
Clin.: Yeah, he’s wound up, maybe he’s on something. Listen, did any of your officers get
hurt? We’d be glad to take a look at them and check them over.
Police: No, don’t worry about it, thanks anyway.
Clin.: By the way, did you need to Taser him to calm him or wrestle him down?
Police: Didn’t need to Taser him, but like I said, it took three of us to wrestle him down. I
think he was hallucinating and must have felt we were after him or something.
Clin.: When you were wrestling him down, did he accidentally get struck on the head?
Police: No, can’t say that he did.
Clin.: The reason I ask is that if he got a blow on the head we need to make sure he
didn’t get a small fracture or something like that?
Police: Hmmm … Well, you might want to take a look, this guy was really wild; someone
might have used a baton on him or he could have smacked his head on the
ground. I’m not sure. It all happened really fast. He was out of control.
Clin.: Okay, thanks a lot for all your help. We’ll take a look at him. I hope the rest of your
night goes better than this. Sounds like you guys did a great job. Thanks for
bringing him in.
This matter-of-fact type of exchange tends to yield accurate answers while unobtrusively
reminding the officers of the dangers of a head blow.
Differential Diagnosis on Mr. Williams and Summary of Key Interviewing Tips

The interview with the police revealed that Mr. Williams had a long history of alcohol
use (severe), although he did not appear intoxicated at that point in time. They also
thought that he had a history of “stuffing his face with any drug he could get his hands
on.” Further interviewing with Mr. Williams revealed that he had a history of DTs. The
physical examination and lab work revealed no other probable cause for the psychotic
presentation. He was felt to be in the early stages of DTs and was begun on Valium
(diazepam). In a matter of several hours he calmed down, and all psychotic symptoms
vanished. His case would be summarized as follows:

Substance withdrawal delirium (alcohol)
Alcohol use disorder (severe)
Rule out unknown substance use disorder
Deferred
Medical Disorders:
Rule out a variety of alcohol-related diseases such as hepatitis, gastritis, and pancreatitis
As we leave the discussion of Mr. Williams, several key points are worth summarizing.
1. Visual hallucinations, especially if they appear to be particularly vivid and real to the
patient, are frequently seen in psychoses caused by physiologic insults to the brain,
including street drugs, medications, and medical disease.
2. Despite the fact that such physiologic psychoses may tend to have some features that
distinguish them from entities such as schizophrenia, all psychoses can present in a
similar fashion. Consequently, any patient presenting for the first time with psychotic
features should be promptly medically evaluated.
3. One of the most frequent physiologic causes of psychotic symptoms is the use of
street drugs or alcohol.
4. Withdrawal from alcohol in heavy drinkers may lead to an alcohol withdrawal
delirium (commonly called DTs). DTs can be fatal if not treated promptly.
5. The onset of a marked psychosis in a matter of hours in a previously normal indi-
vidual is strongly suggestive of a drug-related etiology.
6. Both over-the-counter and prescription medications may cause psychotic states, espe-
cially in the elderly. Anticholinergic medications are notorious for precipitating
deliria.
7. Although not a common presentation, be on the lookout for psychotic process, espe-
cially visual hallucinations, triggered by the use and/or abuse of medications contain-
ing oxycodone or hydrocodone.
8. If police bring in the patient, the officers should be questioned thoroughly, for they
may have pivotal information regarding differential diagnosis.
9. Any patient who presents violently should be thoroughly evaluated for evidence of
psychotic process and the possible use of drugs such as PCP or newer “legal” drugs
such as bath salts, synthetic cannabis, and other designer drugs.
Clinical Presentation #2: Mr. Walker

Mr. Walker is a 20-year-old male. He is thin and his hospital gown tends to hang
forlornly on his gaunt frame. Beneath his black hair a rather handsome face sits
quietly darkening with a day’s worth of beard. He has been admitted to an inpatient
unit after having been referred by a college counseling center, who had seen the
student shortly after his return from Christmas break. One of the unit’s social workers
is performing an initial intake. As the interviewer enters the room, Mr. Walker acknowl-
edges him with a slight nod of his head. His speech is soft and mildly slowed. He
appears almost shy. As he speaks, there is barely a hint of facial expression, his voice
painted gray by a conspicuous lack of highlights. All seems bland. Mr. Walker proceeds
to describe a chaotic situation at home. He is being avidly pursued by three filthy
women who enter his house at night. They attempt to force sex on him. When asked
if he knows who these women are, he nods, stating that one is “that devil Miss
Brown.” He proceeds to describe a recent party he attended, where sex games were
played. He relates that he had been tricked into going. As he entered the kitchen
three men tied him to a chair and stripped him. When asked what happened, he
pauses and proceeds to say, “They violated my anus.” As he says these words a slight
smile steals across his face. It had been verified that no such rape had occurred. His
speech is without any evidence of derailment (loosening of associations), tangential
thought, thought blocking, or illogical thought. He is alert and well oriented. Both
he and his family deny that he has used any street drugs. His family says he has
been acting oddly for almost a year, making vague accusations about a Miss Brown
even during the summer. During the interview the clinician feels uncomfortable and
somewhat frightened.
Discussion of Mr. Walker

Spotting Disturbances of Affect as Seen in Schizophrenia
One of the first things to note about Mr. Walker is the peculiar blandness that he dem-
onstrates when describing brutal scenes of sexual abuse. This blandness represents an
important diagnostic clue, because Mr. Walker is suffering from schizophrenia.
Affect refers to a patient’s manner of expressing emotion and spontaneity through
facial expressions. Criterion A-5 from the DSM-5 includes “diminished emotional expres-
sion,” a concept that is traditionally described as a reduction in affect. Diminished affect
is viewed as one of the negative symptoms of schizophrenia, a cluster of symptoms we
will explore in detail shortly. Abnormalities in affect can be seen in other psychotic states,
but it is particularly common in schizophrenia. At present, let’s turn our attention to the
changes in affect typical of schizophrenia.
A useful interviewing habit consists of asking oneself if the patient seems to be appro-
priately disturbed while describing traumatic incidents. In the case of Mr. Walker, as he
related his rape, there was little display of fear, anxiety, or anger. His affect changed very
little. When present in a mild degree, this type of affect is usually called “restricted.” If
present to a moderate degree, this type of unresponsive affect is usually called “blunted.”
If the patient demonstrates essentially no change in affect, it is usually referred to as a
“flat” affect. Mr. Walker also nicely demonstrates the concept of an inappropriate affect.
Rape victims do not generally smile as they describe their assaults. This peculiar combi-
nation of flattened affect and inappropriate affect is not infrequent in schizophrenia. It
is one of the qualities that can create an unsettling emotional response in a clinician, as
it did in this case.
An important point to remember concerning reduced affects is the ironic and some-
times confusing fact that some antipsychotic medications frequently also cause a blunt-
ing of affect as a side effect. The wary clinician must keep this point in mind, because a
patient inappropriately labeled as having schizophrenia by a previous clinician may
present with a blunted or flat affect related to current medication. This blunted affect
may be misinterpreted by the new clinician as further “proof” that the patient has schizo-
phrenia, resulting in a perpetuation of the first diagnostic error.
Diagnostic Significance of the Presence of Delusions: Delineating Schizophrenia From

Delusional Disorders
Perhaps even more striking than Mr. Walker’s blunted affect is the fact that he is clearly
delusional. The appearance of delusions of any kind should alert the clinician to the
possibility of schizophrenia. A delusion is a false belief that is firmly held by a patient
but is not believed by others in the patient’s general culture. When firmly entrenched,
a patient will persist in his or her delusional belief despite incontrovertible evidence
that it is false. Over the course of time, patients may vary on the intensity of their belief,
a process I like to call having greater or lesser distance (insight) from their delusional
belief. When a patient has gained considerable distance from a delusion, the patient
will be able to see that the belief may very well be untrue. If this perspective is main-
tained, one can say that the patient is no longer delusional but is now experiencing an
overvalued idea.
The delusions of schizophrenia are frequently bizarre in the sense that they are
patently absurd and have no possible factual basis. The patient may feel that alien or
demonic forces are controlling his or her body or that thoughts are being inserted or
withdrawn from his or her body. Other delusions tend to be concerned with magical,
grandiose, or intensely hyper-religious themes. For example, a patient may believe that
God wants the patient to cut off a finger and sprinkle the blood over the earth in order
to bring flowers into bloom. When schizophrenia is highlighted by paranoia, the patient
may present with delusions of persecution or jealousy, as did Mr. Walker. Such delusions,
although clearly not true, may not be bizarre in nature.
But this point raises an important diagnostic issue, for how does one separate schizo-
phrenia from a different DSM-5 diagnosis called a delusional disorder? The distinction
is actually somewhat easier to make than one might assume if one keeps the following
guidance in mind.
In schizophrenia the delusions are only part of the pathologic process. Other aspects
of psychotic process are present in addition to the delusion itself. Specifically, in schizo-
phrenia, if delusions are present, the patient’s delusions are accompanied by one of the
following: some type of hallucinatory process, evidence of disorganized thought, grossly
disorganized or catatonic behavior, or the presence of “negative symptoms” such as the
affective flattening seen with Mr. Walker. Problems with the formation of thought may
manifest as incoherence or as a marked loosening of associations (referred to as “derail-
ment” in the DSM-5). In addition, patients with true schizophrenia will invariably dem-
onstrate a significant decrease in social and/or occupational functioning over time.
In contrast, patients with delusional disorders tend to demonstrate only delusions,
although they can show infrequent hallucinations. If present, these infrequent hallucina-
tions are always tied directly into the patient’s delusional system (as with a patient with
a paranoid delusion about his neighbor complaining of occasionally hearing his neigh-
bor yelling, “I’ll get you someday, watch your back, watch your back,” or a patient
deluded that he is infested with parasites may have tactile hallucinations within his
abdomen). Also in contrast to schizophrenia, patients with delusional disorders tend to
show surprisingly good baseline functioning at home and at work, as well as demonstrat-
ing a reasonably normal and appropriately reactive affect. We will look at the phenom-
enology of delusions and delusional disorders in more detail later in this chapter.
Keep in mind that not all patients with schizophrenia have delusions.
Negative (Deficit) Symptoms of Schizophrenia

An important advance in the DSM-IV system that was continued in the DSM-5 was the
addition of the term “negative symptoms” and a recognition of their importance in the
amount of pain they cause patients. Historically, in the DSM-III, much emphasis was
placed upon those symptoms that people with schizophrenia show that most people do
not experience, such as hallucinations and delusions. These “extra” phenomena are now
called “positive symptoms,” indicating that they are an unwanted “excess.”
We are now aware that schizophrenia also afflicts brain structures in such a way that
the person loses certain normal functions. These lost functions are referred to as “negative
symptoms” or “deficit symptoms,” the latter being the term that I prefer. Such symptoms
include decreased affect, as described above, alogia (decreased speech production and
interest in speaking), avolition (decreased drive and ability to sustain interest), anhedo-
nia (loss of interest in pleasurable activities), and asociality (reduced interpersonal inter-
actions).25 Some clinicians also view anergia (loss of energy) as a deficit symptom.
Empirically, Rado summarized the research findings on the impact of the “deficit
syndrome,” a term referring to patients afflicted with a predominance of negative symp-
toms.26 During the first episode of schizophrenia, negative symptoms appear in patients
somewhere between 50 and 90% of the time. The deficit syndrome is associated with
more severe cognitive disorganization, as well as poorer insight into the illness. Patients
with significant amounts of these deficit symptoms tend to have poorer psychosocial,
vocational, and recreational functioning. They also tend to experience higher levels of
anxiety and a lower appraisal of competence, as well as a decrease in interpersonal skills.
As we shall see later in this chapter, these deficit symptoms are frequently devastating to
both functioning and self-esteem and are in some instances more disabling than positive
psychotic symptoms such as hallucinations and delusions.
The Importance of Family Members in Uncovering Psychotic Process

Mr. Walker’s presentation becomes even more clearly typical of schizophrenia following
an interview with his mother.
Clin.: What does your son do down in his room all day long?
Moth.: That is what is so peculiar. He talks with her.
Moth.: He talks with this devil woman. I’ll hear voices that sound like a woman’s voice
coming up out of the basement. It is really weird. Late at night I can hear him
arguing with her, swearing at her, and sometimes it sounds like holy hell is
breaking out down there. I’m terrified; I never go down there.
Clin.: When he is with you, does it ever look like he is hearing voices?
Moth.: Oh yes, he’s always mumbling to himself like he’s answering someone.
But the strange thing is that he’s not always like this. Sometimes he seems
so calm and almost normal and other times he’s in a frenzy. Just last night he
came screaming up out of that basement with a butcher knife in his hand.
He kept screaming at me that I’d better make them stop. I couldn’t take it
anymore so I brought him in.
From the above, it is apparent that Mr. Walker is hearing voices and clearly fulfills the
criteria for schizophrenia. It also serves to stress the importance of carefully interviewing
family members or other significant others. For whatever reasons, psychotic patients may
withhold information critical to the diagnosis, and the family often gratefully provides
the missing pieces.
Mr. Walker also illustrates the fluctuating nature of psychotic process. Even in schizo-
phrenia, as we shall see later in the chapter, the severity of the psychotic process may
vary substantially. Many an interviewer has been lulled into a belief that a patient is not
psychotic during the interview. In such cases it is always wise to listen carefully to the
family, because the interviewer may simply be catching the patient during a period of
decreased psychotic process. Moreover, patients with psychotic process may not be too
eager to tell the “shrink” that they are plagued by voices. Their more rational side warns
them that such talk may provide a quick ticket into the hospital.
Differential Diagnosis Between Schizophrenia and Mood Disorders With

Psychotic Features
Let us turn our attention to one of the exclusion criteria for schizophrenia as delineated
by the DSM-5. Criterion D directly addresses the issue of affective symptoms. Several
points are worth remembering here that can help us to differentiate between schizophre-
nia and mood (affective) disorders with psychotic features. In the preceding chapter we
noted that a major depression or a bipolar disorder may eventually manifest with psy-
chotic symptoms; thus these diagnoses are important to rule out when psychosis is
suspected. The particular psychotic symptoms may be either mood-congruent or mood-
incongruent. It is important to note that in a major depressive disorder with psychotic features
or a bipolar disorder with psychotic features, the psychotic symptoms generally appear a consider-
able time period after the onset of the mood disorder. It is almost as if the depressive or manic
process builds to a crescendo that culminates with the blooming of psychotic process. In contrast,
with schizophrenia, the psychotic process is usually an earlier part of the process, predating the
most severe mood symptoms.
Diagnostic mistakes can be made in either direction (mislabeling someone with

schizophrenia as having a psychotic mood disorder and vice versa). Factors in such mis-
diagnoses can range from sloppy interviewing and/or a misunderstanding of the phe-
nomenology of these disorders to the fact that some people present with confusing
admixtures of psychotic and mood symptoms. In this regard, Guze reports that most
people suffering from schizophrenia experience affective syndromes at some time during
the course of their illness.27 Moreover, anhedonia is frequently seen in schizophrenia,
where it presents as one of the negative symptoms.28 Such patients may be mistakenly
diagnosed as having a mood disorder. In contrast, some patients are mislabeled as having
schizophrenia when, in actuality, they have a bipolar disorder or major depression. This
error is not a benign one, for such patients might benefit from lithium or antidepressants.
American psychiatrists have tended to over-diagnose schizophrenia, while under-
diagnosing bipolar disorder.29
Two points are worth emphasizing here that can help us with our differential diag-
nosis. First, family members and the records of other mental health professionals can be
invaluable in gaining a clear history of which came first, the psychotic symptoms or the
mood symptoms. Second, it is always important when evaluating a patient who has had
numerous psychotic breaks to return to the first break in an attempt to determine the role of
depressive or manic symptoms in the chronology of the illness.
The role of the timing of mood versus psychotic symptoms is particularly important
in the differential between bipolar disorder (manic phase) and schizophrenia, for an
agitated mania can look exactly like the psychotic presentation of a patient suffering with
schizophrenia. Keep in mind that a patient can be manic without being psychotic. The
mania itself is manifested by excessive energy, unstable mood, agitation, decreased need
for sleep, pressured speech, and other classic manic symptoms. The mania does not
become psychotic unless reality contact is disturbed, as manifested by the presence of
delusions, hallucinations, or other psychotic symptoms such as grossly disorganized
thought. It has been estimated that about 50 to 70% of manic patients display psychotic
symptoms.30
As with depression, psychotic symptoms in mania tend to appear significantly later
than the mood symptoms. This point once again helps to ease the difficulty of distin-
guishing between schizophrenia and mania with psychotic process. However, to make
use of this difference, the interviewer must make a concerted effort to learn about the
very first episode of the patient’s illness.
Interestingly, there is mounting evidence that the clear-cut distinctions between
schizophrenia and psychotic bipolar disorders, delineated above, may be somewhat
misleading.
Let me explain more clearly what I mean. We have already seen in Chapter 9 that even
within the broad category of mood disorders, diagnoses sometimes seem to overlap. For
instance, within mood disorders, especially with late adolescents and young adults who
present with angst ridden depressions (sometimes including psychotic features), the
diagnosis of an agitated major depression is sometimes wrong. In reality, some of these
patients are suffering from a type of mixed bipolar disorder called a dysphoric mania.
In short, there may be more of a continuum within broad diagnostic categories, such as
the mood disorders, than was formally thought. Specifically, the mood disorders of
depressive disorder and bipolar disorder may be more related than has been traditionally
recognized.
Extending this idea, then, is it possible that there may exist continua not just within
a single broad diagnostic category like mood disorders but also between broad diagnostic
categories themselves, for instance, between mood disorders and schizophrenia?
The answer appears to be evolving towards “yes.” The clear-cut distinctions described
above that can distinguish schizophrenia from psychotic mood disorders may prove to
be most true for patients at each end of what, for want of a better term, we will call the
schizo–bipolar continuum. In short, there may be many patients who have a relatively
pure form of schizophrenia (psychotic symptoms appear early, followed by marginal
mood disturbances relatively late in the process) and there may be patients with a rela-
tively pure form of bipolar disorder (manic symptoms appear quite early, followed by
psychotic symptoms relatively late in the disorder). But a significant cohort of patients
seems to lie in-between these two diagnoses.
Schizoaffective Disorder and the Schizo–Bipolar Continuum

It is now apparent that we have stumbled upon a curious diagnostic dilemma. We have
seen that in schizophrenia the psychotic symptoms usually predate marked mood symp-
toms. And in the mood disorders the psychotic symptoms generally appear later in the
process, after the mood symptoms have been around for a while. But what diagnosis is
appropriate when the psychotic symptoms appear at or near the same time as the affec-
tive symptoms? Indeed, even in patients with a relatively classic presentation of schizo-
phrenia, one can find that during the prodrome of the illness, there may be many months
of low-grade mood disruption, especially of a dysthymic nature.
The diagnosis that helps to fill this gap is “schizoaffective disorder,” and it is defined
in the DSM-5 as follows31:
DSM-5 DIAGNOSTIC CRITERIA FOR SCHIZOAFFECTIVE DISORDER

A. An interrupted period of illness during which there is a major mood episode (major depressive or
manic) concurrent with Criterion A of schizophrenia.
Note: The major depressive episode must include Criterion A1: Depressed mood.
B. Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode (depressive
or manic) during the lifetime duration of the illness.
C. Symptoms that meet criteria for a major mood episode are present for the majority of the total
duration of the active and residual portions of the illness.
D. The disturbance is not attributable to the effects of a substance (e.g., a drug of abuse, a medication)
or another medical condition.
Specify whether:
295.70 (F25.0) Bipolar type: This subtype applies if a manic episode is part of the presentation.
Major depressive episodes may also occur.
DSM-5 DIAGNOSTIC CRITERIA FOR SCHIZOAFFECTIVE

DISORDER—Cont’d
295.70 (F25.1) Depressive type: This subtype applies if only major depressive episodes are part of
the presentation.
Specify if:
With catatonia (refer to the criteria for catatonia associated with another mental disorder, pp.119–
120 for definition).
Coding note: Use additional code 293.89 (F06.1) catatonia associated with schizoaffective disorder
to indicate the presence of the comorbid catatonia.
Specify if:
The following course specifiers are only to be used after a 1-year duration of the disorder and if
they are not in contradiction to the diagnostic course criteria.
First episode, currently in acute episode: First manifestation of the disorder meeting the defining
First episode, currently in partial remission: Partial remission is a time period during which an
First episode, currently in full remission: Full remission is a period of time after a previous
episode during which no disorder-specific symptoms are present.
Multiple episode, currently in acute episode: Multiple episodes may be determined after a
minimum of two episodes (i.e., after a first episode, a remission and a minimum of one relapse).
the overall course.
Unspecified
Severity is rated by a quantitative assessment of the primary symptoms of psychosis, including
Rated Dimensions of Psychosis Symptom Severity in the chapter “Assessment Measures.”)
Note: Diagnosis of schizoaffective disorder can be made without using this severity specifier.
The vagueness of this definition certainly would be at home in the campaign speech of any
presidential candidate. But then at this stage of current diagnostic knowledge, this degree
of vagueness may be appropriate. The vagueness of the definition serves to remind us that
categorical diagnostic entities are not necessarily real-life entities, but rather represent
labels for the most commonly observed patterns of behaviors. In this regard, there has been
growing recognition that traditional diagnostic “entities” such as schizophrenia, schizoaf-
fective disorder, and psychotic bipolar disorder, may perhaps be better conceptualized as
being on a dimensional continuum rather than being a set of distinct disease entities.
Future versions of the DSM system may more accurately reflect this dimensional quality.
In the late 1970s, Tsuang pioneered the idea that the diagnosis of schizoaffective dis-
order represents a heterogeneous category with two probable subtypes, an affective
subtype and a schizophrenic subtype. According to this theory, schizoaffective disorder
is not likely to represent a genetically distinct category.32 It appears that Tsuang was ahead
of his time. More recent studies have indicated substantial genetic overlap between
schizophrenia and psychotic bipolar disorder.33,34
In addition to genetic evidence, there is increasing data from cognitive, neurobiologi-
cal, and epidemiological studies that there is significant overlap between schizophrenia
and psychotic bipolar disorder.35,36 Even in their prodromal states, there seems to be some
overlap – for example, the appearance of subtle cognitive changes in both disorders
during this phase.37 A nice summary of how the concept of schizophrenia has been evolv-
ing over the past two centuries, up to and including the DSM-5, has been provided by
Bruijnzeel and Tandon.38 The net result of this exploration of the overlapping character-
istics of schizophrenia, schizoaffective disorder, and bipolar disorder is the growing
interest in conceptualizing a “psychosis spectrum” between schizophrenia and bipolar
disorder, in which the schizoaffective states lie between the purer forms of the syndromes
located at opposing poles of the spectrum.39,40
At the present moment, the bottom line with the differential diagnosis of schizoaf-
fective disorder is that people with schizoaffective disorders have many of the striking
psychotic processes seen in schizophrenia but also have persistent and significant mood
disturbances. They seem to differ from people who have psychotic bipolar disorder or
an agitated, psychotic depression in that people with schizoaffective disorder have periods
when they are quite psychotic but their mood is fairly normal. This latter state is seldom
seen with people suffering from a pure mood disorder, whose psychotic process tends
to “rear its head” primarily during a marked disturbance in mood. People with schizoaf-
fective disorders seem to differ from those with classic schizophrenia in having prolonged
periods of time, both early and throughout the process, in which there are striking mood
symptoms, frequently without accompanying psychotic symptoms. In the DSM-5, the
diagnosis of schizoaffective disorder requires that the disturbance in mood continues for
the majority of the duration of the disorder (as seen in Criterion C, above). If psychotic
symptoms begin to appear without concurrent mood symptoms, then the diagnosis must
be changed to schizophrenia.
These recent insights into the nature of schizoaffective disorder (including the concept
of a schizo–bipolar spectrum) are not merely of academic interest – they have practical
implications for initial interviewers and their patients, for diagnoses play a significant
role in future treatment interventions. When an initial interviewer determines that a
patient meets the criteria for schizophrenia, future clinicians may be less likely to con-
sider the use of mood stabilizers such as lithium and Depakote.
In contrast, the diagnosis of schizoaffective disorder serves to remind clinicians that
the patient may have an affective component to the illness, suggesting the use of such
medications. If there is a bipolar quality to the schizoaffective disorder, it also alerts the
clinician to be cautious in adding an antidepressant, for fear of exacerbating or unleash-
ing an underlying manic process. The diagnosis may also have some prognostic impor-
tance, because some authors feel that schizoaffective disorders have a significantly better
prognosis than schizophrenia.41
Differential Diagnosis on Mr. Walker and Summary of Key Interviewing Tips

No history suggestive of a personality disorder or a medical problem was found
upon further interviewing with Mr. Walker. Apparently he had been displaying a
downhill course for almost a year, thus fulfilling the time criteria for schizophrenia.
His family reported that he had appeared intermittently depressed, but not strikingly
so. They were not entirely clear about the time course of the interplay between
depressive symptoms and the psychotic process, but they did not feel that Mr. Walker
had been consistently depressed. They did not see evidence of a marked depression
before the onset of his delusions, nor during the early months of the process. Once
within the hospital, lab tests and other medical examinations would need to be
ordered to rule out a general medical condition, such as chronic use of metham-
phetamine or hyperthyroidism, as the cause for his psychosis, but his history does
not particularly suggest such an entity. Consequently, the working diagnostic formula-
tion would probably look as follows:

Schizophrenia
Rule out schizoaffective disorder
None
Medical Disorders:
None
Before leaving the discussion of Mr. Walker, several key points are worth summarizing:
1. Aberrations in affect such as blunting, flattening, and inappropriate affect are fre-
quently seen in schizophrenia.
2. Some antipsychotic medications can cause a blunted or flat affect. Consequently,
when a patient is on an antipsychotic, it is difficult to determine whether the unusual
affect is secondary to the medication or a psychopathologic process.
3. In order for a patient presenting with delusions to fulfill the criteria for schizophrenia,
he or she must also demonstrate one of the following: hallucinations, disorganized
speech, grossly disorganized or catatonic behavior, or the negative symptoms of
schizophrenia (e.g., decreased affect, alogia, avolition, anhedonia, and asociality).
4. Psychotic process frequently fluctuates. The interviewer should keep in mind that the
patient may not be strikingly psychotic during the interview itself.
5. Collateral interviews with family members may provide invaluable diagnostic
information.
6. Recent evidence-based research is suggesting that there may be significant genetic,
cognitive, epidemiologic, and phenomenological overlap between schizophrenia and
psychotic bipolar disorder, suggesting a continuum between the two disorders.
7. If you are interviewing a patient who is clearly psychotic, before making the diagnosis
of schizophrenia, carefully look for a history of mood symptoms that may suggest a
schizoaffective disorder, a diagnosis that could have marked implications for psycho-
pharmacologic interventions.
8. Also take a detailed family history, for the presence of many blood relatives who have
experienced mood disorders may further hint that the patient lays somewhere on the
mood end of the schizo–bipolar spectrum.
People coping with schizophrenia may move into partial or full remissions, conditions
that may be indicated in the DSM-5 by adding specifiers such as “multiple episodes,
currently in full remission” or “first episode, currently in partial remission.” It is impor-
tant to remember that patients with schizophrenia need not be psychotic continuously.
The disorder itself can show fluctuations and may also be transformed with the use of
antipsychotic medications.
Clinical Presentation #3: Ms. Hastings

Ms. Hastings walks into her first session at a private outpatient clinic run by a group of
psychologists with a disgruntled look on her face. She is 57 years old and appears a bit
bedraggled. The first words out of her mouth are, “Can you help me with my husband?”
Her speech is fluent, without any evidence of derailment, illogical thought, or bizarre
ideation. In fact, she is somewhat eloquent but clearly upset. When asked to elaborate,
she responds with an indignant snort, “It’s the divorce game, that’s all!” She proceeds to
relate an elaborate tale of infidelity on the part of her husband. At the present time, she
says, he has hired a variety of men to harass her into a state of insanity. Her craziness
will provide grounds for his sought-after divorce. The men are using “conventional spy
tools,” and she is beginning to feel that her own mother may be in on the plot. Her story
is literally illustrated by a journal filled with drawings and time schedules she has com-
piled on the activities of her husband and “his goons next door.” She denies hallucina-
tions or a previous psychiatric history. She also denies most depressive symptoms except,
“I’m edgy of course, wouldn’t you be?”
Discussion of Ms. Hastings

Unlike Mr. Walker, Ms. Hastings does not present with a blunted or odd affect. On the
contrary, she seems convincingly quite normal. Her affect is appropriately upset for
someone believing that she is the object of foul play. She does not complain of any hal-
lucinations, and subsequent interviewing revealed that she has none. There is no evidence
of a formal thought disorder (i.e., problems with the formation of thoughts as seen with
derailment or severely illogical thought) or the other psychotic symptoms frequently seen
in schizophrenia. Furthermore, she has no evidence of any psychotic disorder before the
age of 50.
Types of Delusional Disorders

The only psychopathology that Ms. Hastings displays is a concrete delusional system. As
we noted earlier, such a delusional system alone cannot fulfill the criteria for
schizophrenia unless the delusion is accompanied by at least one other Criterion A

symptom (hallucinations, disorganized speech, grossly disorganized or catatonic behav-
iors, or negative symptoms). Instead, Ms. Hastings displays one of a curious collection
of disorders referred to as delusional disorders. We briefly addressed the distinction
between these disorders and schizophrenia when discussing Mr. Walker. It is now useful
to explore their phenomenology and their implications for the interviewer in an initial
interview. In the DSM-5, these disorders comprise seven types: persecutory type, jealous
type, erotomanic type, somatic type, grandiose type, mixed type, and unspecified type.
All seven of these disorders share the following criteria of a delusional disorder42:
DSM-5 DIAGNOSTIC CRITERIA FOR DELUSIONAL DISORDER

(297.1 (F22))
A. The presence of one (or more) delusions with a duration of 1 month or longer.
B. Criterion A for schizophrenia has never been met.
Note: Hallucinations, if present, are not prominent and are related to the delusional theme (e.g., the
sensation of being infested with insects associated with delusions of infestation).
C. Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired,
and behavior is not obviously bizarre or odd.
D. If manic or major depressive episodes have occurred, these have been brief relative to the duration
of the delusional periods.
E. The disturbance is not attributable to the physiological effects of a substance or another medical
condition and is not better explained by another mental disorder, such as body dysmorphic disorder
or obsessive–compulsive disorder.
Specify whether:
Erotomanic type: This subtype applies when the central theme of the delusion is that another
person is in love with the individual.
Grandiose type: This subtype applies when the central theme of the delusion is the conviction of
having some great (but unrecognized) talent or insight or having made some important discovery.
Jealous type: This subtype applies when the central theme of the individual’s delusion is that his or
her spouse or lover is unfaithful.
Persecutory type: This subtype applies when the central theme of the delusion involves the
individual’s belief that he or she is being conspired against, cheated, spied on, followed, poisoned
or drugged, maliciously maligned, harassed, or obstructed in the pursuit of long-term goals.
Somatic type: This subtype applies when the central theme of the delusion involves bodily functions
or sensations.
Mixed type: This subtype applies when no one delusional theme predominates.
Unspecified type: This subtype applies when the dominant delusional belief cannot be clearly
determined or is not described in the specific types (e.g., referential delusions without a prominent
persecutory or grandiose component).
Specify if:
With bizarre content: Delusions are deemed bizarre if they are clearly implausible, not
understandable, and not derived from ordinary life experiences (e.g., an individual’s belief that a
stranger has removed his or her internal organs and replaced them with someone else’s organs
without leaving any wounds or scars).
Continued
DSM-5 DIAGNOSTIC CRITERIA FOR DELUSIONAL DISORDER

