In the following pages, we will begin a study of the interviewing process. We will be examining the craft in which one human attempts the formidable task of understanding another human. By way of analogy, this task is not unlike exploring a darkened room in an old Victorian house, holding only a candle as a source of illumination. Occasionally, as one explores the shadows, a brisk wind may snuff the candle out and the room will grow less defined. But with patience, the explorer begins to see more clearly. The outlines of the family portraits and oil lamps become more distinct. In a similar fashion, the subtle characteristics of a patient begin gradually to emerge. This quiet uncovering is a process with which some clinicians appear to familiarize themselves more adeptly than others. It is as if these more perceptive clinicians had somehow known the layout of the room before entering it – and indeed, in some respects, they had.
Their a priori knowledge is the topic of this chapter. We will attempt to discern some of the underlying principles that determine whether an initial interview fails or succeeds. As Jung suggests in the epigraph to this chapter, these principles do not harden into rigid rules. Instead they represent flexible guidelines, providing structure to what at first appears structureless.
Perhaps a second analogy may be clarifying at this point. A book on 19th century art by Rosenblum and Janson provides some useful insight.1 In it, the authors attempt to describe the numerous processes that lead to the creation of a work of art, including environmental influences, political concerns, and the goals and limitations of the artist. With each painting, these historians appear to question themselves vigorously concerning concepts such as color, composition, originality, perspective, and theme. In short, Rosenblum and Janson utilize a specific language of art consisting of concisely defined terms. This language provides them with the tools to conceptualize and communicate their understanding. Since the language is one understood by most artists, the concepts of Rosenblum and Janson can be widely discussed and debated.
The work of the art historian is not at all unlike our own; as clinicians, however, we are concerned with a living art. We can better study the characteristics of this living art once we possess a language with which to conceptualize our interviewing styles. With this language, the principles that seem to provide an experienced clinician with a “map of the Victorian room” naturally evolve. From these principles we will garner a more engaging, flexible, and penetrating style of interviewing.
In Search of a Definition
A Bit of Interviewing Examined and the Discovery of a Map
There probably exists no better method for uncovering a definition of interviewing than by analyzing a brief piece of clinical dialogue. Even in a short excerpt, clarifying principles may begin to emerge.
The following dialogue was taken from a videotaped initial interview. Of particular note is the fact that the supervisee was disturbed by a not uncommon problem faced by an interviewer, “the wandering patient.” Specifically, the supervisee commented, “I couldn’t really even get a picture of her major problem (she had presented complaining of being very depressed), because she took off on every subject that came to her mind.” In this excerpt, the interviewer, who had done an excellent job engaging her, uncovering her stresses, and allaying her initial anxieties, for she had never worked with a mental health professional before, was, at this point in the interview, attempting to discover whether she was suffering from the symptoms of a major depressive disorder. He wanted to understand better what symptoms were present and their severity – information that he could subsequently use to collaboratively develop an initial treatment plan with her. The patient, a middle-aged woman, had been describing some problems with her son, who was suffering from an attention-deficit disorder.
Pt.: … He’s a behavior problem; maybe a phase he’s going through. (Interviewer writes note.) He’s exhibiting crying spells, which don’t necessarily have a reason. The teacher is trying to interview him to see what exactly is wrong with the child because he’s tense and crying, which isn’t like him; he’s been a happy-go-lucky kid.
Clin.: Is he still kind of hyperactive?
Pt.: Oh yeah … now that we’ve lowered the medication he’s a little bit better, but I was just mad at the doctor; you know, one of them should have explained it to me.
Clin.: I would think that must be very frustrating to you.
Clin.: And how has this affected your mood?
Pt.: Ah … I have a husband who works shifts (interviewer takes note), and he wants to be in charge of everything. I had a job until last February, when I got laid off. I was working more than full time. My husband does not pitch in at all. I was working about 60 hours a week. He wouldn’t lift a dish, which really gets to you.
Pt.: Especially when you’re working Saturdays and Sundays and you start at 6:30 in the morning and don’t get home ‘til 8:00 at night.
