Introductory Illustration: The Person Beneath the Diagnosis

As the clinician integrates the processes of the first two way-stations on our map of the initial interview – engagement and data gathering – a curious phenomenon emerges. Gradually, the clinician begins to gain an understanding of the world through another person’s eyes. This process does not happen suddenly or dramatically. Instead, like the imperceptible clearing of a mist, the clinician’s conceptualization of the patient’s perspective crystallizes. To return to our analogy of the Victorian room, the nooks and crannies of the environment gradually become more familiar. As interviewers, we are no longer strangers.

Indeed, we have reached the third way-station on our map – a deeper understanding of the person sitting before us. This way-station overlaps with the first two, for an understanding of the patient will not occur unless there is adequate engagement. Moreover, accurate understanding emerges from the facts, feelings, and opinions culled in the process of data gathering. Despite this overlap, from the perspective of person-centered interviewing, the process of understanding warrants a closer examination.

It is our understanding of the unique qualities, circumstances, and cultural determinants of the patient that will lead us not only directly into the fourth way-station on our map – accurate assessment and diagnosis – it will also have a profound impact on the fifth and final way-station on our map – treatment planning. Put succinctly, the success of a treatment plan is ultimately dependent upon the clinician’s ability to understand the person beneath the diagnosis. Clinicians arrive at this understanding by uncovering a compassionate, sophisticated understanding of the multiple systems – from biological and psychological to familial, cultural, and spiritual – that continuously coalesce to create the patient, the clinician, and the patient/clinician dyad.

As we shall see in our next chapter, there are a variety of assessment perspectives that serve as nice complements to one another for accomplishing this integrative task, including differential diagnosis using the DSM-5, viewing the patient as a matrix of intersecting and interacting systems (matrix treatment planning), and understanding the patient’s core pains. An interviewer can shape a useful formulation of what is right and what is wrong with the patient through a skilled delineation of the information needed to utilize these three assessment frameworks. Indeed, these three frameworks provide the classic foundations for collaboratively developing an initial treatment plan by the end of the interview, and these are good foundations. Consequently, we will examine them in detail in the next chapter.

But if one looks at our interview map (Figure 6.1), one will notice that, in addition to an arrow leading from diagnosis and assessment to treatment planning, there is a second arrow that leads to treatment planning. It is the arrow that originates from the understanding of the patient.

Many a well-intentioned interviewer has been trapped by the inviting misconception that ideal treatment plans can be generated by strict algorithms stemming directly from specific DSM-5 diagnoses. The spirit behind this goal is an admirable one, to improve quality of care by ensuring that the best possible evidence-based therapies are utilized. Unfortunately this concept misses a rather simple, but often-overlooked, reality: an “ideal” treatment plan that doesn’t work is not ideal, it is foolish. It is the patient’s interest in and agreement with the treatment plan – as well as his or her ability to follow through with the treatment plan – that will determine whether or not the treatment plan will work. One cannot simply look at a DSM-5 diagnosis and conclude that one can apply a pre-determined best treatment plan dictated by the diagnosis, for it can’t possibly be the best plan for the patient if the patient does not like it and, consequently, will not do it. Treatment plans are created for people, not for diagnoses.

Moreover, effective treatment plans are not really made for people by clinicians, they are co-created by people with their clinicians. This fact is true not only in psychiatry, but in all branches of medicine. A clinician cannot help a patient to control diabetes, asthma, or hypertension unless the patient personally chooses, and helps to sculpt, the treatment plan, and is not blocked by external circumstances (lack of money, problematic circumstances, and cultural roadblocks) from following through with the treatment plan that he or she has chosen.

The art of treatment planning achieves its greatest healing power when it is guided by a sophisticated understanding of the person sitting before the clinician. The search for this understanding during the initial encounter will often reveal many factors, including psychodynamic, interpersonal, and cultural factors, that have little to do with the DSM-5 diagnosis per se, that can suggest powerful ideas for treatment planning. In addition, it is our understanding of the person beneath the diagnosis that will determine whether or not we can collaboratively create a treatment plan that the patient will embrace during the initial interview and in subsequent therapy. Perhaps an illustration will make this point more clear.

