Psychotherapy - How are you taught to "ask questions"?

[aahc]

I am entering a BA in Psychology program, and obviously still have a bit of a ways to go. Once I complete the program, I plan on entering a PsyD program or just follow through working up to an MA, and eventually a PhD in Clinical Psychology (although the PsyD is more attractive to me, if the PhD is more cost efficient that is the way I shall go).

Anyhow, none of the courses I am taking focus on actually conducting psychotherapy. Now I understand that there are courses available at the masters level, but I am just curious now: exactly how are you taught to conduct structured client interviews? After you have the understanding of psychology down, how exactly do you know what to ask the patient to get them where you want them to be?

I've asked a few people before that have some experience in psychotherapy and all I've gotten thus far is "we watched some videos and took some classes", but I'm looking for something a bit more detailed. HOW exactly were these classes taught?

Thanks in advanced for any replies.

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[psychmama]

Hi. First off, to answer your question, learning the skills of clinical interviewing is probably not something you'll get at the undergraduate level. This comes usually with master's or doctoral level training. At the undergrad level the focus is on learning theory and how to do research.

As for grad school, there are a variety of methods used to teach clinical interviewing and therapy. These include books about it, videos, live-demonstrations and lots of role-playing. Then you move onto actually doing it yourself under close supervision by a licensed psychologist. It's a long process. Fascinating and rewarding, but long... Good luck!

 

[JockNerd]

exactly how are you taught to conduct structured client interviews?

Here's how training went for me:
In first year, we had basic courses on theoretical orientations and ethics/logistics at our captive prac site. In the second year we began seeing clients. We each had a supervisor whose job it was to look at where we were and where we wanted to be, and provide us training in that direction as well as in other areas that the supervisor thought we needed and were developmentally prepared for.

So, what this looked like for me, was, I sat down with my supervisor and reviewed my clients in terms of my primary theoretical orientations (REBT, feminist, and interpersonal process/use of self) as well as any secondary orientations that might be useful in each situation with each client. With the help of my supervisor, I conceptualized the clients according to those theoretical models and developed interventions that made sense according to them. This is what I would base interventions on in sessions. For example, I might come up with a fairly clear conceptual model of a client going through depression in an REBT framework. My interventions would then be based on the application of that framework to that client, which would usually consist of something like me teaching active disputing. Or, when it comes to more touchy-feely stuff, I might conceptualize a client's dependency on a partner as a regular communication strategy for him or her, and look for examples of it in our therapeautic relationship, then raise this issue with the client, consist with interpersonal process and use of self.

Does that make sense? I guess the simple answer was that I was taught in an apprenticeship-type situation, and how I was conceptualizing clients informed what I tried to do with them.

 

[KillerDiller]

My training was very similar to JockNerd's except we didn't have a captive practicum site in the first year. Also, in my supervisory experience at my first practicum, the theoretical framework driving the interventions came less from my own views and more from the site where I was working. This made sense because the population I was working with really demanded a behavioral approach and I'm more of a humanist. My supervisor really helped me work through these ideas, though.

Ultimately, you can only learn so much in the classroom. Most of the learning comes from simply doing it and then getting feedback.

 

[Therapist4Chnge]

My training was:

1st year: learn the theory, role play, and observe.
2nd year: apply the theory under close supervision (video/tape recorder).
3rd year: apply the theory under more close supervision (tape recorder).
4th year: focus mostly on group work, but still have regular supervision and review (periodically have my supervisor observe my groups).
5th year: more group work, with regular supervision and review (same observation as above).
6th year: (internship) Close review of skills, close supervision....and hopefully become more autonomous as I move through my training. TBD.

There are literally hundreds/thousands of hours of supervision needed during training. Even in the post doc year(s) there is still supervision.

As for the "questions" to ask....there are a number of classes that cover the skills, but they are mostly developed through practice. I am sure my first role play of an intake was horrid compared to mine now.

 

[erg923]

Some doctoral programs have one class in clinical interviewing and one class overviewing the formal schools/approaches of psychotherapy and thats it. Some programs offer 3 of more classes solely dedicated to one area, such as CBT, or dynamic, or family therapies, etc. It just varies. I learned very little about how to actually conduct a therapy session from classes frankly. I learned alot of the theory through classes though, and I did indeed learn some techniques from reading articles. But really, most of it comes from experience and feedback during supervision with clinical supervisors. I learned how to coduct highly structured diagnostic interviews such as the SCID, CAPS, BPRS, PCL, MADRS, etc. by simply doing them at my labs research traning site, which is over in the med school. However, if you are not in a research oriented enviornment/program, then you may not learn these instuments during grad school. I would take the SCID home and learned it (so you dont fumble around about where to go next when you're in front of a patient) and then would go in and simply do it. Its nerve racking the first time, but you have to do it. My supervisor sat in and observed me do them until she was satisfied I could conduct it thoroughly and had good enough clinical judegment to follow-up with appopriate questions and queries when appopriate. However, my clinical training went as follows:

2nd semester of First year-
We did intakes at out university clinic. All intakes are videotaped for supervision by your supervisor. The therapy was done by 2nd years and above. This was very basic interviewing and gave good experience on working with clinical populations, and good exposure to what different disorders look like. Got good experience with what questions to ask and how to ask them, without too much focus on formal diagnosis (although you were expected to have a solid list of differentials for the therapist to follow-up on and explore). You are also in a supervision group with older students so you can see them doing therapy (by watching their tapes) and hear them talk about their therapy cases during group supervision meetings.

