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Intake Interview Manual

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100% found this document useful (6 votes)

1K views107 pages

Intake Interview Manual

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hungdahoang

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Instructors Manual

for

CLINICAL INTERVIEWING:
INTAKE, ASSESSMENT,
AND THERAPEUTIC
ALLIANCE

with

JOHN SOMMERS-FLANAGAN
AND RITA SOMMERS-FLANAGAN

Manual by
Shirin Shoai, MA
CLINICAL INTERVIEWING: INTAKE, ASSESSMENT, AND THERAPEUTIC ALLIANCE

The Clinical Interviewing: Intake, Assessment, and Therapeutic Alliance

with John Sommers-Flanagan and Rita Sommers-Flanagan (Institutional/
Instructors Version). Video available at www.psychotherapy.net.
Copyright 2014, Psychotherapy.net, LLC. All rights reserved.
Published by Psychotherapy.net
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Mill Valley, CA 94941
Email: [email protected]
Phone: (800) 577-4762 (US & Canada)/(415) 332-3232
Teaching and Training: Instructors, training directors and facilitators
using the Instructors Manual for the video Clinical Interviewing: Intake,
Assessment, and Therapeutic Alliance with John Sommers-Flanagan and Rita
Sommers-Flanagan may reproduce parts of this manual in paper form for
teaching and training purposes only. Otherwise, the text of this publication
may not be reproduced, stored in a retrieval system, or transmitted in any
form or by any meanselectronic, mechanical, photocopying, recording
or otherwisewithout the prior written permission of the publisher,
Psychotherapy.net. The video Clinical Interviewing: Intake, Assessment,
and Therapeutic Alliance with John Sommers-Flanagan and Rita Sommers-
Flanagan (Institutional/Instructors Version) is licensed for group training
and teaching purposes. Broadcasting or transmission of this video via
satellite, Internet, video conferencing, streaming, distance learning courses
or other means is prohibited without the prior written permission of the
publisher.

Shirin Shoai, MA
Clinical Interviewing: Intake, Assessment, and Therapeutic Alliance with John
Sommers-Flanagan and Rita Sommers-Flanagan

Cover design by Julie Giles

Order Information and Continuing Education Credits:

For information on ordering and obtaining continuing education credits
for this and other psychotherapy training videos, please visit us at
www.psychotherapy.net or call 800-577-4762.
2
Psychotherapy.net

Instructors Manual for

CLINICAL INTERVIEWING:
INTAKE, ASSESSMENT, AND THERAPEUTIC
ALLIANCE
WITH JOHN SOMMERS-FLANAGAN
AND RITA SOMMERS-FLANAGAN

Table of Contents
Tips for Making the Best Use of the Video 4
The Sommers-Flanagans Approach to Clinical Interviewing 6
Basic Listening Skills: Summary, Discussion Questions, Role-Plays 8
Directive Listening Responses: Summary, Discussion Questions, Role-Plays 13
Directives & Action Responses: Summary, Discussion Questions, Role-Plays 17
Questions & Therapeutic Questions: Summary, Discussion Questions, Role-
Plays 21
Intake Interview: Summary, Discussion Questions, Role-Plays 26
Mental Status Examination: Summary, Discussion Questions, Role-Plays 31
Suicide Assessment Interview: Summary, Discussion Questions, Role-Plays 36
Reaction Paper Guide for Classrooms and Training 41
Related Websites, Videos and Further Readings 42
Transcript 43
Video Credits 101
Earn Continuing Education Credits for Watching Videos 102
About the Contributors 103
More Psychotherapy.net Videos 104

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CLINICAL INTERVIEWING: INTAKE, ASSESSMENT, AND THERAPEUTIC ALLIANCE

Tips for Making the Best Use of the

Video
1. USE THE TRANSCRIPTS
Make notes in the video Transcript for future reference; the next time
you show the video you will have them available. Highlight or notate
key moments in the video to better facilitate discussion during and after
the video.

2. FACILITATE DISCUSSION
Pause the video at different points to elicit viewers observations and
reactions to the concepts presented. The Discussion Questions sections
provide ideas about key points that can stimulate rich discussions and
learning.

3. ENCOURAGE SHARING OF OPINIONS

Encourage viewers to voice their opinions. What are viewers
impressions of what is presented in the interviews?

4. CONDUCT A ROLE-PLAY
The Role-Play sections guide you through exercises you can assign to
your students in the classroom or training session.

5. SUGGEST READINGS TO ENRICH VIDEO MATERIAL

Assign readings from Related Websites, Videos and Further Reading
prior to or after viewing.

6. ASSIGN A REACTION PAPER

See suggestions in the Reaction Paper section.

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PERSPECTIVE ON VIDEOS AND THE PERSONALITY OF THE

CLINICIAN
Psychotherapy portrayed in videos is less off-the-cuff than therapy
in practice. Clinicians may feel put on the spot to offer a good
demonstration, and clients can be self-conscious in front of a camera.
Clinicians often move more quickly than they would in everyday
practice to demonstrate a particular technique. Despite these factors,
counselors and clients on video can engage in a realistic session that
conveys a wealth of information not contained in books or therapy
transcripts: body language, tone of voice, facial expression, rhythm of
the interaction, quality of the allianceall aspects of the therapeutic
relationship that are unique to an interpersonal encounter.
Psychotherapy is an intensely private matter. Unlike the training in
other professions, students and practitioners rarely have an opportunity
to see their mentors at work. But watching therapy on video is the next
best thing.
One more note: The personal style of counselors is often as important
as their techniques and theories. Counselors are usually drawn to
approaches that mesh well with their own personality. Thus, while we
can certainly pick up ideas from master clinicians, students and trainees
must make the best use of relevant theory, technique and research that
fits their own personal style and the needs of their clients.

PRIVACY AND CONFIDENTIALITY

Because this video contains actual counseling sessions, please take
care to protect the privacy and confidentiality of the clients who have
courageously shared their personal lives with us.

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CLINICAL INTERVIEWING: INTAKE, ASSESSMENT, AND THERAPEUTIC ALLIANCE

The Sommers-Flanagans Approach

to Clinical Interviewing*
The clinical interview has been referred to as the foundation of all
mental health treatment and as arguably the most valuable skill among
psychologists and other mental health practitioners. Professionals from
several different disciplines (i.e., psychologists, psychiatrists, counselors,
and social workers) utilize clinical interviewing procedures. Although
defined differently by different authors, the clinical interview includes
an informed consent process and has as its primary goals (a) initiation
of a therapeutic alliance; (b) assessment or diagnostic data collection;
(c) case formulation; and/or (d) implementation of a psychological
intervention.
All clinical interviews implicitly address the first two primary goals
(i.e., relationship development and assessment or evaluation), while
some also include a case formulation or psychological intervention.
Using the Sommers-Flanagan approach, it is possible to simultaneously
address all of these goals in a single clinical interview. For example, in
a crisis situation, a mental health professional might conduct a clinical
interview designed to quickly establish rapport or an alliance, gather
assessment data, formulate and discuss an initial treatment plan, and
implement an intervention or make a referral.
Overall, the quality and quantity of information gathered and the
intervention applied depends almost entirely on the interviews purpose
and the clinicians theoretical orientation. For example, if the interviews
purpose is to establish a working psychiatric diagnosis, the clinician will
be asking specific questions about patient symptoms. In contrast, if the
purpose of the interview is to establish rapport and initiate a working
alliance, then the interviewer is likely to use more nondirective listening
skills designed to show empathic understanding of the patients
situation, concerns, and emotions.
In this video, John and Rita Sommers-Flanagan guide clinicians
through more basic listening skills onward to more advanced, complex
interviewing activities such as intake interviewing, mental status
examinations, and suicide assessment. For beginning clinicians or
those with more substantial experience, this video presents a systematic
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outline of the skills needed for conducting competent and professional

clinical interviews.

*Adapted from
Sommers-Flanagan, J., Zeleke, W., & Hood, M. E. (2014, in press). The clinical
interview. In R. Cautin and S. Lilienfeld (Eds). The encyclopedia of clinical psychology
(page numbers unknown). London: Wiley-Blackwell.
Sommers-Flanagan, J. and Sommers-Flanagan, R. (2014). Clinical Interviewing, Fift h
Ed.

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CLINICAL INTERVIEWING: INTAKE, ASSESSMENT, AND THERAPEUTIC ALLIANCE

Basic Listening Skills

SUMMARY
Basic listening skills, according to the Sommers-Flanagans, are part
of a wider continuum of clinical interviewing behaviors (or listening
responses) that serve to establish a therapeutic alliance, glean
diagnostic information, set the basis for a treatment plan, and act as a
relational background for therapeutic interventions. This continuum
ranges from less directive, or nondirective, listening behaviors to more
active-directive, complex ones that aim to guide the client toward a
specific therapeutic goal.
Nondirective listening responses include:
Attending behaviors (drawn from clinician Alan Ivey):
eye contact
body posture
voice tone
verbal tracking
Other behaviors presented by the Sommers-Flanagans:
silence
clarifications (verbal prompt)
paraphrasing
reflection of feeling
summarization
It is important to note that these behaviors do not represent a static,
linear set of interventions, but rather can be modified and tailored to
your client, in your own voice. John Sommers-Flanagan emphasizes the
role of therapist authenticity in a clients feeling heard; indeed the very
act of listening, he says, is a gift that clients will resonate with if offered
from a place of awareness.
It is also imperative for therapists to understand the various factors
cultural, personality-based, etc.that may be either implicitly or
explicitly impacting a clients experience. Some clients, for instance, may
balk at too much eye contact or questioning, while others may feel less

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trusting of a therapist who asks fewer questions. The power differential

between therapist and client, furthermore, may mean that a clinician
may be perceived as directive even when he or she isnt intending to
be. The Sommers-Flanagans stress the need for therapists to find a
balance between their natural tone and one that takes into account the
particular qualities of each client.
That said, they also maintain that basic listening is a skill set that can
be learned and will improve with time and practice. As you watch this
section of the video, observe which basic listening behaviors most (and
least) resonate with your personal style, and consider which responses
might be most (or least) impactful to you as a client.

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CLINICAL INTERVIEWING: INTAKE, ASSESSMENT, AND THERAPEUTIC ALLIANCE

Discussion Questions
Professors, training directors and facilitators may use some or all of
these discussion questions, depending on what aspects of the video are
most relevant to the audience.
1. The nondirective approach: What thoughts and feelings arise for
you around the concept of nondirective listening behaviors? Do
they seem like enough to move the interview forward? Do you
prefer a more directive approach? Why or why not?
2. Cross techniques: Do you agree or disagree with Sommers-
Flanagans statement that the therapeutic relationship is inherently
uneven? Have you experienced the sense of a power differential
in your work with clients? In your work with your own therapist?
How have you dealt with this? Have you addressed this issue
outright with your clients and, if so, what was the result?
3. Cultural sensitivity: Have you noticed or been made aware of
cultural differences in your work with clients? If so, how did
you handle it? Which of the basic skills from this section, if any,
triggered this awareness? Can you think of cultural contexts in
which each skill might be considered off-putting to a client?
4. Silence: John Sommers-Flanagan says that beginning therapists
often find silence challenging as an intervention. Is this true for
you? What does silence bring up in you as youre sitting with
someone, client or otherwise? If silence is no longer a challenge for
you, how did you overcome your discomfort with it?

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Role Plays
After watching the video and reviewing Basic Listening Skills in
this manual, break participants into groups of two and have them
role-play a brief interview between a therapist and client in which the
therapist only uses the nondirective listening responses presented in
this section.
One person will start out as the therapist and the other person will be
the client, and then invite participants to switch roles. Therapists can
focus on just one type of response (for instance, silence, clarification,
paraphrasing, reflection of feeling, or summarization), or they can
alternate among the various typesbut they are not allowed to ask
questions or use interventions from elsewhere in the video. Clients
may play themselves, or role-play Jessie from the video, a client or
friend of their own, or they can completely make it up. The primary
emphasis here is on giving the therapist an opportunity to practice
interviewing clients using a variety of basic listening skills, and on
giving the client an opportunity to see what it feels like to participate
in this type of intervention.
After the role-plays, have the groups come together to discuss their
experiences. What did participants learn about the Sommers-
Flanagans approach to basic listening? Invite the clients to talk
about what it was like to role-play someone being interviewed and
how they felt about the approach. How did they feel in relation to the
therapist? What worked and didnt work for them during the session?
Did they feel any defensiveness or other resistance arise? Then,
invite the therapists to talk about their experiences: How did it feel
to facilitate the session? Did they have difficulty sticking to this type
of intervention? Which type of response did they gravitate toward?
Which did they tend to avoid? What would they do differently if they
did it again? Finally, open up a general discussion of what participants
learned about clinical interviewing using basic listening responses.
An alternative is to do this role-play in front of the whole group with
one therapist and one client; the rest of the group can observe, acting
as the advising team to the therapist. The therapist can use the role-
play to focus on one type of skill, or may switch between types. At
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CLINICAL INTERVIEWING: INTAKE, ASSESSMENT, AND THERAPEUTIC ALLIANCE

any point during the session the therapist can timeout to get feedback
from the observation team, and bring it back into the session with
the client. Other observers might jump in if the therapist gets stuck.
Follow up with a discussion on what participants learned about using
the nondirective listening skills presented by the Sommers-Flanagans.

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Directive Listening Reponses

SUMMARY
Moving further along the clinical interviewing skills continuum,
directive listening responses bring progressively more active
components to the therapeutic dyad. Unlike the basic skills of attending
behavior and nondirective listening responses, directive responses bring
the interviewers perspective into the room.
Directive listening responses include:
feeling validation
interpretive reflection of feeling (advanced empathy)
interpretation (can be especially prone to resistance)
reframe
confrontation (pointing out discrepancies between what clients
say they want and what theyre actually doing)
Because these more complex responses go beyond the clients words,
they can lead to greater degrees of client resistance. John Sommers-
Flanagan points out that a gentle approach to these methodssuch
as asking permission to give an interpretation, for example, or asking
a client what he or she thinks of your viewcan lead to greater
engagement and collaboration.
If directive listening is more related to taking a client where the
therapist wants to go, how do you know when it resonates? According
to the Sommers-Flanagans, an interpretation of feeling can be seen
as accurate when it leads a client into deeper material. Even when
the interviewer is incorrect, the clients response can be worked with
empathically. These more advanced skills offer opportunities to deepen
the therapeutic alliance.
Finally, it is important to remember that directive listening skills
also take practice, and they build on the more basic skills presented
previously. Rita Sommers-Flanagan argues that directive responses are
tempting for the beginning interviewer, because theyre more typical of
our cultural discourse; listening well is as crucial as these more active
skills. As you watch this section of the video, observe which directive
listening behaviors are being demonstrated, and reflect on what goals
John is attempting to achieve with TJ.
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CLINICAL INTERVIEWING: INTAKE, ASSESSMENT, AND THERAPEUTIC ALLIANCE

Discussion Questions
1. The value of listening: How does your own life experience impact
your view of listening and/or your capacity to listen? Did your
family and/or culture value nonjudgmental listening as part of a
strong relationship? What examples come to mind as you consider
this? How might the skills in this section help or hinder you in
your work with clients?
2. The directive style: Rita Sommers-Flanagan says that listening
well can be as challenging as the more advanced directive
responses. Do you agree or disagree? Which type of response do
you prefer? Why? What comes up for you as you consider working
in the style that resonates the least?

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Role Plays
After watching the video and reviewing Directive Listening Skills
in this manual, break participants into groups of two and have them
role-play a brief interview between a therapist and client in which the
therapist only uses directive listening responses, using the behaviors
presented in this section.
One person will start out as the therapist and the other person
will be the client, and then invite participants to switch roles.
Therapists can focus on up to two types of responses (for instance,
validation, interpretive feeling reflection, interpretation, reframing,
or confrontation)but they are not allowed to ask questions or
use interventions from elsewhere in the video. Clients may play
themselves, or role-play Trudi from the video, a client or friend of
their own, or they can completely make it up. The primary emphasis
here is on giving the therapist an opportunity to practice interviewing
clients using a variety of directive listening skills, and on giving the
client an opportunity to see what it feels like to participate in this type
of intervention.
After the role-plays, have the groups come together to discuss their
experiences. What did participants learn about the Sommers-
Flanagans approach to directive listening? Invite the clients to talk
about what it was like to role-play someone being interviewed and
how they felt about the approach. How did they feel in relation to the
therapist? What worked and didnt work for them during the session?
Did they feel any defensiveness or other resistance arise? Then,
invite the therapists to talk about their experiences: How did it feel
to facilitate the session? Did they have difficulty sticking to this type
of intervention? Which type of response did they gravitate toward?
Which did they tend to avoid? What would they do differently if they
did it again? Finally, open up a general discussion of what participants
learned about clinical interviewing using directive listening responses.
An alternative is to do this role-play in front of the whole group with
one therapist and one client; the rest of the group can observe, acting
as the advising team to the therapist. The therapist can use the role-
play to focus on one type of skill, or may switch between types. At
any point during the session the therapist can timeout to get feedback
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CLINICAL INTERVIEWING: INTAKE, ASSESSMENT, AND THERAPEUTIC ALLIANCE

from the observation team, and bring it back into the session with
the client. Other observers might jump in if the therapist gets stuck.
Follow up with a discussion on what participants learned about using
the directive listening skills presented by the Sommers-Flanagans.

