Understanding the Challenge of Exploring Sensitive Material
We have spent the last two chapters exploring the nuances and techniques that can help us to gather a comprehensive database in a sensitive fashion, the second way-station on our map. With these two chapters under our belts, you would think we’d be done with the topic of data gathering. We’re not. One critically important caveat to uncovering a useful database has not yet been touched upon – truth. To clarify the issue, let me return to the metaphor with which we opened our study of the clinical interview.
Earlier we had likened the initial interview to a person exploring an old Victorian room with only a candle in hand, the limited light source representing an exterior hindrance to the endeavor at hand. However, a weak light source does not represent the only barrier to the familiarization with the antique furniture scattered about, because the method of exploration can provide internal barriers to the effectiveness of gathering an accurate picture of the room. For instance, one explorer may walk about with his hands held only at shoulder level, hence missing all the curios lying upon a well-polished table. A second explorer may underuse her sense of hearing, thus ignoring the presence of a clock tucked away in a quiet niche beside Sarah Bernhardt’s portrait. A third explorer may be afraid of dark corners, thus never spotting the elaborately carved chess set hidden away in the shadows. Thus, it is not only a matter of determining what data needs to be gathered, it is also a question of determining how one wants to go about gathering it, for one alters the database by the style with which one elicits it.
For these reasons it is beneficial to explore the issues that determine the validity of the database, issues that are affected not only by the defenses of our patients, but by the defenses and idiosyncratic traits of each clinician’s style. On some occasions, it may not be the patient who is standing in the way of accurate information, but rather the clinician.
To understand these limitations and the interviewing techniques that allow us to supersede them, we must first look at what we mean by the term “validity.” Statisticians discuss a variety of forms of validity, including content validity, empirical validity, and construct validity. To discuss all three of these concepts is beyond the scope of our study. Instead, we will look at an admittedly simplified concept of validity, which nevertheless sheds considerable light by its clinical application. From our perspectives as everyday clinicians working in hectic everyday environments, validity can be formulated in a no-nonsense fashion as the answer to a simple question, “Are we hearing the truth?”
And this is not to suggest that our patients are lying, for I have found manipulative deceit to be relatively rare with my patients. No. There are a myriad of other factors that prevent us from uncovering the truth including a host of unconscious defense mechanisms (i.e., rationalization, intellectualization, denial, and repression), the vagaries of memory itself, unrecognized miscommunications between clinician and patient, the limitations of all humans to see and know the truth, and genuine fears related to stigmatization as well as realistic concerns of “what will happen to me or my family members, if I tell the truth?”
Indeed, one of the first rude awakenings for any of us that has ever performed a clinical interview is the revelation that we basically function in the dark. We do not know for certain what is going on in our patient’s mind. We never will. The delicate arabesques of the mind cannot be easily transferred from one individual brain to the next. Even direct conversation is, at best, a second-generation copy of internal experience, brimming with all of the problems associated with second-generation copies such as information drop-outs and distortions.
Yet our ability to sensitively uncover the troubling secrets of our patients – whether they be thoughts of suicide, histories of incest or domestic violence, substance abuse, an eating disorder, or any act that may create shame or guilt – is at the heart of our ability to relieve their pain. We cannot undertake effective crisis intervention, or begin optimal ongoing therapy, if we do not know what the real crisis, stressors, and diagnoses may be.
Besides the simple fact that we need to know the real problem and its extent in order to maximize our ability to help (with a suicidal patient we cannot get a gun out of a house if we do not know it is there in the first place), there is another reason that uncovering hidden pain is such an important set of skills for an interviewer to master: If we are able to help a patient to share a difficult topic, such as domestic violence, incest, or suicidal thought, which he or she may never have shared with another human being before, we are not only uncovering important information, we are providing a powerful new interpersonal experience.