Pt.: I was working in electronic assembly. I was an X-ray technician for 10 years and then we decided to settle down and have a family. I was working at the hospital up in Terryhill. And, uh, he said, and I can see his point …
At first glance, one can quickly empathize with the interviewer’s frustration, for indeed this patient is in no hurry to describe her mood or her depressive symptoms. Instead, when asked directly about her mood, she immediately darts down a side alley into a series of complaints about her husband. She appears to wander from topic to topic. But with a second glance, an interesting observation is apparent concerning the communication pattern between these two co-participants. It is unclear who is wandering more, the patient or the interviewer. It is as if the two had decided to take an evening stroll together, hand in hand.
Specifically, the interviewer had intended to explore for information concerning depression. But when the interviewer asked about mood, the patient chose to move tangentially. At this crucial point, where the patient left the desired topic, the interviewer left with her. Unintentionally the clinician may have immediately rewarded the patient for leaving the desired topic by taking notes. His scribbling may have inadvertently told the patient to continue by suggesting that what the patient was saying was important enough for the clinician to jot down. The interviewer further rewarded the tangentiality of the patient by proffering an empathic statement, “Uh-huh; I’m sure.” As if this were not enough, the clinician followed the patient down the alley by asking a question about the new topic (e.g., “What kind of work?”).
Thus, both the patient and the clinician had an impact upon each other, their interface defining a dyadic system unconsciously committed to the perpetuation of a tangential interview. If we examined the next 10 minutes of this interview, we would see a continuation of this joint rambling, an unproductive process that resulted in almost no further information regarding the patient’s depression and the pain beneath it, material much needed in order to begin collaborative treatment planning and subsequent healing.
This example illustrates the point that interviews define interactional processes, some of which facilitate communication and others of which inhibit communication. These processes are so distinctive that one can name them. For instance, the above process could be named “feeding the wanderer.” If one is trying to uncover specific information within a set topic, then the process of feeding the wanderer represents a maladaptive technique. Curiously, if one were attempting to foster an atmosphere conducive to free association, the same technique might be beneficial. In either case, the interviewer can and should be consciously aware of this technique, implementing it when desirable and avoiding it when it would not be efficacious. For example, in Chapter 3 we will discover that the interviewer may have been able, in the above dialogue, to lead this patient effectively into a less digressive mode of speech through the use of sensitively well-timed focusing statements.
As we search for a definition of the interview process, we have already stumbled upon a cornerstone characteristic of all good clinical interviewing. It is not done solely by habit. Good clinical interviewing is the art of choice. The gifted interviewer always tries to match his or her interviewing techniques and strategies to the uniqueness of the patient, the demands of the clinical situation, and the vibrancies of the patient’s culture. Allen Ivey, whose books I highly recommend, captured this cornerstone brilliantly with his concept of “intentionality,” which is a characteristic both of clinicians, as they engage patients, and patients, as they engage life:
Intentionality, along with cultural intentionality, is acting with a sense of capability and deciding from among a range of alternative actions. The intentional individual has more than one action, thought, or behavior to choose from in responding to changing life situations. The culturally intentional individual can generate alternatives in a given situation and approach a problem from multiple vantage points, using a variety of skills and personal qualities, adapting styles to suit different individuals and cultures.2
In this book our task will be, both for beginning and experienced clinicians, to explore a variety of interviewing techniques and strategies that will allow us to creatively choose which of these are most effective for which patients, enabling us to become more and more adept at creating intentional interviews while nurturing intentional interviewees. With this goal in mind, we can now turn our attention to defining exactly what an interview is. This definition would be equally true for an assessment interview by a social worker or a television interview by a talk show host. The general definition reads as follows:
An interview represents a verbal and nonverbal dialogue between two participants, whose behaviors affect each other’s style of communication, resulting in specific patterns of interaction. In the interview, one participant, who labels himself or herself as the “interviewer,” tends to ask questions in attempts to achieve specific goals, while the other participant generally assumes the role of “answering the questions” but undoubtedly has his or her own goals.
This definition emphasizes the interactional process of the interview. It also allows one to refine the definition depending on the desired goals and the context of the interview. To make this definition more specific to the clinical assessment, one has only to look for the goals particular to the clinical situation.