Imagine a clinician at a busy community mental health center who is in the midst of an initial intake. Further imagine that at this particular center the “intake clinician” is supposed to triage the patient to whatever clinical program would best be able to help that individual, ranging from outpatient individual therapy or group therapies to psychiatric care or other specific programs, such as an incest survivor’s group, an eating disorders group, or a DBT (dialectical behavioral therapy) group.

Now imagine that the interviewer is quite talented at all of the skills we have been discussing thus far, from engagement techniques to facilic principles for creating flowing conversational interviews. The patient is a young woman of about 18, still living at home, hoping to go to college next year if finances can be worked out, who unfortunately has become fairly seriously depressed; indeed, there is a strong family history of depression. We will call our imagined patient, Jennifer.

As the interview is nearing its closing phase, the clinician has become convinced that Jennifer is suffering from a moderately severe, major depressive disorder from the diagnostic perspective of the DSM-5 system. The clinician is also concerned about the depth of the depression and feels that rapid intervention is indicated, although there is no suicidal ideation. The clinician decides to recommend a combination both of a referral to the psychiatrist for medications and to one of the outpatient psychotherapists. The decision to recommend medications is certainly reasonable considering her diagnosis (which is accurate) and the rapid progression of Jennifer’s symptoms and the severity of her pain. Jennifer seems reasonably comfortable with the both recommendations and states she feels she has benefitted from the interview, thanking the clinician in a genuinely warm fashion. There is only one problem: Jennifer never appears for either her meeting with the psychiatrist or her therapist.

Now imagine the exact same scenario with the same patient, but with a different clinician. Once again, this is a talented clinician and empathic interviewer. Indeed, she gathers essentially the same database as our first clinician. She, too, feels the patient meets the criteria for a moderately severe major depressive episode by DSM-5 criteria. She, too, feels that the rapid progression of the depression and the of the depth of Jennifer’s pain suggests the wisdom of using an antidepressant.

On the other hand, during the body of the interview, she does one thing differently than our first clinician. It relates to something that she noticed – a piece of jewelry. A cross is hanging from a simple chain around Jennifer’s neck. It has some decorative elements that suggest it may be an heirloom; perhaps it’s Victorian. Although not expensive, it is clear that the owner of this cross, Jennifer, has taken meticulous care of it:

When this clinician reached the closing phase of the interview, despite the fact that, on a theoretical level, she felt an antidepressant might help significantly, she said the following, “You know, Jennifer. There’s lots of different ways we might be able to help you. But I think a really good way to start is with one of our therapists, you know, a talking therapy. You have been very easy to talk with, and I think you would genuinely enjoy working with one of our therapists. And the two of you could see if talking some stuff out might help with your depression and some of your stresses. How does that sound to you?”

The clinician chose not to mention medications, not because she didn’t believe that an antidepressant might help, but because she felt that if she suggested a medication (just as the family had predicted she would), it would never be taken. And, worse than that, it might risk alienating Jennifer, perhaps leading her to not proceed with any recommendations from the interviewer. Instead, she chose a treatment plan that began with psychotherapy, which also has a good track record with the type of moderately severe depression that Jennifer is describing.

In addition, if the psychotherapy did not provide adequate relief in the ensuing weeks, then it would be the psychotherapist who would be suggesting the use of a medication. If Jennifer had bonded well with the therapist, the therapist’s recommendation for medication would likely have a more positive reception from Jennifer than the same suggestion made by an initial interviewer. Here is a plan that has a shot at working. It is not an ideal plan from an ivory tower, but a realistic plan from the practical world of the clinical trenches where we all work and in which Jennifer lives. The following week Jennifer appears promptly for her session, a cross reassuringly dangling from her neck and an open mind sitting atop it.

As Paracelsus suggested in our opening epigram, this clinician’s treatment plan was implemented by the patient because the clinician used her patient as her book. She read the nonverbal and cultural cues from the pages of this book to collaboratively develop a treatment plan that resonated with the uniqueness of Jennifer’s family milieu and her own spiritual story. In this chapter we will focus upon the art of learning to more astutely understand what patients are saying in their book, as well as learning how to read between the lines of what they are saying in that very same book. Our goal is to view not only the patient in isolation but the patient as part of an ever changing set of psychodynamic forces and cultural systems that point to the person beneath the diagnosis. In this way, we adhere to the age-old wisdom to not judge a book by its cover, a misstep that can occur if a clinician relies too heavily on a DSM-5 diagnosis alone.