We will have convincingly demonstrated, directly to the patient, that he or she was able to talk about a stigmatizing topic in detail, and the listener showed both compassion and understanding. Moreover, the listener did not over- or under-react. The reassuring discovery that there are people in this world that one can talk to about topics even as taboo as incest, domestic violence, and suicide may have already set the stage for the immediate first movement towards healing, for once the patient steps out of our office, he or she has a very difficult decision to make: should they return? It is now this patient’s first-hand knowledge that “it wasn’t so hard to talk with this person about my most frightening secrets” that may prompt them to see us again and to follow up with our immediate treatment recommendations. In these instances, it is the reassuring experience of an unexpected sense of safety, which we created, that has provided the first kindling of hope.
Sometimes the result of helping a patient to share a hidden secret in a safe environment may have an even more dramatic, yet unexpected, effect. It may save the patient’s life at a later date. The memory of such a positive interviewing experience with us, even when we may be functioning as a clinician at a telephone crisis center or in an emergency department, may prompt the caller or patient, months later during a particularly desperate night, to reach for a phone and not a gun.
Also of major importance are those situations in which our patients are a danger to others as well as themselves, or perhaps only to others. We have all interacted with an intoxicated patient, who may also be at risk for committing domestic violence (or has recently done so). And on some occasions during a first meeting, as we have already seen, we may become suspicious that our patient is experiencing psychotic process. At such moments, we will need to raise and explore the possibility of psychosis in a fashion that is not disengaging, yet allows us to uncover possibly dangerous psychotic process directed at others, such as command hallucinations or paranoid delusions. It is here that the skills examined in this chapter (and in our chapters on psychosis; see Part II) may help us to prevent tragedies, such as the unpublicized killing of a parent by a teenaged child suffering from a psychotic manic episode to the much publicized slayings at Virginia Tech or an unsuspecting movie theater in a quiet Colorado town.
As if the above reasons were not enough to emphasize the importance of learning how to sensitively raise and explore taboo material, these skills are also useful for revealing those occasions when the patient’s intentions may not be in his or her own best interest. For instance, a patient suffering from schizophrenia who wants to return to work too quickly, a decision that might result in a severe relapse and perhaps prevent a return to work for years, may not readily tell the interviewer about the persistence of serious auditory hallucinations. On the other hand, a different patient, not suffering from schizophrenia at all but actively seeking disability, may tell the clinician about a plethora of tormenting yet non-existent voices.
Thus, it is important for the interviewer to be alert for signs that the patient harbors a hidden agenda, such as needing a mental health professional to document that the patient is too ill to appear in court or to provide the patient with addictive drugs. For instance, in an emergency department setting, it is not uncommon for people with imminent court appearances to seem unusually interested in hospital admission, because hospitalization may represent a clever and logical excuse for missing the court date.
The validity techniques we are about to explore have been developed over the past several decades by a variety of interviewing innovators across a variety of disciplines including counseling, psychology, psychiatry, nursing, and social work. Some of these techniques are specifically geared to decrease the likelihood of deception, thus increasing the likelihood of valid information. They can even help a patient with antisocial propensities to share more of the truth about their problematic behaviors such as being a perpetrator of domestic violence or other problems with the law. When utilized effectively, these techniques can elicit sensitive material that one might think would never be revealed during an initial contact. And, indeed, it would not have been revealed had not the patient been provided a safe environment for sharing and the interviewer used skilled interviewing techniques within that environment.
As we begin our study of the validity techniques that address the above issues, we will see that they come in four clusters: (1) techniques for improving generalized recall, (2) strategies for avoiding miscommunication, (3) techniques designed to help us raise a sensitive or taboo topic without disengaging the patient, and (4) techniques for carefully exploring a sensitive area once it has been raised.
Validity Techniques: Keys to Eliciting Sensitive Material
Cluster One: Techniques for Improving Generalized Recall
The Dilemma
It is not only our words that bring on the mists that blur reality, as Oscar Wilde described in our opening epigram. Neurons do. As I have interviewed over the years, it has become increasingly clear to me how unreliable memories actually are, even those reported by patients as, “I remember it like it was yesterday.” Neurons are not computer circuits made of microchips; they are biological entities made of goo. This state of affairs contributes to the fact that memories, even when first deposited in long-term biological circuits, are not necessarily exact. Even more striking is the fact that stored memories may be altered by new memories in a completely unconscious fashion.
