Psychiatric Interviewing: The Art of Understanding

Praise for Psychiatric Interviewing, 3rd Edition Advance Praise for the Third Edition Praise for Previous Editions of Psychiatric Interviewing: the Art of Understanding Praise From the Reviewers Praise From the Experts and Faculty for Previous Editions Psychiatric Interviewing Copyright Page Dedication Foreword Foreword to the 2nd Edition Preface A Few Stylistic Notes From the Author Acknowledgments Video Table of Contents 1 The Delicate Dance In Search of a Definition A Bit of Interviewing Examined and the Discovery of a Map Person-Centered Interviewing The Next Step Creating the Therapeutic Alliance First Things First: The Difference Between Engagement and Blending Using Blending to Gauge the Degree of Engagement Conveying Empathy: Traps, Strategies, and Solutions The Empathy Cycle First Phase of the Empathy Cycle: Patient Expresses a Feeling Second Phase of the Empathy Cycle: Clinician Recognizes the Patient’s Feelings Third Phase of the Empathy Cycle: Clinician Conveys Recognition of the Patient’s Feelings Strategic Empathy Interpersonal Stance Empathic Valence Valence of Implied Certainty Valence of Intuited Attribution Basic Guideposts for Effectively Using Strategic Empathy Three Examples of Using Strategic Empathy to Transform Difficult Moments 1: The Paranoid Spiral 2: Transforming Anger with Defusing Statements 3: Shoring Up a Young Empathic Bond with Paraphrasing Statements Generic Paraphrases. The Metaphorical Paraphrase. Frequency, Timing, and Length of Effective Empathic Statements Fourth Phase of the Empathy Cycle: Patient Accurately Perceives the Clinician’s Empathic Statement Fifth Phase of the Empathy Cycle: Patient Communicates an Appropriate Acceptance of the Clinician’s Empathic Statement References 2 Beyond Empathy The Person Before the Letters Inducement of a Safe Relationship Clinician Genuineness Clinician Expertise Collaborative Interviewing Models: New Tools for Enhancing Engagement Solution-Focused Goal Setting The Miracle Question Concluding Statements References 3 The Dynamic Structure of the Interview Introduction: Phase 1 Creating a Safe Environment Addressing Confidentiality Opening: Phase 2 Patient’s Perspective and Conscious Agenda Assessment of the Patient’s Immediate Mental State Clinician’s Perspective of the Patient’s Problems and the Patient’s Unconscious Goals Evaluation of the Interview Itself Degree of Openness Continuum (DOC): Open-Ended Questions, Gentle Commands, Swing Questions, and the Power of Language In Search of an Answer: What Is an Open-Ended Question? Open-Ended Verbalizations Closed-Ended Verbalizations Variable Verbalizations Transforming Shut-Down Interviews Characteristics of Shut-Down Interviews Unlocking Shut-Down Interviews Transforming Wandering Interviews Characteristics of Wandering Interviews Transforming Rehearsed Interviews Characteristics of Rehearsed Interviews Breaking Through a Rehearsed Interview Body of the Interview: Phase 3 The Gathering of the Database Conveying Expertise, the Generation of Hope, and the Return Visit Closing of the Interview: Phase 4 Termination of the Interview: Phase 5 Conclusion References 4 Facilics Sensitively Creating Conversational Interviews Secrets from Everyday Conversation A Solution to the Dilemma Introduction to the Practical Application of Facilics Part I: Learning How to Tag the Flow of the Interview – What Topics, When? Descriptions and Characteristics of Facilic Regions Content Regions Process Regions 1. Free Facilitation Regions 2. Transformational Regions 3. Psychodynamic Regions The Scouting Region: A Unique Combination of Content and Process Part II: Practical Tips for Applying Facilic Principles to the Exploration of Regions Using Time Effectively The Core Conundrum: Well-Timed Tracking Versus Poorly Timed Tracking A Basic Paradigm for Successfully Structuring an Initial Interview Recognizing and Transforming Two Structuring Gremlins 1. Overly Lengthy Scouting Region: The “Five-Minute Fix” 2. The Dead