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Directives & Action Reponses

SUMMARY
Moving further still along the clinical interviewing skills continuum,
directives and action responses move clients toward acting, feeling,
or thinking in particular ways. Rita Sommers-Flanagan notes that
the interviewing skills continuum isnt linear; lots of nondirective
interventions can be experienced as directive, and vice versa.
Directives and action responses include:
psychoeducation
suggestion
agreement-disagreement
advice
self-disclosure
urging
Rita Sommers-Flanagan points out that clinicians with a more reserved
personality may find directives challenging to make. On the other hand,
because it can be exciting to encounter clients who appear ready to
engage and work hard toward change, it can also be tempting to frame
directives in inappropriate ways. John Sommers-Flanagan demonstrates
the importance of integrating nondirective listening skills into this type
of inquiry, showing that interventions can be delivered in authoritarian
or value-laden ways that increase client resistance and undermine a
clinicians credibility. Directives must be collaborative and the client
must always be the final authority.
As you watch this section of the video, observe which directives and
action responses are being demonstrated, and reflect on how you might
structure your interventions differently from John in his session with
Lisa.

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CLINICAL INTERVIEWING: INTAKE, ASSESSMENT, AND THERAPEUTIC ALLIANCE

Discussion Questions
1. Ready to engage: How can you tell when a client is ready to engage
in the work of therapy? Have you ever thought this was the case,
only to discover that it wasnt? How might you check this out with
a client?
2. Bossy vs. passive: Do you consider yourself to be more
forward or reserved when it comes to the idea of using directives
with clients? Do you find any of the various responses from this
section especially engaging? Why? How might you work with this
in a session where such a response might be called for?
3. Bad reframes: In the demo with Lisa, John Sommers-Flanagan
makes a series of authoritative and value-laden reframes. Have you
ever made any of these types of reframes with clients? What led
you to make these interventions? How did your client respond?
How did you work through it?
4. Self-disclosure: What are your personal and professional views on
appropriate self-disclosure? When do you think self-disclosure is
inappropriate? Do you use self-disclosure with your clients? For
what purpose? In your own therapy, has your therapist disclosed
information to you? How did you respond?

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Role Plays
After watching the video and reviewing Directive & Action
Responses in this manual, break participants into groups of two and
have them role-play a brief interview between a therapist and client in
which the therapist only uses directives and action responses, using
the techniques presented in this section.
One person will start out as the therapist and the other person
will be the client, and then invite participants to switch roles.
Therapists can focus on just one or two types of response (for
instance, psychoeducation, suggestion, agreement-disagreement,
advice, or urging)but they are not allowed to ask questions or
use interventions from elsewhere in the video. Clients may play
themselves, or role-play Lisa from the video, a client or friend of their
own, or they can completely make it up. The primary emphasis here is
on giving the therapist an opportunity to practice interviewing clients
using a variety of directives and action responses, and on giving the
client an opportunity to see what it feels like to participate in this type
of intervention.
After the role-plays, have the groups come together to discuss their
experiences. What did participants learn about the Sommers-
Flanagans approach to directives and action responses? Invite the
clients to talk about what it was like to role-play someone being
interviewed and how they felt about the approach. How did they feel
in relation to the therapist? What worked and didnt work for them
during the session? Did they feel any defensiveness or other resistance
arise? Then, invite the therapists to talk about their experiences: How
did it feel to facilitate the session? Did they have difficulty sticking to
this type of intervention? Which type of response did they gravitate
toward? Which did they tend to avoid? What would they do differently
if they did it again? Finally, open up a general discussion of what
participants learned about clinical interviewing using directives and
action responses.
An alternative is to do this role-play in front of the whole group with
one therapist and one client; the rest of the group can observe, acting
as the advising team to the therapist. The therapist can use the role-
19
CLINICAL INTERVIEWING: INTAKE, ASSESSMENT, AND THERAPEUTIC ALLIANCE

play to focus on one type of intervention, or may switch between

types. At any point during the session the therapist can timeout to get
feedback from the observation team, and bring it back into the session
with the client. Other observers might jump in if the therapist gets
stuck. Follow up with a discussion on what participants learned about
using the directives and action responses presented by the Sommers-
Flanagans.

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Questions & Therapeutic Questions

SUMMARY
Questions pose unique challenges for the interviewer, because they
can easily stoke defensiveness in clients. According to the Sommers-
Flanagans, questions are considered advanced listening responses due
to their powerful, intimidating, and controlling natureindeed, they
are all directive, used to guide what clients sayand therefore have the
potential for misuse.
In the video, the Sommers-Flanagans cite several types of questions:
open
closed
indirect
swing
projective/presuppositional
therapeutic (as opposed to assessment-based)
exception
They also highlight several reality therapy questionsdirect, solution-
focused queries that are less therapeutic and more geared toward
problem-solving:
What do you want?
What are you doing?
Is it working?
Should you make a new plan?
As an assessment or therapeutic tool, questions have both benefits and
liabilities. Benefits include greater therapist control, potential deep
exploration, and efficiency in gathering information. Liabilities include
setting the therapist up as expert, focusing on the therapists interests
instead of the clients, and inhibiting client spontaneity.
Questions are a diverse and flexible interviewing tool; they can be
used to stimulate or restrict client talk, facilitate rapport, show interest
in clients, gather information, and focus on solutions, among other
objectives. John Sommers-Flanagan notes that while its important
to tailor the question to the client, almost all types of questions are
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CLINICAL INTERVIEWING: INTAKE, ASSESSMENT, AND THERAPEUTIC ALLIANCE

designed to help move a client toward a more positive future.

As you watch the demonstrations in this section of the video, take note
of the different types of questions and therapeutic questions used by
interviewers Chris and John, and listen for the client responses they
elicit. Which types of questions most resonate with your personality?
With your therapeutic orientation?

*Adapted from
Sommers-Flanagan, J., and R. Sommers-Flanagan. 2014. Clinical Interviewing, Fift h
Ed.

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Discussion Questions
1. Therapeutic questions: The Sommers-Flanagans distinguish
between questions and therapeutic questions in this section. Does
this distinction make sense to you? Does your own theoretical
orientation provide a different set of questions, with different
objectives? How might the various questions here bring fresh
perspective to your work?
2. Client defensiveness: Do you agree with John Sommers-Flanagan
that questions can potentially stoke defensiveness in clients? Why
or why not? Have you observed this in your own work, either as
a therapist or as a client? If you were the therapist, how did you
handle it? Which types of the questions listed in this section might
be more likely to elicit to a defensive response?
3. Personal style: Which of the types of questions listed in this
section most resonate with your personal style? Which least
resonate? Why? Can you think of ways to modify each type to
express the same intention with a client?
4. Benefits and liabilities: What do you think are the benefits and
liabilities of each of the types of questions from this section? When
might a particular type of question be inappropriate? How do you
distinguish between a question that is therapeutically appropriate
and one designed to satisfy your personal curiosity?

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CLINICAL INTERVIEWING: INTAKE, ASSESSMENT, AND THERAPEUTIC ALLIANCE

Role Plays
After watching the video and reviewing Questions and Therapeutic
Questions in this manual, break participants into groups of two and
have them role-play a brief interview between a therapist and client
in which the therapist only asks questions, using the question types
presented in this section.
One person will start out as the therapist and the other person will
be the client, and then invite participants to switch roles. Therapists
can focus on just one type of question (for instance, only projective,
indirect, or swing questions), or they can alternate among the
various typesbut they are not allowed to paraphrase, reflect, or
use interventions from elsewhere in the video. Clients may play
themselves, or role-play Umut from the video, a client or friend of
their own, or they can completely make it up. The primary emphasis
here is on giving the therapist an opportunity to practice interviewing
clients using a variety of questions and therapeutic questions, and on
giving the client an opportunity to see what it feels like to participate
in this type of intervention.
After the role-plays, have the groups come together to discuss their
experiences. What did participants learn about the Sommers-
Flanagans approach to asking questions? Invite the clients to talk
about what it was like to role-play someone being questioned and
how they felt about the approach. How did they feel in relation to the
therapist? What worked and didnt work for them during the session?
Did they feel any defensiveness or other resistance arise? Then,
invite the therapists to talk about their experiences: How did it feel
to facilitate the session? Did they have difficulty sticking to this type
of intervention? Which type of question did they gravitate toward?
Which did they tend to avoid? What would they do differently if they
did it again? Finally, open up a general discussion of what participants
learned about clinical interviewing using questions and therapeutic
questions.
An alternative is to do this role-play in front of the whole group with
one therapist and one client; the rest of the group can observe, acting
as the advising team to the therapist. The therapist can use the role-
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play to focus on one type of question, or may switch between types. At

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CLINICAL INTERVIEWING: INTAKE, ASSESSMENT, AND THERAPEUTIC ALLIANCE

Intake Interview
SUMMARY*
The Sommers-Flanagans present the intake interview as the first of
a set of complex interviewing skills that also includes the mental
status examination and suicide assessment (see later summaries). The
intake interview is primarily an assessment tool, although the task of
establishing a therapeutic alliance is an integral element. Many factors
can shape this, such as the clients temperament or feelings regarding
the intake or interviewer, the intakes setting, or the interviewers own
feelings, among others.
Intake components include the following (each can be expanded upon
or minimized):
identify and explore chief complaint
take personal history and info
review current functioning
A successful intake helps guide clients through a potentially new
process (and new relationship), supports the establishment of safety, and
provides clients with opportunities to reflect. The skills necessary for
conducting a successful intake integrate the basic listening responses
described in previous summaries; while the focus is on assessment,
for instance, therapists can also use empathic statements such as
paraphrases, feeling validation, and nondirective reflection of feeling.
Therefore, intakes require that therapists be flexible enough to follow the
client and establish rapport alongside their commitment to protocol.
In addition to taking stock of symptoms and building an alliance, the
intake interview helps the therapist begin to create a case formulation
and treatment plan. Therapists can engage their clients in this process,
too, thereby furthering rapport, instilling hope, and increasing
commitment to treatment.
As you watch this chapter of the video, observe how Rita Sommers-
Flanagan addresses issues such as family history, physiological and
cognitive symptoms, past vs. present experience, and goal-setting in her
intake interview with Michelle. Notice what resonates with you about
this process. Also consider how your own curiosity about Michelle

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might lead you to ask different questions or make different observations.

*Adapted from
Sommers-Flanagan, J., and R. Sommers-Flanagan. 2014. Clinical Interviewing, Fift h
Ed.

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CLINICAL INTERVIEWING: INTAKE, ASSESSMENT, AND THERAPEUTIC ALLIANCE

Discussion Questions
1. Meeting clients: Have you conducted intake interviews? If so,
what do they tend to be like for you? Do you notice any anxiety or
resistance, either inside you or from your clients? How have you
worked with this? What are some of the challenges you encounter
during intakes? What are some things you enjoy about them?
2. Time constraints: Do you think you have enough time during
intakes to gather all of the information you need to begin
treatment? Do you conduct intakes over the phone, in person, or
in a combination of ways? If in person, do you take just one session
for intakes, or more? What factors influence how much time you
spend?
3. Intake components: What do you consider to be the objectives of a
successful intake? Do your intakes comprise the three components
listed in the video, or do you gather different information from
clients? Is there additional information you prefer to get from or
give to clients during this process?
4. Acknowledging strengths: Rita Sommers-Flanagan asks about
Michelles coping skills and acknowledges her strengths during
the demonstration. How do you think Michelle responded to this?
Do you notice or name your clients coping skills, either during an
intake or throughout treatment? How might you use your clients
strengths to develop your treatment plan?

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Role Plays
After watching the video and reviewing Intake Interview in this
manual, break participants into groups of two and have them role-
play an intake interview between a therapist and client, using the
components presented in this section and building on the listening
skills from earlier in the video.
One person will start out as the therapist and the other person will
be the client, and then invite participants to switch roles. Clients
may play themselves, or role-play Michelle from the video, a client or
friend of their own, or they can completely make it up. The primary
emphasis here is on giving the therapist an opportunity to practice an
intake interview with clients, and on giving the client an opportunity
to see what it feels like to participate in an intake interview using the
Sommers-Flanagans approach.
Identify and explore chief complaint
The therapist should begin by finding out about the clients primary
reason for coming to therapy, with an emphasis on understanding
symptoms. The therapist can inquire about physiological, cognitive,
and emotional symptoms, their triggers, the order in which symptoms
arise, and the like.
Take personal history and information
While maintaining a flow between past and present, the therapist
should get a sense of the clients history, including family dynamics,
family history with similar complaints, legal problems, substance
abuse, and anything else that might be impacting the clients
presenting issue.
Review current functioning
Finally, review the clients current level of functioning, including
any strengths, coping skills, or adaptive self-care the client exhibits.
If you have extra time, consider exploring the clients goals, with an
emphasis on case formulation and instilling hope. Find out what the
client wants in their lifewhat are they missing out on because of the
problem? What would they like to be able to do differently? Would any
intermediate goals or homework assignments help the client?
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CLINICAL INTERVIEWING: INTAKE, ASSESSMENT, AND THERAPEUTIC ALLIANCE

If there isnt sufficient time to do this entire exercise, the instructor

can choose to limit the role-play to just one of the intake components,
as described above.
After the role-plays, have the groups come together to discuss their
experiences. What did participants learn about the Sommers-
Flanagans approach to intakes? Invite the clients to talk about what it
was like to role-play someone being interviewed for the first time and
how they felt about the approach. How did they feel in relation to the
therapist? What worked and didnt work for them during the session?
Did they feel any defensiveness or other resistance arise? Then, invite
the therapists to talk about their experiences: How did it feel to
facilitate the session? Did they have difficulty getting the information
they needed? Which type of questions did they gravitate toward?
Which did they tend to avoid? What would they do differently if they
did it again? Finally, open up a general discussion of what participants
learned about intake interviews.
An alternative is to do this role-play in front of the whole group
with one therapist and one client; the rest of the group can observe,
acting as the advising team to the therapist. The therapist can use
the role-play to focus on one intake component, or may do a more
comprehensive interview. At any point during the session the therapist
can timeout to get feedback from the observation team, and bring
it back into the session with the client. Other observers might jump
in if the therapist gets stuck. Follow up with a discussion on what
participants learned about using the intake model presented by the
Sommers-Flanagans.

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Mental Status Examination

SUMMARY
The purpose of the mental status examination (MSE), another
assessment tool, is to gather data or observations on the client that
you can then organize into what the Sommers-Flanagans refer to as
the nine different mental status examination domains (see below). For
some clinicians, the MSE serves as a fairly standard tool for evaluating
cognitive processes, using a format generally understood among
professionals. John Sommers-Flanagan underscores the need to conduct
this interview in an empathic and collaborative way, particularly in
light of a common concern among new clinicians that such a structured
interview might adversely affect the therapeutic relationship.
The nine domains of the mental status examination are:
Appearance
Behavioral/psychomotor activity
Attitude toward interviewer
Affect & mood
Speech & thought
Perceptual disturbances
Orientation & consciousness
Memory & intelligence
Reliability, judgment, & insight
According to the Sommers-Flanagans, the first three domains
(appearance, behavior/psychomotor activity, and attitude toward
interviewer) are always inferred by the interviewer, in his or her
observation of the client. The last six domains are assessed more
directly, through questioning.
Again, interview questions can be framed in a way that engages rather
than alienates clients, and its important to incorporate empathic
listening responses into this advanced interview. Moreover, as John
Sommers-Flanagan notes of his video demonstrations with Carl, a
clients personality traitsin Carls case, his humor and tangential
referencesare data that can inform the structured questions and
deepen rapport.
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CLINICAL INTERVIEWING: INTAKE, ASSESSMENT, AND THERAPEUTIC ALLIANCE

This section of the video features John Sommers-Flanagan conducting

an MSE with Carl, with additional focus on assessing intermediate
memory. As you watch, consider your reactions to the structure of the
interview, your internal reactions to Carl, and ways you might tailor
such questions based on your own theoretical orientation.