Let me share two personal, non-clinical, encounters with memory drop-out and distortion that powerfully demonstrate the dilemma. I have had a rare opportunity to study my own memory at work (or rather, not at work, as the case may be), for I have kept a journal intermittently for 35 years.
One day I was perusing a journal entry from a trip to London I undertook when I was a third-year medical student, fortunate to be doing my obstetrics rotation in Nottingham, England, as an exchange student. I had gone to London for about a week and had become good friends with a fellow medical student I met there for the first time. He and I, according to several detailed journal entries, had great adventures hopping around pubs in merry old England and walking about Piccadilly Circus. And here is the catch. Despite having clearly spent days with an individual who was important enough for me to devote pages of journal writing to our shared experiences, I had no memory of him. I could not picture his face, a single conversation, or a single moment of laughter. I don’t believe this rather striking example of substantial memory drop-out can be entirely attributed to the pints of bitter (English name for a type of pale beer) I imbibed in our nightly escapades. At least, let’s hope not. To the contrary, it illustrates that memory often has a fatigue to it; memory drop-out is a normal, not atypical, aspect of the human brain.
On another day I stumbled upon a journal entry about a big argument I had had with a relative who had inappropriately yelled and sworn at my 5-year-old son. Being the petty person that I try not to be, I recalled this incident for several years and always got angry, especially about his swearing at my son. I remembered it like it was yesterday. Only one problem: He hadn’t sworn. I was so mad on the day it had happened that I had written down exactly what he said, in quotations, because I wanted it to be available to show him someday if I needed some interpersonal ammo. Talk about petty! But that’s another story altogether. The point for us today is the striking memory distortion that began within hours. In this case, my neurological goo created a “fact” that had no basis in fact. Not only a false fact, but it was the “fact” that most upset me emotionally about the incident. Strange indeed! I have come to believe that such strange happenings are occurring when our patients are reporting “the facts” much more often than we might be aware.
Anchor Questions
Anchor questions are designed to address the above problems to generalized recall by “stirring” the memory banks of the patient. The goal is to activate important memories that we are trying to uncover by kindling memory circuits that are nearby. Anchor questions come in two main types: time-related and location-related.
Anchor Questions (Focused Upon Time)
Danny Carlat, in his outstanding primer on clinical interviewing, coined the term “anchor question.”2 Carlat pulls on the research of Sudman and Bradburn showing that people tend to remember significant distant events in relation to other memorable events that were happening in their lives, or in their culture, near the moment of the memory being recalled.3 A person might be better able to tell us when something happened, not with a question such as, “When did you first begin drinking?” but with a question such as, “Did you begin drinking before or after you started high school?”
Carlat suggests that a variety of events can be used to help people pinpoint the timing of recalled events more effectively including: personal events (graduations, accidents, buying a house, moving to a new city, starting a new job), major cultural events (the assassination of President Kennedy, landing on the moon, the O. J. Simpson trial, 9–11), or cultural markers (holidays like Christmas or New Year’s Eve, the turn of the century). Let’s see the technique at work with a trauma victim, where memories are often hidden in mists. We will picture a woman in her mid-20s who has been dating the same man since high school. They have had their troubles off and on for years. According to her, he has become physically abusive recently:
Pt.: Don’t get me wrong, things haven’t always been bad, or I wouldn’t be with him still.
Clin.: It sounds like you have had many good times in the past. I don’t doubt that. Obviously, the recent violence is very disturbing to all involved. If you can, try to give me a better idea of when he actually started to become violent?
Pt.: Oh, that’s pretty recent.
Clin.: By pretty recent, how do you mean?
Pt.: About a year ago. (pauses) Yeah, I think that’s about right.