(297.1 (F22))—Cont’d
Specify if:
The following course specifiers are only to be used after a 1-year duration of the disorder:
First episode, currently in acute episode: First manifestation of the disorder meeting the defining
First episode, currently in partial remission: Partial remission is a time period during which an
First episode, currently in full remission: Full remission is a period of time after a previous
episode during which no disorder-specific symptoms are present.
Multiple episodes, currently in acute episode.
the overall course.
Unspecified
Severity is rated by a quantitative assessment of the primary symptoms of psychosis, including
Rated Dimensions of Psychosis Symptom Severity in the chapter “Assessment Measures.”)
Note: Diagnosis of delusional disorder can be made without using this severity specifier.
Ms. Hastings demonstrates many of the classic findings that you will encounter when
interviewing a patient suffering from a typical delusional disorder. These patients fre-
quently appear surprisingly normal. One would hardly suspect any psychopathology,
until one uncovers the topics within the delusional system, at which point, these patients
often describe elaborate ramifications and subplots that would gratify the needs of any
soap opera buff. Their delusions are generally unshakeable. They simply do not believe
that there is anything wrong with them, as evidenced by the fact that Ms. Hastings did
not seek help for herself but for the problem she was having with her husband. In the
long run, the striking inability of these patients to see that their beliefs are delusional
can make these patients frustratingly resistant to therapy.
All of the following delusions can occur in other psychotic disorders, such as schizo-
phrenia and deliria, but when seen as the only sign of psychopathology, they are viewed as
the distinct diagnosis called delusional disorders in the DSM-5.
Arguably, the best-known type of delusional disorder is the persecutory (paranoid)
type. Paranoid delusions consist of beliefs that a person, organization, or a bizarre entity
(such as aliens or vampires) are trying to thwart the patient’s goals, harm the patient
psychologically, or physically harm or kill the patient and/or loved ones. The exact nature
of the aggressor may vary from patient to patient and tends to be consistent with the
patient’s cultural matrix. The common manifestations and characteristics of paranoid
delusions may change over time as cultures shift. Thus, in our wired age, it is reasonable
to anticipate that more and more patients will complain of being monitored by the
webcams in their computers or of being clandestinely tracked via their smart phones. (It
should be remembered that both of these processes can, in reality, be accomplished by
hackers.)
A different type of delusional disorder has been referred to as “the Othello syndrome,”
in which the patient becomes convinced that his or her spouse is having a sexual affair,
referred to as the jealous type in the DSM-5.43
In erotomanic delusional disorders, sometimes referred to as Clérambault’s syndrome,
the patient comes to believe that a person has fallen madly in love with him or her. The
patient may proceed to pursue the alleged lover across the country or into the bedroom.
Erotomanic delusions are potentially dangerous, for the patient may eventually grow
intensely angry with the perceived lover, because of the person’s repeated rejections. At
times, this anger manifests itself as, “if I can’t have this person, no one can.” The result
can be violent assaults or murder. The classic “Hollywood stalker” is usually a person
suffering from an erotomanic delusional disorder.
Because of their potential dangerousness, erotomanic delusions are particularly impor-
tant to spot in an initial assessment. To do so effectively, it is important to remember
that the delusion is not that the patient loves the targeted other. The delusion is that the
patient is firmly convinced that the other person is truly in love with the patient, no
matter how frequently or vociferously the targeted person denies any feelings towards
the patient. Consequently, psychotic denial doggedly creates a false and painful world
for the patient, reflected by the patient using rationalizations such as, “She is denying
that she loves me because she needs to maintain her marriage for her children,” or “He
is simply waiting for his wife to die from cancer so that he can marry me.” Such denials
and rationalizations can occur despite the targeted person angrily telling the patient to
leave them alone or filing protective restraining orders.
I have found that the following types of questions are useful for teasing out the pres-
ence of a true erotomanic delusion as opposed to neurotic preoccupation and wishful
thinking. The questions are asked in a sensitive fashion without any hint of an accusatory
tone of voice:
1. “What type of evidence do you have that this person loves you?”
2. “What leads you to think that he (or she) loves you, when he has asked you to never
contact him (or her) again?”
3. “How do you put it together that she loves you, if she has actually gone to court to
get a restraining order against you.”
4. “What do you think is stopping this person from openly admitting their love to you?”
When the answer to the last question is a spouse, partner, or love interest of the targeted
person, the interviewer must keep in mind that the delusional patient could be consider-
ing murdering the person who is in the way of “true love.” The patient may actually
believe that he or she is doing a favor for the targeted love object by releasing them from
an unwanted relationship, through murder, to be with their real love – the patient.
Another type of delusional disorder consists of an unshakeable belief that one has a
serious medical illness, the so-called hypochondriacal paranoia or somatic type of delu-
sional disorder. These patients differ from those suffering from simple hypochondriasis
by the fact that the belief has reached a truly delusional proportion and is essentially
unshakeable. These patients may also believe that a plot has evolved to hide the truth
from them.
People coping with the somatic type of delusional disorder are generally concerned
that there is something wrong with their bodily functions or sensations. For instance, they
may present with the belief that they are emitting a foul odor, infected with a parasite,
or perhaps that they are being infested by insects that are crawling on their skin at night.
They may also feel that a specific body part is deformed or malfunctioning. In the litera-
ture, this disorder is often referred to as a monosymptomatic hypochondriacal psychosis.
(Note that in the DSM-5, if a patient presents with a pathological preoccupation that
there is something grossly wrong with the appearance of a specific body part, whether
non-delusional or delusional, they will more likely meet the diagnosis of body dysmor-
phic disorder, which is a more common disorder than somatic delusional disorder. Body
dysmorphic disorder is viewed in the DSM-5 as sitting within the obsessive–compulsive
disorder spectrum.)
By way of example, one of our patients was convinced that “my muscles of mastica-
tion are disordered.” He had carefully produced a beautifully drawn anatomic atlas
illustrating the problems with his jaw. At the interview he just happened to bring along
a human skull, which he used to demonstrate in a disturbingly convincing fashion his
specific anatomic defects. Sometimes these patients proceed to develop schizophrenia.
The term “mixed subtype” applies when no single delusional theme predominates.
Ms. Hastings seems to fit this mixed subtype, for both jealous and persecutory themes
are strongly displayed. Unspecified type applies when the clinician cannot determine the
underlying delusional belief or is convinced that the patient’s belief is fairly unique and
does not fall into one of the previous categories.
Brief mention should also be made of the shared psychotic disorder. In this relatively
rare condition, sometimes poetically referred to as “folie à deux,” two patients share the
same delusion. One of the patients develops the delusion after the other patient has
evidenced it for some time, and, in this sense, the other patient is said to be induced
into a delusional system. Frequently one of the patients is a dominant and powerful
personality while the second patient tends to be dependent and suggestible. The second
patient’s delusion may even crumble if not in the presence of the dominant figure.44
Paranoid Delusions: Techniques for Uncovering Potential Dangerousness

Persecutory delusions can be seen in delusional disorders, but in everyday practice they
are much more commonly encountered as part of the psychotic process seen in disorders
such as schizophrenia, bipolar disorder, psychotic depression, and substance-induced
psychotic states. No matter where they appear, arguably the most important immediate
task for the clinician is to determine if the patient intends to harm or kill the supposed
persecutor as a means of proactive self-defense. With Ms. Hastings, it would be important
to determine whether she intends harm to either her “cheating” husband or his “goons
next door.”
Robinson has developed two effective questions that can be of immediate value in
addressing this potentially disengaging task in a sensitive fashion45:
1. “Do you feel a need to protect yourself against your husband?”

2. “Have you felt a need to possibly take action against your husband or harm him?”
In addition, Phil Resnick, a leading innovator in forensic psychiatry and risk assessment,
has described an interview strategy that can shed some light on the likelihood of a patient
pre-emptively attacking a supposed persecutor. I will borrow liberally from his writings
in order to more effectively describe his interviewing strategy, which he appropriately
calls, “confrontation with a paranoid persecutor.”46 It should be noted that paranoid
psychotic patients are often suspicious of clinicians, especially if they are fearful of the
consequences of openly sharing (involuntary commitment, police involvement). Thus,
as Resnick emphasizes, rapport should be carefully established before initiating this
approach.
As an example, we will use a patient who has described fears of being killed by the
mafia to an initial interviewer. 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 easily kill him 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. However, they have different thresh-
olds for killing in misperceived self-defense. Such information can help the clinician
decide as to whether hospitalization is indicated, as well as whether a potential victim
should be warned of danger from the patient.
Let us see Resnick’s strategy of “confrontation with a paranoid persecutor” illustrated
with a reconstructed interview directly from his work47:
Clin.: Tell me what’s troubling you?

Pt.: 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.
Clin.: How do you know that this is going on?
Pt.: 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.
Clin.: Do you have any other evidence?
Pt.: I can just tell by looking at her. She has also had less interest in having sex
with me.
Clin.: Have you taken any steps to try to resolve this?
Pt.: 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.
Clin.: 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 mail bag?
Pt.: 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.
Delusions in the Elderly and Paraphrenia

Diagnostically, if a patient presents with a delusional disorder, it is critical to rule out a
psychotic disorder due to another general medical condition. This is particularly true in
patients who first develop delusional symptoms over the age of 40. There exist numerous
medical illnesses that can present with delusions. Perhaps at the top of the list one should
consider a brain tumor, because these tumors tend to occur in later adult life. Indeed,
malignant gliomas tend to arise in middle age, while metastatic tumors from other parts
of the body are more common in the elderly.48 Other frequent general medical causes
include medications, endocrine disorders, infections, and complex partial seizures (tem-
poral lobe epilepsy).
Especially with the elderly, the interviewer should also consider dementia. Roughly
20% of patients with Alzheimer’s disease demonstrate paranoid symptoms at some
point. Paranoid delusions tend to occur later in the process with these patients, although
suspiciousness may occur early on.49
The issue of paranoid symptoms raises a pertinent diagnostic point. Some elderly
patients present with concrete paranoid delusions frequently accompanied by auditory
hallucinations and some other features common in schizophrenia, almost as if these
patients were presenting with a late-onset schizophrenia. This particular syndrome raises
some problems for the DSM-5, because these patients could technically fulfill the criteria
for schizophrenia, for it has no upper limit on age of onset. But it is unclear whether
these psychoses, when first appearing in the elderly, are genetically or phenomenologi-
cally the same as true schizophrenia.
In the DSM-5, if the hallucinations are not prominent, one could probably use the
diagnosis delusional disorder, persecutory type. With prominent hallucinations, the
diagnosis of unspecified schizophrenia spectrum and other psychotic disorder could
probably be used reluctantly, a syndrome that would have been called atypical psychosis
in the DSM-IV-TR. I say “reluctantly” because such presentations are neither uncommon,
atypical, nor unspecified, as these “grab-bag” diagnoses seem to suggest. One study
revealed that at least 10% of patients who were admitted with psychotic features over the
age of 60 presented as described above.
European psychiatry pioneered the study of these late-onset psychoses. In Europe, the
syndrome is frequently called paraphrenia.50,51 In the United States it is more often called
late-onset schizophrenia.52 However, both these terms are reserved for the first-time
appearance of psychosis in older patients, in instances where there is no mood disorder,
delirium, or dementia. Although some authors provide empirical evidence that the syn-
drome can appear commonly before the age of 50, and even below the age of 30,53 most
authors view paraphrenia as a disorder that manifests in the older patient. It can appear
as an early variant, with onset between 40–60 years of age (in which case it tends to
show many of the characteristics of a late-appearing schizophrenia) or as a late-appearing

disorder, first manifesting after the age of 60 (a syndrome which appears to have signifi-
cant differences in phenomenology from classic schizophrenia).
It is these differences in symptom presentation that warrant our attention as initial
interviewers. With the graying of our populations, many clinicians will be working with
the elderly, and late-onset psychosis will be ever more frequently encountered. I prefer
calling this late-appearing psychosis “paraphrenia,” for I am not convinced that it is
merely a late-appearing form of schizophrenia.
Paraphrenia typically presents in late life with well-organized paranoid delusions.
Grandiose, erotic, and somatic delusions can occur, but are much less frequent. Delusions
are often accompanied by auditory hallucinations, thus demarcating them from paranoid
delusional disorders (in which hallucinations are generally absent and, if present, are
infrequent in number). Interestingly, in paraphrenia it is not uncommon for the patient
to experience hallucinations in multiple sensory modalities including olfactory, tactile,
visual, and gustatory.54
Before these overt psychotic symptoms appear, the patient may show prodromal
symptoms for months or even years. These symptoms include suspiciousness, irritability,
seclusiveness, and odd behavior. Unlike patients with schizophrenia, however, these
patients, even when grossly psychotic, do not usually show problems with restricted,
blunted, or inappropriate affect; nor do they demonstrate a formal thought disorder.55
Unlike schizophrenia, these patients tend to show a good preservation of their personali-
ties, fewer negative symptoms, and are less likely to show progressive deterioration than
in classic schizophrenia. They also tend to respond reasonably well to antipsychotic
medications. Paraphrenia is 6- to 10-fold more common in females than males.56
An unusual associated finding is the fact that about 15 to 40% of these patients have
some degree of hearing loss. It has been suggested that a hearing loss may predispose
the patient to misinterpret the conversation of others in such a way as to create paranoid
ideation.
As compared to patients with delusional schizophrenia, where the persecutory delu-
sions not uncommonly have a peculiar or unlikely quality (e.g., being pursued by aliens
or watched by foreign spies), the persecutory delusions in paraphrenia tend to be more
mundane and believable (e.g., a neighbor is trying to break into the patient’s house or
the grocery man is plotting to get the patient’s social security checks).
One more peculiarity of paraphrenia is worth mentioning. A well-designed phenom-
enological study by Castle showed that over half of the patients with paraphrenia reported
an odd belief called a “partition delusion.”57 In a partition delusion, a person is concerned
that people, objects, gases, or some form of radiation is entering their homes, passing
through the objectively impermeable walls. Perhaps this intense fear of home invasion
is prompted by the fact that many of these patients live alone and are socially isolated.
In this regard, it should be kept in mind that delusions are often only shared with
interviewers if interviewers ask directly about them specifically, a trait perhaps even more
common in the elderly. Thus, partition delusions, because of their oddness, will often
go hidden unless asked about directly, as with the following question framed as a
normalization:
“Some of my patients tell me that they are afraid that something is being pushed into
their houses, right through the walls and windows, like a gas, a poison, or even radia-
tion. Do you have any worries like that?”
At times, the interviewer can deftly tie the question directly into a paranoid delusion that
the patient has been sharing, in this instance about a neighbor with which the patient
had formed a persecutory delusion:
“Do you feel that Mr. Roberts is trying to break into your house, or perhaps pass some-
thing dangerous into your house like a gas or a poison, or has figured out a way to
look through your walls?”
Differential Diagnosis on Ms. Hastings and Summary of Key Interviewing Tips

For a moment, let us review the diagnostic issues associated with Ms. Hastings. In this
particular interview, there was little time to explore for personality disorders, and the
clinician would need to defer regarding personality dysfunction. She complained of
peptic ulcer disease, chronic bronchitis, and the recent onset of a hacking cough associ-
ated with a long history of heavy smoking. With such a history of smoking, the issue of
lung cancer is certainly worth considering. Her diagnostic formulation would appear as
follows, if there proved to be no truth to her accusations concerning her husband’s infi-
delity and murderous intentions:
General Psychiatric Disorder:

Delusional disorder (mixed; both jealous and persecutory types present as central
themes)
Rule out psychotic disorder due to another medical condition
Personality Disorder:
Defer
Medical Disorders:
Peptic ulcer disease
Chronic bronchitis
Rule out lung carcinoma
Concerning medical disorders, as mentioned earlier, numerous entities should be ruled

out; however, for the sake of conciseness, it is probably more practical to only list those
diagnoses for which the initial interview has raised some specific suspicions, as with the
cigarette smoking history suggesting lung cancer in the case of Ms. Hastings.
Let us review the major issues that surfaced with the case of Ms. Hastings.
1. The diagnosis of a delusional disorder can be classified into seven subtypes: persecu-
tory, jealous, erotomanic, somatic, grandiose, mixed, and unspecified. (It should be
noted that, at this time, it is not yet clear whether these sub-categories will prove to
have any association with etiology or treatment response.)
2. Outside of the delusional content of their speech, people with delusional disorders
frequently appear and behave quite normally (other than inappropriately pursuing
and contacting the target of the delusional process).
3. If paranoid delusions are present, one must ascertain whether the patient may be
intending to harm or kill the supposed persecutor (specific interviewing techniques
and strategies, such as “confrontation with a paranoid persecutor,” can be intention-
ally utilized to address this critical task).
4. In any patient diagnosed as having a delusional disorder, one should rule out a
general medical cause (a brain tumor, etc.) of the delusional symptoms.
5. Paranoid symptoms are not uncommon with people suffering from primary degen-
erative diseases, such as a neurocognitive disorder due to Alzheimer’s disease
(Alzheimer’s dementia).
6. Paraphrenia, although not currently recognized as a separate DSM-5 diagnosis, may
well represent a specific syndrome in elderly patients. It is characterized by a delu-
sional system that is associated with hallucinations first arising in the elderly.
Clinical Presentation #4: Ms. Fay

Ms. Fay is a 23-year-old divorced woman who is being seen in the outpatient clinic at
a community mental health center for the second time in 2 weeks. She is casually
dressed in jeans and a yellow blouse that tends to overshadow her curly, dull blonde
hair. She has come alone to the clinic and relates, “I just had to talk to someone again.
I’m a nervous wreck.” Indeed, she appears decidedly nervous in that she wriggles uneas-
ily in her chair while incessantly picking at her nails. It seems difficult for her to main-
tain eye contact. She states to the male clinician, “You make me nervous. These are
hard questions.” She relates that things are terrible at home, where she lives with her
mother and her two children. She never gets a moment’s rest and reports significant
problems falling asleep, as well as a general inability to relax. Her speech is mildly
pressured and characterized by an evasive style, which clearly frustrates the interviewer.
She bluntly denies any delusions or hallucinations, but seems greatly concerned with
an incident of sexual abuse from her distant past, which she prefers not to discuss at
the moment. As the interviewer proceeds, she becomes intermittently more anxious and
coyly giggles at times, perhaps out of nervousness. One senses that if she could burrow
beneath her chair to escape scrutiny, she would most surely do so. At the time of her
first evaluation, she was diagnosed as having a relatively severe generalized anxiety
disorder.
Discussion of Ms. Fay

The Life Cycle of a Psychosis
As Ms. Fay had appeared at her previous clinic interview 2 weeks earlier, she currently
presents with an overwhelming sense of anxiety, succinctly stated by Ms. Fay as, “I’m a
nervous wreck.” She flatly denies any overt signs of psychosis such as delusions or hal-
lucinations. She does not demonstrate any marked evidence of a formal thought disorder
such as a gross loosening of associations (derailment). She does not appear overtly psy-
chotic; rather she seems consumed by her own anxiety.
It is this anxiety that warrants more careful exploration, because anxiety stands as one
of the most frequent early signs of a developing psychosis. To further our understanding,
it may be useful to review what could be called the “life cycle” of psychotic process.
There exist certain overt signs of psychotic process, one or more of which must be
present for a clinician to view a patient as experiencing psychotic process. These “hard
signs of psychosis” include the following: hallucinations, delusions, or evidence of a
formal thought disorder (e.g., a moderate to severe loosening of associations or other
problems in the formation of thought). In a strict diagnostic sense, unless at least one
of these signs are present one does not call the patient psychotic by DSM-5 standards.
In addition, in a clinical sense, the following symptoms represent hard signs of psychotic
process: gross disorganization, gross disorientation, and bizarre behavior.
The conservative approach used by the recent DSM systems for using the term “psy-
chosis” is, in my opinion, a wise one, because it eliminates the dangerous habit of loosely
labeling people as psychotic. Such sloppy clinical work can lead to problems, such as the
inappropriate use of the diagnosis “schizophrenia” when the diagnosis “schizotypal
personality” is more appropriate. In a similar vein, it is important to realize that the mere
presence of one of the above hard signs does not necessarily indicate that a patient is psychotic.
For instance, as we shall see later, auditory and visual hallucinations are occasionally
seen in people who are not psychotic and specific cultural nuances may determine
whether or not a particular behavior or experience is psychotic in a pathologic fashion.
It is equally important to realize that in a clinical sense (pathologically experiencing
the world in a strikingly different way than most people within his or her culture) as
opposed to a strict diagnostic sense (meets the criteria for psychosis in the DSM-5), a
patient can be psychotic without demonstrating these hard signs, especially in the earliest
phases of a psychosis or when a psychotic process is fluctuating over time. We can arrive
at a better understanding of this apparent paradox by examining how psychotic process
naturally unfolds.
Most patients do not abruptly develop the hard signs of psychosis in the course of a
day or two, as if the light switch of reason was suddenly snapped off. Instead, patients
with classic psychotic disorders (such as schizophrenia, schizoaffective disorder, bipolar
disorder, and major depressive disorder with psychotic features) generally move more
slowly into the world of psychotic process.
An excellent example of this concept can be provided by looking at one possible mode
of development of a single psychotic symptom such as a delusion. The phenomenologist
Lopez-Ibor has discussed this specific process in detail58 (Figure 11.1). In the following
discussion we will follow his model with some minor adjustments.
Delusional Mood
In the beginning of a psychotic break, the patient frequently develops what Lopez-Ibor
calls a “delusional mood.” During this phase, the patient begins to feel that something
is not quite right. There may be an intensification of perceptions such as sight and sound.
In a sense, the world is almost clearer than before, because the environment appears
LIFE CYCLE OF A DELUSION
delusional mood delusional perception concrete delusion
Possible indicators of psychotic process
A) Soft signs B) Hard signs
Alerts clinician to the possible Usually indicates active

presence of psychosis psychotic process
Can be caused by a variety

of non-psychotic processes
Hard and soft signs of psychosis

Softs signs Hard signs
Unusually intense affect Delusions
Angry or agitated affect Hallucinations
Glimpses of inappropriate affect Moderate or severe formal
Guardedness or suspiciousness thought disorder
Vagueness Gross disorientation
Evidence of a very mild formal Bizarre mannerisms and
thought disorder body language
Pre-occupation with an incident
from distant past
Expectation of familiarity from
interviewer
Inappropriate eye contact
Long latency before responding
or thought blocking
Figure 11.1 Life cycle of a psychotic process.
more vivid. New details never before recognized take on new significance; they may never
have even been noticed before. There frequently exists an unsettling feeling that some-
thing ominous may be about to happen, although at other times life may seem refresh-
ingly vibrant. The following excerpt captures this peculiar state of affairs as described by
a patient who had experienced delusional mood:
If I am to judge by my own experience, this “heightened state of reality” consists of a

considerable number of related sensations, the net result of which is that the outer world
makes a much more vivid and intense impression on me than usual. … The first thing I
note is the peculiar appearance of the lights. … They are not exactly brighter, but deeper,
more intense, perhaps a trifle more ruddy than usual. Certainly my sense of touch is
heightened. … My hearing appears to be more sensitive, and I am able to take in without
disturbance or distraction many different sound impressions at the same time.59
Delusional Perception
Eventually this process becomes more intense, developing a second phase, which is called
“delusional perception,” a term clarified by the phenomenologist Kurt Schneider. With
delusional perception, the perception itself may be normal in a sensory way, but the
patient’s interpretation of the perception is clearly distorted. The anxiety of the patient
begins to snowball as the patient becomes convinced that something is not right and
that danger is present. In this phase, not only is the environment noticed in a more intense
fashion, but also the details of the environment are felt to be directly related to the patient. The
world becomes at once both highly personalized and terrifying. Ideas of reference occur.
In a sense, patients feel that people are talking about them but do not yet know why.
Not knowing that I was ill, I made no attempt to understand what was happening, but
felt that there was some overwhelming significance in all this, produced either by God or
Satan. … The walk of a stranger on the street could be a “sign” to me which I must
interpret. Every face in the windows of a passing streetcar could be engraved on my mind,
all of them concentrating on me and trying to pass me some sort of message.60
At this point the patient may already be showing marked changes in daily functioning,
avoiding this person or that person, meticulously checking on people’s behaviors,
re-reading comments on Facebook to hunt for a hidden personalized meaning, staying
awake at night and ruminating endlessly. In a very real sense of the word, these patients
are already psychotic, because their perception of reality is markedly different than the
reality of those around them. No hard signs of psychosis in a diagnostic sense have
appeared yet, but they are just around the corner.
The Emergence of Concrete Delusional Ideation

In the third phase, the phase of “delusional ideas,” the slippery suspicions of the first
two phases are transformed into concrete beliefs. Patients suddenly “know” what people
are saying about them and why. The paranoid feelings become concrete delusions that
are both more elaborate and entrenched. Here, indeed, the classic hard signs of psychosis
flower. In a sense, as the phenomenologist Clérambault stated, the psychosis is already
old when the delusions have begun. It is almost as if the delusion evolves as an answer
to why the world has felt so ominous to the patient.
Soft Signs of Psychosis: How to Spot Hidden Psychotic Process

As mentioned earlier, psychotic process tends to fluctuate, and patients may move in and
out of these various phases. In the early phases of an initial psychotic episode, or in the
early phases of a psychosis emerging from a sound remission (as might happen when a
psychosis “breaks through” medications), a patient could be having delusions one day
but not the next, as they slip back and forth between non-delusional periods and periods
of delusional perception, delusional mood, or frank delusional ideation. For these
reasons, the initial interviewer needs to pay keen attention to any evidence that the
patient may be in one of the less obvious phases of psychosis. If such soft signs of covert
psychosis are present, then the interviewer more carefully explores for the harder signs.
These soft signs of psychosis are frequently overlooked by clinicians, as was the case with
Ms. Fay during her first visit to the evaluation center. Their phenomenology is worth
examining in more detail.
In the first place it is important to emphasize that the presence of the “soft signs of
psychosis” does not imply that the patient is necessarily psychotic. In fact, usually the
patient with soft signs is not psychotic. In most instances the soft signs are being caused by a
non-psychotic process such as anxiety, an immature interpersonal style, or somewhat idiosyncratic
interpersonal habits. Their importance lies in the fact that their presence alerts the clinician
that psychotic process may be present, and that the interviewer should thoroughly hunt
for it.
For instance, a mild and infrequent loosening of associations, one of the soft signs,
does not necessarily indicate that a patient is actively psychotic. People with schizotypal
personalities may routinely demonstrate this finding, in which case it represents an
ingrained personality style, not evidence of psychosis (see Figure 11.1). The vast majority
of people who present with intense anger are not psychotic (many factors could be at
play, ranging from being appropriately angry to characterologically angry or intoxicated),
but the presence of intense anger in an initial interview, whether it occurs in an outpatient
clinic or an emergency room, should alert the clinician to carefully search for psychotic
process.
There exist a variety of soft signs that suggest a given interviewee may be experiencing
psychotic processs, and that the interviewer should actively look for it, including the
following: (1) mild or infrequent evidence of a formal thought disorder, such as a mild
loosening of associations, infrequent bits of illogical thought, idiosyncratic speech, or
mild to moderate tangential speech; (2) unusually intense affect; (3) angry or agitated
affect; (4) infrequent glimpses of inappropriate affect; (5) guardedness or suspiciousness;
(6) vagueness; (7) preoccupation with an incident from the distant past; (8) immediate
discussion of personal details as if the interviewer already knew the patient well; (9) long
latency before answering questions; (10) poor eye contact in a patient who does not
appear depressed; and (11) inappropriate staring. The list could certainly be made longer,
but the above signs serve as a good introduction.
Note that both verbal and nonverbal clues may suggest underlying psychotic process
(see Figure 11.1). Interviewers must understand the cultural norms for nonverbal behav-
iors, such as eye contact, to make sure that the clinician is not misinterpreting a normal
nonverbal behavior as a soft sign of potential psychotic process – yet another potentially
damaging aspect of the kulturbrille effect.
When a clinician spots some of the soft signs of psychosis, he or she may want to
expand the region of psychotic questioning in more detail, delicately probing for the
hard signs of psychosis, such as evidence of delusions and hallucinations. The belief that
psychotic patients will always spontaneously reveal their hallucinations and delusions
is patently false. Frequently, one must ask for specific symptoms before they are
proffered.
Helping Patients to Share Delusional Material

Tapping Intense Affect
If a patient appears unusually affectively charged or anxious about a particular topic, it
is often rewarding to gently guide the patient into a further discussion of this topic by
showing interest and asking clarifying questions. With this technique one structures the
conversation very little. Instead, an attempt is made to unleash further affect, because as
the patient becomes more and more emotionally involved, defenses may decrease, allow-
ing more dramatic evidence of psychotic process to emerge. Eventually, as the patient
senses a friendly ear, delusional material may be shared. It is not infrequent for interview-
ers to simply run-over these areas of intense affect, thus robbing themselves of a natural
gate into the patient’s psychotic world.
Tapping Odd Language, Illogical Thought, and Idiosyncratic Phrasing
Similarly, when a patient uses an illogical or idiosyncratic phrase, it is often wise to ask
for further elaboration. It is paramount that this request for clarification sounds non-
judgmental and carries a tone of true interest. As the patient proceeds to explain the ideas
behind the reasoning, it is not infrequent for further and more substantial evidence of
psychotic process to emerge. The psychotic patient essentially guides the interviewer into
regions of questioning more likely to unearth substantial evidence of psychosis.
Indirect Techniques for Exploring Delusional Material
Robinson, both in his illuminating book and in his subsequent writing,61,62 has delin-
eated a basic strategy for helping patients to more accurately and comfortably share their
delusional material. The keynote of Robinson’s approach is to demonstrate a gentle,
genuine, and respectful curiosity about the patient’s beliefs. I don’t believe I can explain
it any better than Robinson, so we will let him speak for himself:
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 they occupy the
majority of their thoughts. Your approach is three-fold: (1) grease the wheels so that the
patient feels comfortable sharing information with you, (2) uncover the extent and logic
of the delusional material; and (3) determine the degree to which the delusion has become
entrenched in the patient’s thoughts (i.e., determine how much insight is preserved or how
much distance the patient has from the delusion).
Examples
1. “I’m interested in what you just said, please tell me more.” (greasing the wheels)
2. “How did this all start?” (greasing the wheels)
3. “What has happened so far?” (uncovering the extent and logic)
4. “Why would someone want to do this to you?” (uncovering the extent and logic)
5. “How do you know that this is the situation?” (determining distance)
6. “How do you account for what has taken place?” (determining distance)
Illustrative Dialogue
Clin.: Do you have thoughts that you focus on a lot of the time and feel strongly about?
(looking for overvalued ideas or delusions)
Pt.: I don’t understand what you mean.
Clin.: I’m asking about ideas that you have that perhaps those around you don’t 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.
Pt.: 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 couldn’t understand why, so I’ve
spent a lot of time looking for a non-prescription treatment.
Clin.: That’s interesting. How did this start? (greasing the wheels)
Pt.: 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 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.
Clin.: What happened after that? (uncovering the extent and logic)
Pt.: 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 haven’t been well since
that very moment.
Clin.: How do you know that this is the cause of your physical problems? (determining
distance)
Pt.: Internet research. But before I continue, I need to ask you something?
Clin.: What’s that?
Pt.: Do you believe me?
How to Respond When a Delusional Patient Asks, “Do You Believe Me?”
There is no single or “right” way to respond to such a question from a delusional patient.
But, it is important to feel comfortable with various flexible ways of handling it, for it is
not an uncommon question. The fashion in which the clinician responds can have criti-
cal ramifications for engagement, whether the question is asked in a clinic office, inpa-
tient unit, or emergency department. Wherever it arises, it is important to appear
comfortable when providing an answer. Robinson has some practical and effective
approaches for handling this potentially awkward situation and once again, I believe it
is best to simply let him speak for himself63:
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 even reflect 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 how much more material
the patient will be willing to share. Clinicians do not want to be deceptive, yet we need
to develop enough of an alliance with patients to hear more about their thoughts.
In such situations, you should continue to actively empathize with the patient to preserve
rapport and facilitate the sharing of more information. In addition, tactfully avoid being
the arbiter of reality and telling patients whether or not you agree with them (or whether
or not you think they are right). Examples include statements such as:
1. I’m keeping an open mind.