2nd year-
All psychotherapy at the in-house clinic. We serve community folks as well as college students, so we have some serious stuff there.All your therapy sessions are videotaped so you and supervisor can watch portions of it when you meet each week. You get lots of feedback, sometimes brutal feedback when you're starting out. We are expected to keep a small load of therapy patients (2 or so) at the in house clinic for the rest of your time in the program, although I don't have any right now because all my previous pts have terminated and I have not ben assigned anyone else yet.

3rd and 4th years you apply for outside practicum at places of your choice, as long as they have been approved by the school as a training site. One of these (3rd or 4th year) has to be at least 50 percent assessment. I am a neuropsych track person, so i did mine at a memory clinic and polytrauma clinic at a large VA. All assessment and report writing. Memory clinic was all neuro assessment and polytrauma was primarily MMPI's and quick neuropsych screening batteries. If they needed more for differential, they were referred to a larger neuropsych service in the hospital. Anyway..that should give you the idea of how things go.

 

[zenman]

In addition to all the above, make a list of these books for when you need them:

Field Guide to the Difficult Patient Interview by Frederic Platt
The Psychiatric Interview by Daniel Carlat
The First Interview by James Morrison.

 

[JockNerd]

I'd recommend Ivey & Ivey's Intentional Interviewing and Counseling (I think that's the title). They operationalize things well, and I found it useful to use the book when I watched my tapes, and code my behaviors.

 

[erg923]

what exactly does "coding" your behaviors mean?

 

[JockNerd]

what exactly does "coding" your behaviors mean?

I watched the tapes and coded along with a spreadsheet. So, the first line, corresponding to the first microskill, I think was nonverbals. I would skip through the tape watching my body language for lapses, and between tapes to check if I was doing something undesirable with a particular client. The next lines, I think, were types of verbal interventions arranged by Ivey's levels of interventions (something like questions, then restatements, then paraphrases, then reflections of meaning, then reflections of feeling). I counted my verbals to see what I was doing the most of (e.g. am I bombarding all or particular clients with questions?). This let me refocus verbal interventions later in session (i.e. stop before I speak, and rephrase a question I want to ask as a statement, or stop before I make a reflection of meaning and see if there's a better reflection of feeling). Then there was a section for model-driven interventions (e.g. how did I do with introducing active disputing to that client or his/her situation).

 

[erg923]

Cool. Never had anything like that. My therapy prac was largely humanstic, but with with some CBTish interventions (usually howework assignments though), so we never did any supervsion/training that was that structured. Although we did look at body language and stuff. I really did very little talking for the 1st month or so after my intake with a each client.

 

[JockNerd]

Cool. Never had anything like that. My therapy prac was largely humanstic, but with with some CBTish interventions (usually howework assignments though), so we never did any supervsion/training that was that structured. Although we did look at body language and stuff. I really did very little talking for the 1st month or so after my intake with a each client.

I found it amazingly beneficial. If you charted my improvement in prac, the times at which I was able to do a lot of what I described were the periods of the most significant growth. The amount of structure wasn't representative of everyone in my cohort; plenty of people got very ephemeral supervision too. I was lucky enough to be paired with a supervisor who worked off a competency-based supervision model, and I take criticism well so that accelerate the learning process.

 

[Therapist4Chnge]

I do NOT miss it. It can be very useful, particularly early on in training because it really helps you better "see" non-verbal cues, though it can be really boring.

 

[ClinicalTrainee]

I think the process of learning to do clinical interviews and learning to do therapy are a bit different, though clearly related.

My university has an applied track for undergraduates headed toward the helping professions, and as such, we have an interviewing class for upper level undergraduates. I taught the class last year, and as part of the course the students had to interview subject pool students and write up what they learned and their process in a final paper. (Clearly, these were not real clinical interviews, as the population was primarily not a clinical population).

The question was about how we are taught to do clinical interviews, and as is clear from other responses, it varies across training programs. But some of the main skills are learning attending behaviors (non-verbals), different types of questions (open-ended, leading, etc) and how these types may elicit different responses, and how to reflect/paraphrase, both content and feeling.

A good intake clinician also needs to have a solid understanding of diagnosis and what content areas are important for a comprehensive understanding of the client and his/her issues. The above skills are to help facilitate information gathering and to help build the theraputic alliance.

The original poster said "After you have the understanding of psychology down, how exactly do you know what to ask the patient to get them where you want them to be?" The answer is.....I don't believe that anyone alive has psychology "down" because there is so much that we don't yet know, and everyone is different. Second, I also don't think you can ever *know* exactly what to ask the patient to get them where you want them to be. There have been moments when I've asked a question I thought was brilliant and received a vapid response, and other times I've said things without hardly thinking and seen a thoughtful change-producing response. There are studies that show discrepancies between what clients think is important compared to what therapists think. I find this work fascinating!

Basically, I feel that interviewing/therapy skills are taught by didactic instruction, by modeling (older students, supervisors, videos), through direct feedback (supervision) and through experience. The last two have been especially valuable for me, though I think many supervisors could use some lessons in how to give useful, constructive feedback. I still think I've learned the most from trusting myself and my training, and using my own internal barometer to realize when something I said didn't go over as planned. Self-awareness is, in my opinion, probably the most critical skill needed to be a good clinician.