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Discussion Questions
Professors, training directors and facilitators may use some or all of
these discussion questions, depending on what aspects of the video are
most relevant to the audience.
1. Prior Experience: Have you conducted mental status examinations
with any of your clients? What was your experience like? How
did your clients respond, and how did the results inform your
treatment plan?
2. The nine domains: Based on the demo, how would you assess
Carls mental status, both overall and within each of the nine
domains? Are some domains less clear to you than others?
How would you decide when to make inferences as to a clients
presentation or when to assess more directly? Would this change
based on your particular client?
3. Structured vs. free-form: How do you feel about giving such
a structured type of assessment? Do you prefer more or less
structured interviews? As John Sommers-Flanagan notes, do
you wonder if a mental status interview might adversely affect
the therapeutic relationship? How might you work with a client
resistant to this type of inquiry?
4. Personal reactions: What are your internal reactions to Carl as
you watch the demonstrations? What are your feelings regarding
his humor, physical tics, discussion of bestiality, and general
presentation? How would it be for you to receive this type of
information? Would his responses impact your attempts to build
rapport? Have you worked with clients whove offered surprising
information? How did you handle it?

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CLINICAL INTERVIEWING: INTAKE, ASSESSMENT, AND THERAPEUTIC ALLIANCE

Role Plays*
After watching the video and reviewing Mental Status Examination
in this manual, break participants into groups of two and have them
role-play a brief mental status examination between a therapist
and client. One person will start out as the therapist and the other
person will be the client, and then invite participants to switch roles.
Therapists will focus on just one of the directly assessed domains:
affect and mood. Clients may play themselves, or role-play Carl from
the video, a client or friend of their own, or they can completely make
it up.
During the assessment, therapists may incorporate the clinical
interviewing skills previously presented in the video to build rapport.
Note that the intention of this role-play is not to make conclusive
statements about mental status, but rather to give the therapist an
opportunity to practice conducting a mental status examination with
a client, and on giving the client an opportunity to see what it feels like
to participate in this type of interview.
Client affect
The therapist should begin by finding out about the clients chief
complaint, while noting affect. Affect is the visible moment-to-
moment emotional tone observed by the interviewer (i.e., sadness,
euphoria, irritability, anxiety, fear, anger, happiness, etc.), typically
based on nonverbal behavior. While the client is speaking, observe the
client and identify his or her affective state, informed by the nonverbal
behavior you see. In addition, observe the range and duration of affect:
Is it extremely variable within the session? Finally, is the clients affect
appropriate (does it match the content of the clients story)?
Client mood
In contrast to affect, mood is the clients internal, subjective, verbal
self-reported state. Ask the client about his or her mood directly
with an open-ended question such as, How have you been feeling
lately? or Would you describe your mood for me? rather than a
closed and leading question that suggests an answer (such as Are
you depressed?). Next, using a scale of 0-10, ask the client to rate his
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or her (a) current mood, (b) normal mood, (c) lowest mood in the
past two weeks, and (d) highest mood in the past two weeks. After
obtaining mood ratings, additional follow-up questions may be asked,
such as, Whats going on right now that makes you rate your mood as
a 4? As time allows, take the time to respond empathically.
Finally, write down a brief summary of your findings (one or two
sentences each for affect and mood will suffice).
After the role-plays, have the groups come together to discuss their
experiences. What did participants learn about the Sommers-
Flanagans approach to mental status examinations, particularly affect
and mood? Invite the clients to talk about what it was like to role-play
someone being interviewed and how they felt about the approach.
How did they feel in relation to the therapist? Did they understand the
intention of each question? What worked and didnt work for them
during the session? Did they feel any defensiveness or other resistance
arise? Then, invite the therapists to talk about their experiences: How
did it feel to facilitate the interview? Did they have difficulty sticking
to this type of assessment? What would they do differently if they did
it again? Finally, open up a general discussion of what participants
learned about affect, mood, and mental status examinations.
An alternative is to do this role-play in front of the whole group
with one therapist and one client; the rest of the group can observe,
acting as the advising team to the therapist. At any point during
the interview the therapist can timeout to get feedback from the
observation team, and bring it back into the session with the client.
Other observers might jump in if the therapist gets stuck. Follow up
with a discussion on what participants learned about mental status
examinations as presented by the Sommers-Flanagans.

*Adapted from
Sommers-Flanagan, J., and R. Sommers-Flanagan. 2014. Clinical Interviewing, Fift h
Ed.

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CLINICAL INTERVIEWING: INTAKE, ASSESSMENT, AND THERAPEUTIC ALLIANCE

Suicide Assessment Interview

SUMMARY
Talking about suicide and suicide ideation isnt easy for anyone; for
beginning clinicians, it can be difficult to discern which types of
questions and listening responses will be most helpful to clients, and
when these interventions can best be leveraged. In this section of the
video, John and Rita Sommers-Flanagan discuss the steps involved in
conducting a thorough, empathic suicide assessment interview, and they
offer a demonstration of John sitting with Tommi, a moody client with
intermittent suicidal ideation.
The Sommers-Flanagans name several main components of a suicide
assessment interview:
suicide risk factors (not always direct questions)
depression assessment (symptoms)
exploration of suicidal ideation (direct questions framed in way
the client can answer truthfully)
exploration of suicide plan
determination of suicide intent & reasons for living (getting
reasons can be way of assessing intent)
inference of client self-control; one way to do that is by forming a
collaborative development of a safety plan
John Sommers-Flanagan stresses the importance of asking about suicide
directly. He also demonstrates asking whether the client has a plan;
note that the more basic listening responses can be of great use here,
particularly in paraphrasing the underlying message of the clients
plan (or past attempts, if applicable). In addition to the above points, a
suicide assessment interview can also include asking about exceptions
(Whats going on when youre free from suicidal ideation?), asking
about positive emotions along with the negative, exploring the meaning
a client might create around being alive; and, more diagnostically,
exploring the clients frequency, duration, and intensity of his or her
ideation.
Working with suicidal clients can be especially challenging because
every person is uniqueand so there is no exact formula for making an
assessment. However, the points above constitute an integral outline for
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such an inquiry, and because decision-making is so stressful in this area,

its important to take clear notes and get consultation, both to protect
against liability and ensure a thorough assessment.
As you watch the demonstrations in this section of the video, observe
which interventions John uses with Tommi, and consider what you
might do differently. Also note your internal reaction toward suicidal
clients in general and Tommi in particular, and consider how your
feelings might impact the interview if you were her therapist.

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CLINICAL INTERVIEWING: INTAKE, ASSESSMENT, AND THERAPEUTIC ALLIANCE

Discussion Questions
1. Working with suicidality: Have you ever worked with a client who
had attempted suicide in the past, or with someone contemplating
suicide? How did you respond internally? How did you handle it
with your client? Were your interventions similar to or different
from the ones proposed in the video? If you havent worked with a
suicidal client, what feelings arise for you as you consider this type
of assessment?
2. Cultural inquiry: What did you think of the way John addressed
culture with Tommi? How do you think she felt about this? How
do you know? How might your assessment be affected by an
understanding of your clients cultural background?
3. Following intuition: What feelings or thoughts arise in you as you
consider the many ways to inquire into suicidality? How would
you know which lines of questioning to follow? Would you discuss
your choices with your client directly? Why or why not?
4. Positive vs. negative: John Sommers-Flanagan says that he tends
to focus more on the more positive aspects of a clients experience
during suicide assessments. How is his style similar to of different
from yours in this regard? How might your focus be influenced by
what your client says?

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Role Plays*
After watching the video and reviewing Suicide Assessment
Interview in this manual, break participants into groups of two and
have them role-play a suicide assessment between a therapist and
client, using the components presented in this section and building on
the interviewing skills from earlier in the video.
One person will start out as the therapist and the other person will
be the client, and then invite participants to switch roles. Clients may
play themselves, or role-play Tommi from the video, a client or friend
of their own, or they can completely make it up. The primary emphasis
here is on giving the therapist an opportunity to practice a suicide
assessment with a client, and on giving the client an opportunity to
see what it feels like to participate in a suicide assessment using the
Sommers-Flanagans approach.
Therapists can focus on just one area of assessment, or they can
explore multiple areas as time allows. The interview can include
an assessment of suicide risk factors; symptoms of related mood
disorders; suicidal ideation (framed directly, in a way the client can
answer truthfully); the presence of a suicide plan; suicide intent and
reasons for living (getting reasons can be way of assessing intent);
client self-control. Consider leaving time for the collaborative
development of a safety plan. As the role-play winds down, therapists
can write down a summary of their findings and any questions
regarding next steps.
After the role-plays, have the groups come together to discuss their
experiences. What did participants learn about the Sommers-
Flanagans approach to suicide assessments? Invite the clients to
talk about what it was like to role-play someone being interviewed
and how they felt about the approach. How did they feel in relation
to the therapist? What worked and didnt work for them during the
session? Did they feel any defensiveness or other resistance arise?
Then, invite the therapists to talk about their experiences: How did
it feel to facilitate the interview? Did they have difficulty getting the
information they needed? Which type of questions did they gravitate
toward? Which did they tend to avoid? What would they do differently
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CLINICAL INTERVIEWING: INTAKE, ASSESSMENT, AND THERAPEUTIC ALLIANCE

if they did it again? Finally, open up a general discussion of what

participants learned about suicide assessments.
An alternative is to do this role-play in front of the whole group with
one therapist and one client; the rest of the group can observe, acting
as the advising team to the therapist. The therapist can use the role-
play to focus on one suicide assessment component, or may do a more
comprehensive interview. At any point during the session the therapist
can timeout to get feedback from the observation team, and bring
it back into the session with the client. Other observers might jump
in if the therapist gets stuck. Follow up with a discussion on what
participants learned about suicide assessments as presented by the
Sommers-Flanagans.

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Reaction Paper for Classes and Training

Video: Clinical Interviewing: Intake, Assessment, and
Therapeutic Alliance with John Sommers-Flanagan and
Rita Sommers-Flanagan
Assignment: Complete this reaction paper and return it by the
date noted by the facilitator.
Suggestions for Viewers: Take notes on these questions while
viewing the video and complete the reaction paper afterwards.
Respond to each question below.
Length and Style: 2-4 pages double-spaced. Be brief and concise.
Do NOT provide a full synopsis of the video. This is meant to be a
brief reaction paper that you write soon after watching the video
we want your ideas and reactions.
What to Write: Respond to the following questions in your reaction
paper::
1. Key points: What important points did you learn about the
Sommers-Flanagans approach to clinical interviewing? What
stands out to you about the topics covered?
2. What I found most helpful: As a therapist, what was most
beneficial to you about the techniques presented? What tools or
perspectives did you find helpful and might you use in your own
work? What challenged you to think about something in a new
way?
3. What does not make sense: What principles/techniques/
interventions did not make sense to you? Did anything push your
buttons or bring about a sense of resistance in you, or just not fit
with your own style of working?
4. How I would do it differently: What might you do differently
from the Sommers-Flanagans when starting work with clients?
Be specific about what different approaches, interventions and
techniques you would apply.
5. Other questions/reactions: What questions or reactions did you
have as you viewed the therapy sessions with the clinicians in the
video? Other comments, thoughts or feelings?
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CLINICAL INTERVIEWING: INTAKE, ASSESSMENT, AND THERAPEUTIC ALLIANCE

Related Websites, Videos and Further

Reading
WEB RESOURCES
John Sommers-Flanagans Official Website
http://johnsommersflanagan.com
Training Institute for Suicide Assessment and Clinical Interviewing (TISA)
www.suicideassessment.com
American Counseling Association
www.counseling.org

continuum of listening responses, beginning with the less directive,

almost non-directive listening approaches and extending to the more
complex and directive interviewing or even action skills.
RITA: I think its important before we actually talk about the
techniques that we take a minute to think about a couple of things
that are across techniques in interviewing. One is that because
theres a power differential in the relationship, and we can never not
communicate, the interviewer can be seen as directive even when
theyre not doing anything. Its just associated with the authority.
JOHN: Yeah. Rita, that reminds me. And it goes without saying,
but you know me, Im going to say it anyway, that culture and the
individual characteristics of the client are very important in the
clinical interviewing process. For example, if you dont consider race,
sex, ethnicity, and many other background factors, it may be that
youll be tuned out and insensitive to things that youre doing that
might be off putting to the client. For example, if youre listening
closely, and leaning forward, and nodding vigorously, making great
eye contact, but your client is sort of leaning backwards, and looking
awkward, and uncomfortable, its your problem. It is definitely
not the clients problem. And you need to make some changes in
your approach. I also find that theres a little subjectivity in how I
respond personally to interviews. And for example, when you said, I
understand, I just really kind of dont like that at all. Because I think
technically you cant really understand the deep experience of another
person, especially if the persons from another race or another culture.
RITA: Yeah, yeah, youre right. Its very subjective. And there are,
I think, some bad or ineffective ways of listening that arent just
ineffective. I think they are harmful. I think looking at your watch,
glancing around, yawning
JOHN: Or maybe interrupting, interrupting could be one of those
negative behaviors.
RITA: Yeah, I agree. I think that across cultures, people have some
kind of awareness or radar that tells them when theyre not being
listened to and theyre not being respected, yeah.

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JOHN: So I guess the bottom line is listen well, listen authentically for
you, but also try to calibrate or adjust the way youre listening for the
specific individual who youre with in the room.
RITA: Yeah, I think too I want to underline something I tell my
students over and over again. Listening is a gift. Listening in our
culture, being listened to very, very well, is really a rare and a helpful
gift.
Lets talk about some of these listening techniques, the least directive
set of interviewing skills, non-directive listening responses.
JOHN: Right.
RITA: So the first one is Allen Iveys attending behaviors. And these
include eye contact, body posture, voice tone, and verbal tracking.
JOHN: And Ivey wrote about those as basic micro skills that are
always present in the interviewing interaction. In addition to those,
there are also some non-directive listening responses. These include
silence, clarifications, paraphrasingand theres several different
kinds of paraphrases people can usereflection of feeling, and
summarization.
RITA: Silence can be a very compassionate response. Just sitting
quietly after somebody has shared their pain or their story can be
difficult but very powerful. The important thing is, John, youve got
to have your body, and your mind, and your face all really connected
to the client, really saying, I hear you. Im right here in the room with
you. I can handle this.
JOHN: You know, I think thats a great point. Almost every student
Ive ever worked with has wished that they had exactly the right thing
to say at the right time.
RITA: Right.
JOHN: And sometimes silence is exactly the right thing to say.
Although, I think especially for beginning interviewers, five or 10
seconds of silence can seem like an eternity. And so they can feel
like they need to say something. And even myself, at times, I noticed
I should put my hand over my mouth and try to stop myself from

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CLINICAL INTERVIEWING: INTAKE, ASSESSMENT, AND THERAPEUTIC ALLIANCE

talking too much.