In a broad sense, these assessment goals are as follows:
1. To establish a sound engagement of the patient in a therapeutic alliance
2. To collect a thorough and valid database
3. To develop an evolving and compassionate understanding of the person being interviewed
4. To develop an assessment from which a tentative diagnosis can be made
5. To collaboratively delineate a set of practical problems to be addressed and therapeutic goals to be set
6. To collaboratively develop an appropriate disposition and tentative treatment plan for achieving these goals
7. To begin the healing process by effecting some decrease of anxiety and pain in the patient
8. To instill hope and ensure that the patient will return for the next appointment
Furthermore, the goals of the initial interview will vary depending on the demands of the assessment situation, including issues such as time constraints and the interviewer’s determination of what type of data seems clinically necessary in order to make an appropriate disposition. For instance, a crisis clinician called into an extremely busy emergency department to interview a victim of domestic violence will clearly sculpt a different interview than a therapist performing an initial intake at a community mental health center who, in turn, will create a different initial interview than one undertaken by an analyst asked to spend an hour or two with a well-educated patient requesting psychotherapy for chronic depression. In short, the needs of the clinical situation should determine the style of the interview but can do so only if the clinician remains willing to intentionally and flexibly alter his or her approach.
In any case, the above considerations emphasize one of the frequent challenges facing the initial interviewer, namely to gain a thorough and valid database in a limited amount of time while sensitively engaging the patient. The shorter the time period provided, the more complex the task appears. To return to our Victorian room, it is as if a clinician were being asked to make an inventory of a darkened room in a restricted amount of time while being careful not to disturb the decor too much. No easy task, even for a master of parlor games.
Perhaps this challenge reaches its most formidable peak when an interviewer or consultant is placed in the unenviable role of performing an intake assessment. From his or her assessment, frequently limited to the “50-minute hour” or less time by the numerous time pressures present in a busy clinic, the interviewer must determine the treatment disposition of the patient. We shall now turn our attention to the difficulties inherent in such intake interviews.
The discussion so far has indirectly provided an operational definition of such an assessment interview. From this definition, a map of sorts can be formulated as shown in Figure 1.1. This map, delineating the various goals of the assessment interview, begins with the engagement process, which, in many respects, determines whether the other goals will be successfully achieved. As engagement proceeds, the data-gathering process unfolds, leading to a progressive understanding of the patient. This understanding of the patient as a unique person depends upon the clinician’s ability to see the patient’s view of the world and recognize the patient’s fears, pains, and hopes. As the interview progresses, the clinician begins to formulate a clinical assessment, including a tentative differential diagnosis and a practical list of the patient’s concerns and desired goals. From both the assessment of the patient’s situation and an understanding of the patient as a person, the clinician and patient can co-formulate a treatment plan suited to the individual needs of the interviewee, while acknowledging the constraints placed on treatment by the limitations of the mental health system itself.
These processes of engagement, data gathering, understanding, assessment, and treatment planning are, in actuality, longitudinally intertwining processes. The reverse arrows in the center of the map emphasize this fact, highlighting the clinician’s need to attend to engagement activities throughout the initial interview.
Person-Centered Interviewing
As we use our map to explore our Victorian room, especially as the shadows darken and we meet areas where the patient is hesitant to share, our efforts must be guided by a compass that can provide a sense of direction in the darkness. What is this compass? It is the realization that our major goal for being in this room is simple, concrete, and unwavering – we are there to help the person who has sought our care.
At first glance this axiom may seem so self-evident as to not need to be stated. But any experienced clinician can relate to the intense time pressures of the work, the weariness engendered by the work, the mountains of paper work attached to the work, the administrative hassles hindering the work, and their own unconscious needs sometimes undermining the work that can make it surprisingly easy to lose this sense of direction.
For decades talented innovators, such as Carl Rogers, have felt this point to be so important that terms have been coined such as “client-centered counseling” (and in the fields of medicine and nursing: “patient-centered medicine”) to highlight it. The newest term that has evolved for this concept – “person-centered” – beautifully captures the essence of our mission. It is a term more commonly encountered in European literature.
From the person-centered perspective the clinician views the interviewee as a cascading series of unique moments in time, in which the biology, psychology, intimate relationships, family dynamics, culture, and spirituality of our patient intersect to create the unique person before us. It is an ever-shifting matrix of which we are a part as soon as the patient enters our office. Our goal as clinicians is to understand this uniqueness, help our patients to better understand their strengths and weaknesses, and to learn how to navigate this complex human matrix more effectively.
Throughout the pages of this book we will use a person-centered perspective as our compass. Our interviewing principles, techniques, and strategies will be enriched by our efforts to see the world through the patient’s eyes as well as our own, to make sure that we have a collaborative understanding of what the patient views as his or her problems and his or her goals first before sharing some of our own suggestions. It is a perspective that gently reminds us to understand what the person seeking our help wants us to provide before trying to provide it.
