The Person Before the Letters

Unfortunately many patients when they find themselves in the company of a clinician may adopt the above dictum, especially when exploring sensitive and taboo topics such as suicide, incest, domestic violence, and substance abuse. There are many reasons for their caution. As they approach our office doors, they may notice various letters: M.D., Ph.D., M.S.W., R.N., M.A., but the letters are often relatively unimportant to them. What is important to our patients is simple: Who is the person before the letters? Is the person behind the door going to collaborate with them or patronize them? Will they be accepting or critical, warm or cool, trustworthy or irresponsible, capable or incompetent? All good questions. In addition, our task may be made a great deal more difficult because previous encounters with mental health professionals may not have gone so well.

In short, patients want to know who we are, not so much the facts of our personal lives, but our character, our ethics, and our humanness. They also want to know if we know what the hell we are doing – our expertise. In our own personal lives, before we would ever consider sharing intimate details about ourselves, we seek out answers to these questions about the people we are considering as potential friends and confidants, usually requiring many encounters before deciding whether we feel safe “baring our souls.” A patient is expected to do this type of sharing within minutes of meeting a total stranger, just because the stranger has some letters after his or her name. It is, at best, an odd situation.

Yet it holds much promise for healing and the relief of suffering, if indeed we can forge a resilient therapeutic alliance. How we address each of the above concerns offers opportunities for deepening the engagement process that goes beyond empathy itself. These patient concerns are less roadblocks than they are gateways. And the way we address these issues, how our characters and humanness show themselves, is through the interview itself. There are many interviewing principles, techniques, and strategies that provide concrete methods for talented clinicians to intentionally, and surprisingly rapidly, address these issues. This is a chapter about these principles and techniques, and how we can become such clinicians. And it all begins in the waiting room.

Inducement of a Safe Relationship

The patient’s waiting room period before meeting his or her clinician may pass with an urgent slowness. It is frequently teeming with fears of rejection and with self-recrimination. It is often accompanied by ruminations such as, “Well, it’s finally come to this, I’m so weak I need a shrink.” As professionals we would like to think patients do not feel this way about us, but we should not deceive ourselves. For most people (including many mental health professionals), it is genuinely upsetting to admit the need for help with psychological problems. The sensitive handling of this anxiety represents one of the centerpiece tasks of the initial interviewer. In fact, if it is not handled well, there may not be a second interview.

In his classic book The Psychiatric Interview, Harry Stack Sullivan describes a novel idea he calls “the self-system.” This self-system consists of “a vast system of processes, states of alertness, symbols, and signs of warnings, which protects us from a lowering of self-esteem as we meet new people.”² This self-system, consisting of both conscious and unconscious coping mechanisms, becomes activated in an effort to decrease the anxiety generated by fears of rejection. It is this self-system that rises to a high pitch as a patient absent-mindedly turns the pages of a magazine in the waiting room or plays distractedly with a cell phone.

Three ideas immediately come to mind. First, one of the primary goals of the clinician in the initial interview consists of attempting to decrease the patient’s anxiety and hence the need for an extremely active self-system. Second, the activation of the self-system offers the clinician an excellent preview of the patient’s defenses against interpersonal anxiety. Thus, the opening 10 minutes of the interview provide an unexpected window into the workings of the patient’s mental “guard dogs,” both healthy and rabid. And third, in most cases, the clinician’s own self-system is also aroused when the clinician meets a new patient. The interplay of these three processes lies at the very heart of the engagement process.

As we have seen, to some extent the conveyance of empathy can significantly decrease the patient’s need for an active self-system, but other specific processes can also reassure the interviewee. In the 1950s and 1960s, Carl Rogers developed the concept of “unconditional positive regard,” which he defined as follows: “The therapist communicates to his client a deep and genuine caring for him as a person with potentialities, a caring uncontaminated by evaluations of his thoughts, feelings, or behaviors.”³ It is a powerful statement. It is not unlike the suspension of analytic thought seen in the process of intuition.

Placed into the context of the initial interview, as opposed to ongoing therapy, unconditional positive regard translates as a suspension of moral opinion by the interviewer with respect to the interviewee. In short, the patient comes away with the feeling that the clinician is not going to pass judgment on him. In many cases, this safe feeling contrasts starkly with the patient’s recent experience (and, at times, lifelong experience) of encountering a long string of raised eyebrows on the faces of friends, family members, and employers. It is up to the interviewer not to follow this parade of frowns.