Clin.: I remember you told me that you moved here to New Hampshire about 2 years ago. Had he ever hit or slapped you before you came to New Hampshire? (anchor question focused on time)
Pt.: Hmm. Well (pauses) … yes, yes he did. I remember he slapped me once pretty bad back in our apartment in Pittsburgh. We used to call it “The Nest.” We loved that little place, but yeah, he did slap me there, now that I think about it.
Clin.: How about before that, say back when you were in graduate school? (anchor question focused on time)
Pt.: We weren’t living together then.
Clin.: Oh, I know that. Can you remember though if, perhaps on a date or if he stayed over or something, did he ever hit you or slap you back then?
Pt.: My God. (looks up, with a puzzled and surprised expression) You know, he did. I sort of put it out of my mind. One day, after we came back from a party one of my friends in graduate school had given, he got really mad at me, saying I was flirting with another grad student. I wasn’t, by the way. But he got really mad.
Pt.: He slapped me. Right across my face. It really hurt.
Clin.: Tell me a little more about what happened that night.
Notice the clinician slowly walking the patient back in time with the use of serial time-related anchor questions, a strategy that sometimes yields surprising results both for the interviewer and the patient. In this instance, the gentle uncovering of memories has initiated the therapeutic process. Insight has begun, even during the first interview.
Anchor Questions (Focused on Location)
Here is a technique frequently used by cognitive–behavioral therapists that I have found very useful in the initial interview. It is a form of anchor question, but the goal is slightly different than with the time-focused anchor question of Carlat. It, too, jogs the patient’s memory, but not about a date. Instead, it is used if the patient is about to describe a specific event that occurred – a dissociated event, a panic attack, a suicide attempt, an act of domestic violence – that one fears may be distorted or repressed. The goal is to maximize the validity of the reporting by ensuring that the patient is picturing a specific memory and not just a blurred collection of similar memories. If the patient can re-visit a specific memory bank, the hope is that as they “re-live” the specific memory, more and more details of the memory will spring back.
To accomplish this task, the interviewer asks several questions in a row about the details of where the patient was when the experience occurred. Once locked into a specific memory bank in this manner, the subsequent details often begin to tumble out in a more valid fashion. Naturally, with dissociated memories or violent memories, one only uses these techniques if one feels it is important to uncover certain details and one feels the patient can safely, in a psychological sense, re-visit these memories at that moment.
Suppose a patient has come to you complaining of generalized anxiety, but as you hear more of the story, you become suspicious that they are having panic attacks. In the following dialogue, watch how the interviewer locks the patient into a specific potential panic attack.
Pt.: I guess I’ve always just been sort of wired, but it sure has gotten out of hand.
Clin.: When you say “out of hand” does the anxiety ever come on, really suddenly, out of nowhere, and it is really intense, sort of overwhelming?
Pt.: That doesn’t happen a lot, but it’s what has been happening more and more.
Clin.: I want you to picture the very worst episode like that. (pauses) Can you picture when that was?
Pt.: Oh yeah, absolutely, it was pretty bad.
Clin.: Where were you when it happened? (anchor question focused on location)
Pt.: I was out driving with my son.
Clin.: What road were you on? (anchor question focused on location)
Pt.: I had just picked my son up from school. I was just outside of Concord. (the interviewer has now tapped a specific memory bank, the patient is picturing a real event unfolding in real time)
Pt.: Well, it was really weird. I can’t really explain why it happened, but all of a sudden I got really worried that something bad, real bad, was going to happen. I started breathing really really fast, and I couldn’t stop. It was scary. I actually pulled the car over and …
Tagging Questions
Carlat also describes a nice technique for cuing a patient’s memory about a concrete topic from a list that the patient is having trouble recalling even though the topic is not a sensitive one.4 For instance, a patient may have trouble remembering a specific medication he or she has been on, a type of psychotherapy that has been used, or the name of a therapist.
If one asked a patient, “What medication were you on back in Pennsylvania?” and the patient answered, “You know, I don’t really remember what it was called, I know it was for depression.” Then one could use a tagging question. The clinician does this by simply offering a list of medications from which the patient then tags the correct answer, “Do you remember if it was called Prozac, Zoloft, Celexa, Effexor?” To which the patient might respond, “Oh yeah, that’s it. It was called Celexa. It worked really well for me, but was kind of expensive.”