Zone: Two Errors in One The Eight Golden Rules for Structuring Effectively Exploring Content Regions in a Sensitive Fashion Part III: Facilic Gating – The Fine Art of Making Graceful Transitions Gates: The Pathways of Conversational Flow Spontaneous Gates Natural Gates Manufactured “Gates” Referred Gates Phantom Gates Implied Gates Miscellaneous Gates Introduced Gate Observed Gate The Finishing Touches: Summarizing the Principles of Facilics Concluding Comments References 5 Validity Techniques for Exploring Sensitive Material and Uncovering the Truth Understanding the Challenge of Exploring Sensitive Material Validity Techniques: Keys to Eliciting Sensitive Material Cluster One: Techniques for Improving Generalized Recall The Dilemma Anchor Questions Anchor Questions (Focused Upon Time) Anchor Questions (Focused on Location) Tagging Questions Exaggeration Cluster Two: Validity Techniques for Avoiding Miscommunication Defining Technical Terms Clarifying Norms Cluster Three: Validity Techniques for Raising a Sensitive or Taboo Topic Normalization Shame Attenuation Shame Attenuation Used to Bridge From Pain or Situational Stress Shame Attenuation Used to Uncover Aggressive, Unethical, and Antisocial Behaviors Induction to Bragging Cluster Four: Validity Techniques for Exploring a Sensitive Topic Once It Has Been Raised Behavioral Incident Interviewer 1 Interviewer 2 Helping a Patient to Describe an Episode of Intimate Partner Violence (IPV) Limitations of Behavioral Incidents Gentle Assumption Denial of the Specific Catch-All Question Symptom Amplification Validity Technique Combinations Miscellaneous Tips for Specific Situations Where Validity Is a Concern Malingering Gauging Motivation Taking a Sexual History Interview Illustrating the Use of Various Validity Techniques References 6 Understanding the Person Beneath the Diagnosis Introductory Illustration: The Person Beneath the Diagnosis Part I: Phenomena That Hinder the Understanding of the Person Parataxic Distortion Further Problems With Inaccuracy: The Issue of Reliability Part II: Phenomena That Deepen the Understanding of the Person Beneath the Diagnosis Sullivan’s Interpersonal Perspective Revisited Phenomenological Inquiry The Search for Wellness: Patient Strengths, Skills, and Interests Exploring Component #1 of the Wellness Triad: Patient Strengths Strengths of Knowledge: Strengths of Courage: Strengths of Humanity: Strengths of Justice: Strengths of Temperance: Strengths of Transcendence: Exploring Component #2 of the Wellness Triad: Patient Skills Creative Skills: Task Related: Interpersonal Skills: Athletic Skills: Manual Dexterity: Specific Career Training: Exploring Component #3 of the Wellness Triad: Patient Interests, Hobbies, and Pastimes Part III: Understanding Cultural Diversity – Its Vital Role in the Initial Interview Misperceptions Related to Cultural Biases: Impact on the Initial Therapeutic Alliance Culture Impacting Directly on Treatment Planning in the Initial Interview References 7 Assessment Perspectives and the Human Matrix Clinical Presentation: the Initial Interview The Diagnostic Perspective of the DSM and ICD Systems The Healing Power of Differential Diagnosis Limitations of Formal Diagnostic Systems Such as the DSM and ICD The Loss of Multiaxial Formulation: a Historical Footnote Major Psychiatric Disorders (Other Than Personality Disorders) Personality Disorders Non-Psychiatric Medical Conditions Psychosocial Context and Stressors Level of Current Functioning and Impairment Clinical Application of the DSM-5 Matrix Treatment Planning Introduction Basic Paradigm and History of the Biopsychosocial Treatment Planning Model A Revitalizing Change in Language Matrix Treatment Planning: General Clinical Principles and Specific Applications to Debbie in the Initial Interview First Wing of the Matrix: Biologic Biological Intra-Wing Interventions Biological Inter-Wing Interventions Question #1: Healing Matrix Effects Arising From the Biologic Wing Question #2: Healing Matrix Effects to the Biologic