RITA: Verbal output, yeah, so silence certainly is a skilled tool and an
important one. But of course, we also need some other non-directive
techniques that we can use.
JOHN: Tell me more about that.
RITA: Well, that was one, and verbal prompt. And also we can use
paraphrasing, which means just reflecting back the content that
youve heard. Although, I have to say something about that. When
paraphrasing is done in a clumsy way, I think it can seem like youre
mimicking the client. It can seem kind of robotic.
JOHN: So what youre saying is that although you think paraphrasing
is very important, you really dont like it when its done in kind of a
mimicky or robotic way.
RITA: Thank you, John Carl Rogers John. I hate when you do that.
So what youre saying is you really dont like it when I talk like Carl
Rogers.
RITA: Well, I like Carl Rogers, but so lets move on. How about this.
How about you say something, and Ill demonstrate a clarification.
JOHN: Sounds good. You know, one of the things that is I think true
for me is that sometimes in my students, I have observed them having
naturally good listening skills. Its like they seem to be born to listen,
while other students, its more of a challenge for them.
And they need to work at it a little harder. But what I found is that the
virtually everyone is able to increase or improve their listening skills.
And so that kind of gives me hope for everyone.
RITA: So what I think I hear you saying is that listening skills and
abilities can be something someone naturally has, more or less of. But
in the years youve worked in this area, youve realized that everyone
can learn to be a better listener. Did I get that right?
JOHN: Absolutely right, and it feels good to be heard. And so now
lets watch the magic of listening skills in action. Now this video clip
begins a couple of minutes into a session where the client, Jessie, is
talking about a roommate problem. The therapist, Megan, has a very
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gentle and accepting style, which allows Jessie to explore her concerns
in depth.
Early on, you should especially watch for Megans paraphrase about
Jesse having no time for herself. Because theres not even a hint of a
robot in the room.
JESSIE: I just, I cant. I feel like she uses me as like a sounding board,
and I get nothing in return.
RITA: You said several times while talking that she doesnt listen to
you or doesnt even give you the opportunity to talk. It seems like she
just talks, talks, talks.
JESSIE: Yeah.
MEGAN: And then youre listening, and thats exhausting. Or youre
kind of getting angry and irritated by it.
JESSIE: Yeah, yeah, I do. Its just frustrating when somebody comes
and they talk to you for like half an hour about all of their problems.
And then its like once theyre done, theyre like, OK. I dont care about
how you are, what youre doing.
So shell go off and do whatever, or watch TV, or something. And
whenever I do try to talk to her, shes like either playing a video game
or on her phone. Or shell just start in with oh, did that happen to
you? That happened to me. And its just like, oh my gosh.
MEGAN: Then shell go on into it.
JESSIE: Yeah, and then shell just go off about her own story. I care
about our friendship, because its been like a five or six or something
year-long friendship. And so I would like to continue that. And so I
think we could still be friends, if we didnt live together. But the whole
not living together part has to be crucial. Yeah.
MEGAN: Yeah, it seems like youve talked a lot about the different
things that youre dealing with within this relationship with her, in
terms of not being heard and not enjoying, just not enjoying, being
around her anymore and not wanting to go home.
JESSIE: Thats the worst part.

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CLINICAL INTERVIEWING: INTAKE, ASSESSMENT, AND THERAPEUTIC ALLIANCE

MEGAN: And feeling frustrated by it, but also just it almost seems like
youre not sure what to do about it.
JESSIE: Yeah. I guess Im just not sure how to bring up not living
together anymore. Ill be gone for the summer, so part of me thinks
that would be a way. Because like she has to find a new place or
continue to pay rent where we are. And I dont want to have to do that.
And so part of me wants to be like, well, Im just not going to be here.
So we cant live together because of that. Because you need to get into
a place and start paying before Ill even be here. And so I kind of want
to just approach it that way. But thats definitely not confronting the
real reason of why I dont want to live with her.
MEGAN: Whats hard about that, about confronting her?
JESSIE: Because I like confrontations. And I dont like making people
feel upset. And Im pretty sure that she would cry, and get defensive,
and angry.
And we couldnt continue a friendship. It would be like Im a horrible
person for this, and she wouldnt want to be my friend. I would just
imagine her getting defensive and blame me or something.
MEGAN: So when you think about confronting her, you think that it
would end the relationship. Am I getting that right? Or that it would
kind of lead to that?
JESSIE: Yeah, thats what Im afraid of. Because honestly, I want to say
I cant stand your dogs, and I cant stand your attitude. And I am so
exhausted with you. And I cant continue to live with her. Thats how
I feel.
RITA: That was really nice. You know, we showed that video, we didnt
really talk about summarizing or summarization. Summarizing can
really be a great technique to use, partly because it forces you to listen
so well. Because youre going to list the main points that youve just
heard.
JOHN: Yeah, and I think Megan did a great job of that. Especially
because for myself, and I think many people I know, its so easy for
the points that youre listening to kind of evaporate in your mind as
youre trying to formulate the summary. And she did a great job. She
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identified that the client was feeling very unhappy in the roommate
situation, that she was not wanting to come home, that she didnt feel
heard, that but she really didnt even like her roommate anymore.
RITA: Yeah, that was a great summary. One warning is probably not
to number the items that youre going to say. Because you can get to
number two and suddenly have no idea what number three was. So
John theres one last skill that I think maybe we should talk about
before ending this segment. And that is called the reflection of feeling.
JOHN: Absolutely, and Im really glad that you remembered that. I
find myself just as we go through this production process, its sort of
nerve wrecking. I feel nervous. I feel anxious. I try to keep an external
composure. But on the inside, I feel pressure. Im worried that well
make mistakes, and that maybe its going to be not hopeful, or even
worthless, or even the worst possible scenario that I would just terribly
embarrass myself.
RITA: Yeah, so lots of feelings thereyou feel anxious. You want this
to go well. You have kind of this calm veneer, but underneath theres
anxiety. Theres a kind of worry that this wont go well. And it just
spirals down to the point where we might be wasting peoples time and
really might just be embarrassed.
JOHN: That is very nice. You did a great and accurate job of
identifying a range of different emotions that Im feeling. And I have
to say I really appreciate the fact that stayed with the basic non-
directive reflection of feeling. You didnt interpret anything. You
didnt try to go for my deep-seated neuroses.
RITA: Right, well no, it was tempting. And in the next sections, well
have opportunities for that. But our times up for this section. And
well move on to more directive listening and action responses.
JOHN: Previously on this video, we focused on listening skills and
techniques that help the interviewer stay less directive. And our
therapist on the proceeding video clip, Megan Hopkins, she is a
member of the Sioux Assiniboine tribe. And that particular tribe has
strong values and deep beliefs about the importance of listening to one
another respectfully. And the extent to which you as a professional

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clinical interviewer value listening may also depend on your cultural

background and even on your personal experiences.
RITA: Thats true. You know, being able to stay non-directive and
nonjudgmental is an important part of interviewing. But we also have
to learn how to use more directive interventions and actions in a way
that maintains the therapy relationship.
JOHN: Absolutely. In this next section, we begin moving further along
the continuum toward more complex and more directive listening
responses. These responses are referred to as directive listening
responses, because they still primarily focus on listening. But they also
include components that are progressively more directive.
And so they involve lots of listening, and a little bit of directing, or
pushing clients to see or think about things a bit differently. Directive
listening responses are more judgmental. And they include guidance
or validation from the interviewer. For example, you might use a
feeling validation like, I can sure see why you would feel angry about
that. And thats sort of a validating response. Its no longer non-
directive.
RITA: Right, and you might do an interpretive reflection of feeling,
which takes it a little past the feeling that has been stated. And you
might take a guess at a feeling that might actually be implied or just
underneath what the client is saying.
JOHN: Some people, Rita, refer to that as advanced empathy, because
it goes beyond the clients words. And speaking of going beyond the
clients words, from the psychoanalytic perspective, an even more
directive listening response is interpretation. Interpretations are
designed to put two different observations together and along with
an attentive statement about how they might be related or what they
might mean. These meanings that the interviewer picks up on might
relate to earlier life experiences of the client or perhaps to some kind
of unconscious processes.
RITA: Right, and of course that is sort of theoretically laden. And
some people are little resistant to that kind of interpretation. But
another way of thinking about it is when you take information the

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client is giving you and you link that to a different reality or different
way of seeing reality, and we call that a re-frame. Its also quite
directive.
JOHN: Yeah, and you might even do a gentle confrontation. At least
I prefer gentle confrontations. Because confrontations simply involve
pointing out inconsistencies or discrepancies between what clients are
saying they want and what theyre actually doing.
RITA: In this next set, were going to see John working with Trudy,
whos struggling in her marriage with her husband named Jamie. And
its also important to notice that they have a son named Ross who has
a disability. And Ross is still living with them. It may be subtle, but
notice the difference in tone and style when the interviewers being
slightly more directive than the previous segment with Megan.
TRUDY: And I keep telling him, he doesnt have to do it all today. But
then I think he thinks that Im trying to sabotage his good health. I
dont know. Its just like everything that I do that I think is going to be
a good thing, a positive thing, doesnt turn out that way.
JOHN: Yeah, you mentioned before you feel a little bit scared at the
idea of really being out there kind of on your own. But also I hear
maybe some sadness and some frustration in the relationship now and
that youre not even sure where to start.
TRUDY: You know, I dont. I sit and think about how our relationship
has been in the past. And I realized that it wasnt just since Jamies
first heart attack that things have been different. I just remember
a time when this friend of mine that I was telling you about that is
concerned about me, she called me for lunch one day. And so we made
arrangements go to lunch. And you know what? I took Ross with me.
And I remember her looking at me like, I invited you to lunch. And
Ross was 17 years old. And so consequently, we never talked about
girl things that we might have talked about or anything like that.
It was just about kind of about Ross and trying to keep him in the
conversation, which isnt always easy because he has some autism
problems. And I dont know why I did that.
JOHN: Is it OK with you, Trudy, if I just share with you a thought that

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I have about one of the dynamics that I think might be going on.
TRUDY: Sure.
JOHN: I hear you saying that sometimes Jamie says or wonders if
youre trying to sabotage some of his exercise.
TRUDY: Yeah.
JOHN: But I also hear you maybe sometimes actively sabotaging
the possibility of intimacy with him. And I just wonder what your
reaction is when I say that.
TRUDY: Its very possible. And you know, this is one thing, John. This
just really upsets me about myself when I think about it. I dont think
I even know how to be intimate anymore. It would seem so foreign to
me to spend time with just Jamie and to talk about our feelings.
JOHN: Yeah.
RITA: So in that last section, we saw two interesting things. We saw
an interpretation of feeling, and we saw confrontation. The first, the
interpretation of feeling, led Trudy to go into deeper material. And
thats often an indicator that the interpretation was accurate. And then
we saw the confrontation, which of course was very gentle. We asked
the clients permission, then offered the interpretation, and then asked
her what she thought about it. And again, we saw Trudy just go for it.
And thats an indication that the confrontation was OK with her.
JOHN: One of the reasons I think I like to ask clients permission
to do a confrontation is because Im kind of naturally averse to
confronting people. So its a hard thing for me. And I also think it
helps to engage them in a more collaborative way. The other thing
I noticed about that clip was that although Trudy was talking
about sabotaging a lunch with a friend, I brought it back with the
confrontation to her presenting complaint, which was intimacy with
her husband.
RITA: Yeah, so in this next little clip, were going to watch John
work with TJ. TJ is a 22-year-old young man with issues around
anger, aggression, and social skills. This clip that youre about to see
focuses on TJs anger and aggression. And youll see a paraphrase,

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then an attempt, and an interpretive reflection of feeling, which TJ

corrects, and then a reflection of feeling, and a clarification. Youll
see John creating a context for interpretation and then offering the
interpretation.
TJ:fights with family that dont fully escalate physically, but kind of
break you down.
JOHN: So youve had some fights with your family that have been
emotionally pretty painful, maybe lasting emotional effects, not so
much physical. OK. And when I hear you say that, it sounds like one of
the costs of that is you feel some regret. Have I got that right? Or is it
something else?
TJ: Not completely, more like sympathy.
JOHN: Tell me about that.
TJ: Well, I think emotions are a weakness. And if I have emotions that
make me vulnerable, when people feel sympathetic of it, it doesnt help
me at all.
JOHN: OK. So it is painful to you emotionally to be seen as having a
weakness. And so when your family or people have some sympathy for
you, that actually is something you dont like?
TJ: No.
JOHN: No.
TJ: No, because its like they feel like they have to do something to
make you feel better to get you out of it.
JOHN: OK. Ive heard you use the word weakness at least three times.
TJ: Yup.
JOHN: And sometimes when we talk about anger and anger
management stuff, one of the things we do is we talk about what are
the triggers or the buttons they get pushed that bring that anger up.
And it makes you wonder if maybe one of the buttons or the triggers
for you is a sense of feeling weak. Would you say at that might make
you pretty pissed sometimes?
TJ: Yeah.
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RITA: So John, you were really working with TJ with his emotions and
the triggers that are associated with his aggression. And you did have
that attempt to do an interpretation of feeling, and he was able to say,
not quite right. Yeah. He also, I think, after you corrected, was starting
to get some awareness that even the slightest whiff of weakness was
going to be a trigger for him.
JOHN: Yeah, I do think its good to follow the clients lead on
interpretive material in particular. And so when he clarified or told me
that it wasnt quite right, I wanted to go with his direction rather than
mine. And you know, I think thats really important, partly because
interpretations when they go well are collaborative. And Otto Fenichel
said this over 60 years ago, and that is, that we have to prepare clients
for interpretations and that interpretations are really a way of us
working on the edge of our clients consciousness or awareness.
RITA: Yeah, theres nothing mysterious or woo-woo about
interpretations. Theyre not like mind reading. They really involve
a lot of listening and a lot of work. So directive listening responses
obviously depend more on the view of the interviewer, and the
direction is this a little bit more related to where the interviewer wants
to go than the client.
JOHN: Yeah, directive listening responses are more advanced
responses by clinical interviewers.
RITA: Well, I agree with you in one sense. But I also think that
actually listening really, really well is as hard as some of the more
directive responses.
JOHN: Well, you know, actually I totally agree with you. Youve
convinced me. And really what I was trying to say is I was trying to
make the point that interviewing in a directive way is sometimes
very tempting. And its very natural. Its similar to the way we behave
socially in social environments. And so I do think that to do it well,
it really requires awareness of your goal. It requires sensitivity to the
client, and it requires practice and probably some wisdom as well.
RITA: So in this section, were going to be talking about directives
and action responses, which actually move us a little further along the

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continuum of directive listening skills.

JOHN: Directives are really sort of like prescriptions in that they push
or move clients a little bit toward acting, feeling, or thinking in certain
particular ways. And so its really important when using these kinds
of approaches that we weave back and forth or we integrate into the
approach some less directive or non-directive listening skillsso a
non-directive listening skill like a paraphrase, and then a directive
action response, and then a check in or paraphrase to follow it.
RITA: And you know were talking a lot it about the continuum as
if its a linear sort of process. But actually, its sort of dimensional.
Because something that seems very non-directive can be done in
a way that was experienced as pretty directive. Raised eyebrow, a
tone of voice, choice of words, posture those kinds of things can be
experienced is as a pretty directive or not attractive.
JOHN: I know, Ive seen some people raise one eyebrow. And Ive
never been able to do that.
RITA: Can you raise one nose nostril?
JOHN: I dont want to try, especially not on video.
RITA: OK, fine. So in general, I think the truth is that non-directive
things can be directive and directed things can come off as non-
directive, really depending on how you use them.
JOHN: Yeah, when interviewers start sharing information, or making
suggestions, or expressing agreement, or disagreement, or approval or
disapproval
RITA: Or giving advice
JOHN: Self-disclosing
RITA: Yeah, self-disclosing, urging
JOHN: When those kinds of things are happening, its obvious
that the interviewer is moving toward action. And were trying to
change in those situations the clients way of thinking, or way of
being, or behaving. We are in the realm of the directive, which may
be one reason why directives are most effective with clients who are
in Prochaska andDiClementes action stage in the transtheoretical
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model. These are people who are ready to engage and work hard
toward change.
RITA: Right, right, well, being directive is not a bad thing. Its just
that it comes very natural to some bossy firstborn people. And they
might need, like youve been talking about, to tone it down, to be
aware of when to use it. On the other hand, there are people who are
very passive and the idea of offering something directive can be sort of
terrifying.
So in this next clip, we see John using agreement, suggestion, and he
provides psychoeducational material effectively and appropriately.
Watch how he engages his client Lisa with the information and the
ideas he offers.
LISA: Well, I dont want to take drugs. Ive tried a couple of glasses of
wine at night, doesnt seem to help.
JOHN: That doesnt help either.
LISA: No. Ive tried a good book, and thats fine until I turn off the
light. And then my mind starts racing again. I just feel overwhelmed
and behind. All my life there have been times like that, but Ive been
able to see the big picture and know that its just a bump in the road.
Now Im swallowed up.
JOHN: Yeah, that does sound really intense. Now lets focus on
the sleep just for a little while. There are three kinds of insomnia,
mainly. One is difficulty falling asleep. And thats when you lay there,
oftentimes with racing thoughts, but you cant get to sleep often for
hours.
The second type is early morning awakening. And thats when you
go to sleep, and you sleep most of the night. But maybe 2:00 or 3:00
in the morning, depending on when you went to bed, but way earlier
than you want to wake up, you wake up and then you cant get back
to sleep. And so thats early morning awakening. And the first one is
difficulty falling asleep. And the third one is a thing called choppy
sleep or intermittent insomnia. And thats when maybe you have
some difficulty falling asleep. You go to sleep. You wake up. You go to
sleep. You wake up. And you kind of wake up intermittently through
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the night. Which do you think is the best description of the troubles
youre having?
LISA: The first one.
JOHN: OK. Are you interested if I might suggest to you a few ideas
about how to approach the sleep issue?
LISA: Sure.
JOHN: I know that there are other things that we could and will talk
about. But it seems like if we focus on the sleep for a little while that
that might be useful. Is that OK?
LISA: Yes. I think its all magnified by the fact that I have such a sleep
deficit. And if I can sleep better, Ill handle things better.
JOHN: Yeah, I think that might be true for everybody. The lack of
a good nights sleep can make all of us a little less able to cope with
things. And anything else youve tried to maybe push the thoughts
aside or to speed the onset of sleep for you?
LISA: No.
JOHN: OK. Have you ever heard of mindfulness meditation or have
you ever tried meditating?
LISA: No, I never have.
JOHN: No? OK. Im just going to describe one approach to that. And
actually Ill probably describe several approaches. And what Im going
to do is I just want you to think about them and try them on as Im
talking. OK?
LISA: OK.
JOHN: So theres a guy who did some research long ago. And he
identified four things that people need to experience a relaxed state of
mind. They need a comfortable position.
Im guessing in your bed its comfortable. They need a quiet place. Is it
more or less quiet?
LISA: More or less.
JOHN: OK. Then they need a mental device. And what that means is
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a thought. It could be an image to focus on. It could be a word. Youve