2. I can’t decide without more information.
3. My job is to understand what your views are.
4. 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.)
There is seldom a situation in which a clinician would openly agree with a patient’s delu-
sional thoughts (e.g., saying something like, “Of course I believe you.”). Such false endorse-
ments 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 endorse-
ment with, “You’ll call the police for me then?”
As with all principles there are exceptions in which the clinician may need to temporarily
endorse a delusion, but these are very rare. Such a situation could arise when the clinician
feels that the patient might become violent towards him or her if there is not immediate
agreement with what the patient is saying.
In my own practice, I have found the fourth technique described by Robinson to be one
of my favorites (“The story is an unusual one, so I really want to hear more before making
a decision, tell me about …”). It conveys a respectful interest, yet communicates an open
yet non-affirming stance. It often allows the clinician to quickly return to a sensitive
uncovering of the extent and logic of the patient’s delusion. Let’s see a variation of it at
work:
Pt.: Do you believe me?

Clin.: Well, the story is undoubtedly an unusual one, so I really want to make sure I
understand better what is going on before making a decision. Help me to
understand exactly what problems the parasites are now causing in your body?
(note the tie-in with a personally affectively charged topic for the patient, inviting
spontaneous elaboration, which simultaneously moves the patient away from an
insistence upon knowing whether or not the clinician believes the story at that
exact moment)
Pt.: Oh, they are all over the place (patient continues animatedly). They have entered
my brain so I can’t always think straight or concentrate, and I feel this very subtle
moving in my head. I think it might be the parasites moving around.
Clin.: That sounds very disturbing. (actively empathizing)
Pt.: Oh yeah, oh yeah. It is. They have also moved into my feet, and I have a
strange burning sensation in the bottoms of my feet, especially when I am
walking.
Clin.: What have you been doing to help yourself with the physical problems?
(uncovering the extent and logic of the delusion)
This clinician has adeptly responded to the patient’s inquiry and has effectively continued
to explore the extent of actions the patient has taken regarding his delusion of infesta-
tion. Looking for the extent of action a patient takes on delusional material provides
invaluable information regarding the patient’s “distance” from the delusion (i.e., how
much the patient believes or does not believe that the delusion is absolutely true). In
some types of delusions it also provides critical information related to dangerousness to
self or others. For instance, patients with delusions of infestation have been known to
mutilate themselves by attempting to dig out the parasites, information that the clini-
cian’s last question is attempting to uncover.
Hallucinations and Other “Hard Signs of Psychosis” in the Normal Population

As mentioned earlier, the presence of hallucinations, and the other hard signs of psycho-
sis, does not necessarily indicate that a person is psychotic. Some hallucinations are seen
in people who are not psychotic. Mistaking such a hallucination as a marker of psychosis
can lead to serious misdiagnoses such as schizophrenia or major depression with psy-
chosis. Consequently, it is worth spending time exploring this area of potential misin-
terpretation carefully.
Auditory and Visual Hallucinations in the Normal Population

In the past decade, a variety of studies have helped us to better understand both the
prevalence and phenomenology of non-psychotic auditory hallucinations.64–75 Such
research has provided evidence that “non-clinical individuals” report a lifetime preva-
lence rate of auditory hallucinations ranging 1–2% to 15–18% of the population,76
although others have estimated the prevalence to be as high as 40% in people without
psychiatric disorders.77 The most common types of hallucinations that are not caused by
a psychiatric disorder are hypnogogic hallucinations (experienced as one is falling asleep)
and hypnopompic hallucinations (experienced as one is awakening).
Times of extreme stress and/or prolonged sleep deprivation can also trigger halluci-
natory phenomena in otherwise normal individuals. This process is illustrated by the
rather common appearance of both visual and auditory hallucinations in people who
have lost a spouse. One study involving 300 widowed men and women found that
nearly half had experienced hallucinations of their lost partner with visual hallucina-
tions slightly outnumbering auditory hallucinations.78 Older surviving spouses (ages 40
and over) were more likely to experience hallucinations, with some experiencing hal-
lucinations of their spouse over the course of a decade or more without any evidence
of psychosis.
With an older patient, keep in mind the rather curious, yet not uncommon, Charles
Bonnet syndrome, in which central or ocular visual impairment (as can be seen with
cataracts) produces visual hallucinations.79 This syndrome is considered as being akin to
the “phantom limb” phenomenon but occurring in the visual system. It has been esti-
mated that 60% of elderly patients with a severe visual loss may experience one or more
visual hallucinations. Note that the hallucinations in the Charles Bonnet syndrome are
only visual in nature. They are usually both vivid and complex, often creating surprisingly
convincing images of people or small animals. By way of illustration, a case was reported
in which the patient began spreading birdseed in his room at a long-term care facility in
order to feed the “birds” who were strutting about his room on a daily basis. This syn-
drome can be easily misdiagnosed as psychotic in nature, sometimes mistaken for an
early delirium or part of a dementia in the elderly. If the eye defect can be corrected (as
with cataract surgery) the hallucinations vanish.
Cultural Competence: Its Importance in Distinguishing True Psychotic Symptoms From

Culturally Accepted Behaviors
Not only are hallucinations sometimes experienced in non-psychotic individuals, they
are sometimes enjoyed and even sought. Historical figures of great stature, including
Socrates, Descartes, and Julius Caesar, admitted to auditory hallucinations, as well as
mystics such as Swedenborg and artists such as William Blake. In addition, auditory hal-
lucinations have played an important role in specific spiritual disciplines in the past,
such as the Greek oracles and the chief priests and sadhus of Egypt and India, both with
and without the use of psychedelics or other psychoactive drugs.80 For centuries, shamans
have valued the hallucinations, whether drug-induced or not, that are experienced in
their pathworking trance states, as they still do today. None of these experiences represent
pathologic psychotic states.
Other “hard signs” of psychosis may not be indicative of psychosis in all situations.
Some beliefs such as in witchcraft, ghosts, and extrasensory perceptions are quite accept-
able in various cultures and should not be viewed as delusions per se. Indeed, the con-
cepts of ghosts, channeling, and spells are common in American culture, with shelves
devoted to their exegesis in New Age bookstores and a web teeming with countless New
Age websites. Obviously these bookstore owners, webmasters, and their consumers are
not delusional. Even processes such as a loosening of associations may be seen in cultur-
ally normal phenomena such as channeling and speaking in tongues.
Nor is the presence of disturbing hallucinations necessarily evidence of psychosis,
although their disturbing nature greatly increases the likelihood that the hallucinations
are psychotic in origin. Once again, a cultural familiarity is important.
For instance, in Taiwan, a woman who is coping with the naturally complex emotions
arising following an abortion may experience the persistent crying of a child. From a
Taiwanese religious and cultural perspective, this crying is felt to represent the child’s
dismay that its reincarnation has been prevented. This crying, although an example of a
hallucination and one that is disquieting, should not to be misconstrued as evidence of
psychosis. Without an understanding of this cultural and religious phenomenon, the
patient could easily be mislabeled as experiencing a brief psychotic break or a schizo-
phreniform disorder.81
The Interface Between Cultural Phenomena and the Life Cycle of a Psychosis
We have come to a situation that we encountered earlier, in Chapter 6, but we are now
better prepared to understand it. If you will recall we ended that chapter describing a
young woman with schizophrenia whose mother was a Pentecostal minister. The patient
was suffering from delusions of demon possession, accompanied by intense paranoia
and auditory hallucinations, that would prove to be symptoms of an emerging schizo-
phrenia. Here was an instance in which both the client’s culture, and her mother, clearly
believed in possession and exorcism (non-delusional beliefs in that culture), yet both
the mother and the clinician were able to discern that this particular belief, in this par-
ticular patient, represented a psychotic state. Similarly, in reference to our Taiwanese
example above, a woman 2 months post-abortion could be, by mere chance, simultane-
ously developing schizophrenia or might be developing a major depression with psy-
chotic features triggered by the emotional trauma of the abortion. With such patients,
how does one tell whether hallucinations or beliefs are simply cultural reflections or
represent part of a pathologic process – psychosis?
With our understanding of the life cycle of a psychosis, we can now address this clini-
cal dilemma with a new sophistication and with a clearer-cut interviewing strategy. When
considering whether a hallucination or belief is psychotic in nature, as opposed to a
non-pathologic culturally accepted phenomenon, try to determine whether the halluci-
nation or belief is embedded within a psychotic cluster of phenomena, as might be seen
with delusional mood or delusional perception. This psychotic matrix, although some-
times subtle, will tend to show itself not only while the patient is experiencing his or her
hallucinations but also is likely to have been present before the hallucinations began
and remains after the hallucinations have stopped.
More specifically, psychotic processes seen in disorders such as schizophrenia and
bipolar disorder don’t tend to materialize out of nowhere, nor do they then abruptly
shut-off with the person immediately experiencing the world as totally normal. There is
generally both a prodrome and a residuum that will be highlighted by some of the soft
signs of psychosis. Another tip-off that one is seeing truly psychotic symptoms is that
careful interviewing may uncover the presence of other hard signs of psychosis, not
viewed as normal in that patient’s culture.
Another phenomenon that may alert the astute clinician to the presence of true psy-
chotic process (concerning an otherwise culturally acceptable belief) consists of the
subtle twisting of the culturally held belief into a more vicious and denigrating psychotic
variation. Scott describes a potential illustration of such a psychotic distortion. Among
Bantu peoples, it is culturally acceptable to hear voices that provide instructions to carry
out Bantu customs designed to allay guilt feelings that are shared by the entire tribe. With
psychotic process, these voices may shift into a more accusatory tone in which the hearer
of the voices is singled out as being worthy of guilt. Similarly, with the Bantu, the normal
auditory hallucinations are often of a known person (e.g., a relative), whereas psychotic
voices may emanate from unknown sources.82
You will recall in Chapter 6 that it was the patient’s mother, a Pentecostal minister,
who recognized that her daughter’s experiences were not the typical experiences of
members of her congregation, neither during possession nor following exorcism. Her
daughter’s hallucinations and delusional beliefs were part of an ongoing matrix of delu-
sional mood and delusional perception of an insidious and destructive pattern.
Indeed, two other processes that tend to be seen with genuine psychotic processes, as
opposed to culturally accepted normal experiences, are (1) the intensely disturbing
quality of the phenomena, and (2) their tendency to disrupt normal functioning in an
ongoing fashion. Nevertheless, the presence of hallucinations that seem pleasant at times
does not rule out genuine psychotic disorders. Patients coping with schizophrenia occa-
sionally experience pleasurable voices, and may even miss them when alleviated by
antipsychotic medications.
Returning to our Taiwanese example, most women experiencing post-abortion depres-
sion and hallucinations of “their child” crying are not psychotic. But a specific patient
experiencing this phenomenon who also relates weeks of feeling odd, describes persistent
concerns that somebody or something is observing her, and also relates that she has been
preoccupied with suspicious knocking sounds coming from her heater may actually be
psychotic. In this case, the culturally accepted crying appears to be imbedded in an
ongoing psychotic matrix. Indeed, the crying itself is probably being transformed by the
psychotic process into a new psychotic symptom, for the crying of the infant is now being
experienced with an intensity, meaning, and disruption that non-psychotic, post-abortion
Taiwanese women do not experience. Given time, new hallucinations of voices berating
her and delusions of demons may very well appear, providing conclusive evidence that
she is experiencing psychotic process, not just a culturally accepted hallucination.
Back to Ms. Fay: An Illustration of How to Tap a Piece of Illogical Thought for Underlying
Delusional Material
At this point we can return to Ms. Fay. A re-constructed excerpt of her interview proves
to be particularly germane. In it we shall see some of the soft signs of psychosis; in par-
ticular, the interviewer will follow up on an isolated piece of illogical thought.
Clin.: Tell me a little bit more about what your anxiety has been like.
Pt.: (giggles inappropriately) That’s very hard to say … I get uptight and I just don’t
know what to do with myself. I suppose it all has to do with self-image and all that
stuff.
Clin.: How do you mean? (greasing the wheels for psychotic process)
Pt.: Sometimes when I’m alone I just get really frightened and … I don’t know … well,
I … I don’t know if I’m coming or going. I guess I’m just too anxious to be a
woman. I don’t know what else to say. What else do you want me to talk about?
Clin.: When you say that you are too anxious to be a woman, what exactly are you
referring to? (tapping an odd use of language)
Pt.: I get panicky, you know all goose flesh all over. I never know exactly when it is
going to happen but it always does.
Clin.: But how does that tie in with your being a woman? (looking for illogical thought)
Pt.: It just does. Women have to do certain things and I’m unclear what exactly they are.
It was all so much simpler years ago when my mother was growing up. But today
what with short skirts and rock videos, it’s all more confusing and there is a lot
more responsibility out there, so I’m just too anxious to be a woman and I’m also
too anxious to be a man, so there you have it!
The phrase “I’m just too anxious to be a woman,” is a curious one. The patient did not
appear cognizant of this fact and made no spontaneous attempt to explain herself. At
this point the clinician wisely asked for further clarification. Her subsequent explanation
was also vague, although one can surmise to what she was probably alluding. Her sub-
sequent reply was also somewhat illogical, giving even further suspicion that a psychotic
process is at hand.
Differential Diagnosis on Ms. Fay and Summary of Key Interviewing Tips

As the interview progressed she appeared to become more anxious, but she never dis-
played or related any hard signs of psychosis. Of course, during the interview she did
display a variety of soft signs, including vagueness, guardedness, a few inappropriate
giggles, some small bits of illogical thought, and the hint of a preoccupation with a
distant past sexual event with her brother.
She described a variety of sustained symptoms of generalized anxiety, while denying
any regularly occurring panic attacks. She also described periods of fleeting paranoia and
magical thinking, but said she had always had such feelings “cause I grew up in a bad
family.” She denied any persistent symptoms of depression or mania. But she did
describe episodes of angry outbursts and periods of being very moody. She was evasive
when questioned about previous suicide gestures.
Ms. Fay represents an excellent example of a person who leaves the interviewer with
the feeling that psychotic process is lurking beneath the clinical facade but cannot be
clearly identified. Because of the presence of a large number of soft psychotic symptoms,
the clinician would tend to arrange for both rapid and close follow-up care.
At the end of this interview her diagnostic conceptualization was as follows:

Generalized anxiety disorder (provisional)
Rule out unspecified schizophrenia spectrum and other psychotic disorders
Rule out schizotypal personality
Rule out borderline personality disorder
Medical Disorders:
None known
The diagnosis of unspecified schizophrenia spectrum and other psychotic disorders

(atypical psychosis) was entertained because there were no strong indicators of a mood
disorder and no clear-cut signs of schizophrenia or paranoid disorder, but the clinician
was suspicious of some underlying psychotic process.
This suspicion proved to be well founded, because several weeks later Ms. Fay was
admitted to the hospital with several striking paranoid delusions concerning her brother
accompanied by many of the symptoms of mania. Apparently, the clinician had caught
her at a time when, clinically speaking, she was actively psychotic (for she was already
experiencing the world strikingly differently than others in her culture), but had not yet
developed the hard signs of psychosis in a diagnostic sense. He had, in essence, seen her
“before the storm erupted,” during the phase of delusional mood or delusional percep-
tion. Or she may have actually already had delusional ideas that she was not yet ready
to share. Figure 11.2 summarizes the inter-relationships between the stages of the life
cycle of a psychosis and the appearance of soft and hard signs of psychotic process. It
also re-emphasizes the point that psychotic phenomena tend to fluctuate.
Later interviews with Ms. Fay and with her family revealed a history of intermittent
affective instability with both manic and depressed features. Her psychotic symptoms
appeared early on in the process. It was unclear which appeared first, the affective symp-
toms or the psychotic symptoms. Consequently, her Axis I diagnosis was changed to:
schizoaffective disorder, rule out bipolar disorder. Further observation and history would
eventually determine whether she was experiencing a true bipolar disorder or not.
Fortunately, Ms. Fay eventually stabilized upon a combined treatment of lithium and
Haldol (haloperidol). Even during periods of stability, she continued to appear very
manipulative and quite dramatic. She also continued to have significant problems with
anger and impulsive control. Her parents related these symptoms were life-long in nature,
lending further support to the idea that Ms. Fay might also have some characterologic
problems, such as histrionic or borderline traits or even a borderline personality disorder.
Further interviewing of her personality traits, historically, would be necessary to deter-
mine the presence of personality psychopathology, as we shall see in Chapter 14 on
personality dysfunction.
Ms. Fay serves as an intriguing example of the subtle signs of psychotic process and
the need for the initial interviewer to constantly seek out the soft signs of psychosis. At
times, such dedicated diligence, associated with prompt subsequent treatment, may help
prevent the patient from suffering the full-blown wrath of a psychotic illness.
Before leaving her presentation, it is worth summarizing some of the major points it
highlights.
1. A person may be psychotic in a clinical sense, without demonstrating the hard signs
of psychosis in a diagnostic sense (such as delusions or hallucinations).
2. The so-called soft signs of psychosis should always alert the clinician to the possibil-
ity of a smoldering psychotic process.
3. In the life cycle of a psychosis, hard signs of psychosis generally do not erupt without
a prodromal phase of psychosis in which the patient’s experience of reality is clearly
abnormal but only the soft signs of psychosis are apparent.
Figure 11.2 Evolution of a psychosis.
4. Because psychotic process fluctuates, sometimes even multiple times during a single
day, listen carefully to collaborative sources such as family members, friends, and
inpatient staff, for they may be seeing psychotic process that is absent during your
interview.
5. Generally, it is best to tap areas of intense affect because such areas may be outward
manifestations of delusional material.
6. If the patient uses an odd phrase, shows illogical thought, or utilizes an idiosyncratic
phrase, it is often useful to tap these areas by asking for clarification. In the process
of clarifying, the patient may reveal further evidence of psychotic process.
7. When exploring delusional material: (1) grease the wheels so that the patient feels
comfortable sharing information with you, (2) uncover the extent and logic of the
delusional material, and (3) determine the degree to which the delusion has become
entrenched in the patient’s thoughts.
8. Always consider whether an isolated, seemingly psychotic symptom may be viewed
as normal in the patient’s culture; if so, it may not represent a true marker of psy-
chotic process.
9. Remember that an isolated, culturally acceptable hallucination or belief will not be
embedded in an ongoing matrix of psychotic process and should not be accompa-
nied by the soft signs of psychosis as might be seen in delusional mood or delusional
perception.
10. A patient may have a severe psychotic illness, such as schizophrenia, and also have
a personality disorder.
We can now leave the outpatient clinic at a community mental health center and return
to an emergency room where Mr. Lawrence was brought in by the police and a crisis
clinician. Mr. Lawrence was apparently suffering from an acute exacerbation of his
chronic paranoid schizophrenia.
Clinical Presentation #5: Mr. Lawrence

Mr. Lawrence is a good-looking man about 30 years of age. Despite his good looks he is
not particularly attractive at the moment, because he is in the midst of a rage. He was
found in his apartment smashing a typewriter through the bedroom window. He had
trashed the apartment, madly throwing white paint over his furniture. The landlord
found him screaming. Mr. Lawrence has a long-standing history of schizophrenia with
paranoid delusions. He has been violent at times in the past. Tonight he refuses hospi-
talization, and the crisis worker has to involuntarily commit him, because he apparently
seems to be in the midst of yet another acute psychotic relapse. It took two policemen
to bring Mr. Lawrence into the emergency room, and on the way in he managed to cre-
atively coin a few new obscenities.
Discussion of Mr. Lawrence

At first Mr. Lawrence presented in an agitated and violent manner. At one point he threat-
ened to beat one of the nurses, and subsequently tried to do so, eventually requiring
restraints. It’s possible that somehow the nurse had been incorporated into a delusion,
although the patient denied the typical delusions he had demonstrated in the past.
I was “on-call” and was called to see if I would give permission to have Mr. Lawrence
admitted to the inpatient unit to seclusion (secondary to his violence in the emergency
department). I always prefer seeing any psychotic patient myself before proceeding with
admission and told the ED staff that I was on my way.
By the time I had arrived on the scene I was surprised to find that Mr. Lawrence was
lying calmly on a cart and appeared quite cooperative, but I attributed his calmness to
the sedating effects of the haldol he had been given. He denied any hard signs of psy-
chosis and also denied any recent suicidal gestures, although he commented that he
had been thinking of killing himself several days earlier. Eventually we were able to
remove the restraints, at which point Mr. Lawrence took a peculiar turn in his clinical
course.
He related that he needed to go to the bathroom. As he walked towards the toilet he
appeared to stagger a bit. Once he reached his destination, he looked about, as if he had
been suddenly teleported into an unfamiliar space, and asked, “What am I doing in
here?” When told that he had wanted to go to the bathroom, he appeared puzzled and
denied ever making such a request.
As the interview proceeded Mr. Lawrence began to appear drowsy, which he attributed
to being up all night and drinking heavily. He could only repeat three or four digits
forwards, whereas he had been able to repeat seven forwards earlier. He also began grasp-
ing at some invisible objects near his feet.
If you think that Mr. Lawrence is beginning to sound similar to our first patient, Mr.
Williams, who presented with DTs, it is because Mr. Lawrence is also suffering from a
delirium (sometimes referred to as an acute confusional state in the literature). It was a
delirium that would eventually threaten his life.
The interview was promptly stopped at this point. I relayed my concerns to the emer-
gency room physician that I was suspicious that Mr. Lawrence had overdosed, despite his
denial both to the crisis clinician, earlier, and to myself. An electrocardiogram (ECG)
revealed some subtle abnormalities. Roughly 30 minutes later Mr. Lawrence stopped
breathing. Fortunately, his life was saved through the effective use of an artificial respira-
tor. Imagine, for a moment, what his fate might have been if he had been admitted to a
seclusion room as initially requested by phone.
A Deadly Trap: Missing Deliria in Patients With Illnesses Such as Schizophrenia

In retrospect, the correct diagnosis was a tricyclic overdose leading to a paradoxic rage
response. This rage was followed by a delirium. Mr. Lawrence’s case provides a spring-
board into a discussion of several important points. In the first place, it is important to
note that it was assumed initially, by the crisis clinician and the emergency room staff,
that Mr. Lawrence was merely experiencing an exacerbation of his schizophrenia, because
he had frequently presented with paranoia and violence in the past. This is one of the
more dangerous clinical traps when dealing with a patient who has been labeled with a
chronic psychotic process. It is both easy, and natural, to assume that the old etiologic
agent is at work without vigorously searching for a new one.
A useful point to remember is that psychotic processes caused by a single etiology,

such as schizophrenia, frequently present in a relatively similar fashion during each
episode for a given individual. The soft signs, or early warning signs, are often similar
from episode to episode, as are the subsequent hard signs. The psychotic process tends
to present with an identifying fingerprint of sorts for each patient.
Consequently, in any patient for whom a new episode of psychosis appears distinctly
different to previous episodes, the clinician should become suspicious that something
new has been added to the picture etiologically. In the case of Mr. Lawrence, he usually
presented with delusions and hallucinations. In this episode, neither symptom was
present. This is an arena in which a patient’s previous electronic health record (EHR) can
be remarkably useful, providing a history of the patient’s past episodes.
The second major point has been stated earlier but certainly warrants repeating. Any
patient presenting with a delirium requires an immediate medical evaluation. Crisis clini-
cians are not infrequently faced with this clinical situation and they must constantly be
on the lookout for it. It is critical for all initial evaluators to become adept at recognizing
the clinical presentation of a delirium. With knowledge and common sense, it is not
usually difficult to recognize; yet this diagnosis is frequently missed, often by physicians
themselves.
We can begin our exploration of the presentation of a delirium by reviewing the
DSM-5 criteria, which appear below (for information on the numerous specifiers, see the
DSM-5 itself)83:
DSM-5 DIAGNOSTIC CRITERIA FOR DELIRIUM

A. A disturbance in attention (i.e., reduced ability to direct, focus, sustain, and shift attention) and
awareness (reduced orientation to the environment).
B. The disturbance develops over a short period of time (usually hours to a few days), represents a
change from baseline attention and awareness, and tends to fluctuate in severity during the course
of the day.
C. An additional disturbance in cognition (e.g., memory deficit, disorientation, language, visuospatial
ability, or perception).
D. The disturbances in Criteria A and C are not better explained by another preexisting, established, or
evolving neurocognitive disorder and do not occur in the context of a severely reduced level of
arousal, such as coma.
E. There is evidence from the history, physical examination, or laboratory findings that the disturbance
is a direct physiological consequence of another medical condition, substance intoxication or
withdrawal (i.e., due to a drug of abuse or to a medication), or exposure to a toxin, or is due to
multiple etiologies.
Practical Tips for Spotting a Delirium: The Nature of the Beast

It is important to note that not all delirious patients are disoriented.84,85 Generally these
patients develop disorientation, but at times, especially in the early stages of the process,
they may be completely oriented. In this sense, deliria can present in a variety of fashions,
which is part of the reason they are sometimes misdiagnosed.
The following guidelines provide a practical platform for clinical assessment. In the
first place, a delirium occurs when there exists a rather diffuse pathophysiologic dysfunc-
tion in the brain. Such a diffuse dysfunction will frequently show itself in one of two
ways – a fluctuating level of consciousness or a marked problem with concentration and
the ability to attend to the environment. These two processes should alert the clinician
to the possibility of a delirium. Indeed, if either of these processes appears in a patient
demonstrating the soft or hard signs of psychosis, then one should strongly consider a
delirium work-up.
It therefore becomes critical to evaluate these two aspects during the initial interview
of any psychotic patient. Unfortunately, it is easy to overlook their significance if the
patient is agitated, as was the case with Mr. Lawrence. Let us begin with the evaluation
of the level of consciousness.
People with a delirium tend to present in one of three ways: (1) hypoactive, (2)
hyperactive, or (3) a mixed picture of the previous two states. In the hypoactive state,
which represents the most common state, the patient may appear drowsy or may actually
be hard to arouse. This type of “quiet delirium” is common in elderly patients. Their
somnolent behavior does not bother anyone, and consequently their condition may be
overlooked. In the hyperactive state the patient is “wired.” The patient appears unusually
responsive to any stimulation from the environment and tends to appear driven. This is
sometimes accompanied by marked agitation or aggression. We saw this presentation
earlier with Mr. Williams, the man suffering from DTs. Finally, patients may present with
a mixture. One of the hallmarks of the delirious patient is the tendency for the level of
consciousness to fluctuate. This fluctuation may be so extreme as to move the patient
back and forth between hypoactive and hyperactive states. Mr. Lawrence first presented
to the emergency room staff with a rage-like, hyperactive state and later presented to me
in a drowsy, hypoactive state.
If one is actively looking for changes in the level of consciousness, they are not hard
to spot. But in a busy clinical situation the trick is to be aware of their importance. A
problem arises in the fact that patients tend to move in and out of delirious states rela-
tively quickly. An alert nurse may note a brief episode of delirium that will simply not
be present during clinical rounds the following morning. A frequent physician error is
to assume that if the patient looks good on rounds, then “what’s the fuss?” Unfortunately
such a patient may be developing permanent brain damage during the periods of delir-
ium. Consequently, this type of patient needs a medical work-up despite a good appear-
ance during rounds.
This tendency for the delirious patient to demonstrate a fluctuating level of conscious-
ness is paralleled by changes in the electroencephalogram (EEG).86 In the hypoactive
state, the EEG usually demonstrates a generalized diffuse slowing of the background
activity. During the hyperactive state, fast activity is often seen. At times a normal EEG
may be found.
With regard to determining whether or not the patient is having trouble concentrating
and attending to the environment, the task becomes more difficult. The difficulty lies in
the fact that subtle problems with attention and concentration may not be apparent
unless tested. At times, the clinician may be able to determine that concentration is rea-
sonably good, by noting the patient’s ability to converse in a natural and intelligent
fashion. At other times, as was the case with Mr. Lawrence, more formal testing is
required, especially if the evaluator is truly suspicious of the presence of a delirium.
Four Cognitive Tests Useful for Recognizing a Subtle Delirium