To effectively undertake this search for a more sophisticated understanding, in this chapter we will look at three topics that help clinicians to understand the patient beneath the diagnosis: (1) phenomena that can hinder this understanding (focusing upon ways to avoid them), (2) phenomena that can further it (focusing upon ways to enhance them), and (3) an introduction to cultural diversity and its role in the initial interview.

It is clear that the initial interview is an interpersonal process. Both the patient and the interviewer develop perceptions about each other that will shape both their trust in each other and their affinity towards each other. One could assume that these interpersonal perceptions are created primarily via conscious and/or preconscious processes in both parties. If only it could be so simple. Unfortunately, the patient’s developing image of the clinician and, for that matter, the clinician’s developing image of the patient are influenced by unconscious processes as well. Unknown to the clinician, he or she may resemble a family member of the patient or an ex-spouse, or fill a stereotype of a concrete prejudice. As Sullivan put it, “The real characteristics of the other fellow at that time may be of negligible importance to the interpersonal situation. This we call parataxic distortion.”²

This distorting process can affect the patient or the clinician and sometimes both parties. In actuality, parataxic distortion may evolve from the early seeding of both transference and countertransference; as such, its formation and resolution may play a pivotal role in subsequent therapy. But in the initial interview, such undetected early distortions may beleaguer an already fragile alliance. Moreover, parataxic distortion can lead to remarkably difficult roadblocks to understanding the person beneath the diagnosis. Such unconscious distortion by the patient may lead a patient to mistrust the interviewer with a resulting hesitancy to share critical material necessary for a sophisticated understanding of the patient. Parataxic distortion occurring within the clinician can lead to false impressions and inaccurate “gut instincts” about the patient. Either way, an accurate understanding of the patient is made less likely.

Fortunately, intense parataxic distortion is atypical. But when it does occur, it generally displays itself either through unusually poor blending or by atypically high levels of anxiety in the patient, perhaps even frank antagonism. This weakening of the engagement process represents one more area in which monitoring of the blending process can provide important clues to the engagement itself. Once such weak engagement is recognized, the clinician can begin repair work.

The first step in the repair process consists of questioning whether one’s own actions are somehow disengaging the patient. At times these interviewer self-defeating behaviors may be related to countertransference issues with the patient (parataxic distortion on the part of the clinician as with a patient who unconsciously reminds the clinician of a patient who was deceitful and antagonistic towards the clinician in the past or reminds the clinician of an abuser from the clinician’s own family). In such a situation the clinician may inadvertently “hear” the patient’s story differently than it was described, become overtly suspicious of the truth of the patient’s story, or be repulsed or judgmental about the views of the patient. These unconscious clinician tendencies can prevent a clear picture of the patient from emerging.

When a clinician finds himself or herself having a strong visceral negative reaction to a patient, two self-directed questions can lead to the uncovering of parataxic distortion at play with the clinician: (1) Does this patient remind me of any previous patients? (2) Does this patient remind me of any of my family members, friends/enemies, employers or public figures? Clinicians must be keenly aware of their own beliefs based upon cultural biases, including racial, religious, and political biases. It is surprising how quickly and powerfully a clinician can develop a dislike for a patient who holds a differing political or religious worldview. I have been disturbed by the intensity of stereotyping I’ve seen from both ends of the political spectrum with supervisees who are either Progressives or Conservatives when they discover that their patients are of an opposite political persuasion, a problem that has intensified as America has become a more politically divided nation.

If the clinician discovers that he or she is free of such processes, the clinician can then legitimately wonder whether parataxic distortion is at work in the patient’s mind. If such distortion is suggested, an open exploration may decrease the growing antagonism. For instance, the clinician can ask, “I’m wondering what you’re feeling as we are talking,” or “I sense you are feeling a little displeased with the interview so far, and I’m wondering what’s going on?”