tried counting sheep. Thats an example of a mental device. And well
talk more about that in a moment. And then the fourth thing you
need is passive attitude. And a passive attitude, do you know what I
mean by that?
LISA: Well, go back to the one before.
JOHN: Mental device.
LISA: Yes, at some point I hope youll explain that one to me. And no,
Im not sure exactly what you mean by a passive attitude.
JOHN: OK, well, let me try to explain both. Mental device, the sort of
Zen people who are into meditation would say that your mind is like a
barking dogbark, bark, bark, bark, bark. And it barks when you stop
reading, and you lay down.
And they sometimes say yapping, you know? But a barking or a
yapping dog, and then in order to get that mind to stop barking at you,
you need to give it a bone. You need to give it something to chew one.
And that is what we refer to as a mental device, mental device being
sometimes a mantra. People who do sort of Buddhist stuff might
say the word ohm over and over. People who are religious, I know a
guy who is religious, and he likes to say something they feels sort of
spiritually right to him.
And his mantra is to say, I am here. Here I am. So with his in breath he
says, I am here.
With his out breath, he says, here I am. And that sort of got some
spiritual meaning for him. And so he finds that very soothing, and he
can stick with it.
RITA: So Lisa is obviously happy to get some information and help
with her insomnia. Shes eager to try those ideas.
JOHN: Yeah, I have to say its exciting, maybe little ego boosting, to
have a client whos really ready for action. And so I can provide her
with a little scientifically based psychoeducation. She responds in a
very positive way and is ready to get to work.
RITA: Yeah, its so nice in fact that it can be a little bit seductive, and
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the interviewer whos providing all that information and guidance can
get a little too full of himself. And things can take a nasty turn.
JOHN: Your son and your sons family have moved into your home?
LISA: Yes, and I do love them, and I love my grandbaby. But Ive had
many years of living alone, thinking Ive paid my dues. I raised my
children.
I love having them come back for visits. But this, theres always
somebody under foot. And except for midnight and on, its hard to
find quiet in the house.
JOHN: Yeah, yeah. What great family time, though. Its one of
those things in life if you get the lemons, that sometimes you make
lemonade. And it sounds to me like youre probably getting lots of
great time with your family that you maybe wouldve gotten before.
LISA: Well, I thought that six months ago when they had to move in
because of the unemployment situation. And they asked. And I said
they could. I have room. Id do anything to help them.
But its been six months. And I dont even like lemonade anymore.
JOHN: But think of the six months, I mean, you wouldnt have that
wonderful family time if all this hadnt happened.
LISA: Now Ive worked real hard at adjusting my attitude to accept
what has happened in my life. Im here to talk to you. Im looking for
help because I havent been doing so well over the last few months.
How would you feel? How would you feel if suddenly you had three
people who are noisy and move into your house, and your space, and
impact your work?
JOHN: Im really glad you asked. I mean, Ive actually been kind of
lonely lately. And so it would actually feel nice to me to have a house
full of children and people there. And so I guess what Im trying to
say to you is its really a matter of attitude. And I wonder if maybe
you could consider shifting your attitude toward one that welcomes
the company as opposed to fighting against it. Youre kind of fighting
against it.
LISA: I dont think youre remembering exactly what I told you last
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week. It was all rosy the first three weeks. I didnt imagine it would go
on this long. And I still dont know how long its going to go on.
And it is wearying. I cant keep up my responsibilities with my job,
without sleeping, with all this. Ive talked to them. Theyre very nice
people, but the house isnt that big.
JOHN: Well it sounds to me like you would just like to get rid of them,
maybe just get them completely out of the house
LISA: Well, I
JOHN: as soon as possible.
RITA: Phew. Thank goodness thats over with. That sort of
deteriorated into a disagreement on how Lisa should view her own life.
That was kind of like bad TV therapy.
JOHN: Now as much as I would like to be a bad TV therapist, I want
to emphasize I did that on purpose.
RITA: OK.
JOHN: Although I like the term you used before the clip of its
seductive. It really is. When clients act so interested in what you have
to offer, its seductive and that you start to think that they really want
to know everything about you.
RITA: Yeah.
JOHN: And then you can go overboard with self-disclosure. And you
can go overboard with I think I know whats right for you. And in the
clip where it ended, I could have even gone on and been even more of
authoritarian or authoritative.
RITA: Im not sure you wouldnt won though.
JOHN: No, she was clearly showing a little push back. But I guess the
main point is that even though we might have a really good point
to make, or we might have a really interesting life story to tell, thats
really not the fault
RITA: Its kind of like not the point.
JOHN: Thats not the point we should be making.

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RITA: Right. So directive and action responses need to be developed

collaboratively, and the client is always the final authority.
JOHN: In this final section associated with listening continuum, we
explore questions in general and therapeutic questions in particular.
And we focus on these because questions can be so common,
commonly used. They can also be very effective. But then I think
oftentimes interviewers can misuse questions.
RITA: Why do you feel that way, John?
JOHN: Well, its because I
RITA: I mean, are you feeling kind of insecure about this section?
JOHN: I think right now I am.
RITA: Yeah, I dont understand it. I wonder why you want this section
right here anyway.
JOHN: And right now Im feeling very insecure about the whole thing.
And I guess thats the point. I mean I get the fact the questions can
be very powerful. And they can be intimidating. They can be used
in ways that make clients respond in a defensive wayquestions
like, when did you stop lying to your employer? What are you really
thinking about your mother? And those kinds of things can insinuate
things. They can be used to wound people, definitely used to control
the interview or the conversation.
RITA: And, of course, our clients are not as skilled as your average
politician at sliding away from a question. And so theyre stuck. They
either have to answer the question or be seen as resistant. So questions
can become kind of a no win situation for clients.
JOHN: Yeah. Thats one of the reasons that in teaching I like to assign
the students a pretty long interview where they cant ask any questions
or they just have to use active listening skills to gather information.
And I think that can be a real learning experience for clients for
students, maybe even up to 30 minutes of non-directive listening
without questions.
RITA: Yeah.
JOHN: There are many different types of questions.
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RITA: There are open, closed, indirect, swing, projective, and of

course a group of questions that we just call therapeutic.
JOHN: Now at this point, weve moved a little bit away from
the listening continuum in that questions vary in their level of
directiveness. Theyre all directed, because questions come from the
interviewer and are used to guide, or manage, or control what clients
say. But some questions are much more leading. And others are much
more gentle and less directive.
RITA: In this next clip, our colleague from the University of Montana,
Cris Fiore, demonstrates the use of questions as she works with Umit,
whos a graduate exchange student from Turkey. And youll see the
skilled use of questions woven together with some other non-directive
and directive listening responses. And you know, John, of course this
is how a real clinical interview goes. You weave things together.
You use more and less directive things. And youll notice that even
sometimes Cris will do a paraphrase, but theyll be a rise in her voice.
Theyll be a little inflection change that works the same way as a
question.
FIORE: Hi, how can I help you today?
UMIT: I dont know, its kind of a long winter in Missoula And Im not
used to it. Its my third year in Missoula. Im not used to it. But it was
the longest winter for me, I think.
FIORE: So its not just the weather, because youve been here three
years. It just feels long for you?
UMIT: Yeah, maybe, because I didnt see sunshine a long time. And I
feel weak sometimes. I cannot get up. It makes me thing Missoula or
what Im doing.
FIORE: Oh, so you feel bad enough that you cant get up. Can you tell
me more about that?
UMIT: Where Im from is more than 300 days of sunshine. And
just you know, people are walking around a lot. And just its kind of
crowded. People dont go to bed early. I feel like I just miss sometimes
them.

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RITA: So youre missing home a lot and a big change from Missoula is
we dont have 300 days of sunshine.
UMIT: Yeah, absolutely. You have in August and September, and Im
not here in august or September.
FIORE: OK, so this is a big adjustment for you. But youve been here
three years.
UMIT: Yeah.
FIORE: Whats it like for you during the winter? You mentioned a
little bit that sometimes you dont feel like getting up.
UMIT: Yeah, six or seven hours of sleeping was enough for me. But
now it feels like Im sleeping more than 10 hours.
FIORE: OK.
UMIT: In my culture, we usually hang out a lot of times like three
hours just chatting, four hours. But here, everybodys busy, or at work.
Thats fine. Even if I am free, how can I hang out with people?
FIORE: OK, OK. So you and your friends have a different life here.
UMIT: Yeah.
FIORE: So in the best case scenario, how would you want your day to
look like? What would it look like in the best case scenario?
UMIT: Firstly, I want to finish my homework as early as possible. And
in Turkey, usually my mom cooked for me. Thats why its that way.
FIORE: Its very different. Its all very different here. Do you keep in
contact with your family?
UMIT: Yeah.
FIORE: How often?
UMIT: I call my mom almost every day. Yeah, because if I dont call,
she really misses me. I am the best for her.
And I call her every day. And I call the other family members. I have
six siblings, including me. And three of them have got married. I
just call the others once or twice a week. My expectations are from
friendship, relationship, is different than there.
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FIORE: Right.
UMIT: Thats why it doesnt work sometimes.
FIORE: OK, OK. It sounds like youre adjusting to a lot of different
things.
UMIT: Oh yeah.
FIORE: Food, light, time, how youre spending your time, and also
this difference in how friends are, and even your communication
UMIT: Yes.
FIORE: and thats a lot to adjust to in the time youre here. So what
would be helpful for you at this point? What do you think you could
do with the time that we have talking? How could I be helpful?
UMIT: I dont know. Maybe I have to learn more. I have to accept I am
here in Missoula. And actually, I said all these bad things about living
here.
But there are some good things also. Thats why Im staying here. I
have a chance to go back. But in my culture, its so complicated.
People just judge everything and just gossip. In here, nobody cares
anything. Thats why I love here. You just do your business and go
home. Its the best part of living here.
FIORE: OK.
UMIT: And you can walk around just by yourself. Its not crowded.
There are advantages about living here also.
If theres a party at 8:00 PM, you can go 9:00 PM. And you can leave
9:40. Nobody said anything. But in Turkey, if you go at 9:00 PM. You
might have trouble, because you are late. If you leave early, you will
have trouble. Here is
FIORE: Different expectations, different expectations.
RITA: You know, John, Im struck by how graceful and skilled Cris is.
In that tape, shes simultaneously expressing interest, even her facial
expressions and her mixing of directive, indirective, and questions. It
was really very nice.

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JOHN: Yeah, her attending skills are fabulous. Shes very smooth. But
I wonder if you can say which of the types of questions did she not use
during her interview with Umit?
RITA: And I can say that. It was the indirect question. Partly I noticed
that because I dont think thats really a question. Grammatically, its
not a question.
JOHN: And I think youre absolutely right. Its not, although we use
that language just because it sort of is an implied question. It kind of
draws information out of clients. Another thing I wanted to comment
on in Criss interview is that she uses a question about the best
scenario that is possible for Umit.
And I think that question is an example of a projected question, which
is a therapeutic question, which in the solution-focused theoretical
place, it would be referred to as a presuppositional question. Because it
really asks Umit to project himself into a future place with a better or
best scenario.
RITA: You know, I want to say a little more about that. But first I also
want to note that questions are another one of those techniques that
have cultural meaning and valence. So cultures handle amounts of
questions differently. The appropriateness of questions varies. People
can feel very lost if theyre from a culture where they expect the person
in authority to ask questions and you dont, or pummeled if theyre
not used to a lot of questions.
JOHN: Exactly.
RITA: And as you said, theres a big theoretical link to some kinds
of questions. Theres the big four in the reality therapy questions. Of
course, thats what do you want?
JOHN: And what are you doing? Is it working? And should you make
a new plan?
RITA: Very good.
JOHN: And those are very direct questions that help clients focus
on problem solving as well. But really I think when it comes to
therapeutic questions, those kinds of questions most squarely fall

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in the domain of solution focus theory in therapy. Theyre really

questions.
And there are many different kinds. And they can be used well, and
they can be overdone. But basically what they do is they have clients
focus on positive scenarios, often the future, constructive things that
are already working in their lives.
RITA: Right, right. So I think there is a good example of that in a clip
with TJ. So lets watch just a couple more minutes of John with TJ.
JOHN: I want to go back a little bit. Ive got kind of a hard question for
you. You have had times, 30 times or so, that youve gotten in fights.
Ill bet there have been some times when you almost got in a fight but
then you chose not to, somehow, one way or another. Has that ever
happened? And if so, how did you manage to choose not to fight?
TJ: When it wasnt worth.
JOHN: OK, evaluate.
TJ: Fighting for nothing is stupid.
JOHN: Yeah. What do you think, in our last three minutes, what do
you think as you look at the future for you? What do you think some
of the most important things are that youre going to learn about
yourself, and about staying out of fights?
TJ: Im going to learn about myself. Im definitely going to think about
a lot of things I have done before, the bad things that happened and
whats led up to that.
JOHN: OK.
TJ: See the signs of where its going, stop it before it happens.
RITA: So John, that was great. I really like how you used the exception
question and framed it as saying, this is kind of a hard question.
Because that hooks a kid like TJ to maybe pay attention and see if he
can get it right.
JOHN: Yeah, thank you. I think its a good example of how its
important to gear the therapeutic question to the individual client.
And questions, therapeutic questions, solution-focused questions can
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be asked in many different ways. And yet they almost always focus
on moving the client toward the future and toward a more positive
future.
RITA: So John, if you woke up tomorrow morning
JOHN: And a miracle occurred
RITA: And you suddenly had more spare time, what would that look
like?
JOHN: Well, I think my wife and I would be spending a lot of time in
a video production.
RITA: Yeah, well, I guess we can see where this is going. Obviously you
can see the importance of using those solution-focused questions.
JOHN: And the power of questions, I think, should not be
underestimated.
RITA: Thats right.
JOHN: In this section, Rita is demonstrating an intake interview.
And of course, intake interviews are shaped by the client, by the
interviewer, by the setting, and by just about every factor that you can
imagine. In this particular intake example, the client, Michelle, comes
in and has fi lled out a form. But it only identified in a general in a way
that she was struggling with anxiety in her life. And so you should
watch at the very beginning of this video clip at how quickly Michelle
jumps into her specific problem, describes her symptoms. And
then Rita does a nice job both exploring and sticking with the chief
complaint but also staying with the format or structure of an intake
interview. Keep in mind that some clients will not jump so quickly
into their presenting complaint. I remember back in the day, well
maybe just a few years ago when we were younger, that we might take
three or four sessions just to deeply identify a presenting complaint
and develop a problem formulation.
RITA: OK, so lets watch the beginning of this work with Michelle.
RITA: So Michelle, its nice to meet you.
MICHELLE: Its nice meeting you too.