Four tests come to mind, which as a battery will generally pick up any significant prob-
lems with concentration and the ability to attend to the environment. These four tests
are: digit spans forwards and backwards, the vigilance test, constructions, and an exami-
nation of the patient’s handwriting.
In the digit span test, one asks the patient to repeat a series of digits (starting with
two digits and advancing to seven digits if the patient proceeds to answer correctly) to
see if the patient can place incoming information into immediate memory storage and
then quickly retrieve it. Deliria often disrupt this process.
It is important to ensure that one is testing the patient’s immediate recall memory, as
opposed to the patient’s ability to simply repeat back a digit span without using memory.
To ensure that memory recall is being tested, the clinician can say the following:
“I’m going to give you some numbers to remember. We will start with something easy,
say two numbers, and then we will do longer strings of numbers. Watch me carefully
as I say the number to make sure you got it. Then wait a moment. I will point to you.
Do not repeat the number back to me until I point to you. This will help us to test
your memory. Any questions? … Good, let’s start: eight; five.” (Pauses for several
seconds, and then points to the patient.)
It is important to say the digits in a steady rhythm so as not to allow the patient to
remember clumps of digits. Consistency in rhythm is particularly important when you
are testing for seven-digit recall. If said like a telephone number, the patient may find
them artificially easy to remember.
After testing seven digits forwards, the clinician can ask the patient to recall digits
backwards, once again starting with two-digit recall. With the digit span test one should
expect an average adult to be able to repeat about seven digits forwards and four to five
digits backwards.
In the vigilance test, the clinician recites (for about 1–2 minutes) a string of letters
randomly from the alphabet. The patient is asked to make a hand tap on the table every
time the letter “A” is said. If the patient is experiencing problems attending to the envi-
ronment, both errors of omission and commission will tend to occur, especially as you
go deeper and deeper into the string of letters. A normal adult should make few if any
errors in the vigilance test. As the series continues, some delirious patients will even forget
what letter they are hunting for. I have found this test to be a surprisingly sensitive one
for picking up problems in concentration as seen in subtly delirious states.
The patient may also be asked to make copies of constructions, such as a cross or a
cube. Once again the delirious patient may find such a task difficult. Also note the time
and the ease with which a patient performs constructions. Sometimes a patient can
complete a construction such as a cube correctly, but it requires great time and concen-
tration to do so. In an engineer or architect, such delays may actually indicate early
cognitive dysfunction for they should be able to do a cube with great ease.
Finally, problems with writing (dysgraphia) are common and include spelling errors,
clumsily drawn letters, reduplication of strokes in letters such as “M” or “N,” and
problems with alignment and linguistics.87 The patient can be asked to write his or
her name, a sentence or two of their own creation, and/or copy a sentence or two from
a book or magazine. This test is significantly more telling if one can compare the
patient’s handwriting to a sample of his or her handwriting done prior to the behav-
ioral symptoms. (Keep in mind that tests based upon the patient’s writing are limited
in use to patients who are literate and have been taught to use script, which is fre-
quently not taught in grade schools due to the switch to computer keyboards, although
deliria can also cause errors in printing). In Chapter 16, where we will focus our atten-
tion upon the mental status, I will be demonstrating the effective use of these four
tests in Video Module 16.2.
These four tests represent an excellent quick screen for deficits in concentration,
attending abilities, and immediate recall, but one may have difficulty using them with a
hostile patient. Few hostile patients are eager to demonstrate their artistic abilities or play
word games. When these tests are deemed to be inappropriate, one can learn a great deal
by carefully observing the patient. The delirious patient may demonstrate difficulties in
concentration, attending, and other cognitive problems through an inability to follow
commands, a problem remembering questions, a tendency to appear overly sensitive to
noises and other outside stimuli, or simply an appearance of confusion, as was the case
with Mr. Lawrence in the bathroom. The trick is in remembering to look for these pro-
cesses on a routine basis when encountering a psychotic patient.
Inouye has developed a systematic approach to spotting delirium called the Confusion
Assessment Method (CAM) that many view as one of the best methods for diagnosing
a delirial state, which requires only about 5 minutes to perform.88 As one would expect
from the above considerations, it focuses upon the patient’s problems with both con-
centration and fluctuation in levels of consciousness. The CAM is not a structured test,
but it brings a structured approach to delirial assessments. It focuses upon nine charac-
teristics, symptoms, and behaviors: (1) acuteness of onset, (2) inattention, (3) disturbed
thinking, (4) altered level of consciousness, (5) disorientation, (6) memory impairment,
(7) perceptural disturbances, (8) psychomotor agitation, and (9) psychomotor retarda-
tion. We will not review its use in detail here, but the interested reader can find a manual
for its use on the web.89
Thus far our focus has been on the two key characteristics of a delirium – problems
with concentration/attending to the environment and fluctuations in the level of con-
sciousness. It may be valuable now to review a few of the more common clinical
characteristics.90–92
1. Hallucinations or illusions have been estimated to occur in 40 to 75% of delirious

patients. Visual and auditory hallucinations are frequent, and the presence of visual
hallucinations should always arouse suspicion of a delirious or organic state.
2. Rapidly changing delusions, especially of a paranoid nature, are common. These

delusions tend to be of a much more fleeting and malleable nature than the delusions
seen in schizophrenia or one of the delusional disorders.
3. Other problems with a formal thought disorder such as derailment or illogical
thought may appear.
4. Short-term memory and orientation are frequently impaired.
5. Deliria tend to fluctuate. In particular, patients tend to be more disoriented and deliri-
ous at night, a process that has been referred to as “sundowning.”
6. Deliria tend to emerge in a matter of hours or days, but this is not always the case.
Insidious onsets can occur.
7. Although deliria are generally believed to be related to organic etiologies, it is believed
that stress and psychological mechanisms can lead to a delirious presentation in some
instances.
8. Affect is typically abnormal, with a high incidence of emotions such as fear and
anxiety.
9. A characteristic phenomenon is the tendency for the patient to misidentify the
unfamiliar as familiar. For instance, a nurse’s aide may be identified as a brother or
sister.
A variety of other odd behaviors have been reported during deliria, ranging from wander-
ing aimlessly about the hospital to drinking copiously from the toilet. One particularly
peculiar process has been reported in which the patient continues habitual behaviors in
totally inappropriate places. For instance, in an “occupational delirium,” patients perform
behaviors in the hospital that are normally only done at their place of work. The term
“carphology” has been coined for the behavior of picking at one’s bedclothes, another
abnormal behavior sometimes seen in deliria.
With regard to etiology, the list is extensive. In Table 11.1, a list of common causes is
presented. It is beyond the scope of this book to elaborate on the medical differential
and on the appropriate laboratory and physical examinations. The first and crucial step
remains the uncovering of the delirium during the interview itself.
In a practical sense, interviewers must train themselves to rule out delirium any time a
patient presents with a psychosis. Unless this active process of viewing delirium as a part
of the differential becomes a clinical habit, one runs the risk of missing it. The patient
is the one who pays for such an error, and the cost may be permanent brain damage or
worse.
Differential Diagnosis on Mr. Lawrence and Summary of Key Interviewing Tips

At this point let us summarize the DSM-5 differential diagnosis on Mr. Lawrence:

Medication-induced delirium (overdose on antidepressant)
Schizophrenia in remission
Table 11.1 Common Causes of Delirium
Metabolic
1. Hypoxia, hypercarbia, anemia
2. Electrolyte imbalance, hyperosmolarity
3. Hyperglycemia or hypoglycemia
4. Abnormal levels of magnesium or calcium
5. End-stage liver or kidney disease
6. Vitamin B1 deficiency (Wernicke’s encephalopathy secondary to a thiamine deficiency)
7. Endocrine disorders (hyperthyroidism or hypothyroidism, hyperparathyroidism, and adrenal disorders)
Infections
1. Systemic (e.g., pneumonia, septicemia, malaria, and typhoid)
2. Intracranial (e.g., meningitis, encephalitis)
Neurologic Disorders
1. Hypertensive crisis, stroke, subarachnoid hemorrhage, vasculitis
2. Seizures
3. Trauma
Drug Withdrawal
1. Alcohol hallucinosis, rum fits, delirium tremens
2. Other withdrawal states (e.g., from barbiturates, as well as acute intoxication with street drugs)
Intoxication
1. From agents such as digoxin, levodopa, anticholinergics, and street drugs
Post-operative Sequelae
1. Especially following cardiac surgery
Deferred
Medical Disorders:
Respiratory arrest secondary to overdose
Major points worth reviewing include the following:
1. Psychoses such as those seen with schizophrenia or bipolar disorder often present in
a similar fashion from episode to episode.
2. If a patient’s psychotic presentation seems different than is typical from previous
episodes, then the clinician should strongly consider the possibility of a new etiologic
agent.
3. The presence of a delirium always warrants an aggressive medical evaluation and can
easily be missed in chronic patients.
4. The clinician should always consciously look for evidence of a fluctuating level of
consciousness or a significant problem with concentration and attending to the
environment in all psychotic patients; these two characteristics are tip-offs that a
delirium may be present.
Clinical Presentation #6: Kate

The moment that one sees the look of concern on the faces of this young girl’s parents,
one feels that something is very wrong. Kate is 14 years old. She is slightly overweight.
Her black hair drops in a tangle down her back. Her parents relate that they feel she is
very depressed and that she has become more depressed over the past 2 months. Things
had reached a crisis point when 5 days earlier Kate had thrown a slumber party. No one
came. Since then she has been acting oddly, talking about “reality” and wandering about
the house. The most bizarre incident occurred two nights ago, when Kate knocked at her
parents’ bedroom door at 2:00 A.M. When they opened the door, Kate stood
topless, stating in a dull monotone that she felt a need to talk. At no time had Kate been
delusional or heard voices. During a brief break in her interview, Kate left her examina-
tion area and was found wandering about in the clinical exam area of the ED peeking
behind the curtains of the other examination areas. Kate’s parents had taken her to two
emergency rooms in the past week. At both places her parents were told that she was
hysterical. Referrals were made for outpatient therapy.
Discussion of Kate
During the interview it was easy to see why hysterical traits had been reported. Kate
seemed to be preoccupied, as if pulled into an autistic cocoon. At one point, she turned
and while looking me squarely in the eyes she dramatically said, “Tell me Doctor, what
is reality?” She denied hallucinations and delusions. Her speech was halting and was
interspersed with inappropriate giggles. At times she displayed mild thought blocking
and seemed distracted. She was completely oriented, demonstrated an alert and stable
consciousness, and when cognitively tested, displayed no specific problems with concen-
tration (other than a single error when doing reversed digits and one error on the vigi-
lance test), attending to the environment, or other deficits.
Her numerous soft signs suggested that a psychotic process was present, and she was
hospitalized. Her physical examination was normal in the emergency room without any
neck stiffness nor complaints of headaches. We were somewhat suspicious of drug abuse,
but it seemed unlikely from the history taken from the parents. By the time of admission,
morning had almost broken, and I requested an immediate neurological consult to be
placed upon arrival on the unit, for her presentation seemed difficult to explain, and I
had concerns of a possible neurologic complication such as a central nervous system
infection. The admission bloodwork and the results of the spinal tap performed hours
later by the neurological consultant revealed a diagnosis of viral encephalitis. Approxi-
mately 1 week after her admission, Kate, unfortunately, lay dying in the intensive care unit.
Spotting Non-Delirial Psychoses Caused by Underlying Medical Conditions

Diagnostically speaking, Kate did not present with a delirium. Not all general medical
causes of psychosis manifest as a delirium. While looking over the spectrum of general
medical etiologies of psychotic process outlined in Table 11.2,93 it is important to
Table 11.2 Organic Causes of Psychosis*
Space-Occupying Lesions of the CNS Metabolic and Endocrine Disorders

Brain abscess (bacterial, fungal, tuberculosis, Adrenal disease (Addison’s and Cushing’s
cysticercosis) disease)
Metastatic carcinoma Calcium-related disorders
Primary cerebral tumors Diabetes mellitus
Subdural hematoma Electrolyte imbalance
Hepatic failure
Cerebral Hypoxia Homocystinuria
Anemia Hypoglycemia and hyperglycemia
Lowered cardiac output Pituitary insufficiency
Pulmonary insufficiency Porphyria
Toxic (e.g., carbon monoxide) Thyroid disease (thyrotoxicosis and myxedema)
Uremia
Neurologic Disorders
Nutritional Deficiencies
Alzheimer’s disease
Distant effects of carcinoma B12
Huntington’s chorea Niacin (pellagra)
Normal pressure hydrocephalus Thiamine (Wernicke–Korsakoff syndrome)
Temporal lobe epilepsy
Drugs, Medications, and Toxic
Wilson’s disease
Substances
Vascular Disorders
Alcohol (intoxication and withdrawal)
Aneurysms Amphetamines
Collagen vascular disease Analgesics (e.g., pentazocine [Talwin], meperidine
Hypertensive encephalopathy [Demerol])
Intracranial hemorrhage Anticholinergic agents
Lacunar state Antiparkinsonian agents
Barbiturates and other sedative-hypnotic agents
Infections (intoxication and withdrawal)
Brain abscess Bromides and other heavy metals
Encephalitis and postencephalitic states Carbon disulfide
Malaria Cocaine
Meningitis (bacterial, fungal, tuberculosis) Corticosteroids
Subacute bacterial endocarditis Cycloserine (Seromycin)
Syphilis Digitalis (Crystodigin)
Toxoplasmosis Disulfiram (Antabuse)
Typhoid Hallucinogens
Isoniazid
L-Dopa (e.g., Larodopa)
Marijuana
Propranolol
Reserpine (Serpasil and others)
CNS, Central nervous system.

*Adapted from Bassuk EF, Beck AW, editors. Emergency psychiatry. New York, NY: Plenum Press, 1984.
remember that a psychosis secondary to a general medical condition like encephalitis

can present in a fashion suggestive of any classic psychosis, such as schizophrenia or
bipolar disorder. Frequently, delirium is not a part of the picture. This point once again
emphasizes the need to “think organic” when evaluating a patient presenting with the
onset of psychotic symptoms.
More importantly, in the emergency room, and even in a clinic setting, one of the
critical triage decisions involves ruling out a life-threatening cause of psychosis. The most
common life-threatening illnesses that present with an acute psychosis include the
following94:
1. Hypoglycemia
2. Hypertensive encephalopathy
3. Poor oxygenation (perhaps related to a heart attack, pulmonary embolus, anemia, or
a hemorrhage)
4. Infections such as encephalitis or meningitis
5. Drugs, including medications, street drugs, withdrawal states, industrial toxins, and
actual poisons
6. Intracranial trauma (including hemorrhage, actual trauma related to head injury, and
other causes of increased intracranial pressure)
7. Wernicke’s encephalopathy (not generally life threatening but should be viewed as a
medical emergency, because if untreated, permanent brain damage can occur)
Other serious entities to consider in the differential diagnosis include hepatic failure,
uremia, subacute bacterial endocarditis, and a chronic subdural hematoma. Autoim-
mune encephalitis is another important entity to keep in mind, for it can present with
psychotic symptoms as well as other psychiatric features, including catatonia, anorexia/
bulimia, obsessive–compulsive symptoms, anxiety, depression, and lethargy. These auto-
immune encephalitides are often accompanied by problems with memory and cognition,
and are frequently (but not always) followed by neurological deficits such as seizures,
ataxia, parkinsonism and memory loss. In this collection of disorders, the immune
system inadvertently attacks brain cells as it mounts a response to a pathologic agent
such as seen in rheumatic fever caused by streptococcal infections or a cancer (paraneo-
plastic autoimmune encephalitis). Fortunately, this list does not represent a particularly
extensive differential. If the clinician remembers to think of these entities, they are gener-
ally easy to rule out – but that is an important “if.” In actuality, these entities are rare
enough as causes of acute psychotic process that they are likely to be overlooked, unless
clinicians train themselves to consistently consider them.
When to Refer for a Physical Exam and What to Do If You Can Perform One
A brief, well-directed physical examination will often uncover many of the life-threatening
processes mentioned above, but not always as evidenced by Kate whose physical exam
was normal. In fact, a patient presenting with the onset of new psychotic symptoms
should seldom, if ever, leave an emergency room without a screening physical examina-
tion. If a new patient presents to a community mental health center, college counseling
center, or a private practice with psychotic symptoms, every effort should be made to
have the patient seen as quickly as possible, hopefully immediately after the mental
health assessment.
The physical examination can be performed quickly and is geared towards uncovering
evidence of a life-threatening dysfunction. To this end, it focuses on the following five
areas: (1) vital signs, (2) autonomic system dysfunction, (3) heart and lung dysfunction,
(4) neurologic dysfunction and head trauma, and (5) abnormalities of the eyes.
Abnormal vital signs should be retaken. If they remain abnormal, an etiology for the
dysfunction should be sought. Keep in mind that the pulse may be naturally elevated in
an agitated patient, but agitation alone seldom causes sustained pulses over 120 to 130.
Autonomic dysfunction is frequently present during a life-threatening illness. Agents
such as the anticholinergic medications, mentioned earlier, frequently cause the patient
to present with hyperthermia, blurred vision, dry skin, facial flushing, and delirium. The
mnemonic “hot as a pepper, blind as a bat, dry as a bone, red as a beet, and mad as a
hatter” has been used to describe this toxic state.
A note of caution should be added: the anticholinergic syndrome is often incomplete,
or it may be hidden by other active agents such as opiates. For instance, Mr. Lawrence,
who overdosed on Elavil, an antidepressant with many anticholinergic properties, pre-
sented with an increased pulse and a dry mouth, but his pupils were normal in size and
reactive. His skin color was pale, not flushed as would be expected in a classic anticho-
linergic syndrome. Many contemporary psychiatric and non-psychiatric medications have
anticholinergic properties.
This discussion also emphasizes the usefulness of looking at the patient’s eyes. The
clinician should look for abnormal size or responsiveness of the pupils, as well as asym-
metry. Horizontal and vertical nystagmus should be sought. The eye grounds may reveal
evidence of increased intracranial pressure.
Neurologically, one scans for evidence of focal weakness and changes in reflexes.
Reflexes, including the suck reflex, snout reflex, palmomental reflex, and the Babinski
sign, can be quickly screened. The clinician should check for signs of neck rigidity as well
as for hemotympanum of the ears or other signs of a slight skull fracture.
Finally, the clinician should listen to the heart and lungs if an abnormality of the
cardiovascular or respiratory system is suspected.
A screening physical examination as described earlier can quickly flush out a serious
physical condition, sometimes even in the early stages. A common error in this regard is
to admit an extremely agitated patient directly to a seclusion room and subsequently fail
to perform a follow-up physical examination when the patient has calmed down. Once
the patient has calmed, the physician, nurse clinician, or physician assistant should
attempt a screening examination no matter how late it is at night. At times, when one is
strongly suspicious of the presence of a serious illness, the patient may need to be physi-
cally restrained to allow for examination.
Differential Diagnosis on Kate and Summary of Key Interviewing Tips

At this point we can return to Kate in an effort to summarize her DSM-5 diagnosis. Note
that although Kate does not present with delusions, hallucinations, or a formal thought
disorder other than some mild thought blocking (the three classic hard signs of psycho-
sis), she does present with one extremely odd behavior by history – appearing topless
when knocking at her parents’ bedroom door – and the somewhat odd behavior dem-
onstrated in the emergency department – wandering about in the exam area. These odd
behaviors should appropriately raise the clinician’s suspicion of the presence of an under-
lying psychotic disorder in the differential diagnosis. In addition, the thought blocking
she demonstrated during the interview itself is usually a sign of active psychotic process.
Although Kate has some signs suggestive of delirium (possible episodes of confusion and
mild cognitive deficits), she does not currently meet the criteria for delirium. At the time
of her admission, before any lab work had returned, her differential may have looked as
follows:

Unspecified schizophrenia spectrum and other psychotic disorders (provisional)
Rule out:
1. Brief psychotic disorder
2. Psychotic disorder due to another medical condition
3. Unknown substance use disorder
4. Substance/medication-induced depressive disorder
5. Substance/medication-induced psychotic disorder
6. Major depressive disorder with psychotic features
7. Unspecified delirium
Personality Disorder:
Defer
Medical Disorders:
Rule out general medical causes of psychosis (such as infection, partial complex seizure
disorder, etc.)
Before leaving the topic of Kate’s presentation, it may be of value to summarize some
key points.
1. A delirium is not the only way in which a medical illness may manifest as a psychosis.
Diseases such as encephalitis can mimic processes such as schizophrenia.
2. The clinician should routinely consider the various life-threatening illnesses when
evaluating a patient who is psychotic.
3. A screening physical examination should be performed on any patient presenting
with psychotic features (as well as any appropriate lab work).
4. The absence of all the typical signs of the anticholinergic syndrome does not rule out
this syndrome, because it may present with only some of the physical signs.
Let us now move on to our final case presentation. Ms. Flagstone represents an anomaly
among our other cases: She is not acutely psychotic.
Clinical Presentation #7: Ms. Flagstone

Ms. Flagstone walks into the outpatient clinic at a community mental health center,
dressed in a stylish fashion, with a cigarette in hand, waving it about like a baton of
sorts, until she is politely asked to put it out by the receptionist. During the initial inter-
view with her assigned outpatient therapist, her affect changes periodically as she relates
a long-standing history of “just not going anywhere in my life.” At times she is tearful
but is able to quickly pull herself together. She is very dissatisfied with her poor relation-
ships with men, despite her good looks and thick black hair. Her speech rate and volume
are within normal limits. Although mildly tangential at times, she does not display any
loosening of associations or thought blocking. She is well oriented and denies any history
of delusions. When asked about hallucinations she denies any except for one episode 2
years earlier. She continues as follows:
I’ve really never told anyone this story, but it has had a profound effect on me. At the time
I was extremely upset. Everything was horrible in my life. Fortunately, I was not taking
any drugs or else I might not have found God. I was in my kitchen doing the dishes when
a sudden light filled the room. I just knew it was a message from God. He had come to
bring me back to the His flock. From inside the light I heard the Angel Gabriel speak. He
said, ‘Janet, you are with child.’ I knew this was a test from God and I showed strength
by accepting the mission. He talked with me, and I convinced him of my great love of
God. At that point the angel told me that all was well and that I was back with God, my
father. A blinding light moved in and out of the room many times. The whole thing only
lasted about 15 minutes, but my life has never been the same since.
This episode is the only time that she has ever heard a voice, and she denies that she has
any special mission for God other than to be a good Christian.
Discussion of Ms. Flagstone

Upon further interviewing, the entire episode with the Angel Gabriel seemed to last
roughly 15 to 30 minutes (no soft signs immediately before or after the experience);
moreover, the voice of the angel was loud and distinct. At one point the voice of the
angel actually conversed with the voice of God. Apparently, near the time of this episode,
Ms. Flagstone had been fired from a job and had also been feeling “slightly paranoid
near my co-workers.”
She also related that she undergoes periods in which she feels, “not quite myself, as
if I wasn’t quite real.” These episodes last only for about 10 minutes and occur during
times of intense stress. She finds these episodes very disturbing. Further interviewing
would reveal that Ms. Flagstone had never experienced ongoing psychotic process, yet
how does one explain the voices and the episodes of depersonalization?
“Micropsychotic Episodes” Seen in People Coping With Personality Disorders

The answer lies in the fact that psychotic process is not limited to classic major psychiatric
diagnoses such as schizophrenia, bipolar disorder, major depression, and delirium. A
variety of personality disorders may present with “micropsychotic episodes.” These epi-
sodes tend to last from minutes to hours. At times they may extend longer, but as soon
as the episodes appear to be lasting a day or longer, one should immediately begin sus-
pecting a more serious ongoing psychotic disorder. It is much more characteristic for
these events to be short-lived, as demonstrated by Ms. Flagstone, who upon further
interviewing seemed to fulfill many of the criteria for a histrionic personality disorder;
however, this diagnosis is difficult to verify in a single hour and will require further
interviewing.
Micropsychotic episodes, as experienced by people with personality disorders, are
characteristically precipitated by stress, or they may be unleashed by drug abuse, or both.
Processes such as fleeting paranoid ideation, depersonalization, and derealization are
frequently experienced. If drug abuse or stress is frequent, then both the frequency and
duration of the micropsychotic episodes may increase.
Diagnostically speaking, micropsychotic episodes are seen most frequently in the fol-
lowing three disorders: paranoid personality disorder, schizotypal personality disorder,
and borderline personality disorder. Although seen much more rarely, micropsychotic
episodes have been reported in patients dealing with histrionic and/or narcissistic process
if the patients are under intense stress or their natural defense mechanisms are out-
stripped by the pressures of their daily life. For instance, a highly respected priest with a
severe narcissistic personality disorder, who is discovered to be an active pedophile, may
be at risk for micropsychotic process. The public humiliation may prove to be so intense
as to overcome his protective narcissistic defenses. The result could be intermittent brief
lapses of subtle paranoia.
Psychotic Processes With a Rapid Onset/Offset

In classic psychotic disorders, such as schizophrenia, schizoaffective disorder, bipolar
disorder, and major depression with psychosis, we have seen that the hard signs of psy-
chosis, such as hallucinations and delusions, tend to be imbedded within a psychotic
matrix. These disorders usually have a prodromal phase lasting days, weeks, or even
months, in which the soft signs of psychotic process appear first before the hard signs
appear. We have seen that this phenomenological distinction may help an interviewer to
distinguish between culturally accepted hallucinations and beliefs (that are not psy-
chotic) and genuine psychotic process.
Some psychiatric disorders can create rapidly appearing and disappearing genuine
psychotic process, as we just saw with Ms. Flagstone. There was no prodromal phase with
soft signs of psychosis in the days preceding her micropsychotic episode. The episode
also ended abruptly with an immediate return to her baseline functioning.
In psychotic states precipitated acutely by street drugs and medications, psychotic
symptoms such as hallucinations can also occur very rapidly, in a matter of minutes to
hours. The hallucinogens such as LSD, peyote, and other variants of mescaline, have
striking effects in this respect. As with drugs impacting directly on brain functioning,
other underlying neurologic disorders such as seizure disorders may also precipitate
psychotic phenomena rapidly.
Also keep in mind that particularly intense flashbacks, as sometimes seen in post-
traumatic stress disorder (PTSD), can essentially achieve psychotic proportions in which
hallucinations and/or paranoia may erupt. It is fairly common for people experiencing
intense flashbacks to experience auditory hallucinations of the voices and/or sounds that
were present during the original trauma.
At other times, the PTSD patient will experience an atypical type of flashback in which
the emotions experienced during the assault (such as extreme fear and/or anxiety) will
appear during the flashbacks, occurring without a memory of the exact circumstances of
the traumatic incident. Such episodes may be misinterpreted as being evidence of endur-
ing psychotic or paranoid process if the clinician is unaware of such phenomena. I am
reminded of a patient of mine who would sometimes, without warning, experience
intense fears. Her fear was so great that she would sometimes arm herself with a gun and
point it intermittently towards her front door. The episodes of fear would last for an hour
or two. But there were no associated memories flashing through her mind during these
atypical flashbacks, just fear and hypervigilance. Interestingly, these episodes were often
triggered by the sound of a phone ringing. It was conjectured that perhaps she had been
assaulted at a young age, with the memory still repressed, and that, during the assault,
a phone had been left to ring unanswered in the background.
Differential Diagnosis on Ms. Flagstone and Summary of Key Interviewing Tips

With regard to Ms. Flagstone, her voices and depersonalization episodes probably warrant
the label of micropsychotic episodes. They were always brought on by stress and appeared
abruptly. Further interviewing revealed that they were not preceded by mood states sug-
gestive of the soft signs of psychosis.
After the first interview, the differential on Ms. Flagstone looked something like the
following:

Defer (probably none; but because of her tangential speech and mood shifts, entities
such as cyclothymic disorder or dysthymia could be kept in mind)
Histrionic personality disorder (provisional, but more historical information needed
before diagnosis can be made)
Rule out other specified personality disorder (mixed with histrionic, schizotypal, and
borderline traits)
Medical Disorders:
Rule out partial complex seizures
Recognizing Psychotic Process Triggered by Seizure Disorders

The need to rule out a seizure diagnosis may surprise the reader, and rightly so, because
I have not yet provided some pertinent information. Ms. Flagstone reported that she had
become extremely interested in a variety of philosophical and religious issues. She had
filled nearly 20 journals with her thoughts, none of which were psychotic. She also
reported brief episodes of feeling very uncomfortable in her abdomen, a sensation that
seemed to move upwards into her throat area. All of these phenomena could be com-
ponents of partial complex seizures (formerly called temporal lobe epilepsy), including
her periods of depersonalization and her mood shifts.
Epilepsy presenting with partial complex seizures is the “masquerader par excellence.”
It can mimic essentially any psychiatric disturbance and is particularly good at presenting
as a psychotic disturbance. A query should be made for partial complex seizures in any
patient presenting with psychotic symptoms. Indeed, with our immediately previous
patient, Kate, you will recall that a partial complex seizure disorder was also a part of the
differential diagnosis, especially because of her episodes of odd behavior (such as dis-
tractedly walking about the back halls of the ED).
Psychotic symptoms may emerge during the seizure itself or between seizures (the
period known as the interictal phase). The seizure activity sometimes begins with a phase
known as the aura, in which patients may experience a variety of odd sensations, includ-
ing fear and anxiety. Patients may feel that they are experiencing a given situation for a
second time (known as déjà vu), or they may have the opposite feeling that nothing is
familiar (known as jamais vu). The patient sensing strange and pungent odors may also
be a predominant symptom. Peculiar abdominal feelings are very frequent. In some
cases, these feelings are the only symptoms, and the patient is said to have “abdominal
seizures.”
As the seizure develops, the patient loses conscious awareness and usually displays
various automatisms such as picking at himself or herself, wandering about, and display-
ing bizarre mannerisms or odd behaviors. To uncover such processes, a useful question
remains, “Have you ever found yourself somewhere and you didn’t know how you got
there?” Two other pertinent questions are, “Have you ever had periods of losing con-
sciousness?” and “Have your friends or family ever told you that they have seen you
doing very odd things that you don’t remember?”
Curiously, personality changes or psychotic-like activity may appear between partial
complex seizures during interictal periods.95 Ms. Flagstone reported some of the more
common interictal phenomena seen in such presentations: preoccupation with religious
or moral issues, a tendency to write copiously, decreased sexual drive, intense mystical
experiences, a deepening and intensification of emotions, and what has been called
interpersonal viscosity. This latter term refers to a tendency to want to keep talking and
be near to people.
It is certainly not always possible to explore all these issues during the initial interview
because of time constraints. However, in later sessions these questions should be rigor-
ously pursued if suspicious of seizure activity. Collaborative interviews with family/
friends can be particularly useful if one is suspicious of the presence of partial complex
seizures. Family/friends may be quite puzzled by the behaviors of the patient (periods
of confusion, aimless or bizarre behaviors) and the patient is completely unaware of
them due to post-seizure amnesia.
It is an unfortunate error to label someone as having schizophrenia when the actual
problem is a partial complex seizure disorder. Such a person would be robbed of the
chance to benefit from a course of antiseizure medications, and would also be needlessly
exposed to the potentially serious side effects of antipsychotics.
At this juncture, we are rapidly drawing to a close on our case discussions. It seems
appropriate to summarize some of the points brought forward by the case of Ms.
Flagstone.
1. Some personality disorders may present with psychotic symptoms, so-called micro-
psychotic episodes.
2. Micropsychotic episodes are most common in people coping with paranoid, schizo-
typal, or borderline personality disorders. They are less frequently seen in people with
decompensating histrionic or narcissistic personality disorders during times of intense
stress and/or substance use.
3. These micropsychotic episodes tend to extend from minutes to hours and are often
triggered by stress or drugs. Paranoia, depersonalization, and derealization are
common.
4. Partial complex epilepsy may present with psychotic symptoms both during seizures
or between seizures.
5. Consequently, questions should be asked concerning both the symptoms commonly
seen during a seizure as well as relating to interictal personality change.
We have now concluded our survey of diagnoses that may demonstrate psychotic symp-
toms. Figure 11.3 illustrates the rich diversity of etiologic agents that may present with
psychotic symptoms. As mentioned at the beginning of the chapter, the word “psychosis”
Medication-induced
Drugs and alcohol