Exaggeration
Before leaving the techniques related to improving generalized recall, there is a creative technique for helping to reduce shame if we begin to see it arise as we explore sensitive material. Sometimes, despite our best efforts to convey Rogerian unconditional positive regard, it is obvious that an overly conscientious patient is suddenly feeling an inordinate amount of shame about a “bad” behavior that he or she has just revealed. Although the behavior may seem fairly insignificant, the interviewer should never forget that the accompanying shame in the patient may be far from insignificant. If this is not addressed, such painful moments experienced in the initial interview may drive the patient away from the entire process of therapy. At such times, Othmer and Othmer sometimes employ a validity technique that they call “exaggeration.”5
Exaggeration is a technique for immediately decreasing a patient’s inordinate shame, so as to increase the likelihood that he or she will continue to share sensitive material, while simultaneously securing engagement. In this sense, the technique of exaggeration is not only a validity technique, it is an effective engagement technique.
Exaggeration works by helping the patient understand that when his or her “shameful activity” is put into perspective with other types of human “wrongdoings,” the patient’s activity is not of great magnitude, highlighting the fact that you, as an interviewer, are far from aghast at the patient’s revelation. Effective “exaggeration” requires a well-timed sense of humor by the clinician, employed in an already well-secured therapeutic alliance. When done well, as demonstrated below, it can release a marked amount of interpersonal tension that otherwise could have resulted in disengagement.
In this vignette, the patient is a conservatively dressed woman with her hair tied into a meticulous bun. She is a successful department store manager with a portable “time-clock” for a superego. She strives for perfection and expects it of herself. She has unfortunately developed a nagging generalized anxiety disorder, for which she has reluctantly sought treatment, despite the admonitions of her superego that “strong people do not go to therapists.” In her social history she shares what for her is a major sin of the past, stealing a candy bar from a drugstore when she was 10 years old. And even worse, she got away with it. Up to this point, the interviewer has established a nice rapport with her, but she senses the surprising intensity of the patient’s shame:
Clin.: In the past, have you ever had any problems with the law or arrests?
Pt.: I was never arrested (pauses, eyes briefly turn to the floor). But I did steal something once. I know it was a wrong thing to do.
Clin.: Oh, what did you steal?
Pt.: I stole a candy bar when I was about 10. I feel badly about it. I know it wasn’t right to do (patient appears clearly uncomfortable with herself and hastens to add) – I haven’t stolen anything since.
Clin.: So let me get this straight. At 10 years old you entered a store, pulled out a knife, stole $200 worth of clothing, pocketed $500 of jewelry, and, as you left, kicked the store owner’s half-blind cat (clinician smiles).
Pt.: (Absolutely aghast) Oh my gosh no! (she suddenly catches on to the humor and smiles for the first time in 20 minutes) Of course not (sheepishly smiling). I guess it wasn’t that bad after all.
Clin.: Not bad (said with a feigned sternness). Why, you stole a Milky Way bar, didn’t you! One of the big ones too, I bet. My gosh, I have a mind to call the cops right now, but the statute of limitations has probably expired.
Pt.: (laughing and smiling) Okay, okay, I get the point. I take things too seriously sometimes (continues to chuckle).
Clin.: (with a normal tone of voice) You know, Jane, let me go out on a limb here. I bet you tend to get down on yourself pretty hard.
Pt.: Well, I guess you could say that (smiling).
Clin.: Maybe that is something we can take a look at in the therapy. It may be one of the reasons that you are so anxious. Does that sound like a good idea to you?
Pt.: Yes. I think that would be a very good thing to do. Although I’m a little bit afraid to do it.
In most cases, “exaggeration” is utilized by employing much shorter phrases. When it is done well, as with this delightful bit of interviewing, it can effectively transform some difficult moments.