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RITA: And I would like to start today by just checking in with you on
what brought you in today for the counseling.
MICHELLE: OK. This feels a little bit weird. Ive never gone to see a
counselor before. So Im not exactly sure how to start.
But I had a couple of, I guess what they called panic attacks. I went to
the hospital for one, because I didnt know what was wrong. And I was
kind of freaking out. So I went there.
I thought theres something wrong with me. And they said that there
wasnt anything physically wrong with me. But I was having some
anxiety issues. So they said to come here to the clinic. And so I did.
RITA: Wow.
MICHELLE: So I really dont know other than that.
RITA: Wow. So you had a couple of those happen?
MICHELLE: Yeah, well the first one was the one that I wentwell, I
had a couple littler ones before that. But the first big one was the one I
went to the hospital for. Because I just felt like my chest was hurting.
I couldnt breathe. And I thought maybe, I dont know. I didnt know
what to think.
So I went there, and they ran a battery of tests, and blood pressure,
and all that kind of stuff. And so then they said that I was OK. But
I should probably check in with a mental health person. And that
kind of made me feel weird, because Ive never had anything like this
happen before.
RITA: Yeah, so it kind of like uh-oh. Theyre telling me somethings
in my head. And you felt weird about it. But here you are, decided to
go after it. So is it OK if I ask you a little bit about what led up to those
experiences?
MICHELLE: Sure. Well, a couple of them seemed like that came out of
the blue. But Ive been having some stress at school. Im a second year
at the university up here.
RITA: Yeah, so you had a couple of those classroom-based sort of uhh.
MICHELLE: Well, the other one I was at a concert, like at a bar. And

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there was lots of people there. And I was kind of right in the middle of
the crowd. So it wasnt at school, but it kind of seemed like when there
was a lot of people it made me
RITA: Just that crowded feeling, and then
MICHELLE: Like I cant get out, and I need to get out. And I cant get
out.
RITA: OK, whats the first physical symptom or thought? Which
comes first?
MICHELLE: Usually its the chest heaviness.
RITA: So right here?
MICHELLE: I cant breathe. And then just kind of then it feels like
I cant get out. And I need to. Then I freak myself out I think at that
point.
RITA: What starts to go on in your head?
MICHELLE: I think that I cant get out. Im not going to be able to
get out. I need to be able to get out. What happens if I cant get out?
And then it just sort of feeds on itself from there. And I start breathing
heavy. My chest starts hurting more. Then it just kind of gets worse,
and worse, and worse.
RITA: Im guessing about that point you thought, OK, fine. Ill go see
somebody.
MICHELLE: I know, I kind of tried to play it off like, if the bad one
doesnt happen again, then I can probably deal with the other one.
Like I said, Ive never talked to a counselor. So I wasnt really sure I
wanted to or not. But at this point, I was like, well, if it works, great. If
not, then I guess Im not any worse off than I was before.
RITA: All right. OK. So I think what Id like to do, if its all right with
you, is kind of go backwards for a few minutes. But I do want to note
that were pretty clear on what our goal would be in working together.
MICHELLE: Yeah.
RITA: And that would be
MICHELLE: No more panicking, which would be delightful.
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RITA: Yeah, yeah. And we may not be able to go right to no more

panic, but maybe an intermediate goal would be how to handle when
that heaviness comes, when those thoughts start, how to handle that.
And maybe in some way we gradually get control of it as sort of steps
toward the ultimate goal of no more panic attacks. Does that seem
OK?
MICHELLE: Anythings better than whats going on now, I think.
RITA: Yeah, yeah.
MICHELLE: So Im pretty much game for whatever.
RITA: You know, I do want to notice a couple things, though, and that
is youve coped with some things that are pretty scary. And you had
a lot of common sense, sort of got yourself out of the situation. You
breathed. You walked. You gave yourself permission not to go back to
class. And so Im just noticing that youve got a lot of skills already
MICHELLE: Cool.
RITA: that well probably notice again.
RITA: So, John, its a little bit startling when he client arrives and has
already got a diagnosis and is ready to begin fi xing the problem.
JOHN: Absolutely, you can feel, I think, like you have a lot of pressure
on you to jump immediately into fi xing the problem. But Im glad that
instead that you kept exploring the presenting complaint or the chief
complaint, and then you went a little bit into other areas and really
were building and gathering information that helped with establishing
the beginning of a treatment plan. In particular, I liked the fact that
you identified for the client, for Michelle, what was heaviness in your
chest. And that seemed to be a trigger for her panic attacks.
RITA: Right, right. I did intentionally transition to history. But before
I went there, I really had noticed some strengths in Michelle and
wanted to reflect those before we went into history taking.
JOHN: At the risk of complimenting you too much, I really did
like the way that you focused on her strengths. And I liked the way
you developed with her some intermediate goals rather than sort of
feeding into the idea that the goal is to eliminate all panic attacks. In
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fact, it can be very discouraging for clients if thats their only goal.
And you helped her see that there might be some intermediate goals
along the way.
RITA: Yeah, I did explicitly foreshadow that shift. Then we did do
some history taking. And that was important, I think, to signal that
we were going to make that shift, especially in an intake interview.
Because clients dont know where things are going.
JOHN: And you know, gathering at least a little information about
personal history is important. I think its important from the clients
perspective. And there are many different ways of doing it. But clients
often have a sense of continuing from the past to the present to
the future. Now lets watch as Ritas intake interview with Michelle
continues.
RITA: So lets do a little bit of background. You cant go see a shrink
without a little background.
MICHELLE: Do I have to lay down on the couch?
RITA: Yeah, yeah, if you would, please.
MICHELLE: All right, thatd be awesome.
RITA: Yeah.
MICHELLE: My dad was around until I was about four, and then they
divorced. And I didnt really have a lot of contact with my dad after
that. My mom was a single mom and took care of me.
She was a nurse. And so she was working a lot, but she had somebody
to watch me during the night, so she was there during the day a lot.
But sometimes she had to sleep, but a lot of times she was there,
especially after I went to school. Then shed sleep while I was at school
and be up when I was up. And then after she put me to bed, shed go to
work late night.
RITA: Oh my gosh, she sounds like a pretty hardworking mom.
MICHELLE: Yeah, she was very hardworking and very supportive.
RITA: Is she still alive?
MICHELLE: She is, yeah.
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RITA: Hows your relationship these days?

MICHELLE: Its good. Shes, like I said, very supportive and has
always been there for me.
RITA: Brothers, sisters?
MICHELLE: I have two older brothers. Ones in the Navy, and hes on
deployment. So thats kind of nerve wracking. And then the other one
is at school at a university in California.
So theyre both gone. And Im kind of close with my mom and go over
and visit her all the times, and stuff like that. They still keep in touch
and things like that, but theyre obviously not around as much.
RITA: So do you know if either of them have had anything like what
youre coping with?
MICHELLE: I think that not the brother thats in the Navy, because
they wouldnt allow him in with anything like that. But I think
the one in California mentioned that he had been diagnosed with
something like generalized something like with anxiety. Like he just
was worried about a lot of stuff all the time.
We talk sometimes, but not super often. But I think I remember him
saying something like that. And then hes on medication for it.
RITA: OK. I should have asked this before, but did they give you any
medication at the hospital?
MICHELLE: No.
RITA: OK.
MICHELLE: Nope.
RITA: So how about mom and anxiety?
MICHELLE: I mean, shes always seemed like a real worrier. But
shes never seen anybody for it or anything. Shes one of those kind
of catastrophic thinkers thats always like, what happens if this
happens? And then you lose your car. Then you wont have a job. And
then youll be a bum. Its kind of like that all the time with her, just a
constant run it into the ground. I learned at an early age not to tell are
things that I thought might be at all dangerous seeming. Because she
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wouldnt let me do them.

RITA: Just gets up in arms and yeah.
MICHELLE: So Id just do them and not tell her.
RITA: Yeah, yeah, interesting. So you protect her a little bit from
things that would make her anxious. So do you mind if I ask you
about your drug and alcohol history a little?
MICHELLE: Sure. I really used to like smoking pot a lot. I quit
probably six months, eight months ago.
The first year of pharmacy I was able to do it without really studying
or being that concerned about getting buckled down. But now its
getting harder, so I really felt like I needed to stop. But Ive been
smoking pot pretty much since I was 11 or 12. I started with one of my
older brothers. I really liked it, because it mellowed me out. I was laid
back.
RITA: How long ago? Whats the last time?
MICHELLE: About six, seven months ago, I would say.
RITA: So you just kind of stopped cold turkey?
MICHELLE: Yeah, I was just like this is not helpful for me right now. I
dont need to do this anymore. But my boyfriend kept something. And
that, like I said, is part of
RITA: Problems, yeah, yeah.
MICHELLE: And I mean, me being in the area that Im going into, I
really cant have somebody with pot sitting in my house smoking. If
he got busted, then my career is basically down the toilet. So, I dont
know if thats something I want to be connected to for the rest of my
life. And at this point, weve been together off and on for four years. I
feel like either I need to be done or we need to do something.
RITA: Its kind of a point of stress right now or a point of concern?
Yeah. OK, so Im wondering about other drugs or caffeine, those kinds
of substances in your life
MICHELLE: Right now?
RITA: Right now, yeah.
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MICHELLE: I drink quite a bit of caffeine, probably, well it depends

on whats going on. Because if its like a time when an exams coming
up, I end up drinking a crap load of it. Ill drink a couple pots to cram
for a test and stay up most of the night. On normal basis, Ill probably
have three, four cups of coffee in the morning and then maybe a soda
in the afternoon.
RITA: OK. Are you drinking that kind of heavily caffeinated sodas?
Or energy drinks?
MICHELLE: No, I dont really go for those. They make me kind
of crazy feeling. But mostly like definitely caffeinated, though, like
Mountain Dew, I like Mountain Dew quite a bit, or Pepsi, Coke, those
kinds of things.
RITA: All right. Any problems with the law in your history?
MICHELLE: I did get a couple of minor possessions for alcohol when
I was younger. And then I got a possession of marijuana also and
paraphernalia when I was younger.
RITA: OK. All right. One thing I like to ask people too is what are you
doing to take care of yourself?
MICHELLE: Well, its kind of hard when you work all the time and
also are a student and kind of crazy relationship. But Ive tried to start
working out lately. Ive been swimming some at the university pool.
Ive really gotten to like that. I never really had done that before. So
thats something that Ive kind of liked. Just in the last couple months
Ive started doing that, kind of since this started. I was like, I need to
maybe try to do something thats going to slow this roll a little bit.
RITA: So you are doing a little swimming and other things?
MICHELLE: I pretty much just hang out with friends. Although now
I kind of worry if we go somewhere thats got a lot of people. Like that
concert was out with friends.
RITA: Right
MICHELLE: So Ive kind of curtailed some of my social engagements
just because Im worried about freaking out. And then what are my
friends going to think? And then I dont want to be weird.
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RITA: So its starting to kind of affect your friendships and social life,
your work and school a little bit.
MICHELLE: Yeah.
RITA: So its kind of bleeding out into some places that make it
difficult.
MICHELLE: Yeah.
RITA: Yeah.
MICHELLE: Absolutely. Which is, like I said, part of the reason that
I
RITA: Here you are.
MICHELLE: bucked up and came to counseling.
RITA: Yeah.
JOHN: Rita, you did a nice job of exploring Michelles personal
history. One of the things that I might say is that there are many
different ways to explore personal history. And one of things I found
really useful is to do an early memory, or sometimes in my work with
young adults and adolescents, I will kind of jointly draw a family tree
with them, sort of like an Adlerian family constellation or just a basic
genogram. And doing that collaboratively to explore history seems
to be a pretty effective way to go back into the past and identify some
issues or themes that the client has faced.
RITA: I do think working with the client to understand the family
in some way, whether its a family tree or genogram. It helps a lot.
I was trying to help Michelle take a look at the possibility of other
family members having problems coping with anxiety or panic. And
of course, I also wanted to convey to her that I saw her as coping with
anxiety rather than being victimized by it or struggling with it.
JOHN: And you really made a nice flow from the past back to the
present, which is a key part of the intake interview. Every intake
interview is unique and selective, and that you focus a little bit on
slightly different content here and there, and emphasize different
things. But most intakes include the coverage of the least these
three main general areas, the first of which is the identification and
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exploration of the clients chief complaint. Thats kind of the first

general area.
RITA: Right, and then of course, personal history and information
related to that.
JOHN: Right, and many ways to get that information and sometimes
many areas within the personal history. And finally, theres a
transition back to or review of the clients current functioning. How is
the client doing now?
RITA: Right.
JOHN: Each of these areas can be expanded upon or minimized.
For example, depending on your setting and your clients presenting
problem, it might be important to gather specific information about
the clients family history, or maybe military history, or maybe drug
and alcohol history.
RITA: Yeah, the purpose of the intake, the goals, the theoretical
orientation, the resources, the length of time that you have, these are
all can influence what the interviewer focuses and what amount of
time you have to deal with it.
JOHN: Right, Rita, you focused on the relevant historical and current
coping issues that Michelle had. And I think you did a really nice
job of that. I specially was glad that you focused on her caffeine use,
which can trigger panic and also focusing on self-care and some of
the medical issues, just really important and relevant pieces of the
interview with Michelle.
RITA: Right, right. You know, it was interesting. There was a part of
the tape we didnt show. But Michelle starts making any connection
between her stopping the use of pot, which she had used since she
was 11 or 12 and the onset of those panic symptoms. So the client
herself was starting to make connections that might end up being very
important.
JOHN: Which is something that can happen in a good intake
interview, because it provides the client with opportunities to reflect.
RITA: Right. So in this next section, well watch as the interview

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shifts toward case formulation, homework, and instilling the hope for
change, making sure we take full advantage of that placebo effect.
RITA: Well, let me do a little summary of what Ive heard. And then
maybe we can talk about some plans for our next sessions together.
And if you dont mind, I might even give you a little bit of homework.
MICHELLE: OK. Do you think this is something that people get
better from?
RITA: Yeah.
MICHELLE: OK, because Im kind of worried about it.
RITA: Yeah. And the good news is that actually the problem that you
brought in today is one of those that shows really goo results.
MICHELLE: Oh good, because I dont like it at all. And it really scares
me quite a bit.
RITA: Yeah, yeah. So thats kind of the good news. The bad news, of
course, is that anything like this requires some work, and some time,
and understanding. And it doesnt go away magically. You already
tried that.
MICHELLE: Yeah, ignoring, ignoring it didnt work.
RITA: Denying, yeah. Yeah, but I think theres a really good chance
that we can make a big difference in this. And its certainly worth a
try.
MICHELLE: Cant be any worse than I was before. The way that I am
avoiding things already now, like going out with friends, like even
when I have to go to big classes, Im kind of like, ahh. I sit on the edges
of the things or in the back. And sometimes I cant hear as well.
So I think that Im worried like Ive seen those shows of the shut-in
people that stay in their house and never leave. And that scares me.
Im not by any means at that point, but I just worry if its getting worse
and worse that things could get worse. And then I could end up with a
grocery delivery and thats the only people that talk to me.
RITA: Yeah, or youre sitting in the car at Walmart like a homeless
person.

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MICHELLE: Yeah, exactly.

RITA: Right, right. So does this remind you of anybody that weve
talked about today?
MICHELLE: Not really.
RITA: Thats a trick question. You told me your mom catastrophizes.
MICHELLE: Wow, Im surprised I didnt make that connection.
RITA: Its funny how we mirror our mothers sometimes.
MICHELLE: I know, well its lalala and just like totally space it out
after a while. But she does leave the house. So that I guess was the
part. But yeah, I dont want to end up like my mom either. Thatd be
terrible. I mean, shes very nice.
RITA: Oh, yeah, but that tendency to do to be able to take one difficult
life event and go uh-oh. This is going to leave to this.
MICHELLE: Its going to blow up
RITA: This is going to lead to this. And then Ill be homeless and shut-
in. And then I wont get a suntan anymore.
MICHELLE: Yeah, I guess thats where I was going with that. That
sounds exactly like her. Ive become my mother.
RITA: No, you havent, no, no, no. We learn a lot from our parents
and their coping styles. And one coping style is to face right into it a
tough potential reality and say, if I dont do something about this, it
could go there.
So its not a bad or good thing. Its just one of the ways youve learn to
deal with things. And the good outcome of that is it brought you here.
Because you kind of looked down that road and said, hmm. I think I
dont want to go there. So, here you are.
JOHN: Rita, I really liked the way you made the connection between
Michelles tendency to do a catastrophizing in her thinking with what
she had identified herself before as her moms tendency to do the same
thing. You also wove in something that was very smooth, and that is
suggesting to Michelle that maybe the path of the catastrophizing was
not very much pathology. And so I think by doing that, you kind of
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give her an opportunity to choose to work on it or not.