Schizophrenia
Bipolar disorder
Major depressive disorder
Schizophreniform disorder
PSYCHOSIS
Delusional disorder
Brief psychotic disorder
Schizoaffective disorder
Delirium, dementia or a psychotic
disorder due to a another Personality disorder with
medical condition micropsychotic episodes
Atypical psychosis
Figure 11.3 Diagnostic possibilities when considering psychosis.
is not a diagnosis. The presence of psychotic symptoms mandates that the clinician try
to delineate the possible disorder and the etiologic agent of that disorder.
In order to perform an effective initial assessment, we must possess a sound and flex-
ible knowledge base concerning the differential diagnosis of psychotic process. In this
chapter we have attempted to provide just such a base. Hopefully, we have also shown
that the performing of differential diagnosis from a person-centered perspective is,
indeed, a delicate art in which the clinician always balances the uncovering of diagnostic
symptoms with a keen sensitivity to the uniqueness of each patient’s experience of those
symptoms.
But we have only touched upon how the horrors of psychotic process invade the inner
worlds of our patients and disrupt the familial and societal matrix of which these worlds
are an integrated part. Much remains to be examined if we are to have the tools necessary
to more sensitively explore this world with our patients through the art of interviewing.
In this regard, it seems only fitting to end this chapter with the wise quotation that we
have seen before from the pen of Sir William Osler, “It is much more important to know
what sort of patient has a disease than to know what sort of disease a patient has.” With
the completion of this chapter, we now know the disease. In the next chapter we will
come to know the person beneath it.
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CHAPTER 12
Interviewing Techniques for
Understanding the Person
Beneath the Psychosis
In this unnerved – in this pitiable condition – I feel that the period will sooner or later
arrive when I must abandon life and reason together, in some struggle with the grim phan-
tasm, Fear.
Edgar Allan Poe
The Fall of the House of Usher
Poe aptly describes the fear and anxiety that so frequently walk hand-in-hand with the
process known as psychosis. Amidst this tapestry of fear and anxiety, a plethora of psy-
chological traps are interwoven, including hallucinatory phenomena, oddities of percep-
tion, and difficulties in language formation and cognition. In this chapter we will attempt
to move, wing by wing, through the matrices of our patients to better understand the
destruction that psychotic process causes the people beneath these diagnoses.
As we saw in Chapter 10 where we discovered that depression can cause widespread
disruption across a patient’s matrix, psychotic process spreads throughout each and every
wing of our patients’ matrices like a virus, wreaking havoc on each wing, from the bio-
logical to the familial and the spiritual. The more we understand the nuances of this
destruction and its movement, the more likely we will be able to develop interviewing
techniques and strategies that can help our patients to share their pain with us; this is
the goal of this chapter. We will also discover that psychotic process can impact on the
interview process itself.
Our abilities to navigate these hurdles and to sensitively spot the subtle emergence
of psychotic process is one of the most pivotal and sophisticated skills that any mental
health professional can bring to the table. It is a skill that can help us to begin the
healing process, whether one is a college counselor sitting with a student experiencing
a first break of schizophrenia, a social worker functioning as a crisis worker in an
emergency room encountering a patient with a drug-induced psychosis, or a psychiatrist
working with a patient admitted to an inpatient unit with command hallucinations to
kill himself.
THE PAIN BENEATH PSYCHOTIC PROCESS

Fields of Interaction
I. The Biological Wing of the Matrix
Sleep Disturbances in Psychosis
One of the major physiologic moorings of our daily lives is the routine appearance of
the phenomenon known as sleep. If one’s sleep patterns are disturbed, one quickly begins
to feel “not quite oneself.” It appears as no surprise then that a sleep disturbance often
appears early in the psychotic process.
As psychotic process begins to gain momentum, the patient often experiences severe
problems falling asleep. In some instances the patient will eventually undergo a day/
night reversal, in which sleep occurs during the daylight hours and the night becomes a
time of agitation. The patient may also experience other sleep disturbances, such as early
morning awakening, especially if the psychosis is part of a major depression.
This difficulty with falling asleep stands as a sensitive sign of impending psychosis,
frequently appearing during periods of delusional mood or delusional perception. The
patient sometimes denies this sleep disturbance. Consequently, it is useful to ask family
members about the patient’s sleep, because they have frequently been awake themselves,
coping with the growing restlessness of their family member.
Psychotic Disruption of the “Sensation of the Physical Boundaries of the Body” and the
Concept of a “Porous Ego”
Leaving the area of sleep disruption, one is confronted with another set of somatic con-
cerns created by psychotic process, and these concerns are far removed from normal
experiences like sleep: Psychotic patients frequently have problems with determining the
limits of their bodies, and in a parallel sense, the limits of their sense of self, their “real-
ness,” or sense of “mineness,” so to speak.
It has been suggested that patients experiencing psychotic process often regress to an
infantile state in which the body is viewed as part self and part object.1 At such points,
the person may experience such intense feelings of depersonalization or derealization
that they actually move past these phenomena into odd psychotic experiences in which
the patient loses the sense of self or autonomy of self. One such type of experience is
known as a “made volitional act,” vividly described by one patient as follows:
I look at my arms and they aren’t mine. They move without my direction. Somebody else
moves them: All my limbs and my thoughts are attached to strings and these strings are
pulled by others. I know not who I am. I have no control. I don’t live in me. The outside
and I are all the same.2
When intense, such feelings may be associated with a terrifying sense of impending
annihilation. Perhaps, this blurring of inner and outer reality is the almost otherworldly
fear that Roderick Usher felt was his destiny in Poe’s story. It is important to realize the
Interviewing techniques for understanding the person beneath the psychosis 509
intensity of these fears, because they provide insight into the sometimes violent and
drastic measures of psychotic patients.
The above quotation leads us into a more sophisticated exploration of psychotic dis-
ruptions in the boundaries of the ego. In essence, one can view psychotic patients as
possessing a “porous ego.” The world seems to invade their skins in a distinctly unpleas-
ant fashion. They experience a variety of sensations, which seem to enter from the outside
world while becoming one with them. It is this unidirectional invasion of their integrity
that is partially responsible for their fear and anxiety.3 It is this feeling of invasion, and
the dissolution of the integrity of the body, that characterizes many of what have come
to be known as Schneiderian symptoms.
Schneiderian First-Rank Symptoms of Psychosis

Kurt Schneider, one of the 20th century’s leading European psychiatric innovators, was a
pupil of the great phenomenologist Karl Jaspers. Schneider descriptively captured the
weird sensations of these invasion experiences. He mistakenly thought that the presence
of any of these symptoms, if not caused by another medical condition, almost guaranteed
the presence of schizophrenia. He consequently called these symptoms “first-rank symp-
toms” of schizophrenia (often referred to as FRS in the clinical literature). The notion of
these symptoms as near confirmation of the presence of schizophrenia proved to be
incorrect, for these symptoms can be seen fairly frequently with other diagnoses in which
there is psychotic process. But Schneider’s symptoms are an excellent inventory of
common psychotic phenomena, whatever their etiology, and questions concerning them
should be part of any interviewer’s repertoire. There is considerable evidence that they
are, indeed, more common in schizophrenia than in other causes of psychosis such as
mood disorders or in psychotic disorders caused by a medical condition.
Schneider described 11 symptoms, of which seven are characterized by feelings of
invasion by the outside world. These seven symptoms are: (1) somatic passivity experi-
ences, (2) made feelings, (3) made impulses, (4) made volitional acts, (5) thought with-
drawal, (6) thought insertion, and (7) thought broadcasting. The remaining four
Schneiderian symptoms are delusional perception (a symptom we discussed in great
detail in the previous chapter) and several types of auditory hallucinations – audible
thoughts, voices arguing, and voices commenting upon one’s actions.
The literature on Schneiderian FRS can be confusing, for Schneider, to some degree,
did not clearly define them in his own writings, resulting in various interpretations being
given by subsequent writers.4,5 To me, the symptoms are best understood by remembering
that Schneider was greatly influenced by the philosophy and psychology of phenomenol-
ogy. Phenomenologists are primarily interested in understanding the fashion in which
human beings experience being in the world, including the individual’s unique concerns
as to how their experiences are related to their sense of self and to others. In a general
sense, phenomenologists are less interested in secondarily categorizing experiences as
specific “things” such as delusions or hallucinations than in trying to understand, as best
they can, how a unique human being has experienced a unique phenomenon within his
or her mind. Let me clarify this somewhat-confusing abstraction with a specific Schneide-
rian symptom – thought withdrawal.
A patient can experience thought withdrawal in different ways. A patient may literally
feel a thought being withdrawn from his or her brain/skull as a perception (a haptic hal-
lucination) or a patient could cognitively believe that his or her thoughts are being
withdrawn, without necessarily feeling it as a sensation (a delusion, without any precipi-
tating hallucination). Both of these are experienced by patients as real inner phenomena
or truths. I believe that for Schneider, it was this inner experience of thought withdrawal
that was most important, not whether the patient’s experience could be subsequently
classified as a hallucination versus a delusion.
Likewise, a patient could interpret this inner phenomenon in various fashions. The
patient could, in a nebulous way, simply feel as if a nonspecific, non-identified outside
agent had done the withdrawing (a feeling state not a delusion); or the patient might
vaguely believe that an outside entity had withdrawn the thought (an over-valued idea);
alternatively, he or she could definitely believe that an outside agent had withdrawn the
thought (a true delusion); further yet, he or she could arrive at a specific belief as to who
(a neighbor) or what (a demon) had withdrawn the thought (an elaboration and refine-
ment of the patient’s delusion).
In my opinion, Schneider, as a phenomenologist, was most likely interested in all of
these aspects, viewing them as integral parts of the patient’s inner experience. It was not
that the person had either a hallucination and/or a delusion that would matter most to
a classic phenomenologist. It was the fact that a person had experienced the phenome-
non of thought withdrawal and had been concerned about it (in whatever unique fashion
it was experienced and in whatever unique fashion the patient had experienced the
concern) that raised Schneider’s suspicion that the patient was experiencing a psychotic
world.
It is also important to understand that Schneider did not believe that the mere pres-
ence of one of these symptoms indicated the existence of psychotic process or even
psychopathology. The symptom had to be embedded within a psychotic matrix, as we
described in our previous chapter. He warned, “a psychotic phenomenon is not like a
defective stone in an otherwise perfect mosaic.”6 The need to examine the specific
symptom within the overall context of the patient’s experience Schneider described as
the requirement for the presence of “phenomenological leverage.” This leverage (psy-
chotic matrix) had to be present in order to determine that a symptom was truly psychotic
in nature.7 With these clarifications in mind, let’s take a closer look at Schneider’s first-
rank symptoms.
Exploring Somatic Passivity and “Made Feelings”: The World of the Porous Ego
Schneider did a marvelous job of capturing the essence of these psychotic sensations,
which, traditionally, clinicians have a hard time uncovering because they are so foreign
to normal experience. A clinician can empathize with paranoia to some extent, because
we have all experienced fear of other people to some degree or another. But “somatic
passivity” and “made feelings” are something altogether different. They are psychologi-
cally foreign phenomena to most clinicians, hence are easily missed. Moreover, despite
the damaging power of these symptoms (and the consequent value of targeting them
for relief via supportive reassurance, cognitive–behavioral therapy, or medications, etc.),
many patients – because the symptoms sound so “crazy” to others in the patient’s
everyday culture – will not share them unless directly asked about them by the
interviewer.
With somatic passivity experiences, the patient is the reluctant recipient of bodily
sensations against his will by a force outside of his control such as suddenly feeling that
his intestines are wriggling about inside his abdomen or that his organs are shifting
about. It is easy to see how such peculiar sensations could plant the seeds of delusional
material such as a paranoid fear that someone is purposely twisting the patient’s insides
or that parasites or snakes have infested his intestines. The following type of question
can help to bring such sensations to light:
“Do you ever feel that something is moving or squirming inside of your body?”
Similarly, in made feelings, made impulses, and made volitional acts, the patient once
again feels that something is “being done to them.” Personal control is taken from the
patient (sometimes referred to in the literature as delusions of control). This distinct and
remarkably unnerving feeling that “I am being made to feel something, made to want
to do something, or actually being made to do a specific act against my will” (such as
assaulting or killing someone), is the unifying perception of all three of Schneider’s
“made” symptoms. It is a poignant example of a “porous ego,” made vulnerable to inva-
sion at any moment by psychotic process. Mellor, in a classic article on Schneiderian FRS,
quotes a patient who describes the oddness of a “made feeling”:
I cry, tears roll down my cheeks and I look unhappy, but inside I have a cold anger because
they are using me in this way, and it is not me who is unhappy, but they are projecting
unhappiness into my brain.8
Another of Mellor’s patients insightfully describes the sensation of “made volitional acts”
of which we already saw one example above. In this instance, the patient is describing
that his fingers pick up objects but, “I don’t control them … I sit there watching them
move, and they are quite independent, what they do has nothing to do with me. I am
just a puppet … I am just a puppet who is manipulated by cosmic strings.”9
Notice how it would be natural for any person experiencing these “made sensations”
or somatic passivity experiences to wonder who or what is causing them. This drive to
figure out, “what is happening to me?” is totally normal. Unfortunately, as the patient
seeks out an answer, they will inevitably come upon an unrealistic answer for the original
sensation is psychotic in nature. Their resulting explanation for the made feeling or
somatic passivity experience – a demon is making me feel hate or parasites have invaded
my intestines – is a delusion. Thus we see that delusions are often the result of a person’s
natural hunt for answers to an unnatural, psychotic experience. This sequential understanding
complements what we saw in the last chapter when we described the “life cycle of a
delusion” and the concept that the presence of delusions is evidence of an old
psychosis.
Armed with an understanding of this life cycle of a delusion, an interviewer may be

better able to spot the emergence of subtle psychotic process. This could result in lower
anti-psychotic dosages, and perhaps a much less virulent episode of psychosis, for the
patient. For instance, a talented interviewer may uncover an insidiously emerging first
break of schizophrenia or the earliest signs of a break-through in a patient’s psychotic
process (previously well-controlled by medications) despite the fact that the patient is
denying the presence of delusions. The clinician can accomplish this task by utilizing
questions that are designed to uncover the type of made symptoms or somatic passivity
experiences that often pre-date delusional thoughts.
The following questions can be of value in uncovering these unsettling sensations, all
of which can lead to the development of delusional material:
“Have you ever felt that something or someone is making you feel an emotion, as if
something is making you feel angry, sad, or bitter?” (uncovers made feelings)
“Does it sometimes feel like something or someone is giving you urges that you would
never want to do normally, like the urge to yell out at a stranger, use a profanity, or
even hurt someone physically?” (uncovers made impulses)
“Right before you assaulted your boss, and I know you feel very badly about that now,
what were you feeling, right before you hit him? (an open-ended indirect method of
potentially uncovering made volitional acts)
“Have you ever felt that something or someone made you actually assault your boss?”
(a closed-ended direct method of uncovering made volitional acts)
Thought Withdrawal and Thought Insertion

Two other Schneiderian symptoms – thought withdrawal and thought insertion – are
reflections of a porous ego. Both sensations are extraordinarily unsettling.
Once again, the operative words are “to me,” in that the patient feels that these phe-
nomena are being done “to me” by some outside force. In normal day-to-day function-
ing, all of us have the discrete sensation that we exist and that we do things to the world
about us and even to ourselves. It is a distinct sensation of intentionality. This sensation
of intentionality is so innate that people are generally unaware of it. It simply is. But
with all of the Schneiderian symptoms discussed thus far, the patient feels that there is
some external, disembodied force that is capable of causing them to feel and do things,
creating a penultimate fear of loss of control.
So it is with thought withdrawal and thought insertion. In the former, the patients
feel, become suspicious, or believe that their thoughts are literally being pulled out of
their minds by an alien force. If not present immediately, paranoid delusions are usually
quick to follow, as the patient tries to understand or explain the etiology of his or her
sensations. Inwardly the patient may feel that his or her mind has had a thought
removed, sometimes even in mid-sentence. In an interview, this inward experience may
show itself outwardly. The patient may demonstrate thought blocking, in which a sen-
tence is disrupted before completion and the patient cannot recover his or her train of
thought. Thought withdrawal can be addressed as follows:
“Have you ever felt that some person or perhaps something like a demon or perhaps
the web can pull or remove your thoughts from you, you know, against your
will?”
In contrast, with thought insertion, the patient feels or believes that thoughts from a
different entity are being forced or pushed into his or her mind. The phenomenon is a
truly weird experience, often accompanied by over-valued ideas or delusions frequently
tied into demon possession or other types of paranoid delusions, such as a computer or
smart phone pushing thoughts into the patient’s mind. I have found the following ques-
tions to be of use in exploring these sensations:
“You mentioned that your neighbor, Ben, is trying to control you. Does he try to do
things like control your thoughts or even literally push his own thoughts into your
mind?”
“Does it ever feel to you that you can literally feel Satan pushing these feelings into your
mind, against your will?”
“Have you ever felt that thoughts are being pushed into your mind through your smart
phone that aren’t your own?”
Thought Broadcasting (Unintentional and Intentional)

Unfortunately, the patient’s porous ego may also allow for the passive escape of thoughts,
feelings, and desires. The result may be fears that aggressive fantasies will be heard by
others in the room or, even worse, that in a magical sense, these violent ideas may auto-
matically become reality. A common feeling is that the patient’s thoughts are leaking, as
elegantly described below:
My difficulty is an outgo of my silent thought. It goes as it comes. I may think whatever

I please, but whatever I do think goes as it comes. I suppose the constant irritation and
annoyance they have kept up around me has affected the tension of nerve, so that unlike
others who have the same phenomenal power, it goes as rapidly as my mind thinks. I have
but to think a thought and it reaches other minds in sound without an effort on my part,
and is sounded for a distance, I suppose, of 2 or 3 miles.10
This type of passive thought broadcasting is sometimes called “thought diffusion.” I find
the term “thought leakage” more descriptive of the fear attached to the phenomenon by
the people experiencing it. One can imagine the intense concern accompanying such a
phenomenon, for suddenly there is no privacy whatsoever. What one thinks, others can
hear. Generally, thought leaking is experienced in very negative terms. Patients may even
feel that their thoughts are being beamed out on radio or television, or simultaneously
magically posted on Facebook or other social media.
Note that thought broadcasting is a decidedly different sensation to thought with-
drawal. The locus of the experience is not that something is being actively done to oneself
(an agent is pulling my thoughts out), but that one’s thoughts are leaking outwards
through a porous ego.
In some rarer instances of thought broadcasting, it feels to patients that they are
capable of intentionally sending thoughts from their minds. In such instances, the
thought broadcasting may be viewed in a pleasurable light – as a special ability or skill.
The following questions can be used to uncover both types of thought broadcasting
(unintentional leakage or an intentional sending of thoughts):
“Jim, are you ever worried that other people can read or hear your thoughts without your
awareness, or perhaps your inner thoughts are somehow posted on the web without
your knowing it?”
“Sometimes people have told me that they have been lucky enough to develop some
unusual or special powers, like ESP. For instance, some people have told me that they
have the ability to send their thoughts outward into the minds of others, sometimes
great distances. Have you ever experienced anything like that, even just a little bit?”
One can quickly sense the inherent strangeness of a world encountered with a porous
ego. One can more easily intuit why these patients frequently seem preoccupied or lost
in thought. It requires tremendous attention to try to sort out the meanings of so odd
and intrusive a world. The clinician must also bear in mind that these patients are fre-
quently attempting to determine which of their sensations are real and which are false.
To the degree that they possess a “distance” from their psychosis, they will realize that
much is unreal. As the psychosis deepens, this distance is lost, and the inexplicable
becomes a reality that needs no explanations.
Spotting Medication-Induced Akathisia

Thus far, the focus has been on the somatic sensations and physiologic ramifications of
psychotic process. However, with the advent of antipsychotic medications, which have
remarkably enhanced our ability to decrease psychotic process, a new set of problems
has unfortunately appeared. Antipsychotics can negatively impact on the extrapyramidal
structures of the brain known as the basal ganglia (areas such as the globus pallidus and
putamen) that lie deep within the brain beneath the cortex; they are important brain
centers, regulating movement and many other activities.
Patients may develop significant movement-related side effects, especially with tradi-
tional antipsychotics such as Haldol and Prolixin, when the physiology of these brain
structures is adversely effected. These side effects are less common with newer atypical
antipsychotics such as Risperdol, Clozaril, and Seroquel, but certainly can still be seen
with these medications, sometimes quite severely. We already discussed one of these
extrapyramidal side effects in which the patient’s affect becomes blunted or flat (no
expression) secondary to an antipsychotic-induced Parkinson’s syndrome. We saw that
this blunting could be easily mistaken by an interviewer for the blunted affect so char-
acteristic of schizophrenia.
A second side effect, akathisia, can also confuse the initial interviewer, because it can
be mistaken for evidence of psychotic agitation. Akathisia is most commonly caused by
both typical and atypical antipsychotics, but it can also be triggered by other medications
including selective serotonin reuptake inhibitor (SSRI) antidepressants, as well as two
antiemetics. Akathisia represents a symptom in which patients feel that a part or all of
their body needs to move. It is a deep-seated feeling of restlessness. Generally it will show
itself as the physical sign of moving about in an agitated fashion, sometimes with a
smallish, prance-like step.
It is important to remember that akathisia is a subjective symptom, not a physical
sign. In this sense the patient may not always appear agitated or be pacing. Instead, the
person may only experience the unpleasant sensation of feeling intensely restless. By way
of illustration, if in addition to akathisia the patient has also developed the stiff-like
Parkinson’s syndrome described above, the patient may move very little, despite an
intense drive to move. Needless to say, this type of paradoxical situation creates an
extremely discordant sensation for the patient.
It is easy to mistake akathisia for psychotic agitation; consequently the interviewer
must be alert for it. When severe, akathisia represents a new and bizarre sensation that
a patient already having problems with psychotic process certainly could do without.
Some authors have reported incidents in which they felt that akathisia either worsened
a psychotic state or, at times, predisposed the patient to inflict self-damage, including
suicide.
In the following direct transcription, a young professional describes his experiences
with akathisia. At the time of the transcript he was no longer psychotic. When the medi-
cation had been utilized, he had been suffering from a frightening delusional system. He
had also been told about akathisia and its transitory nature, but his psychotic process
appears to have disrupted this information. I have never heard akathisia or its interplay
with psychotic process so eloquently described:
Pt.: I was very aware of a different kind of feeling from what I usually have. It felt as if
it was most immediately recognizable in the morning, in that I felt that I just
couldn’t go through with my normal morning routine, like taking a shower and
shaving and everything I do to get ready for work. It felt more like I couldn’t do it
because I couldn’t stand to wait that long, to go through those things which were
such routine motion.
Clin.: Like, what are some of things that were routine?
Pt.: Well, like standing under the shower. It just seemed impossible to stand under the
shower for any much longer and once I got done with the shower it seemed
impossible to stand there and dry myself.
Clin.: Okay. What do you mean when you say it wasn’t possible. What was it that you felt
would happen if you did stay there?
Pt.: That I would break out of my skin or something like that. But, uh, that I would be
so upset and unsettled that I would just be totally destroyed I think. It’s just very
unsettling.
Clin.: Now, did the experience change over time? In other words, were there parts of the
day where you would feel worse than other parts?
Pt.: It was pretty much general all day. When I got to work, I have a sit-down job. I do
remember that it was hard to stay put. It was really hard to sit. I do a lot of reading
in my job and it was very hard to concentrate on the things I have to read, and as a
consequence it made me feel ineffectual in my work. I just felt totally wiped out at
work. I felt like I really couldn’t keep working if I were to keep having this feeling.
Clin.: You mentioned the ineffectual feeling. Did you start to feel upset about being
ineffectual?
Pt.: Oh, sure. Yeah, I felt that I was going to be a failure, really, if I were to keep feeling
this way. I thought it would become evident right away to all the people around me
that I was really screwing this up and that I really couldn’t do my job anymore.
And, in fact, I even got a little panicky about that.
Clin.: Describe that to me.
Pt.: Yeah, I just felt like being between a rock and a hard place because the feeling was
that I had to sit there and keep doing my work because I was at work. On the other
hand, my body felt like I just couldn’t keep doing that anymore, and, uh, it was like
you were in a crisis every second is what it was really like. Between wanting to stay
there and do your job and being unable to do so.
Clin.: Did you have any fears that somehow or other that this state would not go away?
You know, that this was going to continue?
Pt.: Definitely. I had the fear that the drug had set off something in my system whereby,
even if I stopped the drug, that I was going to continue to have this feeling. What
was definitely very much a part of the feeling was the fact that how could I go
through the rest of my life feeling this way? That was very much a part of it.
Clin.: Now, what types of things did this sort of lead you to think then, that you couldn’t
do your work and that this state might not change?
Pt.: Uhmm, I felt depressed about it, and, uh, it led me to feel scared and afraid that
something was going to happen.
Clin.: Do you think that you got more frightened or nervous than you had been before?
In other words, did the unpleasant sensation increase your own anxiety just because
you were having it?
Pt.: Oh, yes. Definitely. I was very anxious being around other people, that they might
perceive that I was in this agitated state.
Clin.: Did you have any feelings that you should try to hurt yourself or that you might
hurt yourself? … because of the …
Pt.: Yes, it did seem, it did occur to me that it would be easier not to live than to live
this way. That probably seems really heavy, but that did occur to me. I did, I had a
resurgence of suicidal thoughts during those feelings.
Clin.: What kinds of things were you thinking at the time?
Pt.: Uh, usually blowing my head off. Really, I was thinking about that and just ending
it all because it just, I think every drug I ever took, I always had the fear that it
would do something, … that it would never go away again.
One aspect that can help the interviewer attempt to sort out akathisia from psychotic
agitation is the fact that akathisia represents a true bodily sensation. Patients will gener-
ally describe a need to move, an actual restlessness within the limbs. This is not generally
the case when the agitation is caused by psychotic process. If the patient lacks other
psychotic symptoms that could be triggering intense anxiety, then it is also more likely
that akathisia is the main problem. But at times the only way to distinguish akathisia
from psychotic agitation is to attempt to treat one or the other process. Fortunately with
the patient described above, the akathisia was greatly relieved by lowering the dose of
the antipsychotic.
Interviewing patients who are experiencing extrapyramidal side effects is often a daily
experience for mental health professionals across disciplines, especially if one works in
a community mental health center, an inpatient unit, or an emergency room. Let us now
turn our attention to a puzzling syndrome that a clinician is a great deal less likely to
see on a frequent basis, but is nevertheless important to understand. Indeed, it is its rela-
tive rarity that makes it important that we review interviewing techniques that can help
us to reach these patients when we do encounter it.
Establishing an Alliance With a Patient Experiencing Catatonia

In the 1800s, catatonia was a relatively frequently seen syndrome, especially if one was
walking the back wards of “insane asylums.” It is much less frequently encountered by
the clinicians of today. Nevertheless, it is encountered. When it is, contemporary clini-
cians must be prepared to help patients suffering from it. Skilled interviewing may be
the first step towards breaking the psychological chains that bind these patients so tightly
to a world beyond human interaction.
Psychotic process can disrupt the normal control of activity levels to an extreme degree,
resulting in aberrant patient behavior ranging from agitated catatonia, in which the patient
cannot stop moving, to stuporous catatonia, in which the patient shows little movement
at all. It is to this peculiar state of stuporous catatonia that we shall turn our attention.
At one time, catatonia was generally believed to be primarily associated with schizo-
phrenia. More recently, it has been viewed as a symptom complex that is not only seen
in schizophrenia but also in mood disorders, hysterical dissociation, and in a variety of
medical illnesses including autoimmune encephalitides triggered by infectious agents
and cancers.11
Stuporous catatonia is often associated with mutism, lack of movement, negativism
(as shown by a tendency to not comply with any requests), and ambitendency. This latter
trait reveals itself as a hesitancy to complete behaviors, demonstrated by actions such as
extending one’s hand to shake and then removing it. All of these behaviors have been
referred to as the “negative symptoms of catatonia” (not to be confused with the negative
symptoms of schizophrenia, described in the previous chapter).
Stuporous catatonia is also associated with the so-called positive symptoms of cata-
tonia (once again not to be confused with the positive symptoms of schizophrenia), such
as the holding of bizarre postures, the senseless repetition of the clinician’s words, and
waxy flexibility. This latter phenomenon manifests itself as a bizarre willingness to hold
one’s body in any position to which it is moved.
The initial interviewer is faced with the question of how to approach a catatonic
patient. It is not clear exactly what such patients are experiencing, and most likely the
experience varies from one patient to another. Apparently some patients seem well aware
of what is going on around them whereas others may be lost in peculiar feelings of
timelessness and autism.
When speaking with a patient experiencing catatonia, gentleness is imperative. It can
seem second nature to talk more loudly if someone is not responding to your questions.
Remain gentle in tone, calm in pace of your speech. Always keep in mind that the patient
may be processing your words quite effectively, either consciously or unconsciously. One
simply does not know. Consequently, speak normally and be sure to say whatever you
want to communicate, for the patient may not acknowledge what you are saying on the
spot, but he or she may be silently processing it in the moment or later that day. A simple
comment such as, “It’s okay not to talk now, but any time you feel like talking, please
do so. And feel free to ask any of the staff if I’m around. I’ll try to talk with you as soon
as I am available. It would be a nice thing to do.”
A logical question arises as to whether one should attempt a nonverbal technique
such as touching the patient. Generally speaking, I believe that in an initial interview the
answer is no, primarily because one simply does not know what these patients are expe-
riencing. If delusional or actively hallucinating, the patient may perceive the clinician as
attacking. Moreover, some of these patients can move almost immediately from stillness
into hyperactive states.
I am reminded of one such patient who I inadvisedly touched. She was lying on the
floor in an unresponsive state. We were concerned about the possibility of an overdose.
When she did not respond to loud questions, I shook her shoulders. To my shock she
immediately grabbed me and attempted to bite me. Apparently, drugs were not the issue.
However, in certain unusual instances the clinician may decide that it would be useful
to touch a catatonic patient. If such a decision is reached, then some simple principles
should be followed. In the first place, someone else should be in the room, and safety
officers should be aware that the patient may be unpredictable. The patient should be
told in a calm and reassuring voice exactly who the clinician is and what the clinician is
about to do. Patients should also be told why they are being touched and that if at any
point they want to be left alone they should simply say so. The clinician should be pre-
pared to quickly take evasive action.
I am reminded of a woman in her mid-30s, suffering from schizophrenia. During the
interview she sat with her head wrenched straight back while wincing with apparent pain.
For about 10 minutes she refused to answer any questions. Her neck continued to hyper-
extend, as her face further contorted in pain. A second clinician stepped in at this point
and said the following, “Ms. Jackson, I am one of the physicians here. I can see that you
are in some kind of pain. I am concerned that you may be having a type of drug side
effect (dystonic response to her antipsychotic), and I would like to see if I can help relieve
your pain. In a moment you will feel me touching the back of your head. I will be trying
to see if I can get your neck to move more freely. If you want me to stop, just tell me.”
The clinician proceeded to do just as he said, while continuously informing the patient
as to his next move. In about a minute, the patient’s neck straightened, allowing the
interview to continue, although she went on to speak in a disorganized fashion. Her neck
spasm was hysterical, not medication related.
II. The Psychological Wing of the Matrix