Cluster Two: Validity Techniques for Avoiding Miscommunication
Defining Technical Terms
Some terms we use, such as diagnostic terms or terms for complex symptoms, are clearly potentially confusing. Terms such as bipolar disorder, psychosis, and paranoia are inherently technical. Naturally we would always explain them. But, sometimes, a term is frequently used by both professionals and the lay public (depression, addiction) and not always in the same way. It’s easy to slip these words into a conversation and not realize that they are being misinterpreted. It is here that Carlat has yet another nice interviewing strategy – simply put, define the technical term even though it doesn’t sound that technical. Carlat provides such a nice example of this technique that I’ll just let him share it himself6:
Clin.: How old were you when you first remember feeling depressed?
Pt.: Hard to say. It feels like I have always been depressed.
Clin.: Just to clarify, I’m not talking about the kind of sadness that we all experience from time to time. I’m trying to understand when you first felt what we call a clinical depression, and by that I mean that you were so down that it seriously affected your functioning, so that, for example, it might have interfered with your sleep, your appetite, your ability to concentrate, your ability to work. When do you remember first experiencing something that severe?
Pt.: Oh, that just started a month ago. I’ve never been depressed like this before. Ever.
It’s possible that this patient is suffering from a long-term dysthymic disorder in addition to her more recent major depression. The clinician’s interviewing skills have prevented the mistake of viewing her as suffering from many years of a major depression, which could have led to some missteps in treatment recommendations.
Clarifying Norms
I have found over the years that it is not just technical terms that can lead to miscommunication between interviewer and patient. A common problem arises when exploring sensitive or taboo topics in which the culture, in general, or the patient’s family, in particular, has taken a traditionally enabling stance. I have seen many clinicians ask patients questions such as, “Have you ever been sexually abused by someone” and receive a convincing “no” when, in reality, there has been substantial abuse. This problem is not about stigma. In fact, it is the opposite problem.
This phenomenon arises because the patient grew up in a family where psychological, physical, and/or sexually abusive behavior was the norm, and the patient has no idea (although they often have vague misgivings about the behaviors) that what was done was inappropriate. Thus, the patient above was not minimizing; he or she literally does not know that he or she was abused. I think you will not infrequently encounter this type of miscommunication when enquiring about sexual abuse, physical abuse, verbal abuse, and drinking behaviors (many families accept alcoholic behavior as normal). Be on the lookout for it.
When raising these topics in an initial interview, I often find it useful to use a strategy I call “clarifying norms” early on. I will use sexual abuse as an example:
Clin.: You mentioned that your dad was a heavy drinker and hit you a lot. Sometimes when drinking and violence are around, there can also be sexual abuse. Did your dad ever sexually abuse you that you can remember?
Pt.: Oh no, nothing like that, not that I remember (said with conviction). I mean if he tried something like that, I wouldn’t have let him.
Clin.: Of course, problems like that can occur in different ways. At any point, as you were growing up, did your dad try to do things like touching you in your private areas, fondling you or doing things like asking you to watch him undress or did he watch you undress or shower? (clarifying norms) Although these can be hard to talk about, try to remember if he did any of those types of things with you?
Pt.: Well, sort of. I mean, he used to watch me shower all the time (pauses) – he still asks me to do it when I go home sometimes (the patient is 17 years old), but I don’t let him anymore.
Clin.: When he used to do that, what exactly did he do?
Pt.: He sort of snuck in the bathroom while I was showering and just asked me to pull back the curtains.
Clin.: When he did that, did he keep his clothes on, or did he take them off?
Pt.: No, he usually pulled his pants down.
Clin.: When he did stuff like that, did he touch himself, you know, masturbate.
Pt.: (patient looks sheepish) Yeah, now that’s the part of it I didn’t like. Maybe he shouldn’t have done that.
Clin.: Did your mom know about this?
Pt.: Nope. (pauses) He told me he would hurt me bad if I ever told my mom. (pauses) You know, I think my dad might have had sex with my little sister.
Here is some really nice interviewing in which important material is being uncovered. The little sister is 12, and she is still at home. The validity technique of clarifying norms has pulled vital information to the forefront with minimal disengagement. If the clinician had accepted the first “no” of the patient and not clarified the norms, possibly none of this information would have emerged.