In person-centered interviewing the patient is not viewed as the problem but as a unique individual filled with solutions to the many problems that life invariably brings to all of us. There is a humbleness to a person-centered interviewer. It is the wisdom that, even at our best, we do not know all the answers, for we do not even know all the questions. Thus it is intensely important to listen to what our patients have to teach us and the questions that they bring us.
The Next Step
In this book we will focus upon the particularly challenging type of interview described above – the initial assessment – for the principles needed to perform it gracefully can be generalized to most other types of interviews, including emergency department interviews or crisis lines, where a great deal less time may be available. In short, the difficulties presented by the initial assessment interview provide tremendous opportunities for learning skills critical to understanding the core issue of most interviews, the delicate interplay between engagement, data gathering, and time. Many of these same skills will ultimately also be of use in psychotherapy itself.
In Part I of this book we will sequentially explore each of the processes defined by our map with a separate chapter (sometimes multiple chapters). In this chapter we will look at the first way-station on our map, engagement and its relationship to empathy.
Now is an appropriate time to introduce our integrated video program and to view our first video. As described in the Preface, more than 7.5 hours of video instruction are integrated throughout the text. These video modules provide didactic material that consolidates what has been read, adds new material and nuance, and provides video illustrations of the interviewing techniques. Video boxes within the text (as appears immediately below) will alert the reader to the video opportunities as they arise. Note that video modules are accessed via the e-book, for which directions for easy access appear on the inside of the front cover of the book.
Creating the Therapeutic Alliance
First Things First: The Difference Between Engagement and Blending
From the first moment in which they see, hear, smell, and touch each other, the clinician and the patient begin the engagement process. In this complex interplay they reflect their sensory information onto the slippery screen of their memories. From these comparisons, both the clinician and the patient attempt to determine where each will fit into the other’s life. Even as simple a gesture as a handshake can lead to lasting impressions. The experienced clinician may note whether he or she encounters the iron fingers of a Hercules bent upon establishing control or the dampened palm of a Charlie Brown expecting imminent rejection.
Ironically, at this same moment, the patient will have begun his or her own “mental status” on the clinician. This process can be seen clearly in the patient who greets the clinician’s outstretched hand not with a handshake but with a look of disdain. As the clinician responds to the patient’s rejection of a simple social amenity, who can doubt that the patient will be gaining some hints about the psychological workings of the clinician. For example, one interviewer, perhaps with an obsessive need to “do things my way,” may further extend his or her hand, testily adding, “Don’t you want to shake?” Another clinician, perhaps jaded from overwork, may dryly comment, “Not in the mood for shaking today, are we?”
In either case, the patient has struck a rich vein from which to mine answers to questions such as the following: (1) Will this interviewer get angry with me?, (2) Will this interviewer make me do things I don’t want to do?, and (3) Am I safe here? This example hints at the complex and mutual activities affecting the engagement process, during which territorial issues are initially addressed.
Before proceeding, it is important to define two terms, engagement and blending. Engagement refers to the ongoing development of a sense of safety and respect from which patients feel increasingly free to share their problems, while gaining an increased confidence in the clinician’s potential to understand them. Blending represents the behavioral and emotional clues from the interview that suggest that this engagement process is proceeding effectively. Stated differently, engagement defines a set of goals, and the concept of blending provides a method of monitoring the effectiveness of the strategies utilized to achieve those goals.
Not all writers emphasize the distinction between engagement and blending, but I feel it is an important one. Its significance lies in the fact that it does one little good to study engagement techniques if one does not develop a reliable method of measuring the effectiveness of these techniques in the interview itself. The concept of blending provides an avenue for active self-monitoring by the clinician. Problems in blending can alert the interviewer to the need to change interview strategies before serious damage to the clinician–patient alliance has developed.