This type of non-defensive statement may help to defuse the situation, because it brings hostile feelings into the open, where they can at least be approached. Moreover, the clinician should not be afraid to uncover specific feelings of ill will, such as, “I find you very controlling,” because these feelings can be tapped for clues of psychodynamic significance, which may be addressed later in the interview with questions such as, “When have you felt similar feelings in the past?” Once again, the emphasis rests upon allowing the patient to openly express his or her view of the world, in this case, of the interview itself. This emphasis upon understanding the patient’s view of the world provides the gateway to a better understanding of who the patient really is.

Sullivan, who died in 1949, is viewed as a pivotal innovator in what he called the interpersonal theory of psychiatry.³ His work pioneered the realization that patients are not social isolates. To understand a person, one must delve into the person’s current interactions with family, friends, culture, and even the therapist’s unconscious itself. More recently, theorists such as Ogden have expanded the study of the specific interactions occurring unconsciously between the therapist and the patient, a psychoanalytic concept called “intersubjectivity.”⁴

Intersubjectivity teases apart the dynamic interplay between the therapist’s subjective experience during the interview with the patient’s subjective experience, highlighting the fact, as we saw with Sullivan’s parataxic distortion, that an interviewer’s own unconscious may have the potential to distort both the conscious and unconscious “facts” of the patient’s story, thus hiding the real person beneath the diagnosis. Jonathon Dunn, referring to intersubjective theorists, succinctly summarizes as follows:

These theorists see the analyst and the patient together constructing the clinical data from the interaction of both members’ particular psychic qualities and subjective realities. The analyst’s perceptions of the patient’s psychology are always shaped by the analyst’s subjectivity.⁵

I love Dunn’s use of the words “constructing the clinical data,” for they serve to remind us that the “facts” garnered in an interview are actually educated guesses of what happened. These guesses are sculpted by the interplay of what really happened with the chisel strokes made by both the patient’s and the clinician’s unconscious processes. The interviewing instrument in an initial interview – the clinician – is not a thermometer that has been calibrated for accuracy. The interviewer is more of a human eyeglass that may have been fitted by personal history with lenses that are prone to see a world with some distortion. The real patient sitting before the clinician may be a good deal different from the one sitting inside the clinician’s head.

It seems naive to assume a simple causative agent for most examples of human anxiety. For instance, research in neuroscience has unmasked many physiologic as well as psychosocial precipitants to anxiety. In this section we will focus on some of the interpersonal forces at work in the creation of anxiety as it unfolds in an initial interview. Much of the following discussion is borrowed directly from the work of John Whitehorn,⁷ as well as further insightful work by Harry Stack Sullivan,⁸ both pivotal pioneers of interpersonal psychology.

To begin our discussion, the following question is worth considering as the interview proceeds: “How does this patient feel that he or she is viewed by others?” In many instances, the answers to this question will provide clues to the patient’s immediate presence in our office. Guilt, shame, inadequacy, and fear of failure – these concerns are the stuff of neurosis. Many of the paralyzing defenses developed by people are erected to deflect such painful feelings. Whitehorn cogently expressed this idea, “Even in deadly warfare one’s greatest apprehension is not of death but of being maimed or of failing in one’s duty, and that, in large part, because one dreads the reactions of other persons. This is not to downplay the fear of death but rather to emphasize the fear of life.”⁹

In another sense, developmentally speaking, the child appears to incorporate its sense of self-worth through a synthesis of perceived parental and family attitudes towards it. Indeed, persons demonstrating poorly developed personality states, such as the borderline personality and the narcissistic personality, have frequently evolved from chaotic childhoods. These developmental issues highlight the importance of interpersonal issues in the birth and feeding of unpleasant affects such as anxiety and depression. An actress once told me, “I can play any role once I understand what the character feels guilty about.”

With regard to the art of understanding the person at a more sophisticated level in the initial interview, these concerns suggest the utility of a sensitive search for answers to the question “How does this patient feel that he or she is viewed by others?” In particular, certain questions concerning the adolescent years may help to open the interpersonal door a bit, such as:

This list could almost be endless, but these questions represent samples of pathways into interpersonal affect related to past and perhaps current symptomatology. Of course, besides these reflections on the past, the interviewer will also pay heed to the patient’s immediate concerns about spouse, family members, friends, bosses, and fellow employees, as well as any current harassment problems on the web.