Cluster Three: Validity Techniques for Raising a Sensitive or Taboo Topic
Normalization
In this technique, first delineated in the clinical literature in the 2nd edition of this book, the interviewer phrases the question so that the patient realizes that he or she is not the only person who has ever experienced the behaviors or problems under scrutiny.7 We saw normalization demonstrated with some of the natural gates that we viewed in Video Module 4.1 in our previous chapter. This technique can be very useful in raising essentially any sensitive or taboo area. It is particularly useful with a patient who seems to be guilt ridden or filled with social anxiety that they are odd or doing something bad.
It is a simple technique in which we begin the question by stating or implying that we have heard this behavior from others, metacommunicating that the patient is far from alone in having experienced these feelings or behaviors. Normalizations often begin with words such as, “Sometimes people who have …”
Let’s look at a couple of examples to see how it works:
a. “Some of my patients who are really worried about their weight, have told me that they will do things to make sure that they don’t gain weight like force themselves to vomit after a meal. Have you ever found yourself doing something like that?”
b. “Sometimes when people get really angry they say things they later regret. Has that ever happened to you?”
c. “It’s not unusual when there has been a lot of drinking in a family, like you told me your dad was doing when you were growing up, for there to be some violence. Did your dad ever hit you or your mom or brothers and sisters?”
Normalization is also one of my favorite ways to raise the topic of suicide as with:
“Sometimes when people are as depressed as you have been, they find themselves having thoughts of killing themselves. Have you been having any thoughts like that?”
Numerous variations of normalization can be used to raise the topic of suicide, depending upon the painful circumstances of the patient:
“Sometimes when people have lost their spouse, and I know how much Anne meant to you, they find themselves having thoughts of killing themselves. Have you had any thoughts like that?”
“Sometimes when people are in as much pain as you are describing, they find themselves having thoughts of killing themselves. Have you had any thoughts like that?”
Said with a gentle tone of voice, normalizations often allow a patient to share suicidal thought more openly.
Let us take a look at a similar, but slightly different, validity technique, also very useful for raising the topic of suicide, as well as many other sensitive areas.
Shame Attenuation
There are two types of shame attenuation, also first described in an earlier edition of this book.8 In the first type, the interviewer cues off of the pain or the situational stress of the patient to enter a sensitive topic, such as suicide. In the second type, the interviewer cues off of the patient’s own defense mechanisms (typically rationalizations) to uncover material that the culture views as “bad,” such as criminal behavior or substance abuse. Let’s take a look at the first type of shame attenuation and how it can offer us yet another graceful bridge into suicidal ideation and other sensitive topics.
Shame Attenuation Used to Bridge From Pain or Situational Stress
With the first type of shame attenuation, the patient’s own pain or situational stress is used as the gateway to sensitive topics such as suicide or psychotic process (note that there is no mention of any other people in the following question, as we would have seen with a normalization). In practice, the first type of shame attenuation, when bridging off of pain, looks like this:
If bridging off of the patient’s stress, this first type of shame attenuation looks something like this:
Very simple, and perhaps a tad less wordy than most normalizations. And, when said with a gentle tone of voice, very effective. One of the things I really like about this first type of shame attenuation when used to raise the topic of suicide (or any other sensitive topic) is how easy it is to use, and it can be used with just about any patient, no matter what the patient’s circumstances, for psychological pain and personalized stress are ubiquitous. It is one of my favorite ways to raise the topic of suicide.
By using shame attenuation as a bridge from pain, an interviewer can sensitively raise many other difficult topics. For instance, raising the topic of psychosis is often viewed as difficult to do in an engaging fashion, and rightly so. It is safe to assume that not many patients like the idea that their interviewer suspects they are psychotic. But, with the use of shame attenuation, even this daunting challenge to engagement is surprisingly easy. I have found the following question effective at this task: “With all of the pain you have been having, are your thoughts ever so intense that they sound almost like a voice to you?”