Using Blending to Gauge the Degree of Engagement
One can assess blending by utilizing three complementary approaches: a subjective method, an objective method, and a patient’s self-report. With regard to the subjective technique, an interviewer can learn what sensations he or she experiences when engagement is optimal – in essence, what a good interview feels like. Educators have suggested that once this internal and idiosyncratic feeling stage has been identified, the clinician can use it as a type of thermometer, to determine the intensity of blending at any given moment.3
Naturally, this subjective feeling will vary from one interviewer to another. Consequently it may help to examine some of the descriptions clinicians have related concerning this feeling state.
a. “To me good blending feels more like a conversation and a lot less like an interview or interrogation.”
b. “I know blending has occurred when suddenly I realize during the interview that I’m actually talking with a person with real pain, not a case with imagined defenses.”
c. “When the blending is good, I notice that I feel more relaxed, sometimes even giving off a sigh. Curiously I also feel more interested.”
These descriptions suggest the personal uniqueness of the blending process. It is this personal uniqueness that allows the concept of blending to function as such a reliable and sensitive tool for monitoring the degree of engagement. If clinicians can train themselves to intermittently check the progress of blending, they will have discovered a window from which to study the unfolding engagement process. To this extent, the interview becomes less nebulous and more tangible. It evolves into something that can be modified.
This increased tangibility can be furthered by utilizing the second major avenue for monitoring the blending process, an objective look at the behavioral characteristics of the interview itself. The behavioral clues suggested by body language will be discussed in Chapter 8. In this chapter, an examination of the timing and structural characteristics of the verbal exchange will be highlighted.
The issue facing the interviewer involves finding concrete behavioral cues from the verbal exchange that indicate the presence of good blending. Wiens4 and colleagues have provided some simple but fascinating methods of analyzing the temporal characteristics of speech by studying three major speech variables: duration of utterance (DOU), reaction time latency (RTL), and the percentage of interruptions. The DOU can be roughly equated with the length of time taken up by the interviewee’s response following a question. The RTL represents the length of time it takes an interviewee to respond to a question. The percentage of interruptions represents the tendency for the interviewee to cut the clinician off before a question has been finished. One can look at all of these variables in relation to the clinician’s speech patterns as well.
With regard to blending, these variables offer a potentially more objective measure of effectiveness, because certain patterns of exchange may suggest weak blending. For instance, a guarded or suspicious patient often produces curt responses to questions (a short DOU), long pauses before answering (long RTL), and occasional cut-offs as the patient corrects the interviewer for inaccuracies in his or her statements. If an interviewer spots such a pattern emerging, it may be a clue to ineffective engagement.
Another example at the opposite end of a continuum concerns the hypomanic, histrionic, or anxious patient who tends to wander. These wandering patients frequently present with a long DOU and a very brief RTL and may also actually cut the interviewer off frequently, a process triggered by the patient’s over-eagerness to make their points. Interestingly, the interviewer may find himself or herself reciprocating with cut-offs in a vain effort to get a word in edgewise.
Moreover, with histrionic, hypomanic, or manic patients, the blending is frequently marked by a peculiar superficial quality. With regard to spontaneity of speech, these patients often open-up inappropriately quickly, as opposed to the gradual increase in blending seen with most patients. Consequently, the observed blending possesses a one-sided and shallow quality, aptly called by one student “unipolar blending.”
In the above two examples, we have seen that variations in basic patterns of verbal output, such as a DOU and RTL, can provide objective indications of the adequacy of the blending process. One might ask whether this objective technique offers any advantage over the subjective approach described previously. I believe that it does. But one method does not appear more valuable than another; rather each method complements the other. For instance, occasionally clinicians are duped by their subjective sense of blending into missing the psychopathology of patients with histrionic defenses or those experiencing hypomania.
One of the reasons this problem occurs is that the clinician feels at a subjective level that the blending is unusually good. Indeed, the clinician is fascinated by the patient’s story. In actuality, the blending is artificially good, representing the unipolar blending just described. In fact, unipolar blending, if recognized by the clinician, could provide the clue that “something is wrong here.” The patient’s engaging style and subtle dramatics are misleading the clinician. If in this instance the clinician could step back to look at the DOU and RTL, the clinician might recognize the hallmarks of a unipolar blending and consequently evaluate the possible psychopathologic causes of it. In this case, the objective technique sidesteps the confusion created by judging the blending process solely by the subjective method.
The other advantage of paying attention to more concrete parameters such as DOU and RTL is the ability to use these criteria to judge the effectiveness of a specific technique employed by the clinician. If, for example, the clinician attempts to actively engage a patient who seems hesitant to talk, one of the earliest and most easily recognized markers of success will be an increase in DOU. Corresponding changes in the subjective feeling of increased blending may appear only later and may be less easily recognized.