Auditory Hallucinations: Their Nature, Phenomenology, and Exploration
Auditory hallucinations are false perceptions of sounds, both human and non-human.
They represent one of the trademarks of psychotic process. To the layperson, the presence
of “voices” is practically synonymous with madness. To the clinician, auditory
hallucinations are one of the true hard signs of psychosis, although, as we have already
seen, they can be experienced by people without psychopathology.
As described by Waters in an excellent overview of auditory hallucinations, the most
common type of hallucination in psychiatric disorders is a voice.12 These voices may be
of people known to the patient, unknown to the patient, reality based (as with a family
member, political leader, or celebrity), or imagined (as with a god, a demon, or an angel).
The voices are commonly single words, but often contain complete sentences or ques-
tions and, at times, are quite complex, including multiple voices conversing (often com-
menting on the patient’s behavior) as well as voices with which the patient engages in
an ongoing conversation.
Hallucinations may also be nonverbal, composed of grunting sounds, machine noises,
unrecognizable sounds, and music.13 One of my patients, a college student suffering from
a psychotic bipolar disorder, told me that about 30 minutes before he would descend
into his most harrowing psychotic periods (characterized by vicious demonic voices), he
would often hear, very distinctly, the pleasant music of an ice-cream truck. He related he
could hear the truck approaching and leaving, and the music was indistinguishable from
the real thing.
He would later discover that he could creatively use this phenomenon as an early
warning sign of an acute psychotic worsening. As soon as he heard the ice-cream truck,
he took a prn (i.e., as needed) dose of his antipsychotic medication often effectively
short-circuiting the demonic voices. Quite remarkable and quite resourceful! It highlights
that each person must determine how to interact with his or her unique hallucinatory
processes. In this case the patient used one type of pleasurable hallucination – the music
of an ice-cream truck – to help him prevent the occurrence of a disturbing type of hal-
lucination – demonic voices.
Auditory hallucinations are commonly seen in psychiatric disorders. It has been
reported that 75% of patients with schizophrenia and between 20 to 50% of patients
with bipolar disorder experience auditory hallucinations. Many clinicians think of audi-
tory hallucinations in association with these two disorders, but it is important to realize
that they can appear with many other disorders. Approximately 10% of patients with
major depressive disorder experience auditory hallucinations and prevalence rates of up
to 40% have been reported for patients with post-traumatic stress disorder, generally
experienced during intense flashbacks.14
Determining whether a patient is having hallucinations, whether abnormal or normal,
is not as easy as one might think, because, for the most part, the clinician must depend
upon the patient’s self-report. As we have seen, errors in validity appear more frequently
when one must depend upon patient opinion as opposed to the elucidation of behav-
ioral incidents. Because of this, it may be best to start with a basic question regarding
the nature of auditory hallucinations, such as “Are they heard inside your head or outside
of your head?” The answer may come as a bit of a surprise.
The Directional Location of Auditory Hallucinations

For quite some time, clinicians tended to clump reports of auditory hallucinations into
two categories: pseudohallucinations and true hallucinations. This distinction may well
have found its most fertile roots in the writings of Karl Jaspers, whose work we encoun-
tered before in Chapter 10. Jaspers seemed to believe that there was no continuum
between hearing one’s thoughts and hearing true hallucinations. Patients either had hal-
lucinations or they did not. With true hallucinations he felt that two elements were
always present. First, the hallucination was substantial in the sense that it seemed real
and had many of the sensory qualities of a real perception. Second, the hallucination
seemed to occupy space. With an auditory hallucination, this suggests that the voice came
from a given area outside the head.
But Jaspers was incorrect, as Fish and others have pointed out, and modern clinical
experience has borne out.15–17 There does appear to be a continuum, and I have talked
with many patients with schizophrenia who describe their voices as “being in my head.”
In some instances, as the psychotic process progresses, these voices move out into space
and truly seem more real at that point. In other cases, the voices seem to be originating
either from inside or outside the patient’s head, often appearing to be quite real in either
circumstance. But the bottom line remains that auditory hallucinations can be experi-
enced in both ways. And the DSM-5 accepts both voices from inside and outside the
head as representing hallucinatory phenomena.
The concept of the apparent localizability of a hallucination might be better viewed
with regard to whether a voice is heard within the mind (which has no location) or
outside the mind (where a location can be assigned). With some patients, the voice is
heard only within the mind. In contrast, with many hallucinations the voice can be
physically located, and this location may even be reported as being inside the patient’s
head as with “A radio transmitter is broadcasting from inside my head, where my neigh-
bor implanted it.” The internal terrain of the body can actually represent a geographic
space and a source of hallucinatory phenomena in this regard. With other patients, the
voice is heard as coming through the ear, on the surface of the body, or anywhere in
external space.18
Copolov and colleagues reviewed the literature devoted to the location of auditory
hallucinations and performed a study on these phenomena. They found that 34.5% of
their patients reported hearing the voices inside their heads, 27.9% outside their heads,
and 37.6% both inside and outside; these proportions were similar to the previous
studies they reviewed.19 There appeared to be little clinical significance – in terms of
severity of symptoms and the patient distress – when comparing where the patients
perceived their voices originating.
There was evidence that patients who heard their voices internally tended to exhibit
better reality testing and distance from their psychotic process than patients who heard
their voices externally. Counter-intuitively, however, patients who heard command hal-
lucinations only externally, reported being able to resist the commands more effectively than
patients who heard them only internally or both internally and externally. We will discuss
the significance and techniques for exploring command hallucinations shortly.
On a diagnostic note, it is important to be on the lookout for the relatively rare dis-
order of dissociative identity disorder (DID; previously known as multiple personality
disorder). In this disorder, patients may internally hear the voices of their alters. Keep in
mind that if a patient reports hearing voices internally, it is unlikely that he or she has
dissociative identity disorder. It is much more likely that the patient has schizophrenia
or some other psychotic disorder. Note that in DID the voices will generally not be
imbedded in a psychotic matrix as described in Chapter 11. Thus in DID one does not
tend to see elements such as delusional mood, delusional perception, and other phe-
nomena suggestive of a budding psychotic process, a useful point for discriminating
between the voices of DID and the voices seen in psychotic disorders such as
schizophrenia.
The Reality of Auditory Hallucinations to the Patient
Auditory hallucinations are viewed as veridical perceptual phenomena, a term that
simply means that patients frequently are convinced of the veracity or realness of the
hallucinations. On the other hand, each patient is a unique individual and their distance
(insight) from these hallucinatory phenomena can vary. In an interview it is useful to
explore what a patient means if he or she comments that his or her voices sound real.
Such patients, upon more detailed interviewing, may tell the clinician that the voices are
quite real but do not sound exactly like normal voices. It is not uncommon for psychotic
patients to be able to identify their hallucinations as abnormal. Sometimes they may
even have names for them.
If a clinician is attempting to decide whether or not a patient is faking hallucinations,
these points become important. A patient who is malingering may tend to describe the
voices as sounding exactly like normal voices, which remains possible in psychosis but
is not typical. The malingerer may also describe the voices as happening all of a sudden,
unaware that hard psychotic symptoms usually have subtle prodromal phases such as
delusional mood and delusional perception. Moreover, the voices found in processes
such as schizophrenia are frequently hostile in nature and often hurl nasty and/or
obscene insults at the patient.
The following type of question can be useful in recognizing malingered
hallucinations:
“Have you ever found that, on a very good day when you have really been feeling fine,
out of nowhere, the voices start in on you, just like that, out of nowhere?” (a positive
response is suggestive of malingering)
Distinction Between Auditory Hallucinations and Auditory Illusions

The difference between auditory hallucinations and auditory illusions is the same as the
difference between visual hallucinations and visual illusions; this latter we discussed in
Chapter 11. An auditory hallucination occurs without any auditory stimulus, whereas an
auditory illusion is a distortion of an actual sound. Thus, an example of an auditory illu-
sion would be a paranoid patient hearing the words, “I hate you. I’m going to slit your
throat” when his friend actually said, “I’d never be late for you. I’m going to be exactly
where I told you I’d be before.” Obviously, an auditory illusion can be as frightening or
as dangerous as an actual auditory hallucination.
Another distinction should be made. There is an odd phenomenon known as a func-
tional auditory hallucination. In this process, an external sound triggers, sometimes fairly
consistently, an actual auditory hallucination. Both the triggering sound and the auditory
hallucination are heard quite clearly without any distortion.20 For instance, the sound of
a phone ringing triggers a hallucination of a neighbor’s voice denigrating the patient
from the next apartment. Both the sound of the phone ringing and the sound of the
neighbor’s voice are distinct and heard clearly without distorting one another. Thus, in
a functional hallucination, the extraneous environmental sound merely functions as a
trigger for the auditory hallucination.
The Uniqueness of Auditory Hallucinations
From the perspective of person-centered interviewing, it is critical to understand that
hallucinations, although they may share various characteristics among patients as we
have been describing, are, ultimately, phenomenologically unique to each person expe-
riencing them. In a wonderful paper, Stephane and colleagues21 have described the phe-
nomenological structure of auditory verbal hallucinations.
They found that voices vary along 20 phenomena and continua. For instance, voices
differ in their acoustic qualities from clear (like external speech) to deep (like internal
speech or thinking in words). Other acoustic qualities included the personification (male,
female, robot) and loudness. Another variable is of the time course of the hallucinatory
process (constant versus episodic). The linguistics of the voices can clearly vary as in the
syntax (first person, second person, or third person) and the complexity of the commu-
nication (hearing words versus sentences versus conversations). Yet another prominent
feature was what Stephane called the “affective relatedness,” a rather fancy name for
whether the voices were comforting or pleasurable versus frightening or bothersome.
Considering that Stephane and colleagues found over 15 other characteristics, one can
see that voices can present with remarkable variation from person to person. Table 12.1
summarizes Stephanes’s phenomenological categories.
Schneiderian Symptoms Related to Auditory Hallucinations

Kurt Schneider provides further insight into the qualities that may impact on how a
particular patient experiences his or her voices. As you will recall, three of Schneider’s 11
first-rank symptoms concern voices. One of these symptoms consists of the patient expe-
riencing audible thoughts. In this phenomenon, the patient hears his or her thoughts
just after having the thought, almost like an internal echo. Alternatively, the patient may
hear an undecipherable voice, the content of the speech only becoming clear a few
seconds after hearing it. The other two Schneiderian symptoms consist of arguing voices
and multiple voices commenting on the patient’s activities, patterns of hallucinatory
dialogue that are not uncommon in schizophrenia.
The Relationship Between the Patient and the Patient’s Voices
It is not only the clinician that has many questions to ask regarding voices. Each patient
experiencing voices is seeking answers to a plethora of pressing questions relating to his
or her personal relationship to the voices themselves. To the patient, each voice has its
own demands and supposed expectations, much like a family member or friend. Patients
are frequently searching for answers to the following types of questions: (1) Is this voice
real or unreal? (2) Who or what is creating it? (3) Does it mean me harm or good?
Table 12.1 Phenomenological Forms of Auditory Verbal Hallucinations.
FORMS DIMENSIONS CHARACTERISTICS
Acoustic qualities Clarity Clear (like external speech) vs. deep

(like internal speech/thinking in
words)
Personification Man’s voice, woman’s voice, or
other agent (alien, robot, etc.)
Loudness Softer vs. louder vs. similar to normal
conversational volume
Location Inner space In the head, or other parts of the
body
Outer space
Number of voices One, more than one
Direction Voices talk among themselves
Voices talk to the patient
Linguistic Syntax First (I) vs. second (you, name) vs.
third person (he/she, name)
Complexity Hearing words vs. hearing sentences
vs. hearing conversations
Content Range Repetitive vs. systematized
Focus Self vs. non-self
Order First order (hear voices)
Second order (talk back to the voices)
Third order (converse with the voices)
Replay Experiential (heard in real life)
Arising from patient’s speech
Arising from patient’s thoughts
Source attribution Self
Other Someone familiar, God/spiritual
being, or deceased person
Time course Time dimension Constant vs. episodic
Modulation Worsening vs. improving
Mode of occurrence Spontaneous
Triggered By intentional will or by other triggers
Happens when Speaking or listening to speech
Listening to non-speech sounds
Doing activities requiring attention
Control strategies Listening to speech or speaking
Listening to non-speech sounds
Doing activities requiring attention
Affective relatedness Comforting
Bothersome/intrusive
From Waters F. Auditory hallucinations in psychiatric illness. Psychiatr Times 2010;27(3):54–58. Based on Stephane M,
Thuras P, Nasrallah H, Georgopoulos AP. The internal structure of the phenomenology of auditory verbal hallucinations.
Schizophr Res 2003;61:185–193.
(4) Will it go away when I want it to go away or am I stuck with it? (5) Do other people
hear it? (6) Can it read my thoughts? (7) Does it want me to do something? (8) Must I
do what it wants?
Waters elegantly describes how the answers to such questions coalesce to create a
powerful relationship for the patient, a relationship that can match or exceed the impor-
tance of relationships with actual family members, friends, or society at large:
The content of voices is usually highly personalized. The voices frequently express what the
person is feeling or thinking and speak about his or her fears or worries. Psychiatric patients
view the content of voices to be meaningful and to have personal relevance. The voices are
interpreted to be the manifestation of real people or entities, and this experience contributes
to the intense emotional response to the voices. The personalized content and subjective
reality of voices play a role in the development of strong beliefs about the intent and power
of the voices, and a complicated and intense relationship frequently ensues between patients
and their voices.22
Patients search for answers to their questions about the nature of their voices upon their
very first “contact” with them. The following excerpt lucidly presents the eerie world
created by such a first meeting:
Seated on a steamer chair on the boardwalk of Coney Island, I heard the voice for the
first time. It was as positive and persistent as any voice I had ever heard. It said slowly,
“Jayson, you are worthless. You’ve never been useful, and you’ve never been any good.” I
shook my head unbelievingly, trying to drive out the sound of the words, and as if I had
heard nothing, continued to talk with my neighbor. Suddenly, clearer, deeper, and even
louder than before, the deep voice came at me again, right in my ear this time, and getting
me tight and shivery inside. “Larry Jayson, I told you before you weren’t any good. Why
are you sitting here making believe you’re as good as anyone else when you’re not? Whom
are you fooling? You’re no good,” the voice said slowly in the same deep tones. “You’ve
never been any good or use on earth. There is the ocean. You might as well drown yourself.
Just walk in and keep walking.” As soon as the voice was through, I knew, by its cold
command, I had to obey it.23
Uncovering and Sensitively Exploring Auditory Hallucinations

I find that sensitively and thoroughly exploring with a patient his or her hallucinatory
phenomena frequently enhances engagement significantly. Patients can sense when a
clinician truly wants to find out the nuances of their experiences and is not viewing the
patient as a mere “case” with symptomatic DSM-5 criteria, but as a unique individual
with highly personalized symptoms and beliefs about those symptoms. In addition, it
can be immensely useful to uncover the phenomenology of the patient’s hallucinations,
for subtle changes in this phenomenology may provide the first signs that a particular
antipsychotic or behavioral technique for minimizing the impact of voices is working
(decreases in the frequency or intensity of the voices, movements of the voices inwards,
increased distance from the voices, etc.).
In the last analysis, there exists no better method of learning about this topic than
the experience of asking questions about auditory hallucinations to numerous people,
ranging from psychotic to normal. Only in this manner will the clinician develop a sound
sense of the range of normal and abnormal responses.
The question now becomes one of, “How do we approach uncovering the vast array
of phenomena we have discussed above in a sensitive and effective manner?”
Sensitively Raising the Topic of Auditory Hallucinations

At the moment that an interviewer decides to raise the topic of auditory hallucinations
in a interview, one of two very different situations may exist: (1) to that point in the
interview, the patient has given no indication of being psychotic (the interviewer is not
particularly suspicious of psychosis, but is screening to see if psychotic process may be
present or has been experienced in the past), or (2) the patient has already given evidence
of psychotic process in the interview.
Let us explore the first situation. We have already seen that psychotic process, even in
disorders such as schizophrenia, can fluctuate greatly. The fact that a patient has not
appeared psychotic to that point in the interview does not necessarily prove that the
patient is not psychotic. Moreover, we have also seen that patients with personality dis-
orders such as borderline, schizotypal, paranoid, narcissistic, and histrionic personality
disorders may have experienced micropsychotic states in the past while appearing com-
pletely normal during the initial interview itself. Thus, all patients should be screened
for psychotic process in an initial interview; the trick is to raise the topic of hallucinations
in a sensitive fashion without disengaging them.
As we discussed, and I demonstrated in Video Module 4.1 in our chapter on facil-
ics, the following type of question is one of my favorite ways of raising the topic of
voices:
“When you are feeling very depressed, do your thoughts ever get so intense that they
sound almost like a voice to you?”
The clinician can substitute words such as “anxious” or “stressed” or “upset” for the word
“depressed” in the above question, choosing whatever emotion seems most appropriate
for a specific patient.
The wording of this question allows the topic to be broached in a non-affrontive
fashion, because the interviewer is tying the phenomenon directly into the patient’s pain.
It is further softened by the clinician’s use of the words “like a voice,” a phrasing that
offers a reassuring “backdoor” to the reluctant patient who might fear being viewed as
“crazy.” He or she might respond with something like, “Not really a voice, but sort of
like one.” If this is the case, further inquiry by the interviewer may reveal that the patient
is actually experiencing hallucinations.
Various other options exist for unobtrusively raising the topic of hallucinations
in a patient who has not demonstrated psychotic process to that point in the
interview. The following question is used in the Schedules for Clinical Assessment in
Neuropsychiatry24:
“Do you ever seem to hear noises or voices when there is nobody about, and no ordinary
explanation seems possible?”
Now let us turn our attention to the second situation – the patient has already demon-
strated psychotic material in the interview. For instance, a patient may already have talked
about a delusional system. In such situations, it is useful to try to seamlessly tie the
inquiry about auditory hallucinations to the patient’s delusional story. Thus, a patient
who has been describing paranoid delusions about a neighbor named Fred can be asked
the following question, “Do you ever hear Fred’s voice when he is not actually present
in the room with you?” or “Do you ever feel that Fred is trying to talk with you or direct
your thoughts from his house or when you are at work?”
Sensitively Exploring the Phenomenology of Auditory Hallucinations Once Raised
Once the topic of auditory hallucinations has been sensitively raised, the clinician faces
the important task of exploring the patient’s voices phenomenologically. This means that
an effort is made to better understand the uniqueness of the specific patient’s hallucina-
tions as described above, ranging from concrete characteristics (such as loudness, fre-
quency, and content) to more abstract characteristics (such as the patient’s relationship
with the voice or voices). The following questions, in whatever order seems natural to use
with a specific patient, can be used to explore the phenomenology of the patient’s voices
once raised in the initial interview and in subsequent sessions. Generally, it is not pos-
sible to ask all of these questions in an initial interview because of time constraints, but
you can pick and choose from this list:
a. “Tell me what the voices sound like to you.”

b. “Do they sound just like real voices or can you tell the difference?”
c. “How do you tell the difference?”
d. “Some patients tell me they hear their voices only inside their heads, and other
patients tell me they hear them only outside their heads, and some patients tell me
they hear them both inside and outside of their heads. How do you hear your voices?”
e. “Are they loud or soft?”
f. “How often do you hear them?”
g. “Are they male or female or something else?”
h. “Do you recognize who is talking to you?”
i. “Do you have a name for the voice?”
j. “What does the voice say to you?”
k. “Do your voices sometimes taunt you or say mean things about you?”
l. “Do they ever say nice things to you?”
m. “Does the voice ever tell you to hurt yourself?” (looking for command hallucinations
to self-mutilate such as enucleation of an eye or castration)
n. “Does the voice ever tell you to kill yourself?”
o. “Does the voice ever tell you hurt someone else or kill someone else?”
p. “Do you think they are real or do you think they are created by your imagination?”
q. “Do you wish they would stay or go away?”
r. “Do you do anything to try to stop them or make them go away?”

s. “When you first heard the voices, what did you think they were?”
t. “What feelings do you have as you hear the voices?”
u. “Do you ever hear several voices talking to each other about you?”
Although it is not possible, nor perhaps advisable, to cover all of these questions in an
initial assessment, when a patient relates hearing voices, one should always ask about command
hallucinations. Furthermore, if one becomes the treating clinician for the patient, the
above list becomes an excellent doorway, over the course of ensuing sessions, for achiev-
ing a better understanding of the patient’s hallucinatory phenomena.
Illustrative Transcript of a Clinician Exploring Auditory Hallucinations
To bring the above techniques and interviewing strategies to life, let us examine a brief,
direct transcript from one of my interviews. The patient, whom we shall call Kenney,
self-referred to a psychiatric assessment center during summer school. He was dressed in
a casual short-sleeved shirt with shorts that seemed to be a bit tighter than necessary.
Kenney presented with a pleasant affect, and an engaging naiveté, telling the charge nurse,
“I just stopped by because I think I might benefit from some counseling, I’m really feeling
uptight.” Apparently, Kenney had benefited from counseling provided by the outpatient
department associated with this assessment center a year earlier.
For the first 15 minutes of the interview, Kenney appeared like many other anxious
and over-worked college students, complaining of feeling overwhelmed at school and
overwhelmed by the prospect of dating, which he was terrified of doing but really wanted
to be doing.
Deeper into the interview, I decided to use a technique for indirectly uncovering psy-
chotic process, described earlier (tapping odd language or idiosyncratic phrasing – see
Chapter 11, page 474). I asked Kenney to explain in more detail what he had meant
when he had said earlier in the interview that, “the pressure I feel in my head to achieve
is so intense it’s like there is a guy inside me pushing me all the time.” I didn’t expect to
find anything psychotic, but I was just making sure, for the intensity of Kenney’s anxiety
represented a “soft sign” of potential psychotic process. I gently asked Kenney to explain
what he meant by the statement. To my surprise, my question tapped a veritable powder
keg of psychotic process. Kenney shared a highly disturbing delusional system in which
he believed he was possessed by a demon.
We will pickup the interview at a point where Kenney had been describing in some
detail the demon that had invaded him and at which juncture I decided to raise the topic
of auditory hallucinations. I used some of the questions listed above to better understand
the phenomenology of Kenney’s hallucinations. Note the way in which these questions
can help a patient to share the unique personal quality of their hallucinations. In this
instance, from a psychodynamic perspective, Kenney’s exceptionally overactive superego
distinctly flavors his hallucinatory process:
Pt.: The only way to describe it is … it’s another guy. And that’s a very good way to
describe it – it is another guy.
Clin.: Once again to me, it sounds like a very frightening type of experience – to feel like
there is this thing inside you. (said gently)
Pt.: Yeah, it is, like (pauses) … like, I mean I feel sorry for other people that it’s
happening to.
Clin.: Do you ever hear his voice?
Pt.: I don’t actually hear it. Well, I don’t actually hear it in my ears, but somehow I
hear it.
Clin.: When you are having that experience, does it sound exactly like your normal
thoughts, or are you quite aware that something different is happening and you are
hearing his voice?
Pt.: It’s a feeling, like … it sounds like my thoughts, but they’re a little bit different, the
way I hear them.
Clin.: And how do you hear them?
Pt.: They just seem to come to me. (reflects for a moment) … They just seem to come
to me.
Clin.: Does the voice ever tell you to hurt yourself?
Pt.: Yeah, that’s what it’s telling me.
Clin.: What exactly will it say?
Pt.: Well, he’ll say (pauses) … he’ll find another way to do it … Like he’ll say, like don’t
study, do bad on the test. And that’s his way of saying, “Hurt myself.” And once I
do bad on the test, it will be easy for him to talk to me. It will be hard to not listen
to him.
Clin.: It changes if you feel you have failed at some level?
Pt.: I can hear him louder.
Clin.: Does he ever tell you to cut yourself or to take pills or anything like that?
Pt.: He tells me a little bit, and it makes me feel that way also. He’ll hint sort of. No,
he’ll tell me, he’ll tell me.
Clin.: What will he say?
Pt.: He’ll say mostly, (whispers) “Do it.” He’ll say, “Do it.” Scary …
Clin.: Yeah, it is, I’m sure it is. (Kenney nervously smiles)
When first asked about command hallucinations (“Does the voice ever tell you to hurt
yourself”), it is fascinating to see that Kenney’s first response is that the voices command
him to hurt himself by hurting his grades, a clever punitive superego if ever there was
one! Only upon subsequent, specific questioning about physically dangerous commands
(“Does he ever tell you to cut yourself or to take pills or anything like that?”) am I able
to uncover commands that are much more dangerous in nature.
Exploring Command Hallucinations

Command hallucinations are defined as any voice that tells a patient to perform a specific
act. Such commands may range from telling the patient to go for a walk to imploring
the patient to harm himself or others. Their presence, in some instances (e.g., when sug-
gesting violence), may strongly suggest the need for prompt hospitalization, sometimes
immediately. Often knowledge of dangerous command hallucinations is not volunteered
by the patient, as witnessed by Kenney above. Consequently, the clinician must actively
inquire about their existence.
In the 1980s various papers purported that there appeared to be little or no statisti-
cal correlation between command hallucinations and dangerous activities such as
suicide.25–28 However, if one looks at these papers, it becomes evident that none of the
research carefully categorized the hallucinatory phenomena along the critical predictive
phenomenological variables that we shall examine below. Indeed, the research was
generally based on hospital charts, which are notorious for poor reporting of the nuances
of patient phenomenology. No one knows whether these voices were at one end or
the other end of the continuum of dangerousness. Consequently, the statistical analyses
were, in my opinion, essentially meaningless.
In contrast, a well-designed quantitative study by Shawyer and colleagues demon-
strated that some patients do, indeed, act upon command hallucinations, exactly as clini-
cians have reported over decades of experience.29 Furthermore, they isolated several
statistical factors that were correlated with an increased likelihood of a patient acting
upon his or her command hallucinations, including: increased age of the patient, the
view by the patient that the command is positive and will have beneficial results (e.g.,
killing a neighbor will end poverty), and that the command hallucination is tied in
tightly with a well-developed delusional system. In their study, antipsychotic medication
proved to be protective.
In addition, using a phenomenological research framework, Junginger directly inter-
viewed patients in great detail who had recently experienced command hallucinations,
to investigate the likelihood that a patient might act upon the command.30 Of the 20
patients who experienced dangerous command hallucinations, eight acted on them,
providing rather striking support for the potential dangerousness of command
hallucinations.
It is hoped that future research, well grounded both in phenomenology and empirical
studies, will provide better guidelines for predicting the dangerousness of command hal-
lucinations. However, even if better statistics become available, it is crucial to remember
that an act of violence is not merely a statistical event. It is a phenomenological one as
well, determined by the unique processes at work during a specific moment in time in
a unique individual’s psyche. Any given patient may kill himself or herself or another
person, whether the statistics suggest that he or she is at risk to do so or not. Apparently,
patients are not always aware of the statistical rules that they are meant to follow.
As we await better research studies to guide our predictions of dangerousness related
to command hallucinations, it remains the task of each individual interviewer to explore
the personal nature of the patient’s experience of his or her command hallucinations.
Such explorations, admittedly subjective in nature, may still represent our best chance
to reasonably foresee a dangerous act and potentially prevent it.
Phenomenologically speaking, command hallucinations are not black or white experi-
ences, in the sense that the patient either has them or does not. In actuality, command
hallucinations can differ in numerous ways. Some of the defining characteristics include
the content of the commands, the auditory quality of the commands (loudness, duration,
and frequency), the degree to which the patient feels able to resist the commands, and
the emotional impact on the patient (does the patient know the voice and what is the
patient’s perceived attitude of the voice towards himself or herself). In my opinion, all
of these variables could have an impact on how dangerous the command hallucinations
might be.
With these variables in mind, command hallucinations can vary from being relatively
innocuous phenomena with little frequency and impact on the patient to dangerous
phenomena in which the voices incessantly hammer at the patient in an effort to provoke
violence. Some people who suffer from chronic schizophrenia have adapted to their
voices and pay them little heed. I am reminded of a 65-year-old vet I was initially inter-
viewing to follow in a VA clinic, who, when asked about command hallucinations,
responded, with a twinkle in his eye, “Doc, don’t get bent out of shape. The Devil has
been telling me to kill myself since I was 16 years old. I didn’t listen to him then, and
I’m sure as hell not gonna listen to him now.” His command hallucinations, even though
related to violence, were of minimal concern. At the other end of the continuum,
command hallucinations can be acutely harassing, loud, insistent, and dangerous. The
question now is: How do we explore the characteristics of these potentially dangerous
phenomena?
Exploring the Content of Command Hallucinations
Command hallucinations can clearly vary in dangerousness depending upon their
content. Any voice that tells the patient to do something is a command hallucination.
On the benign side, the voice might command the patient to “Shut the door,” or “Change
your profile picture on Facebook.” On a more humorous note regarding ourselves, it is
not uncommon for a voice to tell a patient during an interview, “Don’t listen to this guy,”
or “Don’t answer his questions, he’s an idiot!” At the other end of the continuum,
command hallucinations can push for highly dangerous activities towards the self (“Cut
your eye out!” or “Just shoot yourself, just pull the damn trigger, you asshole!”) or
towards other people (“Push him in front of the subway!” or “Slit his throat!”). Swearing
and viciousness commonly accompany command hallucinations, in some instances
increasing the likelihood that the patient may act upon them because of the ferocity of
their tone.
Clearly, the more dangerous the content, the more concern for safety the clinician will
have. However, even if the commands are quite benign, once a voice has begun to give
commands the clinician should routinely follow up with the patient in future sessions,
to see if the voice advances from benign to dangerous content. Once command halluci-
nations have begun, such an advance towards violent content may be forthcoming.
With command hallucinations, the simplest of questions is often the best for their
elicitation, such as, “Do your voices ever tell you to do things?” If the patient answers
yes, then one can simply follow up with, “What do they tell you to do?” No matter
what the patient says, at some point it is important to ask specifically about dangerous-
ness, as with, “Do the voices ever tell you to hurt yourself or kill yourself?” This can
then be followed by, “Do the voices ever tell you to hurt others or that you should kill
someone?”
Exploring the Auditory Quality of Command Hallucinations
To some degree, the auditory quality of hallucinations can influence the amount of pres-
sure they place upon the patient to act on them. I have been surprised at how loud
patients report some hallucinations to be. Loudness, long repetitive duration of the com-
mands, and high frequency of occurrence, especially if the patient reports being inces-
santly barraged by the voices, may all contribute to a greater likelihood of a patient acting
upon the commands.
Once again, simple questioning around these issues are often the best such as, “How
loud do the voices get?”, “How often do you hear the commands?”, “Does the voice
repeat the commands to kill yourself over and over?”, “Does the voice insist that you
do so?”
Keep in mind that even though louder more frequent voices may be more compelling
with most patients, for some patients even a whispered command may be enough to
trigger violence, especially if it is being whispered by a highly valued or respected source.
Exploring the Degree to Which a Patient Feels Able to Resist a Command Hallucination
Patients may have surprisingly good insight into their ability to resist the entreaties of a
command hallucination. It behooves clinicians to collaboratively tap their potential
wisdom. Patient reassurances that they will not act are important, but limited in reli-
ability. Conversely, patients’ perspectives that they are not going to be able to control
their urges to act should be taken very seriously. Indeed, sometimes the fear a patient
has that he or she is about to do something that, at heart, he or she does not want to
do is almost palpable to a clinician. Such patients are often relieved to be hospitalized;
indeed, hospitalization is often required in these situations, whether voluntary or
involuntary.
I find the following questions to be of value, and the interviewer can use any one or
a combination of them. (Let us assume here, for the sake of clarity, that the patient has
been describing voices coming from Satan.)
1. “To what extent do you think you can stop yourself from doing what Satan is asking
you to do?”
2. “How concerned are you that you are going to do what Satan is asking you to do?”
3. “Should I, you, or your family be worried that you are going to do what Satan wants
you to do?”
Another useful follow-up to these questions is, “Have you done anything to stop yourself
from doing what Satan is asking you to do?” To such a question, a patient might respond,
“Yeah, I took all of the knives in my house and put them in a shoebox and taped it all
up with duct tape. Then I put it away up in the attic in a spot that is really hard to get
to.” Such a response provides some hints of safety, for it clearly shows that the patient
is trying to protect himself and/or others. Looking at the dangerous side, however, the
answer reveals how real the voice appears to the patient and the extent of the patient’s
own concern that he or she may act upon the command hallucinations. In either case,
it is worthwhile information for the interviewer to know.
Exploring the Emotional Impact of Command Hallucinations on a Patient