RITA: Right, yeah, I think it kind of led to a little bit of an insight,
which I think sometimes motivates people. When you have an
insight into the way you are and a way you might want to change, you
actually might have a little motivation to do things like homework.
So we did have a homework assignment, as you saw. And then we had
summary, enclosure, and we had a plan to get back together, including
permission for her to call the clinic earlier. Because when you are
dealing with panic attacks, sometimes you need that reassurance that
you can make contact earlier. So in this section, were going to watch
a mental status examination with a young man named Carl. This is a
general check in. He was referred because of some odd ideation and
bizarre behaviors. So his vocational instructors and educators were a
little bit concerned.
JOHN: A traditional mental status examination includes about nine
domains. And the first threeappearance, behavior or psychomotor
activity, and attitudes toward the interviewer or examinerare always
just inferred. In other words, you just observe the clients and then you
make some inferences about those three categories. The remaining
six categories are usually assessed in a little bit more of a direct way.
And these other six categories include affect and mood together,
speech and thought together, perceptual disturbances, orientation
and consciousness, memory and intelligence, as well as reliability,
judgment, and insight.
RITA: As I look at that list, it seems to me that the clients speech is
something more inferred or observed.
JOHN: I think youre right. Its usually inferred or observed more
indirectly also. Although in the upcoming interview, I accidentally
forgot to ask one of the speech assessment items, which is to ask Carl
to repeat after meno ifs, ands, or buts.
RITA: So, well, no ifs, ands, or buts, lets watch a little section of Carl.
Carl is a 19-year-old young man who is a student at Trapper Creek
Job Corps. He has a lot of adjustment struggles and eccentricities.
And youll notice that he also has some tick-like mannerisms. We
both met with Carl in earlier sessions. And weve talked about those
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mannerisms. So in this tape you wont here us inquiring about those.

JOHN: As you get ready to watch this mental status examination
interview with Carl, it might be a good idea to pull out a piece of paper
and jot down a few notes in each of the nine domains as you observe
the interview.
JOHN: Well, Carl, thank you for coming in. And what I would like
to do with you today is just a very standard interview that is sort of a
way for me to get to know how your brain is working. And so what Im
going to do is Im going to ask you some questions.
But first I just want to start off by sort of asking some very easy
questions. And then some of the questions will get harder as we go.
And so, does that sound OK to you?
CARL: Yeah, that sounds OK.
JOHN: First one is state your full name.
CARL: Ive actually had quite a few different names growing up. You
want my current name?
JOHN: Whatever you would like.
CARL: Carl Dunn.
JOHN: OK. You said youve had quite a few different names growing
up.
CARL: Yes, actually, my mother changed her name. I dont know
whether or not she legally changed them or anything. But she always
changed our last name depending on what guy or girl she was dating
at the time.
And I was CJ once. I tried to be Todd the second time, but the name
just kind of sounded ridiculous. Ive got Warren, Jr., Raccoon because
of the rings around my eyes.
JOHN: Whats your favorite name for yourself?
CARL: Just Carl Dunn.
JOHN: Carl Dunn, OK.
CARL: I dont really have a favorite name for myself, I just pick
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whichever one sticks better.

JOHN: OK. Well, Ill just stick with Carl if thats OK.
CARL: OK.
JOHN: And what is todays date, Carl?
CARL: 3-29-2012, I believe.
JOHN: OK. All right. What day of the week is it?
CARL: No, its 3-20, and I dont remember what day it is. OK, what?
JOHN: What day of the week is it?
CARL: OK, its Thursday.
JOHN: Thursday, OK. And can you tell me what season of the year it
is?
CARL: It seems to be spring, going from winter into spring. But
judged by the weather, its still kind of wintery. Theres a lot of snow.
JOHN: So were going from winter into spring.
CARL: Yeah.
JOHN: Yeah. Which one do you think were in?
CARL: Here spring, but back at Job Corps, winter.
JOHN: OK. And what is the name of the town or city where you are
living now?
CARL: Darby.
JOHN: Darby. OK. OK. Now this is a hard question. Do you know
who the governor of Montana is?
CARL: No.
JOHN: No, OK. So my next question is going to be a test of your
memory. Is that OK if we do that?
CARL: Yeah.
JOHN: So Im going to say three things. And all you need to do is
when Im finished saying them, you repeat them back.
CARL: OK.
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JOHN: OK. So the three things are cup, newspaper, banana.

CARL: OK.
JOHN: What are the three things?
CARL: Cup, newspaper, banana.
JOHN: OK. All right, good work. Now this one is a little bit harder.
You ready for something a little bit more of a mental challenge? Id
like you to begin with the number 100 and then count backwards by
sevens. So its like 100
CARL: Oh yeah. 100, 93, 86, 79, 72, 65, 58, 51, 44.
JOHN: You can stop, good work. That seemed pretty easy for you.
CARL: It was pretty easy. I used to be able to multiply double digit
numbers.
JOHN: Yeah, so youre pretty good with math. Youre pretty good with
numbers.
CARL: Yeah, I used to be a lot better reading. In the second grade,
I knew words that none of the college teachers I used to visit knew.
And I was able to read beyond a college level and in a couple other
languages. And then I forgot all that. But thats another story.
JOHN: Sure. So try this one. Spell the word world backwards.
CARL: D-L-R-O-W.
JOHN: OK. Now who is currently the president of the United States?
CARL: I believe its still Obama.
JOHN: OK. Do you know who was president before Obama?
CARL: Bush, I believe.
JOHN: OK, do you know who was president before Bush?
CARL: No, I dont remember who it was before Bush. I mean, I know
who it is. I just dont remember the name.
JOHN: OK. Can you describe the person?
CARL: A Christian white guy.

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JOHN: OK.
CARL: Ill know him when I see him.
JOHN: OK.
CARL: Then before that was Bush.
JOHN: OK, so before the Christian white guy there was Bush. And
then
CARL: Another Christian white guy. OK, Ill remember the faces. If I
see a face of the president, Ill be able to recognize it.
JOHN: You can recognize
CARL: I dont really know that much about the presidents.
JOHN: Do who was before the first Bush?
CARL: His father.
JOHN: OK.
CARL: Before Bush, it was his father Bush. Before him was the other
Christian white guy.
JOHN: OK.
CARL: Why is it that all the presidents up until Obama were Christian
white males?
JOHN: I dont know.
CARL: You dont know.
JOHN: Why do you think?
CARL: Because people are naturally judgmental, and there are a lot
of racist people out there. Everythings always going to be fair. Its
always going to have something to do with looks, religion, and ethnic
national background, stuff like that. Christianity and stuff like that
just happens to be one of the more powerful religions. So coming from
that aspect, lots of people are compelled by their religious beliefs to do
a lot of things. It would all make sense that the government in general
would look for white Christian males.
JOHN: OK. Sounds good. Now Im going to ask you some questions
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that are a little different, questions about feelings. OK.

CARL: Feelings, feelings, yes.
JOHN: And my first question about that is how are you feeling right
now?
CARL: Calm, thats about it.
JOHN: OK. So youre feeling calm. If you were to rate your mood, zero
is the worst possible mood. Its like youre so down and depressed that
youre just going to kill yourself. Its over. And 10 is the happiest you
could possibly feel. Youre so happy maybeI dont know what you
do when youre really happybut maybe youre dancing, and singing,
and youre just super happy. On that scale of zero to 10, how would
you rate your mood right now?
CARL: Right down the middle.
JOHN: Youre about a five, you think? Down the middle?
CARL: Well, I had a pretty good day. But yesterday was pretty crappy.
And Ive got some stressful things on my mind. So its about a five.
JOHN: So youre about a five.
CARL: Yeah, its right there in the middle.
JOHN: OK. Now if you were to say the worst mood youve had for the
last three months.
JOHN: You know, Rita, many professionals I think are a little
reluctant to do something as structured and evaluative as a mental
status examination for fear that it might adversely affect the report
or the therapeutic relationship. One thing that I found, and maybe
its just because Im a little bit weird, is that I actually find that using
that kind of structure and the assessment parts of the mental status
examination can be framed in a way that engages the clients and I
think at least doesnt adversely affect the relationship. And I think I
try to frame questions as they might be difficult. And I try to respond
empathically when clients have trouble or struggle with the questions.
RITA: I think you do put people at least. I like how you kind of ask
permission. You tell them its going to be a hard question.

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But even with all of that reassurance, you can feel the anxiety that
comes up in Carl when he cant get something right. And then he
says, he was able to multiply double digit numbers in second grade.
But really, there is always that urge to ask about the past, to explore.
And mental status exams are about the functioning of the client in the
present.
JOHN: So even Carls defensiveness that we saw, and maybe his
exaggeration, and his use of humor, thats all data that the mental
status examiner or the clinical interviewer can use to make statements
within those nine different domains. In particular, I think at the very
least, we know Carl is a creative young man.
RITA: Yes, we do. And one thing that has always been a little
confusing for me in mental status exams is affect and mood. So the
strategies for assessing those are important.
Remember that affect is something that you infer, that you observe.
And mood is something that you actually ask about. And you ask
about the mood now with some rating form. And then you can also
ask about mood the past three months, the highest, the lowest, do an
average with that.
JOHN: And you get a chance to compare where the client is now with
previous highs and lows. In this next section
RITA: Yeah, lets watch another one.
JOHN: OK, in this next section, I start off by doing an assessment of
Carls intermediate memory. And one thing I think that well discover
is he has an excellent intermediate memory. He also shows that he has
a pretty darn good sense of humor.
RITA: All right.
JOHN: Now Ive got kind of a tricky question for you. You ready?
CARL: Does this question do back flips? Then its not very tricky, is it?
JOHN: All right, I guess not.
CARL: OK.
JOHN: Remember a few minutes ago I asked you to remember three

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things that I said? Can you remember what those three things are?
CARL: Cup, banana, and newspaper.
JOHN: OK. Youve got them.
CARL: Well, it was cup, newspaper, banana, in that order. But still.
JOHN: You got all three anyway. You even remember the order they
came in.
CARL: Of course, of course, Im smarter than your average Job Corps
kid, which is about average.
JOHN: OK. All right, now I have some questions. Those were
questions about your feelings and emotions. And now have some
questions that are more about your thinking, OK?
And then we might come back to feeling a little bit too. But tell me,
lets see. Do you ever get any thoughts stuck in your head, they just
kind of go over, and over, and over?
CARL: Ive got millions of those. Which one do you want?
JOHN: What would be a typical that gets stuck in your head?
CARL: Well, I sometimes whenever something happens, I picture
another event happening as a result of it that gets stuck in my head.
Songs get stuck in my head. Voices get stuck in my head.
JOHN: Yeah.
CARL: They dont really [UNINTELLIGIBLE], but they just kind
of sit there. And they used to tell me to do things, but now I get into
arguments with them on occasion.
JOHN: OK, so you have some songs that get stuck in your head and
then some voices that get stuck in your head.
CARL: Well, yeah, I like to make up the voices, because it helps drown
out the music. I mean, the voice thing is intentional. Because it helps
get the songs, and the thoughts, and memories out of my head. So
thats kind of like a self-help right there.
JOHN: So one of the ways you get something thats stuck in your head
out of your head is maybe you sort of creative these voices in your
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head? And they kind

CARL: Its kind of like an invisible imaginary friend.
JOHN: OK. Do you have a consistent, invisible imaginary friend?
CARL: No, not really, because theyre not technically imaginary
friends. Theyre just little bodily voices that I made up in my head.
Theyre like a little thoughts that I created, like I find a way create a
thought that overpowers all the other noises and stuff that I hear in
my head. They kind of just [UNINTELLIGIBLE] these other voices
thatits pretty much Im using my imagination.
JOHN: Sure. This is just a different kind of question. Do you have any
beliefs that other people think are strange or odd? Unusual beliefs?
CARL: Quite a few, actually.
JOHN: Well, give me an example. What would be an unusual belief?
RITA: Well, I really dont care if anybodys into bestiality. I mean, for
starters, there are guys out there that are raping little kids, people out
there getting violated 24-7. There are necrophiliacs. There are all this
other stuff. I mean, unless its like the most powerful out of the seven
sins out there.
And animals, for instance, for that example, theyre pretty much
born to mate. I mean, I really dont care. The only reason why its
considered a bad thing is because people just didnt understand it back
then, which is nothing really to understand. The only risk is that they
find a new kind of STD.
JOHN: So one of your unusual beliefs might be that you dont
CARL: I really dont care about bestiality. I dont think
JOHN: One way or another, It doesnt matter to you much. Yeah.
CARL: Yeah.
JOHN: I have some more questions for you. Are you ready? Do you
ever see or hear things that other people dont see or hear?
CARL: Sometimes I see ghosts. But other people see them too.
JOHN: OK. And do you ever think that the radio or the television is
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speaking directly to you?

CARL: Right. I dont think that the radio or the televisions speaking
directly to me.
JOHN: That would be a no.
CARL: No.
JOHN: Defi nitely not, OK.
CARL: I mean, unless the TV turned on and the guy saidand I just
happen to be sitting in my room, by myself, in my house. Lets say I
have a house, in my house and watching TV. And the TV magically
comes on and Im single at the time, and the guy goes, are you lonely?
A little. Even a little lonely? Oh, yeah, yeah. Are you sitting underneath
the covers withIm not going to get into that. Im just saying, Im
probably not going to believe it unless some really weird stuff goes on.
JOHN: OK. So for the most part, youre saying probably absolutely
not.
CARL: Im trying to watch my language here.
JOHN: Yeah. Has anyone ever tried to steal your thoughts or read
your mind? I know thats kind of an unusual question. Its OK. Some
people think that. And thats just mostly why Im asking.
CARL: People try to steal other thoughts or read their mind. So thats
original. Well, how do I answer this one?
JOHN: Yes or no.
CARL: I never thought that anybody was trying to steal or read
my mind. But I used to have friends and family and stuff that were
Wiccan. And Ive met quite a few people
JOHN: Speaking of knowledge, Ive got a few more questions for you.
CARL: Yes, yes.
JOHN: And these are a little more knowledge based. So in what way is
a pencil and a computer alike?
CARL: You write with them. You can transfer knowledge from one
spot to another with it. Pretty much the only difference between a
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pencil and a computer is that the computers electrical and the pencil,
you cant store small bits of data on, except for the pencils entire
system and [UNINTELLIGIBLE] the computer or across multiple
components. So yeah, theres a lot of differences in them two. But
theyre pretty much the same thing.
JOHN: There are a lot of differences, but they can use some of the
same purpose.
CARL: Yes, the same purpose, they even have the same function.
JOHN: Yeah.
CARL: Dont they? Just ones one-handed. The others two-handed.
Theres a lot of differences.
JOHN: What if in the future some time
CARL: Its pretty much the person doing the exact same thing.
JOHN: OK. What if in the future some time you found a gun hidden
in the bushes near your home. What would you do?
CARL: If I found a gun in the bushes around my home, I would
probablybecause I always have a friend like this thats either in the
police division or has worked for the government or something. Id
just get them to check the gun, see if theres any signs that may have
been used to harm somebody, if not, register the gun and keep it for
myself.
JOHN: So youd get somebody to check the gun out?
CARL: Yes. Then Id see if I could get the gun registered so I could
keep it.
JOHN: And see if you could keep it.
CARL: Because its a free gun.
JOHN: Yeah, and the last question, and then if you have questions for
me Ill try to answer them. But what would you do if a close friend of
yours obviously had a drug or an alcohol problem?
CARL: Well, as far as the getting drunk part goes, I actually do care
if they get drunk. So I would do what I can to take care of it. Well, if
somebody, though, did do drugs but it didnt affect them in a negative
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way, per se, like if it was like marijuana or hemp, I really wouldnt care
as long as they
JOHN: But lets say they had a serious problem.
CARL: Oh, an actual problem, then Id try to help them with it. Id try
to get them off of it.
JOHN: Youd try to be helpful?
CARL: Id try to tell them to [UNINTELLIGIBLE] down the doses,
come up with strategies. But I wouldnt really try to make anybody
quit just cold turkey. I wouldnt.
JOHN: Try to help them cut down.
CARL: Yeah.
JOHN: OK.
CARL: Because I really dont care. I mean, marijuana could help the
world. But the lumber company got pissed. And then marijuana is
illegalized because of all of its uses.
JOHN: Well now, questions for me.
JOHN: The purpose of the mental status examination is to gather data
or observations on the client that you can then organize into the nine
different mental status examination domains. But as you probably
noticed, my preference is to try to do that in a way that is empathic
and collaborative.
RITA: Which I think is great, I really think that its a great
relationship building thing. And you actually get more information
that way. But of course, that accounts for some of the wide ranging
and sometimes tangential content that you saw with Carl. But it is
important information.
JOHN: Although it would make the interview shorter if I stayed a little
more structured. Now if you watched the mental status examination
interview with Carl and you jotted down a few notes in those nine
different areas, now would be a really good time for you to look back
at those notes and the nine areas and to try to make a few statements
that are a little more conclusive about what you saw in Carl during