Of even more immediate concern to the interviewer is the generalization of the patient’s interpersonal fears to the interview itself. As mentioned earlier, the patient’s self-system may be activated by the perceived threat of rejection or disapproval from the interviewer, or problems with parataxic distortion may undermine a newly emerging therapeutic alliance. Whitehorn, once again, crystallizes the idea, “The patient’s attitudes are not likely to appear at first, in answer to prepared questions, but later, in reaction to what he feels is the interviewer’s response to his statements.”¹⁰ In this regard, the clinician may be aptly rewarded by reflecting upon the following two queries: (1) How is this particular patient trying to come across to me? and (2) Why does he or she feel a need to present himself or herself in this fashion?

Some patients may feel that either the clinician or their friends think that they must be weak or “nuts” to be “seeing a shrink.” This anxiety can seriously hamper engagement and may be partially alleviated by allowing some ventilation later in the interview with questions such as, “What has it been like for you to come to see a mental health professional?” Such a question may provide reassuring feelings of interpersonal safety for the patient, because he or she realizes that the clinician is aware of the all-too-human anxieties associated with admitting a need for help.

Another possible method of gaining insight into interpersonal issues arises from asking patients to describe their attitudes toward others. As Whitehorn states, “A fruitful field of study lies in a consideration of his sentiments or prejudices, that is, his attitudes toward father, mother, siblings and other significant others, toward church and state, toward his home town and toward secret societies, antisemitism, Socialism, Fascism, and other ‘isms.’ In the discussion of such matters, the patient reveals more clearly than in response to direct questions the character of his ideals and the way in which he has come to dramatize his role in life.”¹¹

During an interview with an adolescent boy of about 14 years of age, the wisdom of this approach became apparent to me. The boy was suffering from a severe depression and seemed reluctant to talk about himself, but to my surprise he was not reluctant to talk about others. The request, “Tell me about some of the things you would change at school,” led to a long and revealing discussion of complex social issues such as his school’s policy towards racial integration and his own contempt for prejudice. Clearly this was not a boy interested only in the next football game or party. His detailed analysis suggested that he was a person preoccupied with powerful moral concerns, which, when on overtime, could transform into harsh superego admonishings. His world was tense and dotted with rights and wrongs, creating an intrapsychic field of land mines.

This boy’s interview also raises another pertinent issue, “Can an interviewer probe too much or too quickly?” Generally speaking, when questioning is done sensitively, it infrequently goes too far. But the trick lies in being attuned to the degree of interpersonal guilt generated by the patient’s responses. If the questions generate too much guilt, the initial interviewer may find that an impressively thorough database has been gathered but that there is no patient present with whom to discuss this database at the second appointment.

To avoid this problem, the interviewer can watch vigilantly for signs of embarrassment or shame in the patient, perhaps indicated by an averted gaze or a hesitant first step into speech. This awareness is combined with a common sense attitude towards which subject areas typically produce anxiety. When present, these signs may suggest the presence of potentially disengaging guilt, at which point the clinician may opt to reduce the tension by gently asking a question such as, “What has it been like for you to share such complicated material today?”

Asked calmly and sincerely, such questions demonstrate Rogers’ unconditional positive regard while allowing patients to ventilate fears of clinician rejection, discovering to their surprise that such rejection is not imminent. The clinician can further decrease tension by positively reinforcing the patient’s courage for sharing delicate material with phrases such as, “You’ve done an excellent job of sharing difficult material. It’s really helping me to understand what you’ve been experiencing.”

A combination of these techniques was useful in allaying the intense interpersonal anxieties generated in a man of about 30 years of age who had presented for an initial assessment. Ostensibly requesting self-assertiveness training, he eventually related a striking list of paraphilias, including voyeurism, exhibitionism, and frotteurism (rubbing one’s genitals against people in crowded public places). As he spoke, eye contact vanished, while his hands picked at one another. Near the end of the session, the dialogue evolved roughly as follows:

Related posts:

Validity Techniques for Exploring Sensitive Material and Uncovering the Truth Personality Disorders Nonverbal Behavior Beyond Empathy The Dynamic Structure of the Interview Personality Disorders

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