Patients can respond with surprising diversity to their command hallucinations. If you
will recall the 65-year-old vet I described earlier, he had grown accustomed to the Devil’s
jabber and essentially ignored it. His unconcerned response to a voice ascribed to a figure
as culturally potent as the Devil is atypical in my experience, yet nicely highlights the
uniqueness of each patient’s response.
One avenue to explore is the importance and/or authority that the patient ascribes to
the owner of the voice. When the voice is attributed to a powerful personal figure, whether
alive or deceased (father, mother, spouse, intimate friend), well-known cultural icon
(political figure, president, pope, or revered Hollywood icon), or an imagined supernatu-
ral figure (God, Satan, demon or angel), the patient may feel more pressure to comply
with the orders of the voice.
This can be particularly dangerous, as implied by the research of Shawyer and col-
leagues, if the authoritative figure is tied into a concrete delusional system in which some
greater good will occur if the patient complies with the entreaties of the voice. For
instance, the patient may hear God saying that, “world peace will occur, if only you would
slay your newborn child.” Or a similar but contrasting example might be that during a
postpartum psychotic episode, a mother believes that her newborn has been possessed
by Satan and hears Satan yelling incessantly, “If you don’t slit your own throat, I will
torture your baby forever here and in eternity.”
In addition to the patient’s view of his or her relationship to the voice and the appro-
priateness to do what the voice wants to be done, the patient’s perceived relationship to
the owner of the voice as reflected by the actual tone of voice of the hallucination, may
play a role in the dangerousness of the command hallucinations. In this respect, particu-
larly vicious voices with denigrations, exhortations, and a malevolent tone of voice can,
in my opinion, break down a person’s natural desires to resist a voice. Indeed, a patient
harangued incessantly by a voice may kill themselves to escape the voice or because the
person is worried that he or she is about to give in to the voice’s exhortations to hurt or
kill another person. Throw some alcohol, street drugs, or sleeplessness into the picture
and we may have an imminently dangerous situation.
Psychotic Disruptions in Cognition, Logic, and Communication

Besides abnormalities of perception, the psychotic patient’s thought process itself is often
disrupted by the psychotic process. Thoughts may become speeded up and racing in
nature, as is also seen in mania. It becomes difficult to concentrate as evidenced by the
following patient description:
I just can’t concentrate on anything. There’s too much going on in my head and I can’t
sort it out. My thoughts wander around in circles without getting anywhere. I try to read
even a paragraph in a book but it takes me ages because each bit I read starts me thinking
in 10 different directions at once.31
This excerpt also hints at another disquieting characteristic sometimes seen. Psychotic
thinking has an internally “contagious” quality to it, in the sense that it triggers a mul-
titude of associations, sometimes close in nature and at other times distant and dis-
jointed. This trend of creative but dystonic associations, which are not under the patient’s
control, is nicely captured in the following excerpt:
My trouble is that I’ve got too many thoughts. You might think about something – let’s
say that ashtray – and just think, oh yes, that’s for putting my cigarette in, but I would
think of it and then I would think of a dozen different things connected with it at the
same time.32
This internal abnormality in thought process will frequently show itself externally with
a loosening of associations (derailment) in the patient’s speech. The characteristics of
derailment will be examined in detail in Chapter 16 on the mental status.
At other times, thought processes may become, perhaps because of the previously
mentioned abnormalities, somewhat disrupted. Patients may stop in midsentence and
be unable to return to their original topic. This process, mentioned earlier, is known as
thought blocking. It represents a strongly suggestive sign of psychosis. It is useful to
quietly ask patients what has happened at these moments. Sometimes the patient’s
thought has been disrupted by an auditory hallucination. At other times the disruption
is related to the patient experiencing thought withdrawal.
It is important to know if a patient is actively hearing voices during the interview,
because the patient may feel that the clinician is producing the messages. Generally, it is
not good for rapport to be perceived as commenting, “You’re a drunken slob,” or threat-
ening, “I’m going to chop off your fingers.” This actively hallucinatory state represents
the type of situation in which violence can erupt towards the interviewer.
It has already become apparent that the patient’s thought processes are frequently
affected during a psychosis. Another common problem is the presence of truly illogical
thought. One of the more frequent breakdowns in formal logic is the appearance of what
Rosenbaum has called predicative thinking. This means that the person views things as
similar or identical because they are connected by the same predicate (verb). The follow-
ing example shows this process at work:
Major premise: Jesus Christ was persecuted.
Minor premise: I am persecuted.
Conclusion: Therefore, I am Jesus Christ.33
Other distinct problems with logic, as well as the emergence of magical thought as seen
in young children, frequently accompany psychotic process. But it is not necessarily a
phenomenon that is either present or not present. Many patients will demonstrate
varying degrees of normal logic.
How to Safely Interact With an Illogical, Agitated Psychotic Patient

The recognition that a psychotic patient may be losing their ability to think logically is
of immediate practical use when approaching a patient who is both psychotic and agi-
tated. It is probably a mistake to assume, before talking with the patient, that he or she
either can or cannot be talked down. Instead the interviewer should gently attempt to
engage the patient in conversation. While doing this, the clinician can decide to what
degree the patient’s logic is intact. If it is reasonably intact, the interviewer may try to
talk with the patient and perhaps alleviate some of the patient’s anger. If, with this
technique, the patient’s anger begins to escalate or if it becomes subsequently apparent

that the patient’s logic is severely impaired, it is probably best to quickly back off from
the patient and proceed with appropriate safety procedures.
To further attempt to reason with such a patient does not make much sense, because
the patient is not processing the clinician’s words in a normal fashion. Further interac-
tion may push the patient towards violence. The key lies in carefully assessing the impact
of one’s interaction and proceeding appropriately.
A similar situation arises if the clinician discovers that the patient has incorporated
the clinician into a delusional system. This brings to mind a patient whom I observed
in an interview as a supervisor. She had a ragged appearance and sat in her chair spitting
her words into a hostile world. As soon as I sat down she yelled out, “You’re the one
who called me a prostitute the other day. You’re the one who has been spying on me!”
I had never seen her before, and even if I had, I would not have spoken to her as she
was suggesting.
No matter what I said in my defense she immediately grew angrier, and so I quickly
shut up. Such a retreat is not only the better part of valor, but also represents a sound
clinical maneuver, because this patient was not hearing a word that I was saying. It
becomes easier to understand her hostile position if one realizes that she truly believed
that I had belittled her publicly. Clinicians cannot quickly detach themselves from such
a delusional web.
Unobtrusively Screening for Paranoid Process, Delusions, and Other Psychotic Process
The initial interviewer has much more access to the process of blending with non-agitated
patients than with agitated patients. The question then becomes one of: How does one
broach the subject of paranoia without offending a patient who has not shown signs of
psychotic process to that point in the interview? The art is to enter the topic of paranoia
by keying off the content of the patient’s conversation, utilizing natural, implied, or
referred gates as follows:
Pt.: I don’t know what to do with myself. I just, I just feel the whole thing is a mess.
Probably, I don’t know, probably the baby is not even aware of our arguments.
When we were first married, everything was so much better. But when the mill shut
down a third time and he lost his job for good, well it all became history.
Clin.: It sounds like an ugly situation at home. Has the tension ever gotten so bad that he
has struck you?
Pt.: Thank God no. I’d leave him, honestly I would.
Clin.: Do you think that in any way he is trying to hurt you, perhaps even trying to get
your friends against you?
Pt.: Oh he’s tried to hurt me in the sense of making me feel guilt, but he knows better
than to mess with me or my friends.
In this subtle fashion, the clinician has smoothly made a foray into the region of para-
noid process. The patient’s comments do not suggest the presence of paranoid ideation.
There is probably no need to explore further for paranoia. With questioning such as that
shown above, most paranoid patients would probably have nibbled at the “bait.” The
clinician has scouted for paranoid ideation without the patient having any idea that such
an exploration of psychotic material has occurred.
This leads to the issue of broaching psychotic topics other than paranoia in a non-
threatening fashion. For most interviewers this type of questioning is most difficult when
interviewing a patient in whom the clinician doubts the presence of psychotic process.
Some authors have suggested that interviewers should never ask questions about voices
and other psychotic phenomena unless they strongly suspect their presence. To do so,
they argue, will disengage the patient.
But, as we have already noted when we were discussing the life cycle of a psychotic
process in the previous chapter, damaging psychopathology may be missed with such an
approach. Psychotic process can fluctuate in disorders such as schizophrenia and bipolar
disorder. Or it can be infrequently experienced as micropsychotic episodes seen with
some personality disorders. Such patients may look remarkably intact during any given
interview. For instance, if the interviewer chooses to not screen for psychotic process in
the initial interview, he or she risks missing a painful yet treatable disorder such as
schizotypal personality disorder.
There are other reasons that I have my doubts about such blanket avoidance of this
area of questioning. In the first place, I have seldom, if ever, seen such questioning result
in any lasting problems with engagement in a nonpsychotic patient. I have seen a handful
of patients balk at it, but with skillful engagement techniques, the blending is quickly
restored. Moreover, most patients do not seem offended at all. Thus I generally ask all
my patients about psychotic process at some point in the initial interview
But there is another reason to ask about psychotic phenomena, even when psychosis
is not apparent – a very practical one. When patients do initially balk at such question-
ing, their emotional over-reactions provide a window into their defenses and psychody-
namics, as seen in the following reconstructed dialogue. Let’s return for a moment to an
interviewer raising the topic of auditory hallucinations. The interviewer happened to be
me, and I was using one of my favorite questions for doing so:
Pt.: Let’s get it straight, things have been tough all over for everybody involved and I’ve
been damn upset.
Clin.: When you are really feeling upset, have your thoughts ever gotten so intense and
bothersome that they sound almost like a voice?
Pt.: Oh great, here come the crazy questions (said angrily). Well I got news for you. I’m
not crazy and I’ve been asked all those questions before. (The patient reaches over
and squeezes her boyfriend’s hand, smiling at him while subsequently tossing a
little sneer towards me.)
This hostile display was far from the typical response that I generally receive to this ques-
tion. Indeed, it suggested to me that, from a psychodynamic perspective, this patient was
experiencing a narcissistic insult from my question. It led me to wonder why she might
need to do so, opening a window into an interior pain that might lie just below the
surface of her anger.
Her atypical response alerted me to be particularly gentle with future questions as
well as suggesting the wisdom of looking for possible personality dysfunction in my
subsequent social history later in that same interview. Such idiosyncratic responses may
suggest the expansion of diagnostic categories not considered earlier. In this case, further
interviewing revealed that she was coping with a full-blown borderline personality.
Once entering the facilic content region regarding psychotic process, it is not necessary
to beat it into the ground. Quickly, the clinician will achieve some idea as to whether
the region is worth expanding further. If hints of psychotic process emerge, then a full
expansion may be warranted. If no hints emerge, the topic may be left after only a few
probe questions. Part of the art lies in learning how to smoothly enter these psychotic
regions.
Some questions that may be used effectively as gates into psychotic material are shown
below:
a. “Have you had experiences that seemed odd or frightening to you?”

b. “Earlier we talked about your nightmares. Have you ever had similar types of fright-
ening images bothering you during the day?”
c. “You had been talking about some of your talents. Have you ever felt that you had
some unusual abilities such as ESP?”
d. “You mentioned earlier that one of your favorite activities is watching TV (or YouTube).
Have you ever been frightened by the TV (or YouTube)?” Depending on what the
patient says, one might pursue this with a question such as: “Did it ever seem like
the people on TV (or YouTube) were watching you or that they literally were aware
of private aspects of your life?”
e. “When you are on Twitter, do you ever feel that tweets from strangers or famous
people are actually about you or directed to you personally?”
f. “You had mentioned earlier that your sister had apparently been hearing voices. Have
you ever had similar experiences?”
Another excellent method of entering psychotic material is through the discussion of

religious issues as shown below:
Pt.: I have always been a fairly religious person. My father was a devout Lutheran.
Religion runs in our family.
Clin.: On a moment-by-moment basis, how much is God a part of your life?
Pt.: (long pause) He is my life and my breath, so be it.
Clin.: It sounds like He is a very important part of your life. Sometimes people who are
close to God feel that He has a special mission or role for them to play. Do you feel
that you may be lucky enough that God has such a role for you?
Pt.: Yes, I do. I am to bring peace to all nations. And I shall bring a calmness to all that
I touch.
Clearly it would be worth exploring the psychotic region more thoroughly with this
patient. But the important issue from our viewpoint is the naturalness of the gate pro-
vided by religious discussion. Even as the topic was first entered, the intensity of the
patient’s feelings probably suggested to the clinician that something was up.
Understanding the Demoralization and Self-Denigration Spurred by Psychotic Process

Thus far we have focused on the complex impact of psychotic process on specific aspects
of psychological functioning, such as perception and thought process. This impact is
indeed both terrifying and terrible. But what of the “self”? What is the impact of chronic
psychotic process and of the deficit (negative) symptoms of diseases like schizophrenia
upon a person’s self-image and self-respect?
In many ways, I feel that this impact is the most damaging of all. As we saw earlier,
the negative symptoms of schizophrenia, such as low interest, low drive, and low energy
are powerful and insidious, often lingering indefinitely, long after the voices and delu-
sions have faded. Almost all people coping with schizophrenia initially view these symp-
toms not as part of the disease but as symbols of their own inadequacy as people. As the
deficit symptoms make it difficult, and at times impossible, to work, people frequently
get caught up in a vicious process of self-belittlement. Sometimes frustrated and weary
family members feed this cycle by misinterpreting these negative symptoms as laziness
and psychological weakness, and they wonder, “The voices are gone so why doesn’t he
just get a job and get on with his life?”
As patients watch their siblings and friends go on to develop successful marriages,
careers, and identities, they find themselves left behind in a race that seems unwin-
nable. It is very easy, and all too human, to decide it is not worth the risk of failure
to enter such a race. The patient soon finds himself or herself intensely afraid of
further humiliation. Many patients find themselves lost in a labyrinth of self-doubt,
and they often adopt a role as “the black sheep” of the family. This intense demor-
alization, which is often at its worst between psychotic episodes (when the negative
symptoms adamantly persist), is often the prelude to suicide, as we shall discuss in
Chapter 17.
Schizophrenia rapes the soul. From the very first interview, it is important for the
clinician to remember that one of the main tasks in intervention is to help the
patient heal this pain and to believe in himself or herself again. People with schizo-
phrenia should not be pitied. Indeed, some of the most courageous and “tough”
individuals whom I have had the pleasure to meet are coping with this traumatizing
disease with dignity and resourcefulness. This recovery process begins in the very first
interview.
For the clinician it begins with the realization that we are all “people” first. The
patient’s “diagnosis,” albeit very important, plays a secondary role in our understanding.
This feeling grows, with experience, as we clinicians truly realize that the person in front
of us is not a medical term but a person just like ourselves. We, too, or our friends or
family members, could develop bipolar disorder or schizophrenia. Like death, mental
illness respects no social, educational, or economic boundaries.
For the patient, it begins with a realization that he or she is not a disease entity but
a person coping with a disease. In this sense, I think that it is best for both the clinician
and the patient to abandon terms such as “schizophrenic.” Such terms insidiously lead
to stigmatization and identification with the disease. I have never met a schizophrenic.
But I have met many different people coping with schizophrenia. This distinction may
be subtle, but it is telling.
I am convinced that this sense of respect and empowerment from a clinician shows
through in the very first encounter with the patient. Clinicians who convey this perspec-
tive often have much more success both in the initial interview and in all subsequent
work. Clinicians who do not convey this feeling are often sitting alone in their offices
during follow-up appointments.
This perspective is elegantly described by Patricia Deegan in an article that I highly
recommend, “Recovery: The Lived Experience of Rehabilitation”:
It is important to understand that persons with a disability do not “get rehabilitated” in

the sense that cars “get” tuned up or televisions “get repaired.” Disabled persons are not
passive recipients of rehabilitation services. Rather, they experience themselves as recovering
a new sense of self and of purpose within and beyond the limits of the disability. This
distinction between rehabilitation and recovery is important. Rehabilitation refers to the
services and technologies that are made available to disabled persons so that they might
learn to adapt to their world. Recovery refers to the lived or real life experience of persons
as they accept and overcome the challenge of the disability.34
The understanding, from this section, of the damage incurred on the psychological wing
of a patient’s matrix is at the very heart of the healing process that first begins in the
initial interview. It also conveys the delicate interplays that occur between individuals
dealing with chronic psychotic disorders and the people around them. Let’s take a closer
look at these interactions in a broader sense.
III. The Dyadic Wing of the Matrix

Uncovering Social Withdrawal and Recognizing Social Inappropriateness
It is not infrequent for people with psychotic process to become socially withdrawn. In
particular, when the psychosis is secondary to schizophrenia, episodes of social with-
drawal are extremely frequent.35 This social withdrawal could be related to the tendency
for the patient to enter a more autistic world. In an effort to sort out the tremendous
number of peculiar sensations and thoughts, the person suffering from a psychotic
process may find it necessary to withdraw. Social contact becomes painfully disruptive.
In other patients in whom aggressive drives may be building to a pitch, people may be
avoided because of a fear of loss of control.
However, there is another aspect to this entire issue that brings us directly to the
dyadic system itself. Frequently, people coping with schizophrenia will display behav-
iors that are socially inappropriate. As we saw in Chapter 8 on nonverbal behavior,
psychotic patients often show some disturbance in the normal nonverbal rules of
conversation. This may range from sitting or standing inappropriately close to the
clinician (creating an uncomfortable sense of immediacy in other people) to display-
ing odd or restricted affects (creating a sense of puzzlement or disconnectedness in
other people). Because of the tremendous need of these patients to attend to the
troubled thoughts in their own minds their ability to empathize is frequently strikingly
diminished.
The Impact of Psychotic Process on the Interviewer’s Emotions and Behaviors

Clinicians should also be aware of their own feelings of confusion that may develop as
they interview patients experiencing psychotic process. This confusion in the clinician
may be caused by psychotic processes in the patient, such as a subtle loosening of asso-
ciations or bits of illogical thought. If the clinician can recognize his or her own subjective
feeling of confusion, then a more thorough pursuit of psychotic process and content may
be wise. The confusion in the clinician mirrors the confusion or disorganization of the
patient.
A word of caution seems in order here. Clinicians lucky enough to be gifted with a
particularly intuitive sense of empathy can fall into a trap. The patient may be displaying
subtle signs of disorganized thought, but the clinician ignores these signs because he or
she understands “what the patient is thinking.” Indeed the clinician might understand;
however, the patient is still psychotic. When hunting for evidence of formal thought
disorder (problems in the formation of thought such as a loosening of associations), the
question is not whether we understand the patient but whether a non-professional,
perhaps sitting beside the patient on a bus, would understand the patient. At the other
extreme, sometimes a well-trained clinician will recognize a formal thought disorder
before it would even be evident to a layperson.
All of the above disturbances in dyadic communication may lead to an uncomfortable
sensation in a clinician. The sensation has been described as not being able “to feel”
with the patient, in short, an inability to experience an empathic bond with the patient.
This peculiar sensation has been called the “precox feeling.”36 It is felt to be particularly
suggestive of schizophrenia. Used appropriately, as an intuitive guide suggesting the need
to carefully explore for the criteria of schizophrenia, the precox feeling is a useful tool.
It should never be used as a criterion of schizophrenia or as a justification for labeling
someone as having schizophrenia.
People with psychotic process can also create feelings of frustration in the initial
interviewer. This may result when the patient’s lack of insight results in the patient reject-
ing avenues of help such as case management, psychotherapy, medication, or hospitaliza-
tion. It can be particularly frustrating to work with a paranoid patient who clearly needs
help but feels strongly that “nothing is wrong with me.”
In these instances, it is important to accept the naturalness of one’s frustration while
avoiding a demonstration of this frustration to the patient. These countertransference
problems tend to surface as extensive and sometimes heated attempts to convince the
patient of his or her illness. Such attempts are probably far more counterproductive than
they are productive. It is often best to calmly discuss one’s views and then acknowledge
openly that the patient and oneself seem to have a difference of opinion as with:
“Well, we obviously disagree on whether or not you have bipolar disorder, and that’s
okay, we can agree to disagree (said calmly and with a genuine sincerity). I will always
share with you what I really believe, and I know that you will do the same with me.
And I appreciate your doing so today. We simply have differing opinions on this, and
you are certainly entitled to your own opinion. And, of course, I could be wrong. Only
time will help both of us to sort out exactly what is going on.”
The patient should know that if he or she feels a desire to talk again or experiences a
change of opinion, that the clinician is always available for another meeting.
Frustration may also evolve when the interviewer feels that a patient is somehow in
control of the psychotic process, “flipping it on” when it is advantageous to do so. At
some level this manipulation may actually occur on both the conscious and unconscious
plane.
I remember a man about 30 years old who initially spoke in a disorganized and
delusion-littered fashion. As he felt more comfortable with me his thinking became more
organized. When I subsequently probed even in a subtle fashion into his personal life,
he would quickly become disorganized and mumble about “the cheesedogs that were
going to drop a nuclear warhead on Pittsburgh.” Oddly enough I do not think he was
particularly conscious of this process.
One can better conceptualize such behavior if one assumes that at some level, to the
degree that the patient has both insight and motivation, the patient may be able to par-
tially rein in psychotic process. I believe that this tendency to hide potentially embar-
rassing psychotic material would be a natural one. This self-modulation must require a
considerable amount of effort and concentration. Perhaps at times, and depending on
the interpersonal situation, the patient might find it simply easier to just let things go as
they may. At such points, the psychotic process may emerge in a more pressing fashion
as seen above. To the degree that we understand this process, our frustration levels may
decrease.
Frustration may also arise with patients suffering from schizophrenia who are persis-
tently negative during the interview. As Michels suggests, the interviewer may gently point
out that automatically saying “No” to everything is as much a relinquishment of control
as saying “Yes” to all the clinician’s requests.37 Jointly agreeing upon a topic to discuss
may also open up avenues for better engagement.
The Impact of the Interviewer’s Behaviors on Psychotic Process

Thus far the emphasis has been on the patient’s effect on the clinician. With patients
dealing with psychotic process, it is also important to realize that clinicians may need to
monitor their own impact on the patient. In Chapter 1 (see pages 23–27) we discussed
in detail some of the changes in style that may help to facilitate blending with paranoid
patients, such as decreasing the use of empathic statements with a high valence regarding
implied certainty or intuited attribution. It is also important to realize that, because of
disturbances in logic and reality testing, normally well-received statements by a clinician
may be hostilely received. Michels points out, for instance, that with one of his patients
the word “leg” had taken on a highly sexualized meaning.38 Consequently, when the
clinician would use the word, it was received as a sexual topic, probably carrying a variety
of unwanted overtones.
Sometimes when people struggling with psychotic process are cooperative but fright-
ened, it goes a long way to simply reassure them that they are in a safe environment.
Especially if such patients are disorganized as well as frightened, it is useful to tell them
what is happening, to ask them to raise any questions they may have, and to structure
the interview for them. If the patient is forced to handle an unstructured interview, filled
with open-ended questions, gentle commands, and pregnant pauses, the interview itself
may become traumatizing. Gentle structuring will sometimes actually result in a more
organized production of speech as the psychotic defenses recede.
Along similar lines, in some instances an empathic interviewer may so decrease the
anxiety level of a subtly psychotic patient that the observable psychotic process temporar-
ily disappears or recedes significantly. Ironically, the clinician’s style will have distorted
the clinical picture, amply reminding us that as the interview proceeds we become a part
of the dyadic system, whether we intend to or not. In a similar fashion, an involvement
with the psychotic process itself awaits the friends and family members of the patient.
Unfortunately, unlike clinicians, they are not generally trained to handle such bizarre
interactions.
IV. The Familial, Cultural, and Societal Wing of the Matrix

Understanding the Exquisite Pain of Family Members
Psychosis, despite its propensity for autistic withdrawal, is a family matter. No person
in the immediate vicinity of the patient will be able to remain uninvolved for long.
Few processes can so ravage a family and its underlying structure. This is particularly
true when the process is chronic in nature such as with schizophrenia or bipolar
disorder.
It is hard to put into words the exquisite pain of watching a child or spouse being
tortured by psychotic process. The pain is heightened further once a family member
understands that the heart-rending process may continue for years or even be life-long
in nature. Both the dreams of the patient and of his family are sometimes forever
destroyed, a remarkably traumatizing experience for parents, siblings, and the patient.
This devastation will rapidly intensify as the family members try to cope with the
damaging matrix effects caused by the psychotic process in their loved one: potential
financial ruin for themselves, the need for their child to sometimes live at home even as
an adult, and stigmatization from both culture and friends. In addition, almost all
parents must cope with two powerfully demoralizing processes: a numbing feeling of
helplessness and a sometimes-overwhelming caretaker fatigue. For these reasons, family
members will be not only an invaluable source of information for helping our patients
but also a targeted group for therapeutic intervention and healing by our teams.
Many of the readers of this book are all-too-well aware of these pains, for they have
a loved one stricken by a severe mental illness. Those readers who do not, may very well
be destined to experience such pain with a loved one in the future, whether it be a spouse,
a partner, a child, a friend, or a fellow mental health professional. But unlike ourselves,
most family members are ill equipped with the knowledge that could help them under-
stand and cope with the bizarre behaviors of their loved ones.
One can imagine what it is like for family members to become the object of the
penetrating hatred that may erupt when one is perceived as part of a patient’s delu-
sional system. In some instances, family members are physically assaulted, and in rare
instances they are killed by the very people they have loved most. Obviously, both
family and friends must cope with powerfully conflicting feelings, including
embarrassment, guilt, fear, compassion, helplessness, bitterness, love, and the desire to
abandon the patient.
I remember working with one family whose plight illustrates some of the many pro-
cesses at work in the family system. The family was of Creole background. The patient
was an attractive woman in her mid-30s who sat with a defiant jut to her jaw. Upon her
head she wore a faded scarf that lent a sad elegance to her. She had become progressively
depressed, and her mind was swarming with religious delusions. She had had to stop
work and had been living with her mother and a brother, both of whom were taking
care of her children. These family members had not wanted her to seek professional help
because they felt that she would get over it with God’s help.
But she had recently spent several days with another brother who had angrily insisted
that help be sought. Already the psychosis was beginning to dig its claws into the struc-
tural foundations of the family. It is common for family tensions to crystallize around
issues such as, “What to do with Jim (or Sandy).”
While waiting in the emergency room, the patient, whom we shall call Ms. Jenkins,
stood up and began to perform a ritualistic chant. It was sad indeed to watch the mother
and brother hide their embarrassment as they struggled to get her back into her seat.
Later, this same mother and brother would undercut our efforts to hospitalize Ms.
Jenkins. Her mother wearily looked at us saying, “I don’t think there is much really wrong
with her. I don’t think she needs to be in a hospital. She’ll pull out of it on her own. But
thank you for your help.” Her thanks were sincerely given.
The next day the Jenkins family was back. Ms. Jenkins had been acting bizarrely
throughout the night. In the waiting room the mother sat with her arm around her daugh-
ter, her eyes red from the painful recognition that her daughter was no longer the same
person she had raised. Schizoaffective disorder had shifted the matrix. Perhaps forever.
In this regard, it appears useful to remember that, at some level, family members will
be mourning the loss of “the person they knew.” As with any mourning process, various
stages such as denial, anger, bargaining, depression, and acceptance will intermingle and
be experienced at different times. The Jenkins family highlights a common problem
facing the initial interviewer – the presence of a powerful system of denial among family
members. By understanding the mourning of family members, it may help decrease the
angry countertransference feelings that can naturally arise in a clinician when encounter-
ing a frustrating rejection of their help prompted by a parent or spouse in denial.
From the above discussion, it can be seen that in few cases does the initial interview
with a psychotic patient end with the patient. At some early point, the family warrants
an assessment, as well as a chance for later counseling and the potential for the healing
that we can offer. Keep in mind that some family members may become seriously
depressed and perhaps even suicidal, a powerful example of a damaging matrix effect.
Psychosis is, indeed, a family affair.
The tensions of the family may, at some level, precipitate or aggravate the psychotic
process itself, sometimes unintentionally. Research such as the Environmental/Personal
Indicators in the Course of Schizophrenia (EPICS) Project has shown that families in
which members are overly involved with the patient, whether in a hostile way or, perhaps,
even in an overly concerned caring fashion, may hinder recovery, even when the patient
complies with medication use.39 Family counseling seems to significantly decrease relapse
rates. This emphasizes the importance of assessing the family and beginning an alliance
with them. Frequently, the initial interviewer is the first person to meet the family and
consequently represents a key person in the attempts to build the much-needed alliance
described above.
Not only is the family affected, but also other important social networks may begin to
collapse around the patient. Jobs may be lost and friendships may become strained and
decline. It is difficult to remain friends with a person who has developed a severe psy-
chotic process. Frequently, both friends and family members will be dealing with feelings
of guilt. A simple phrase said early during an interview may be comforting such as, “I just
finished talking with your friend, who seems very disturbed. I bet you’ve gone through a
lot recently. It was nice of you to come with him today.” As with the patient, engagement
issues remain critical during the opening phases of collaborative interviews.
Practical Techniques for Engaging Family Members in the Initial Interview

Along these lines, it is important to remember that many parents (as well as siblings and
children) of patients with schizophrenia and bipolar disorder come to us with a check-
ered history with mental health professionals. They have often met many fine profes-
sionals, but, not infrequently, they have also unfortunately “been put through the
wringer,” not only by the disease afflicting their children but also by some of the profes-
sionals supposedly helping with this disease.
It is critical in the initial meeting to win over these parents, as well as other family
members/friends. The goal is to help them with their immense pain and also to set the
stage for a joint effort to help their loved one as he or she recovers.
Opening the Conversation in an Initial Encounter With a Family Member
Murray-Swank and colleagues, in their outstanding article “Practical Strategies for Build-
ing an Alliance with the Families of Patients who have Severe Mental Illness” (complete
article available in Appendix IV), point out that it is helpful to meet the family “where
they are at” by both inviting the family’s participation and exploring their opinions on
what is happening, as illustrated below40:
“Thanks for taking the time to meet with me today about [name’s] treatment. To begin,
it would be helpful to get your thoughts about the problems that [name] is seeking
treatment for. If it is OK 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 [name’s] 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 two questions:
“What is your understanding of what that diagnosis means?”
“Do you agree with the diagnosis?”
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 relative’s psychiatric problems. In addition, such questions can provide useful
information to guide the patient’s treatment. For example, family members often have
valuable observations about prodromal symptoms that signal a risk for relapse in the
patient.41
During the course of this first meeting, many parents will have some of the following
unexpressed fears. Some will have all of these fears, and some will have none. However,
as the interview proceeds, the clinician should take the time to try to sensitively address
and dismantle these concerns. Some of these concerns are listed, directly followed by
samples of clinician statements that can help to allay them:
1. This clinician doesn’t really care what I have to say.