In this regard, it becomes important for the clinician to work out the potentially disturbing feelings raised by emotionally charged issues such as divorce, religion, sexual orientation, suicide, violence, child abuse, rape, and abortion. No matter what the clinician’s view of these activities, in the initial interview, the goal remains to show no judgment to the patient. Instead, the interviewer attempts to convey interest in finding out the significance of these ideas to the patient, recognizing the truth in the very wise statement of Armond Nicholi, Jr., that “whether the patient is young or old, neatly groomed or disheveled, outgoing or withdrawn, articulate, highly integrated or totally disintegrated, of high or low socioeconomic status, the skilled clinician realizes that the patient, as a fellow human being, is considerably more like himself than he is different …”⁴

Practically, one effective method of spotting potentially disruptive topics for oneself consists of monitoring interviews for topics that one consistently avoids. For instance, one interviewer may discover that he or she seldom knows anything about the religious beliefs of his or her patients, whereas another interviewer never asks about sexuality. Such gaps in data gathering may point to precisely those topics about which the interviewer has strong opinions. It is in these areas that conveying unconditional positive regard may be problematic.

It is not only controversial issues that can disrupt the conveyance of unconditional positive regard. In fact, as clinicians we may unwittingly sound like parents at the most unlikely times. In the following dialogue with a young man suffering from paranoid schizophrenia, this disconcerting process rears its head in a subtle form:

This clinician’s choice of words has created an atmosphere potentially suggestive of a parent’s reprimand. Indeed, the interviewer’s last statement sounds suspiciously like a threat to go to the principal’s office.

As a contrast, in the following dialogue, a different approach yields a different interaction with significantly less activation of the patient’s self-system:

This interviewer has successfully conveyed concern without a price tag of obedience. Ironically, later in the interview, I would suspect the latter clinician would be in a more favorable position to persuade the patient to try an antipsychotic again.

This discussion suggests another characteristic – non-defensiveness – that contributes to a feeling of safety for the patient. Patients are very quick to perceive defensiveness in an interviewer. Defensive posturing by the clinician may create in the interviewee the feeling that “I’ve got to watch what I say here.” The following example illustrates a defensive position by the clinician, as a woman describes her anguish concerning her son’s problems with schizophrenia:

Here we see the paternalistic tone that can so readily destroy a patient’s trust. The clinician’s self-system has been activated, resulting in a defensive, “educational” posture, which only serves to reciprocally activate the patient’s own self-system. This interaction might have been avoided with the following approach, beginning with a gentle empathic statement in which the clinician’s intuition about the mother’s inner world is right on the mark:

Our discussion of the principles behind the development of a safe alliance began with the words of Harry Stack Sullivan. Sullivan also provides an important note upon which to close our discussion. One of the contributing factors to the development of an overactive self-system is the not-so-maladaptive fear that strangers may harbor ulterior motives. In short, a patient may fear that he or she is going to be used or even abused.

It is hoped that conscious abuse of a patient is a rarity in our field, but less sinister abuse may enter the picture unconsciously. Clinicians may have ulterior motives of which they have little, if any, awareness. For example, a clinician may depend on a patient for the gratification of the clinician’s need to feel liked or important. If the patient feels that the clinician needs something from them, such as respect, caring, or fondness, the relationship is no longer a safe one. Once again, the patient is faced with watching what he or she says, from the fear that professional help will be withdrawn if certain needs are not satisfied.

Sullivan stated this principle elegantly:

He [the clinician] is an expert having expert knowledge of interpersonal relations, personality problems, and so on; he has no traffic in the satisfactions which may come from interpersonal relations, and he does not pursue prestige or standing in the eyes of his patients, or at the expense of his patients. In accordance with this definition, the psychiatrist is quite obviously uninterested in what the patient might have to offer, temporarily or permanently, as a companion, and quite resistant to any support by the patient for his prestige, importance, and so on. It is only if the psychiatrist is very clearly aware of this taboo, as it were, on trafficking in the ordinary commodities of interpersonal relations, that many suspicious people discover that they can deal with him and can actually communicate to him their problems with other people.⁵

Besides offering a safe relationship, the initial interviewer also actively engages the patient in a positive fashion, utilizing those gestures and words that suggest to the patient that future interaction will be enjoyable and rewarding, as seen in our next topic.

Clinician Genuineness

The term “genuineness” has been described by a variety of researchers.^6,7 As was the case with empathy, genuineness appears to be a nebulous term at first glance. Once again, an operative definition provides clarification. One can state that “being genuine” occurs when the following is present:

The behavioral characteristics of the clinician suggest to the patient that the clinician is feeling at ease both with himself and with the patient. It is frequently marked by three characteristics in the clinician: (1) responsiveness, (2) spontaneity, and (3) consistency.