Wing From Other Wings Second Wing of the Matrix: Psychological Psychological Intra-Wing Interventions Psychological Inter-Wing Interventions Question #1: Healing Matrix Effects on Other Wings Arising From the Psychological Wing Question #2: Healing Matrix Effects to the Psychological Wing From Other Wings Third Wing of the Matrix: Dyadic Dyadic Intra-Wing Interventions Dyadic Inter-Wing Matrix Effects Fourth Wing of the Matrix: Family Familial Intra-Wing Interventions Familial Inter-Wing Matrix Interventions Fifth Wing of the Matrix: Cultural, Societal, and Environmental Cultural, Societal, and Environmental Intra-Wing Interventions Cultural, Societal, and Environmental Inter-Wing Matrix Interventions Sixth Wing of the Matrix: Worldview (Framework for Meaning) Worldview Intra-Wing Interventions Worldview Inter-Wing Matrix Interventions Conclusion: Matrix Treatment Planning Redux Assessment of Core Pains Review of the Clinical Course of Ms. Baker Conclusion References 8 Nonverbal Behavior Introduction Basic Terminology of Nonverbal Behavior Nonverbal Communications (Emblems) Nonverbal Activities A Cautionary Note on Interpreting Nonverbal Behaviors and Nonverbal Research Organization of the Chapter Part 1: Core Fields of Study in Nonverbal Behavior Proxemics Kinesics Paralanguage Immediacy and Context: the Delicate Interface of Proxemics, Kinesics, and Paralanguage Immediacy Nonverbal Context Part 2: Clinical Application of Nonverbal Behavior Section A: Assessment of the Patient Nonverbal Hints of Hidden Psychopathology Uncovering Hidden Psychotic Process Nonverbal Hints of Classic Psychiatric Diagnoses Nonverbal Hints of Specific Personality Diagnoses Nonverbal Indicators of Anxiety Nonverbal Hints of Deception Nonverbal Correlates of Patient Ambivalence and Discordance Nonverbal Signals During Collaborative Treatment Planning Nonverbal Behaviors Functioning as Social Scripts Section B: Utilization of Nonverbal Behaviors to Engage Patients Seating Arrangement and Proxemics Intentional Use of Head Nodding and Other Facilitative Techniques Nonverbal Techniques for Engaging Guarded or Paranoid Patients Clinician’s Self-Awareness of Paralanguage The Impact of Clinician Gestures and Facial Expressions on the Patient A Few Notes on Note Taking Nonverbal Aspects of Calming Potentially Violent Patients Recognizing Contextual Clues of Impending Violence Nonverbal Clues of Impending Violence Nonverbal Techniques for Calming a Potentially Violent Patient Part 3: Bold New Frontiers – the Nonverbal Impact of Technology, the Web, and Mobile Connectedness on Interviewing Interactive Audio-Visual Technology (IATV) and the “Phantom Presence Effect” Interviewing on the Telephone Problems Assessing Patients on the Phone Problems Engaging Patients on the Phone The Ultimate Nonverbal Challenge: Interviews Done by Chatting, Instant Messaging, and Texting Conclusion References 9 Mood Disorders Introduction Diagnostic Systems: There Has Never Been a Perfect One and There Never Will Be The Nature of the Dilemma for Front-Line Clinicians Validity Versus Reliability Construct Validity, Face Validity, and Descriptive Essence Categorical Diagnostic Systems Versus Dimensional Diagnostic Systems Categorical Diagnostic Systems Dimensional Diagnostic Systems A Pivotal Step Forward in the DSM-5 First Steps in the Differential Diagnosis of Mood Disorders Clinical Presentations and Discussions Clinical Presentation #1: Mr. Evans Discussion of Mr. Evans The Painful World of Anhedonia: Its Role in Diagnosis Uncovering the Neurovegetative Symptoms of Depression What Are the Neurovegetative Symptoms of Depression? Tips for Exploring Early Morning Awakening and Other Sleep Disturbances Sensitively Asking Patients About Libido Gracefully Weaving the Neurovegetative Symptoms Into the Interview The Concept of Melancholia Anxiety: Another Important Dimensional Specifier The Role of Substance Abuse in the Differential Diagnoses of Depression Important Data Points When Taking a Past Psychiatric History Spotting