A third method of determining the degree of blending consists of the patient’s self-report. Occasionally, a patient will spontaneously tell an interviewer to what degree the interaction is enjoyable. More commonly, the interviewer may inquire, as the interview winds down, “What was it like talking with me today?”
To this question, some patients may pointedly discuss specific concerns, sometimes providing appropriate and constructive criticism. Often, due to a reluctance to appear unappreciative or rude, patients will reply that everything was fine, even if it was not, but their nonverbals may betray their true feelings. A hesitant “yes” surely indicates some discomfort upon the part of the patient, providing us with a rich opportunity to non-defensively uncover their concerns and address them. At such moments of hesitation, the clinician can comment, “You know you look a little hesitant there, is there anything I may have done or said that might have made you uncomfortable?” The answers are sometimes surprising. By non-defensively exploring the patient’s concerns, we will have greatly increased the likelihood that there is going to be a second interview.
Other surprises may appear when the self-report contradicts the subjective and objective methods of evaluating blending. For instance, I am reminded of a young man who appeared somewhat disinterested as we spoke. He talked softly and with little animation. As we proceeded, I felt awkward, as if this were going to be a bad mix of personalities. Although both the objective and subjective signs of blending suggested poor engagement, to my surprise, at the end of the interview he reported feeling very at home with me. He stated that he had enjoyed the interview, and he appeared sincere.
His diagnosis was paranoid schizophrenia in remission. It was either a residual blunting of affect from his schizophrenia or perhaps a side effect from an antipsychotic that was creating both an outward and an inward suggestion of poor blending; the engagement was not, in truth, weak. This disparity highlighted the type of miscommunication that this patient could easily convey to other people, an aloofness that was both disarming and misleading. Attention to blending by self-report greatly enhanced my understanding of the manner in which this patient embraces the world and is embraced by the world. It also suggested the possible utility of social skills training or perhaps a medication adjustment.
Thus, the clinician can benefit from learning to judge blending by combining the subjective, objective, and self-report approaches. With these three techniques in mind, the interview becomes at once less mystifying and more gratifying. The gratification arises from the realization that the interviewer can learn to creatively alter the interview process itself.
Once blending has been analyzed, the clinician possesses a concrete idea of the strength of the engagement process with any particular patient at any given moment. Weak engagement may indicate that invalid data is more likely. It may also be a harbinger that the patient may be less interested in the clinician’s treatment recommendations or recommendations for follow-up. Moreover, a weak engagement process suggests one of the following three conditions:
1. The interviewer’s actions are actively disengaging the patient
2. The interviewee’s psychopathologic processes or defenses are interfering with engagement
If the clinician feels that the damaged blending can be attributed to the first condition, then the clinician can attempt to consciously alter his or her style of interaction. For instance, a paranoid patient may be put off by an extroverted style of interviewing. In such an instance, the clinician may decide to tone down their extroversion in an effort to ease the patient’s fears.
If the weak blending can be ascribed to the second condition, then the clinician may be alerted to the types of psychopathology that could be blocking the blending, such as with the histrionic process described earlier. Naturally, if the third condition is the issue, increased attention to both style of interaction and psychopathology can be brought into play.
At this point we have reviewed three methods of directly assessing blending that allow us to indirectly assess the engagement process itself. It is valuable to reflect on the map of the interviewing process delineated earlier. On this map, the interviewer begins with the engagement process for a good reason. The engagement process affects all subsequent goals of the interview.
More specifically, poor engagement raises significant doubts about the validity of the database because patients generally do not freely share with people they do not like. Moreover, without effective engagement, one will seldom gain knowledge of the intimate corners of the patient’s “room” alluded to in our comparison of an interview with an exploration of a dark Victorian room. Hence, the clinician leaves with only a superficial understanding of the patient’s pain. Furthermore, without valid data falling into place, the clinician’s assessment and diagnosis are frequently in significant jeopardy. Finally, if the engagement process proceeds poorly, the patient may never return for a second appointment, casting the shadow of irrelevance over the work of the first interview.
Thus one is left with the realization that this somewhat nebulous concept of engagement appears to be the pivotal process on which much of clinical practice turns. Fortunately, this process is not as mercurial as it first appears. The dance of engagement begins with empathy.
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