Clinician intervention: “One of the things I want to emphasize early on is how
important your input and background information is 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
doesn’t work.”
2. This clinician thinks that we are the problem.
Clinician intervention: “You know, there are some people out there who think parents
somehow cause schizophrenia. Let me assure you of one thing. I don’t buy that for
one minute. Schizophrenia is a brain disease like epilepsy. Some of the most loving
parents whom I have ever met have children who develop schizophrenia. Just in
talking with you today, I am struck by how much you love John. I think he is very
lucky to have you. Some parents would have abandoned him by now.”
3. This guy is not going to understand how much pain we’ve been through.
Clinician intervention: “You must have gone through a lot over the years. I’m sure it
just must seem like it goes on and on. I have no miracles to offer, but I promise you
that we will do our very best to help you and your son. How have you coped with
all this? Have you had very much support?”
4. This “Bozo” is going to change these meds.
Clinician intervention: “One of the most foolish things a physician [nurse clinician]
can do is to change meds before talking with parents and the patient about what is
working. Your input is vital. I have no intention of making a recommendation regard-
ing your son’s meds until after we talk in detail. By the way, if your son agrees, I would
like to always try to talk with you and get your thoughts about any potential major
med changes. What is your opinion about this particular set of medications?”
5. This guy is closed to our ideas and thinks he knows it all.
Clinician intervention: “If you have any new ideas about helping John, please let me
or the case manager know. If you find interesting articles or hear about new treat-
ments, please let me know, and I’ll find out about them, if I’m not familiar with them
for some reason. I like to stay on top of new treatments.”
It always pays to find out at an early stage what the family has experienced with other
mental health professionals. The best way to find out is to simply ask. Your inquiry also
metacommunicates that it matters to you what they think of your care. A question such
as the following can help, “I’m wondering what your experience with previous psychia-
trists (substitute whatever your own professional discipline might be) has been like?” It
is also useful to ask, “What are some of the things I can do that would help you? For
instance, how frequently would you like to meet with me?”
The first meeting is also a good time to provide family members with avenues of
support outside of professional help. One of the best places to start is by providing family
members with the telephone number of the local chapter of the National Alliance for
the Mentally Ill (NAMI) if they are not already aware of it. NAMI (www.nami.org) is an
ongoing support group originated by family members who have a relative with a serious
mental illness. Its membership may also include people coping with mental illnesses
and mental health professionals, thus creating a well-rounded representation of people
affected by mental illnesses. It is a superb organization and has chapters all over the
United States. Similar organizations exist in countries throughout the world.
A second platform of support can be found in the many excellent books designed to
help family members who have a loved one coping with a mental illness. Two of my
favorites are Mueser’s The Complete Family Guide to Schizophrenia42 and Torrey’s Surviving
Schizophrenia: A Manual for Families.43
Tips for Initial Interviews With Family Members on Inpatient Units
Once again we shall turn our attention to the wisdom of Murray-Swank and colleagues,
who emphasize the importance of “taking a read” on the emotional state of family
members upon admitting a child or other loved one. Especially if the family member
has never been on an inpatient unit, the environment can appear frightening and over-
whelming; these feelings are often magnified if the unit is a locked one. The following
sensitive acknowledgement of the jarring nature of the situation can be greatly
appreciated:
“I realize that you have really been through a lot during this time – you may be feeling
anxious, worried, overwhelmed, angry, or maybe a combination of many different
feelings – this is certainly understandable, normal, and to be expected as you are
dealing with everything going on with [consumer’s name].”44
This shock of encountering the environment of a locked inpatient unit for the first time
is amplified if the parent or loved one has participated in an involuntary hospitalization.
Experiencing their child’s rage and sense of betrayal creates a pain that is beyond words.
Parents, or other family members, are often besieged by guilt and second thoughts about
having done the right thing. As Murray-Swank asserts, a reassuring comment, such as
that below, at the right moment can be 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 didn’t
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.”45
Obviously, we could spend many more pages addressing interviewing techniques and
strategies for interviewing family members in a variety of clinical settings, including com-
munity mental health center clinics, inpatient units, private practices, and emergency
rooms, but we are limited by space and time. As the reader works with family members
in these situations, I have found the following three interviewing principles, created by
Mueser and Glynn, to be of help in guiding my interventions: (1) try to let the family
know they are not alone, (2) provide support and allow relatives to vent, and (3) attempt
to instill hope.46
Talking With Patients About Involving Their Family Members in Assessment and Treatment
To initiate contact with families of adult patients, it is necessary to ask a patient to identify
members of his or her family and to obtain the patient’s permission to speak with them.
This process is not always an easy task, for psychotic process has often strained family
relations markedly through no fault of anyone involved. Once again, the insights of
Murray-Swank and colleagues provide an outstanding platform for navigating this deli-
cate tightrope. Consequently, the remaining paragraphs of this section are directly adapted
from their work.47
Patients will 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 find out who, if anybody, the patient considers to be their “family support system,”
and what role these individuals may play in helping them manage their psychiatric dis-
order (if any). For example:
“I would like to ask you some questions to better understand your family relationships
and support system. Do you have people you would consider to be your family or 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 their support network who are not relatives (e.g., friend, pastor, Alcoholics
Anonymous/Narcotics Anonymous sponsor). After identifying the key members of the
support network, it is helpful to learn about patients’ level of contact with these individu-
als – for example: (1) Does the patient live with a family member? (2) If not, how close
do family members live? and (3) How often does the patient talk, text, e-mail, commu-
nicate via Facebook, or get together with family members. Next, it is important to under-
stand the role that these individuals play in supporting the patient, including any
involvement in their mental health treatment. For example:
“So, you have said that you are closest to your two brothers, who you get together with
every couple of weeks. I’m 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. Inter-
viewers should use techniques such as summaries and reflections to gain an understand-
ing of the patient’s experience and help him or her feel supported. Finally, if not yet
known, the interviewer can assess the degree to which family members have been
involved in the patient’s mental health treatment in the past and the patient’s preferences
with regard to involving family in the present. For example, the following questions
might be of use regarding a patient’s siblings:
1. “Have your brothers or sisters been involved in your mental health care by coming
in to meet with your doctor or team in the past?
2. “Have they ever attended any kind of educational programs or groups?”
3. “Would you like to have some or all of your brothers and sisters 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 their family. This
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 family in their
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.
Personally, I feel that if genuinely caring family members would like to be involved,
it can be of immense comfort and support to have appropriately open channels of com-
munication. It is terribly frustrating, and sometimes quite frightening, for a family
member to be told that they cannot hear anything about treatment “because of
confidentiality.”
If such is the case, the pain of exclusion can be softened with sensitive interventions
such as the following, which skillfully employs Leston Haven’s counterprojection tech-
nique (see pages e169–e173):
“As you probably know, medical information is private and protected. Therefore, I can’t
share any specific information about [name’s] treatment at this time without her per-
mission. I know it’s hard for family members in these kind of 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.”
On a final note, it should be remembered that in a situation where there are concerns that the
patient may be at risk for suicide or violence, confidentiality is trumped by the need to procure
the information necessary to perform a sound risk assessment. Information from family members
may be life saving in this regard; at such times, confidentiality must be broken. If at all possible,
in such situations, consult with a supervisor or colleague to decide whether the crisis
requires an over-riding of confidentiality, and document the reasons for such an over-ride
carefully.
Cultural and Societal Impacts on Psychotic Process

Encountering Culture-Bound Syndromes and Behaviors
Psychotic process can show itself in different fashions depending upon the matrix effects
of any given culture. These distinctive presentations are often called “culture-bound syn-
dromes,” a term that I hope will someday be replaced, for, in my opinion, all diagnoses
are culture bound. The DSM-5 diagnoses are, by definition, defined by Western culture
and, hence, culture bound by it. Indeed, contemporary cultural psychiatry recognizes that
all classification systems are inherently culture bound.48 Perhaps it is simply more accu-
rate to state that these syndromes are not found in Western culture unless they are being
experienced by an immigrant or visitor.
What is important to take from these syndromes is the realization that cultures shape
psychotic process. Consequently, a talented interviewer must always be aware of the
culture of origin of the patient and keep an eye out for cultural variations and symptoms
that may be out of the ordinary for the clinician. Without such an awareness, an inter-
viewer may miss a psychotic process, or, equally problematic, misread a patient’s behavior
as psychotic when it is a normal experience within the patient’s culture of origin, an issue
we have addressed in earlier chapters.
Missing Culturally Specific Psychotic Process
Let us look at our first problem facing an initial interviewer – missing a psychotic process
that is limited to a specific culture. Picture a young Chinese graduate student attending
a major university in the United States, who has brought his reluctant father into a com-
munity mental health center commenting, “I don’t know what’s wrong with my Dad.
He’s been visiting me for the past 2 weeks and he’s really wound up about something,
but he won’t tell me what’s going on. At night he locks himself up in the guest bedroom
and gets really mad if I knock or try to talk to him. I’m really worried about him.”
The student’s 55-year-old father presents in a friendly, yet clearly hesitant fashion. He
reluctantly describes being upset and anxious, relates marked problems with sleep, and
demonstrates an unusually intense affect. He admits to some episodes of yelling at his
son, highly atypical for him and terribly embarrassing to admit.
The clinician wisely realizes that the patient is demonstrating some soft signs of psy-
chosis, indicated by the intensity of his anxiety and the presence of his atypical, angry
outbursts. Consequently, the interviewer delicately asks about a variety of psychotic
symptoms including auditory hallucinations, paranoid feelings, and delusions, concerns
about alien control, as well as sensitively probing for psychotic hyper-religiosity. Nothing.
The clinician believes that a psychotic process is unlikely and feels that some variant
of a severe generalized anxiety disorder or social phobia may be present. Alternatively,
perhaps there is a powerful situational stress present that the patient is hesitant to share,
such as financial concerns or marital distress. All of these are reasonable speculations.
Unfortunately, all of them are wrong.
What the interviewer doesn’t know to ask is the following question, which a clinician
in China might know would be worth an inquiry in a potentially psychotic male: “Some-
times when we least expect it, we can have fears that are really quite frightening, but
might seem sort of strange to us or embarrassing because they are very private fears. They
are so private, it makes them hard to talk about. For instance, sometimes people will get
really worried about their bodies. Back in China I know that some men will get worried
about their penis being damaged or somehow being pulled up into their bodies. I know
that, sometimes in China, some men are even frightened that this could cause them to
die. I’m wondering if you have heard of that or might even be worried about it?”
Bingo. The student’s father looks up and shyly nods his head yes. He is experiencing
a syndrome known as koro. Koro is generally seen in China and South East Asia. Depend-
ing upon locale, it is variously called shuk yang, shook yong, suo yang (Chinese), jinjinia
bemar (Assam), or rok-joo (Thailand).49 In women, the syndrome revolves around a fear
of retraction of the vulva or nipples. Our point is that, because of the sexually intimate
nature of this delusional fear, it would probably never have been spontaneously men-
tioned by the patient above unless he was directly asked about it. Our graduate student’s
father easily could have left this clinic without anyone knowing what he was experiencing
and, consequently, no hope for effective attention and treatment.
Before leaving the problem of missing psychotic syndromes, let us look at an actual
clinical example of a culturally specific syndrome that could be puzzling to an interviewer
familiar only with Western psychotic presentations. It is described by Mezzich and
colleagues:
A 28-year-old mainland Chinese man living in the United States for several years was
hospitalized in a psychiatric ward with delusions and hallucinations of 2 to 3 week’s dura-
tion. These began after he took up the practice of qi-gong, a form of meditation, as treat-
ment for his severe intermittent backaches and chronic exhaustion. According to the
patient, feelings of qi (“vital energy”) were circulating in the “wrong direction” in his
body, and he heard the voices of supernatural beings commenting on how he should practice
qi-gong. He denied depressed mood, appetite or weight changes, substance abuse, or a
history of psychosis. The results of extensive medical evaluation, including electroencepha-
lography and magnetic resonance imaging, were normal. Haloperidol substantially reduced
his delusions and hallucinations, but follow-up information is unavailable because he did
not keep his appointment after discharge.
Transient psychotic symptoms in connection with qi-gong practices are not uncommon,
but duration for more than a few days is unusual. The patient’s picture meets criteria in
the Chinese classification system for qi-gong-induced psychosis …”50
There are numerous other culturally specific disorders, some of which are psychotic:
locura (Latinos); occasionally psychotic: amok (Malaysia), iich’aa (Navajo), boufee delirante
(West Africa and Haiti), Taijin kyofusho (South Asia); and non-psychotic: billis, colera,
muina (Latino), Kufungisisa (Shona of Zimbabwe), hwa-byung (Korean). The interested

reader can find nice descriptions of the symptoms seen in these disorders in the appen-
dices of the DSM-IV-TR51 and the DSM-5.52
Our goal here is not to review all the culturally specific syndromes, a task far beyond
the reaches of our book, but to alert the clinician of the need to be aware of such disor-
ders and the role they may play in an initial interview.
Mistaking Culturally Normal Phenomena for Psychotic Process Redux

Let us now look at our second problem facing an initial interviewer – mistaking a normal
process that is specific to a local culture for a psychotic process. We have addressed this
issue several times before, yet I feel it is important to review it, for it is quite likely that
a contemporary clinician will need to thoroughly understand this phenomenon and its
clinical ramifications. World travel, immigration and emigration, and the development
of the web have intermixed cultures to a far greater degree than the world has ever before
experienced.
By way of example, let us picture a recently graduated psychiatrist, psychiatric nurse,
or social worker who is either Black, White, or Hispanic in cultural heritage. Following
graduation from an esteemed program in the Southwest of the United States, he or she
moves to Minnesota for an excellent job opportunity that has become available at a local
community mental health center in Minneapolis. It is highly likely that such a young
professional will quickly find himself or herself in a room interviewing a Hmong
immigrant.
Asian Americans and Pacific Islanders (AAPIs) are one of the fastest growing and the
most diverse ethnic groups in the United States. The Asian American population has
increased from 7 million in 1990 to 12 million in 2004. The Hmong are a significant
subgroup of this influx. They have a relatively recent history in the U.S. with many of
them being war refugees following the Vietnam War. One of their main destinations has
been the Twin Cities of Minnesota, this area having the fastest growth rate of South East
Asian immigrants.
As Lee and colleagues have noted, many of the Hmong are victims of multiple psy-
chological insults from years spent in refugee camps, traumas related to war, poverty,
unemployment, and forced relocation.53 The psychological impact of all these experi-
ences is further exacerbated by the loss of social networks, traditional roles, and social
status. As one can imagine, mental health problems are high, with 50% of Cambodian
refugees experiencing depression even after living in the United States for 20 years.
And here our clinician, whether he or she is Black, White, or Hispanic, will stumble
upon a potential problem: the misidentification of a Hmong patient with a major depres-
sion as being actively psychotic when he or she is not. Frankly, it’s an easy mistake to
make if one is not aware of certain cross-cultural factors. It is a classic kulturbrille effect
as we delineated in Chapter 6 (see pages 210–212).
Although most Hmong have a word for feeling emotionally “very distressed” – nyuaj
siab [nu-shea] – it is not the same syndrome as the Western term for depression. In fact,
they don’t really have a word for depression per se. The situation is further complicated
by the fact that the Hmong believe that nyuaj siab and what Western clinicians would
call depression, as well as many other illnesses, are often caused by the presence of spirits
and ghosts.54
As Al-Issa has pointed out, many non-Western cultures do not make as clear a distinc-
tion between what is real and what is imagined as Western cultures maintain.55 Conse-
quently, a patient from a non-Western culture, such as the Hmong, may be predisposed
to talk more openly with a clinician about such things as spirits and ghosts, relating
matter-of-factly that they see such entities and indeed hear their voices. An interviewer
not familiar with these cultural traditions could easily view the Hmong patient’s talk of
voices as evidence of psychotic process, a striking kulturbrille effect.
Of course, some Hmong patients who are talking about spirit voices may actually be
psychotic. A savvy interviewer will be able to spot such patients, because, if psychotic in
nature, the voices will be embedded in a matrix of the prodromal signs of psychotic
process. Such a patient would most likely, upon careful interviewing, describe symptoms
such as delusional mood and delusional perception while demonstrating a plethora of
the soft signs of psychosis.
The Community Mental Health Center as a Subculture

In Chapter 10 on depression and its impact on the patient’s matrix, we talked about the
importance of understanding the patient’s specific subculture. This is equally true with
patients dealing with chronic psychotic process. Here, though, we encounter a new and
somewhat expected, but often ignored, twist.
Patients with chronic psychotic processes such as schizophrenia, schizoaffective dis-
order, and bipolar disorder frequently become members of a new subculture. As these
patients lose their friends, spend long stays in hospitals, and wear out their welcome with
relatives, they end up spending progressively more time with each other. If actively
engaged in treatment, these patients may spend large amounts of time at the community
mental health center itself, or perhaps at local clubhouses and patient-run support
centers or at government-supported residential centers.
In addition, our society, through stigmatization, fear, and ignorance, gradually pushes
people with chronic mental illnesses into a social caste of sorts. Patients frequently
become outcasts from the mainstream of society. It is important for the initial interviewer
to understand the dynamics of this, because it can manifest as a veiled hostility from the
patient. And sometimes this animosity is not so veiled.
Whatever the causes, community mental health centers are important subcultures that
can strongly influence the views of our patients with regard to their treatment. It is useful
for clinicians to learn about these biases. For example, the local patients may develop
prejudicial views on certain medications. If all of a patient’s friends hate the drug Risp-
erdol (respiridone), it does not make a lot of sense to send the patient home on Risper-
dol, when a different antipsychotic may be just as effective and is not a medication that
is blackballed by that subculture.
In this regard, when talking with patients about the potential use of a particular
medication, I find it useful to inquire, “Do you know anybody around here that is taking
Risperdol [replace with whatever med is being considered]?” If the patient says yes,
I simply ask, “What do they think about it?” and often follow up with, “What do patients
in general seem to think about [whatever the medication might be] around here?”
Such a question can provide considerable insight into the gestalt of the community
mental health center subculture of the patient. I once asked a patient about Paxil and
was quite fascinated by the response, “Oh Paxil, Paxil causes a real nasty side effect. We
have a name for it, we call it ‘Paxil-head’ it really gets you wound up.” Paxil was clearly
not the choice for this patient.
Language and Culture: Potential Roadblocks When Uncovering Psychotic Process
As our final topic regarding culture and its impact on how people experience psychotic
process and subsequently communicate that experience with others, we shall look at an
often overlooked barrier to uncovering psychotic process: language. Other than the
abnormalities in nonverbal behaviors that sometimes indicate the presence of psychotic
process, the clinician is dependent upon the self-report of the patient and/or the reports
of concerned loved ones for uncovering psychotic process. For this reason, psychotic
process can be an elusive phenomenon to spot. Patients may be hesitant to share psy-
chotic processes for numerous reasons, ranging from fear of stigmatization to misinter-
pretation of what is being asked by the clinician.
We have already seen that the words we choose can play a pivotal role as to whether
a patient feels safe enough to share psychotic process, but our words are always embed-
ded in the complexities of our personal languages. Language can limit what can be easily
shared with a clinician and what is difficult to share with a clinician who does not speak
the patient’s native language. For instance, we have already seen that with certain Hmong
patients it is hard for them to share depression for the simple reason that they do not
have a word for depression.
Let us now look at a brilliant example of this phenomenon from an actual clinical
vignette shared by Junji Takeshita from the University of Hawaii:
A 79-year-old Filipino male was admitted to an inpatient psychiatric unit through the
court system. He had a delusional belief that his wife was trying to kill him, so he decided
to murder her first. When interviewed in English by a non-Filipino psychiatrist, no delu-
sions or other odd beliefs were noted. He was cooperative and was a model patient on the
ward. However, the psychiatrist felt that poor fluency in English limited the interview.
As a result, the psychiatrist asked several members of the Filipino nursing staff to serve as
interpreters. They noted that the patient was fluent in Ilocano, but had significantly less
understanding of Tagalog, both of which are Filipino dialects. Fixed and extensive delu-
sions about multiple family members trying to kill him were elaborated in Ilocano, while
only fragments of paranoid thoughts were revealed in Tagalog. Interestingly enough, no
delusions were detected when he was interviewed in English.56
Money is tight in all mental health centers. Consequently, interpreters, as well as mental
health professionals who can also interpret, are precious commodities. The above illus-
tration from Takeshita shows us one place to prioritize their use – the uncovering of
psychotic process.
Generally, when interviewing a patient whose language you do not speak fluently, if
you are suspicious of psychotic process, strongly consider having the patient re-interviewed.
Try to find an interpreter who speaks the exact language of the patient, or as close as
possible to this. In the above vignette we saw that even the differences between two local
dialects (Ilocano and Tagalog in the Filipino culture) determined whether psychotic
process was shared or not shared. The nuances created by language when discussing the
delusional content of psychotic process, as well as the presence of hallucinatory phenom-
ena, tend to be lost when patients are not conversing in their native tongue. As we can
see with the strikingly paranoid delusions of the above patient, the breakdown in com-
munication caused by language barriers can leave potentially dangerous, or even lethal,
psychotic process untapped.
Takeshita further points out a curious, but important, occurrence occasionally seen in
initial interviews. During psychotic episodes, otherwise-bilingual patients may be less
able, or even unable, to communicate effectively in whatever their second language may
be, in the above case English. With greater and greater disorganization in thinking, some
patients regress and may rely entirely upon their primary language.57
Another potential problem with language is how it relates to and reflects stigmatiza-
tion. For example, in some cultures, serious mental illnesses such as schizophrenia or
psychotic bipolar disorder are viewed as signs of family or personal failure; thus, these
illnesses are sometimes alluded to by the use of euphemisms. If the initial interviewer is
not familiar with these euphemisms, major psychiatric disorders can be missed when
exploring a patient’s past psychiatric history or when taking a family history. Also be
aware that family members may hide serious disorders in relatives when providing a
family history.
By way of illustration, in Japan neurasthenia continues to be used as a euphemism for
serious disorders such as schizophrenia. Another Japanese term, shinshinsho, directly
relates to psychosomatic concerns, but frequently this “psychosomatic” label serves as a
euphemism for a more serious mental illness in the relative. In this instance, a psycho-
somatic illness is significantly less stigmatizing than admitting that one’s loved one has
schizophrenia.58
When interviewing White Americans in the United States, I have sometimes found
that the term “nervous breakdown” is proffered when I am taking a family history. Upon
careful questioning, this term often belies the necessity of a psychiatric hospitalization
in the relative. At a minimum, I have found that the term “nervous breakdown” is gener-
ally used to describe an episode of agitated major depression and, at a maximum, a
psychotic or manic episode.
V. The Wing of the Matrix Encompassing Worldview and Spirituality

Psychotic Destruction of the Patient’s Religious Worldview
Through the window of psychosis, the problem is not so much that the world is mean-
ingless, but rather the world is too meaningful. As the patient copes with a suffocating
mixture of bizarre and unscreened sensory experiences, the world is gradually trans-
formed into a desert filled with burning bushes. The patient finds little rest from the
intensity of the delusional world, and this intensity creates the driven quality so charac-
teristic of psychotic process.
One of the saddest aspects of psychotic process remains the irony that it can make a
patient so religiously preoccupied, that religion is no longer a practical support system.
Instead of providing a calm guidance, religious issues become disturbing. This type of
overzealous religious ideation is frequently seen with schizophrenia and mania.
Psychotic religious preoccupation may represent an unconscious effort to replace pre-
vious areas that had provided a sense of meaning to the patient. For instance, the patient’s
family ties may have become critically weakened, thus depriving the patient of a powerful
framework for meaning. In some unfortunate instances, patients may actually come to
view themselves as burdens upon their families. In such situations, one can easily see why
a grandiose religious delusion may serve as a source of much needed solace. It could
represent a very real resurrection of sorts, a resurrection of the patient’s self-esteem.
This process brings to light a curious aspect of the psychotic patient’s search for a
framework for meaning. With some patients, the psychotic delusions literally become
the focal points of their lives. When these delusions disappear, so can the meaning
behind life.
The Personalized Meaning of Psychotic Symptoms to Patients

Regarding the potential loss of meaning precipitated by the break-up of a delusional
belief, I am reminded of a young man with whom I worked who was suffering from
schizophrenia. We shall call him Jake. Jake had been admitted to my unit during a par-
ticularly severe initial psychotic break heralding the onset of schizophrenia. I found him
to be very likeable and very sad.
Lean and wispy-haired, Jake spoke with an almost child-like innocence. To me, his
outlook and demeanor were, indeed, almost more akin to a child than an adult. On the
other hand his social responsibilities were all-too adult. He was married to a tough, yet
loving, 17-year-old girl who was pregnant with Jake’s child. Neither expectant parent was
employed, both were without marketable skills, and both were about to be thrown out
of their housing. In addition, both were estranged from their families of origin. Put
bluntly, the social and interpersonal wings of their matrices were a tragic shambles. Jake
knew it. And Jake felt it was all his fault.
Jake was beset by a bevy of horrifying hallucinations and delusions of persecution.
Demons of retribution and judgment were flying about the chambers of his mind. Their
voices echoed loudly in the hallways of his consciousness. It was a tough inner landscape.
And it was terrifying.
On the other hand, there was one delusion that Jake accepted with open arms. He
believed that he could intentionally broadcast his thoughts. As he phrased it during my
initial interview with him, “I’m the best there is, Dr. Shea. Nobody can send their
thoughts faster or further than me.” As he came out of his psychosis, in addition to all
of his disturbing delusions disappearing, his delusion of thought broadcasting also began
to fade. One evening as we were talking by his bedside, he seemed out of sorts. I asked
him what was the matter. Jake turned to me, his eyes almost frightened – as if they sensed
something bad was about to happen; he said, “I can’t do it, can I, Dr. Shea?”
Puzzled, I asked him what he meant. He replied, “Send my thoughts out. I can’t do
that, can I?” I responded, “Well, that particular belief is probably part of your schizo-
phrenia too. I’m sorry it wasn’t true for you.” Jake paused for moment, and then he
began to weep profusely. Apparently his delusion was serving as a last-ditch prop for
a severely battered ego. Several years later, I heard that Jake had died from a self-inflicted
gunshot.
As clinicians we will undoubtedly be working with patients in various stages of belief
and disbelief concerning their delusions. Jake reminds us that it is important to try to
understand the significance of these beliefs to the patient at the time of their presenta-
tion. He reminds us that there is always a person beneath the psychosis, beneath each
and every delusion.
Even if the patient’s psychosis is being caused primarily by biologic dysfunction, the
fact remains that the content of the delusions are directly related to the patient’s psycho-
logical constitution, including the patient’s upbringing, memories, values, culture, and
spirituality. In that sense, one may find important clues to underlying fears, strengths,
and issues in these seemingly illogical fantasies.
Finally, it cannot be emphasized enough that the presence of a chronic, severe mental
illness often leads to a quiet desperation that is to be expected when one’s dreams are
being shattered. Accompanied by the intense guilt and shame of “having become a
failure” – a misconception often enhanced by a stigmatizing culture – patients often
lose a belief that there is a purpose and meaning for their existence. The shattering of
such a critical spiritual support is undoubtedly one of the precipitants of the suicidal
ideation we frequently see in patients afflicted by severe psychotic illnesses, as witnessed
by Jake.
It is time to end our survey of methods for exploring psychosis. You might recall that
we began our two chapters dedicated to uncovering psychotic process by visiting the
writings of Gérard De Nerval. De Nerval was the symbolist poet who, unfortunately, was
found hanging from an iron gate in a darkened alleyway of Paris. On that dismal night,
who knows what the voices were saying to him or in what personal hell he found himself.
What we do have are his words. As we reread them now, perhaps aided by our enhanced
understanding of psychotic process from the last two chapters, we will hear them with
a new respect for both their brilliance and the pain that brilliance echoes:
I seemed to myself a hero living under the very eyes of the gods; everything in nature
assumed new aspects, and secret voices came to me from the plants, the trees, animals,
the meanest insects, to warn and to encourage me. The words of my companions had
mysterious messages, the sense of which I alone understood.
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Psychiatric Interviewing - Shawn Christopher Shea

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What are some of the principles that determine whether an initial interview fails or succeeds?

What are some of the principles that determine whether an initial interview fails or succeeds?

How can a language of clinical interviewing help conceptualize and communicate understanding?

How can a language of clinical interviewing help conceptualize and communicate understanding?

Descargado de ClinicalKey.es desde Fundacion Universitaria Juan N Corpas marzo 04, 2017.

1. To establish a sound engagement of the patient in a therapeutic alliance

6. To collaboratively develop an appropriate disposition and tentative treatment plan

Figure 1.1 Map of the interviewing process.

These processes of engagement, data gathering, understanding, assessment, and treat-

The Next Step

VIDEO MODULE 1.1

CREATING THE THERAPEUTIC ALLIANCE

Using Blending to Gauge the Degree of Engagement

CONVEYING EMPATHY: TRAPS, STRATEGIES, AND SOLUTIONS

First Phase of the Empathy Cycle: Patient Expresses a Feeling

Clin.: Tell me a little about John’s behavior with other children.

Clin.: You had mentioned something about his speech earlier.

Third Phase of the Empathy Cycle: Clinician Conveys Recognition

of empathic statements remains their uncanny ability to promptly disengage a small

Empathic statements made to guarded patients, from whatever etiology, frequently

patient’s statement, an example of an empathic statement with a low valence of certainty

Valence of Intuited Attribution

Basic Guideposts for Effectively Using Strategic Empathy

1. In general, empathic statements represent extremely valuable methods for strengthen-

VIDEO MODULE 1.2

Three Examples of Using Strategic Empathy to Transform Difficult Moments

Clin.: That must be frightening to be constantly watched by others. [high valence of

What a difference intentional interviewing makes. Language counts. As opposed to our

2: Transforming Anger with Defusing Statements

a. It makes sense to me that you would be upset.

3: Shoring Up a Young Empathic Bond with Paraphrasing Statements

They follow with another example as well:

The Metaphorical Paraphrase. Sommers-Flanagan and Sommers-Flanagan have

In an initial interview, we generally use metaphorical paraphrases as a means of enrich-

Frequency, Timing, and Length of Effective Empathic Statements

well-received clinicians frequently seem to scatter empathic statements throughout their

Large amounts of empathy appear to be communicated through facial expressions, body

Fifth Phase of the Empathy Cycle: Patient Communicates an Appropriate

THE PERSON BEFORE THE LETTERS

INDUCEMENT OF A SAFE RELATIONSHIP

This clinician’s choice of words has created an atmosphere potentially suggestive of a

He [the clinician] is an expert having expert knowledge of interpersonal relations, person-

This rather extreme form of non-responsiveness can produce an immediate increase

demonstrated by the clinician’s willingness to explore the patient’s world in a shared

Patient: I want to know what you really think of me.

The response of Counselor B demonstrates a willingness to share exploration, including

In short, all of these metacommunications serve to increase the patient’s confidence in

VIDEO MODULE 2.1

When reflecting upon the power of fact-oriented questions to enhance engagement, I am

COLLABORATIVE INTERVIEWING MODELS: NEW TOOLS FOR

Solution-Focused Goal Setting

Clin.: What’s the problem that brings you here today?

1. “What would make this a helpful visit?”

Clin.: What’s the problem that brings you here today?

When employing solution-focused interviewing techniques for uncovering the patient’s

The Miracle Question

The clinical interview manifests as a relationship. As with all relationships, it undergoes

Figure 3.1 Map of the interviewing process.

Creating a Safe Environment

1. Who is this clinician?