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,CHAPTER 1
The Delicate Dance: Engagement
and Empathy
When a doctor tells me that he adheres strictly to this or that method, I have my doubts
about his therapeutic effect. … I treat every patient as individually as possible, because the
solution of the problem is always an individual one …
Carl G. Jung
Memories, Dreams, Reflections
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 concern-
ing 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.
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,4 Clinical interviewing: the principles behind the art
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.
Pt.: It was.
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.
Clin.: Uh-huh; I’m sure.
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, The delicate dance: engagement and empathy 5
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.
Clin.: What kind of work?
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 communica-
tion 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, mat-
erial 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 effec-
tively into a less digressive mode of speech through the use of sensitively well-timed
focusing statements.
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