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that interview. And even better, it would be a really good idea to

compare those notes and those conclusions with your classmates so
that you can get a little bit more objective in how you are evaluating
the mental status examination data.
RITA: In this section, were going to demonstrate a suicide assessment
interview. Were going to see John working with a young woman
named Tommi, whos been referred by staff at Trapper Creek Job
Corps, where John has seen Tommi one another time in a group
setting. So he doesnt know her very well.
The staff is worried about her because shes moody. And shes had
intermittent suicidal ideation. So they want a mental status sort of
check in on that.
You will see as the tape begins that were a little ways into this session.
John started an assessment of mood and depression. Because Tommis
indicated shes a little bit down. And also shes talked a small amount
about her family troubles and some other areas of concern, like
personal insecurities, that are affecting her mood. So well go ahead
and watch some of this tape.
JOHN: I know from our conversation before also that youre Native
Alaskan.
TOMMI: Yes.
JOHN: And youre from a tribe in Alaska. Thats your main tribal
connection.
TOMMI: Yeah, yup.
JOHN: And thats the
TOMMI: Yupik.
JOHN: Yupik.
TOMMI: The Y-U-P-I-K.
JOHN: Y-U-P-I-K. And as were talking today, if theres anything that
maybe from your cultural background or from your tribal perspective
that I maybe am not getting, I hope that you would feel free to say, hey,
John. From my perspective or from my cultural perspective, this is the

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way we think about or this is the way we do it. And so would that be
OK if you let me know if Im going the wrong direction?
TOMMI: Thatd be fine.
JOHN: OK. A All right. And sometimes when people are down, it
affects them in a lot of different areas. And one of the places that it can
affect you is the way you think. OK, it can affect some thoughts you
have about yourself.
CARL: Yeah.
JOHN: Or about the world, or about the future. So Im wondering if in
particular youre having any negative thoughts about yourself, or the
world, or the future outlook of things.
TOMMI: Sometimes I feel really hopeless. I dont know, like things
seem to get worse all the time. So I dont really think about the future.
JOHN: Sometimes people when theyre feeling down, they have some
physical symptoms too. Like sometimes people have trouble sleeping.
Sometimes they have trouble eating. Or then sometimes they sleep too
much and sometimes they eat too much. Have you had anything like
that going on?
TOMMI: Yeah. I havent been sleeping. You cant really sleep when
youre too busy thinking.
JOHN: So your mind is kind of buzzing along at night, and so its hard
to lay down and really get yourself to go to sleep?
TOMMI: But once I do sleep, I dont want to wake up. Id rather stay
asleep and dream and actually have to wake up and deal with reality.
JOHN: Yeah.
TOMMI: So.
JOHN: Sometimes people have their social relationships sort of
affected by when youre down too. And Im wondering how your social
life is going. Is it going OK? You have some contacts and connections?
TOMMI: I have friends, but it seems like everyones having fun. And
Im there just to be there. Like, they call me a zombie.
JOHN: Im going to just ask this question directly. Tell me because
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sometimes when people feel down, its really not unusual for people to
also think about suicide or about death. And Im wondering if youve
had any thoughts about suicide, or about death, and stuff like that?
TOMMI: Theres been some.
JOHN: OK. So you had some thoughts.
TOMMI: Yeah, more than some probably, daily basis.
JOHN: Think about that most of the day, part of the day.
TOMMI: Whenever, sometimes its never. But maybe sometimes its
like throughout the day.
JOHN: OK. What are some times when youre not thinking about
death or suicide? Whats usually going on when youre free from those
thoughts?
TOMMI: When Im not thinking about suicide?
JOHN: Yeah.
TOMMI: Probably singing.
JOHN: OK, when youre singing? OK. So kind of engaged in making
music in some ways, and that sort of takes you away from those more
negative and sad
TOMMI: Yeah, I write poetry too.
JOHN: OK. And thats helpful?
TOMMI: Yeah.
JOHN: OK. Sometimes when people think about suicide, they think
about it in a very active way, like, oh heres how I think I would kill
myself. And sometimes people think about it in a less active way. Its
like, oh, I just kind of wish I was dead. But I dont really have a plan or
any specific ideas about how I might end my life.
Which is more true for you? Do you have some specific ideas about
a plan or a way that you would end your life? Or do you just sort of
think, ah, I wish I
TOMMI: Well, I have a couple plans. But theres days where its
inactive.
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JOHN: Inactive in its not

TOMMI: Its like I wish I was dead.
JOHN: OK.
TOMMI: Or the world would be better with me or something like
that.
JOHN: OK.
TOMMI: So I could hurt the people in my family, and they would feel
bad for it. But I was either going to shoot myself. But that was out of
the plan, because there was no guns in the house. So I was going to
hang myself in my room and write on the walls everything that ever
hurt me to my parents. So whenever they decided, wow, shes been in
her room too long, they could go in there and tah-dah. Yeah.
JOHN: So one parts for you is to send a message to your parents about
how you feel.
TOMMI: Yeah.
JOHN: About how youve been treated.
RITA: Well, its certainly clear that not all of these interactions are
scripted or planned ahead of time. Theyre very real. And so theyre
not perfect. Well talk about some things that happened that went well
and some things that maybe you wish youd included.
JOHN: Right.
RITA: So one thing I noticed right away was a kind of interesting
where she spelled the name of her tribe. And at that moment in the
interview, her move lifted. She smiled. Thats kind of interesting.
JOHN: Yeah, I notice that also. I thought it was interesting. Im not
sure what to make of it. Its one of those things I kind of put in the
back of my head. It might be worth exploring somewhat later. Maybe
theres something meaningful and affectively uplifting about her
connection with her tribe.
RITA: Yeah, there was something there. I also noticed that she was
speaking and processing pretty slowly. She wasnt at all agitated or
hostile. But her tone was actually almost kind of flat.
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JOHN: Yeah, and thats not very unusual for people who have sort
of a unipolar depression that doesnt have much agitation in it. And
I noticed that when I was trying to do was to assess her cognitive,
her physical, and her social depressive symptoms. I noticed she had
some symptoms in each of those areas. And then I asked directly
about suicide. And I was glad of that. But I felt a little bad that I never
explored the frequency, duration, and intensity of her suicide ideation
very completely.
RITA: Right, frequency, duration
JOHN: Intensity.
RITA: But you did ask directly about suicide and about wanting to die
or kill herself, which is very hard to do. And you did it in a way that I
thought was acceptable. She went with it. She answered you. The other
thing I liked is you asked about times that shes free of any suicidal
ideation.
JOHN: Which I think is really important to sort of flow into some
positive emotions or positive situations as much as possible during a
suicide assessment interview. And you know, when someone admits
to suicidal thoughts, its also important to check on suicidal plan. And
the plan can be something thats sort of underneath the surface that
you need to ask directly about as well.
TOMMI: I tried two times and I realized that I was being selfish. So I
guess, I dont know, mostly selfish.
JOHN: So you tried a couple of times. And it sounds like after those,
your conclusion, what you came to in your mind, was that feels selfish.
And that youre not really wanting to do that?
TOMMI: Well, I tried two times to kill myself, two different
occasions. So I just thought, well, two times of trying to kill yourself
and you didnt die. Why didnt I die? Maybe Im supposed to be here.
So I dont know. Ive been trying to think positive, but I dont know.
JOHN: Maybe surviving means something.
TOMMI: Yeah.
JOHN: Its maybe thats a message from the universe or from
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TOMMI: Something.
RITA: Wow, that was an interesting exchange. You know, I had the
feeling that she really wanted to ask her more about those two suicide
attempts.
JOHN: Yeah, I think youre probably right. And it was a hard choice.
I ended up deciding to go with exploring the meaning of her staying
alive, which seemed also important to her. Thats one of the challenges
in the suicide assessment interview is do you go more for deeper
assessment of suicide, or suicidal plans, or thoughts, or even previous
attempts, or do you focus a little more strategically on the positive and
more hopeful parts of the interview?
RITA: Yeah, OK, well, lets watch a little bit more.
TOMMI: Well, I guess theres no good reason to commit suicide. But
you know, I dont know what Im trying to say. My friend committed
suicide because he got caught with a can of chew. He got kicked off the
wrestling team.
JOHN: OK.
TOMMI: Yep, he shot himself in the head.
JOHN: And as you say that to me, I think that it sounds like you feel
both sad and a little bit angry that he killed himself.
TOMMI: Well, Im sad. Dont get me wrong. He was a good kid. It
makes me angry because you hurt a lot of people when you take your
life. Like who are you to take your own life? Like youre hurting your
family, your friends. I dont know.
JOHN: Yeah. Yeah. So I hear you saying reasons to live, one is suicide
you kind of hurt people, maybe even people you dont intend to hurt.
Another reason is youve got a brother who you think the world of you
want to help him in his life.
TOMMI: Yeah, I guess I dont want him to end up like me.
JOHN: I just want to check in with you on maybe a little plan you to
stay safe. Because I know youve had some thoughts about suicide. It
sounds like for the most part, and let me know if Ive got this right,
that for the most part youre pretty clear that you want to live and
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move forward toward your dream and be a positive influence with

your brother.
Have I got that right? Thats the main thing. Now if you were in a
situation and you were feeling suicidal, what would help you feel
better?
TOMMI: Thats a really hard question, because when something really
gets me down, I dont really think about what makes me happy. Im
kind of pessimistic in some way.
JOHN: But the good thing is right now, youre at a three or four. So
youre not all the way down there at a zero or one.
TOMMI: Yeah.
JOHN: So right now when youre feeling a little better, what do you
think, what could you remind yourself, oh, heres what I think I should
do when or if I start to feel more suicidal? What would be a healthy
thing you could do.
TOMMI: Well, Id say eat, but thats not too healthy.
JOHN: Well, it depends on what you eat, I guess.
TOMMI: Well, I binge eat sometimes.
JOHN: So maybe having a small, nutritious meal.
TOMMI: No, working out or singing karaoke or something.
JOHN: Working out, singing, OK, those would help. Would it help to
call somebody, talk with a friend?
TOMMI: I dont really like to talk to people about things they never
went through.
JOHN: OK.
TOMMI: They dont understand. They can sit there and be like yeah.
JOHN: Anybody on your list of friends who might understand?
TOMMI: Nope.
JOHN: Nope. Not even the person who was on the phone with you for
three hours?

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TOMMI: Theyd be able to understand, but Id rather call my sister.

Because we grew up together. We know what we went through.
JOHN: OK. So the possible things you might do is you might work
out. You might sing. You might call your sister. Anything else that
would help a tiny bit? Write some good poetry?
TOMMI: Yeah.
JOHN: Yeah?
TOMMI: Write some poetry.
JOHN: You know, one of the things I just want to say, and then well
probably stop here in just a minute, is that its hard to know when
people are going to feel down, right? And so its good to have a plan
ahead of time for what youre going to do. Because when youre feeling
down, then sometimes youre not very creative. And you can think of
all the good options. So what Im wondering is if you and I can agree
that if you have a really down time that you will try working out,
singing, calling your sister, writing poetry, and maybe even add that
to, if you really were terribly suicidal, maybe even call 911, try to get
some help?
TOMMI: Yeah.
RITA: So you know, this section is really tough. And this whole
enterprise of suicide assessment is tough. People are unique. And there
is no exact formula for assessing suicidality. I really appreciate the way
you worked to make the assessment a positive therapeutic experience.
But its also a scary endeavor.
JOHN: You know, it was stressful and challenging. Tommi, I think, is
a very interesting and complicated young woman. Its hard. I think at
times she was very cooperative with me. And there are times when she
was much more challenging. Shes a bright young woman. There are a
lot of factors mixed in there.
I think I probably, if I erred on one side, it was toward being more
positive and focusing on maybe more therapeutic questions and whats
going well for her and maybe ignored a little bit of negative side. One
interesting thing that I didnt bring up earlier is that when she talked

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about her suicidal plan, which had been in the past, and that was a
good thing, she also was talking about an underlying motive. And
thats often the case with a suicide plan.
And for hers, it was a little bit of a revenge motive, a little bit of a
send a message to my parents motive. And so I think thats a place
where you can take the opportunity to turn a discussion about a plan
into something thats more therapeutic and help her focus on how
could she give that message to her parents without having it involve
anything to do with suicide.
RITA: So even though every suicide assessment is unique, there are
some factors that should be considered in each interview.
JOHN: Thats absolutely true. And now if you look at the slide, you
can see that the first part of a comprehensive suicide assessment
interview involves evaluating suicide risk factors. And oftentimes,
you dont do all that directly. But you find out about the different
suicidal factors that may be operating. Typically, you do a depression
assessment. Because almost always there are some depression
symptoms. You do an exploration of the suicide ideation. You ask
directly. You want to frame that in a way the client can answer
truthfully. Also you explore the suicide plan and move on to trying to
determine whether or not the client has a high level of suicide intent.
And one of the ways of doing that is to check in to their reasons for
living. And then the last categories are two try to infer the clients
level of self-control. And one way of doing that is to try to develop a
collaborative and cooperative safety plan between you and your client.
RITA: So if we were going to do a little summary, Tommi has tried
suicide twice by her own account. She has a good friend who killed
himself. Her family background includes some substance abuse, and
probably some physical abuse, and a very serious addiction problem
that Tommi herself has.
So certainly, shes in a high risk population. But on the other hand,
shes future-oriented. And shes in a setting thats structured and is
providing her with the opportunity to work on vocational skills and
on her sobriety.

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JOHN: What youre saying reminds me of the fact that we need to talk
about decision making. And that could be one of the most stressful
and tormenting things I think for a mental health professional is
deciding, well, how do I act in this particular situation? I think
because of the things you said, including the fact that she has a pretty
high mood rating and she collaborated on a safety plan, that in fact, I
probably wouldnt go toward hospitalization.
RITA: Right, yeah.
JOHN: But its really important to integrate or to weave in some
documentation of what youre doing and some consultation with other
professionals in order to protect yourself from liability and to make
sure youre doing a thorough comprehensive suicide assessment.
RITA: Right, yeah. And you know that not only brings us to the end of
this section but to the end of the DVD.
JOHN: You know one thing Im struck at the end of this whole
production is just how much there always is to learn, and how
complicated individuals are, and how many different ways you can
look at the clients with whom youre working, and how many different
ways there are two approach the clinical interview.
RITA: Right. You know, if I was going to offer a summarization of
that, Id pretty much say, you think that its a lifelong learning process.
JOHN: And youd be pretty much right about that.
RITA: And we both hope that this has been helpful to you in your
journey toward becoming a really excellent clinical interviewer.
Thanks.

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Video Credits
Produced by: Irish Luck Productions
Directed by: John Sommers-Flanagan, PhD and Rita Sommers-Flanagan
Video Post-Production: John Welch
Graphic Design: Julie Giles
Copyright 2012, Wiley

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About the Contributors

VIDEO PARTICIPANTS
John Sommers-Flanagan, PhD, is a professor of counselor education at
the University of Montana. He received his doctorate in psychology in
1986, completing his pre-doctoral internship at Upstate Medical Center in
Syracuse, NY. John is currently a mental health consultant with Trapper
Creek Job Corps. He served as executive director of Families First Parenting
Programs from 1995 to 2003 and was previously co-host of a radio talk show
on Montana Public Radio titled, What is it with Men? His work with youth
and parents has been captured for educational purposes on a number of
different local and national video productions. John primarily specializes in
working with children, parents, and families. He is author or coauthor of over
40 professional publications, including seven books. John is widely sought as a
keynote speaker and professional workshop presenter throughout the United
States and Canada.
Rita Sommers-Flanagan, PhD, has been a professor of counselor education
at the University of Montana for the past 21 years. Her favorite teaching and
research areas are ethics and womens issues, and she served as the director of
Womens Studies at the University of Montana, as well as the acting director
of the Practical Ethics Center. She is the author and co-author of over 40
articles and book chapters, and most recently authored a chapter entitled
Boundaries, Multiple Roles, and Professional Relationships in the new APA
Handbook on Ethics in Psychology. She is also a clinical psychologist, and has
worked with youth, families, and women for many years.

MANUAL AUTHOR
Shirin Shoai, MA, is a freelance writer for Psychotherapy.net as well as a
Marriage and Family Therapist (MFT) intern at the Marina Counseling
Center in San Francisco, CA. She holds a masters degree in integral
counseling psychology from the California Institute of Integral Studies
(CIIS) and has more than a decade of communications experience at CBS
Interactive, Apple, and other companies.
.

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