Perhaps there exists no better arena for examining these characteristics of clinician genuineness than looking at the reactions of a clinician to patient humor. When faced with humor some clinicians display a curious sense of awkwardness, as if humor should not be allowed during an interview. In essence, these clinicians “run-over” the moment of humor. Rather than responding with a smile or a chuckle, they maintain a somber expression.

This rather extreme form of non-responsiveness can produce an immediate increase in patient anxiety, not unlike the discomfort many of us have had the misfortune of experiencing in a social setting, when one of our jokes is followed by an absence of laughter. Ironically, such clinicians may argue that their non-responsiveness represents professionalism, but it seems odd that professional behavior should result in increased patient anxiety during the early stages of an interview. Moreover, this same lack of clinician responsiveness may be uniformly provided in response to a variety of patient affects, including tearfulness, anger, and fear, all in the name of professionalism.

Many patients balk at such pseudo-professionalism, preferring a clinician who interacts with a gentle responsiveness. In the final analysis, the mark of a true professional seems to be his or her lack of a need to feign professionalism. Such clinicians quickly and easily appear at ease with both their body language and their reactivity. They are attentively relaxed. Moreover, they bring to the interview a sense of appropriate spontaneity, the second characteristic of genuine interaction as described in our definition.

This spontaneity does not exist as a license for sharing whatever comes to mind. To the contrary, a skilled clinician consistently assesses the potential impact of all statements, but also possesses the ability to share some spontaneous feelings if they are deemed appropriate for the patient. This spontaneous quality often demonstrates itself in characteristics such as a well-timed sense of humor, a flexible method of structuring the interview, and a non-defensive attitude towards questions voiced by the patient.

As just mentioned, one must be careful about the degree of responsiveness and spontaneity one displays. Both too much and too little can present problems. For instance, a buoyant interviewer can intimidate certain patients, whereas a wooden interviewer may frighten them. In regard to the latter, if the frightened patient feels too uncomfortable with the clinician to share suicidal ideation, then the unresponsive interviewer may truly regret having presented a wooden attitude. The clinician needs to nurture a flexible style. The degree of spontaneity and responsiveness will probably vary from one patient to another and with the clinical setting.

To this point, the myth of “professional blandness” may have evolved from a misinterpretation of the psychoanalytic concept of presenting a neutral screen upon which the patient can project his or her transference. This neutral screen concept does not represent a dictum for unresponsiveness. In the first place, an expressionless presentation hardly represents a neutral stance, as Ryle⁸ has commented, for such a bland reaction typically suggests that the non-responder dislikes the other participant. This supposed “neutral stance” is, in actuality, potentially very disengaging. Moreover, rather than providing a blank screen, it seems to bias the patient towards negative transference.

Even if one adhered to this neutral stance theory for therapeutic application, and few talented analysts I have met do so in a strict sense, it does not necessarily follow that the neutral stance is effective for assessment interviewing. Indeed, as we have seen, one of the major goals of the initial interview remains the development of a sound therapeutic alliance, which will, it is hoped, lead to a sincere interest in coming to a second appointment. A wooden interview hardly lends itself to the facilitation of engagement.

It seems timely to examine consistency, the third element commonly characterizing a genuine interaction. Gerard Egan has emphasized the importance of consistency, as demonstrated by the clinician’s willingness to explore the patient’s world in a shared manner while respecting the patient’s present limitations and defenses. More specifically, the clinician avoids discordant actions, such as appearing warmly responsive in part of the interview and coolly distant later; nor does the clinician suddenly become confrontational, as demonstrated by Counselor A in the following example provided by Egan.⁹

The response of Counselor B demonstrates a willingness to share exploration, including a foray into the developing interviewer–interviewee relationship.

Together, the traits of appropriate responsiveness, spontaneity, and consistency coalesce to create an appealing milieu for the sharing of problems. When adroitly blended, these three traits of genuineness convey a sense of emotional balance in the clinician, a balance that suggests a possible source of help to the person in need.

In the following dialogue, these traits, as well as a sense of non-defensiveness, are elegantly displayed in a situation in which a therapist could easily have swallowed his or her foot. In this interaction, the clinician, a physician, had determined from the preceding conversation that the patient was pleasant and well integrated but very anxious. Consequently, the interviewer felt that humor could be safely employed.

Related posts:

Validity Techniques for Exploring Sensitive Material and Uncovering the Truth Personality Disorders Understanding the Person Beneath the Diagnosis Nonverbal Behavior The Dynamic Structure of the Interview Personality Disorders

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