It’s a wonderfully phrased question for it arises naturally from the patient’s immediately preceding self-report of pain and also leaves a “face-saving out” for the patient with the words, “almost like a voice.” Thus, he or she does not have to admit to hearing voices immediately and can say something like, “Well, sort of, but I don’t think they are voices.” With further questioning, we can sort out whether or not we feel voices may be present. If present, we can follow up by hunting for command hallucinations (voices that are telling the patient to do something) such as commands to kill themselves or harm another.
As we saw demonstrated in our chapter on facilics, both normalizations and shame attenuations are often utilized with natural gates. Their use with natural gates is particularly popular for transitioning from a non-sensitive topic into a sensitive or taboo topic.
Shame Attenuation Used to Uncover Aggressive, Unethical, and Antisocial Behaviors
Let us, for a moment, take a look at our second type of shame attenuation. It can be highly effective at entering a topic such as substance abuse or violence by cuing off the patient’s own rationalizations and defense mechanisms for doing the behavior. Unlike our first type of shame attenuation (in which we cued off of the patient’s legitimate pain or reality-based stress), in the second type of shame attenuation we will cue off of a patient’s distorted view of reality caused by common everyday defense mechanisms. Not infrequently, what a patient states as the problem (e.g., “my boss is an asshole”) is not necessarily the real problem (or the only problem). The patient’s behaviors may be the main problem, as with alcoholism.
The challenge with trying to uncover behaviors viewed as bad by the culture (such as antisocial behaviors) is the fact that if the patient answers positively to our question, he or she may feel they are admitting that “I’m a bad person” or will get into trouble. The natural result is a feeling of shame and/or guilt, which can clearly act as a deterrent to open expression on the part of the patient and can also damage engagement. The word “attenuate,” which simply means “lessen,” was used for this validity technique because this technique is very effective at lessening the patient’s shame or guilt by phrasing the question using the lens of the patient’s own rationalizations. The basic premise of this form of shame attenuation is that if we can figure out the patient’s rationalizations for why he or she is doing something and then ask the question from the perspective of the patient’s own rationalizations, perhaps the patient may be more likely to answer openly.
To effectively use this second type of shame attenuation, the interviewer must be able to do two things: (1) intuit how the patient has rationalized their own behaviors so that they seem okay to do and (2) ask the question while viewing the situation through the eyes of the patient and using the patient’s rationalizations. A shame attenuation can either be a statement made before a question (that places the context of the question from the patient’s perspective) or can be part of the question itself. This technique is a little harder to understand until we see it used.
For example, picture a patient who relates feeling depressed and angry at the world. As you move deeper into the interview, you begin to intuit that the patient is a big-time drinker with essentially no insight into his or her drinking problem.
If a clinician chose to ask, “Do you think you have a drinking problem?” many such patients would answer with a rather shocked “no.” In addition, the question itself might disengage the patient. But in the following example we will see a different approach – the application of shame attenuation – that results not only in more valid information but causes no disengagement at all:
Pt.: I guess some of my best times are with my friends. I really would rather be with my male friends than with my wife and some of her losers. Talk about boring, they invented the word.
Clin.: Are these the same guys who are your drinking buddies?
Clin.: Well where do you guys like to go for a brew?
Pt.: All over the place. We’ll tie one on anyplace anytime.
Clin.: You know, when you are out with your buddies like that, do you have a problem holding your liquor or are you pretty good at holding your liquor? (shame attenuation)
Pt.: Oh, I don’t have any problems holding my liquor. I’m not the best mind you, but I can hold my own.
Clin.: How much can you put-down in a single night?
Pt.: Oh a six-pack, twelve-pack, no problem (said with a cheerful sense of pride).
Clin.: How often in a given week do you drink a six-pack or twelve-pack, in all seriousness.
Pt.: In all seriousness … I’d say two or three nights a week. Well, make that two nights. It’s usually only on weekend nights that I really go after it. By the way, I held down a case one night (pauses) well I sort of held it down (smiles sheepishly).
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