Bipolar I Disorder: Traps and Nuances Bipolar I Disorder Classic Euphoric Mania Psychotic Process in Mania The Importance of Family Members and Collaborative Sources When Delineating Mania Cognitive Deficits in Mania Differential Diagnosis on Mr. Evans and Summary of Key Interviewing Tips Clinical Presentation #2: Danny Ramirez Discussion of Danny Ramirez Bipolar I Disorder, Mixed Presentation History Repeats Itself: An Evolving Diagnosis A Practical Solution From the DSM-5 “Dysphoric Mania”: One Type of Mixed Bipolar Disorder Differentiating a Dysphoric Mania From an Agitated Depression Three Practical Tips for Spotting a Dysphoric Mania. Historical Tip-Offs That Raise the Suspicion of Mixed Bipolar States in General Over-Diagnosing Bipolar Disorder: A Serious Diagnostic Error Bipolar II Disorder Substance/Medication-Induced Bipolar and Related Disorder Recognizing Suicidal Ideation Unleashed During Partial Manic Responses to a Medication Cyclothymic Disorder and Rapid Cycling Differential Diagnosis on Danny Ramirez and Summary of Key Interviewing Tips Clinical Presentation #3: Mr. Whitstone Discussion of Mr. Whitstone Patient Hesitancies to Admit to Depression and How to Transform Them Cross-Cultural Issues in Recognizing Depression Problems With Concentration and Cognitive Functioning in Depression Spotting Atypical Depression Psychotic Process in Depression Ruling Out Non-Psychiatric Biological Causes of Depression Differential Diagnosis on Mr. Whitstone and Summary of Key Interviewing Tips Clinical Presentation #4: Ms. Wilkins Discussion of Ms. Wilkins The Need to Determine the Persistence of Depressive Symptoms and How to Do It Red Herrings: Disorders That Mimic Major Depressions Tips for Delineating an Accurate History of the Presenting Disorder Ruling Out Peripartum Depressions, Grief, Adjustment Disorders, and V-Codes Differential Diagnosis on Ms. Wilkins and Summary of Key Interviewing Tips Clinical Presentation #5: Mr. Collier Discussion of Mr. Collier Techniques for Eliciting a Family History Difficulties in Taking a Family History and How to Transform Them Cross-Cultural Sensitivity When Taking a Family History Family History as a Reflection of Family Dynamics Differential Diagnosis on Mr. Collier and Summary of Key Interviewing Tips References 10 Interviewing Techniques for Understanding the Person Beneath the Mood Disorder Introduction The Pain Beneath Depression Fields of Interaction The Biological Wing of the Matrix The Psychological Wing of the Matrix 1. Depressive Changes in How the World Is Perceived The Window Shade Response 2. Cognitive Changes Caused by Depression Changes in the Flow of Thought and Ideational Caging Cognitive Distortions as Conceptualized by Aaron Beck First Distortion in Beck’s Triad: Negative View of the World Second Distortion in Beck’s Triad: Negative Self-Concept Third Distortion in Beck’s Triad: Negative View of the Future 3. Alterations in Thought Content Found in Depression Depressive Loneliness Depressive Guilt and Self-Loathing Depressive Helplessness Depressive Hopelessness 4. Psychodynamic Defenses and Their Role in Depression The Dyadic Wing of the Matrix The Impact of the Patient’s Depression on the Interviewer How a Clinician’s Behaviors Can Submerge a Depression From View Effectively Addressing Tearfulness The Familial and Societal Wing of the Matrix An Illustration of the Insidious Impact of Depression on a Family Addressing the Pain of Family Members Uncovering Potentially Damaging Family Impacts on the Patient The Impact of Depression on Societal and Cultural Systems Cultural Impacts on the Patient’s Depression The Wing of the Matrix Encompassing Worldview and Spirituality References 11 Psychotic Disorders Introduction The Differential Diagnosis of Psychotic States Clinical Presentations and Discussions Clinical Presentation #1: Mr. Williams Discussion of Mr. Williams Phenomenology of Visual Hallucinations and Illusions: Their Diagnostic Implications Recognizing Psychotic Process Induced by Alcohol Withdrawal Recognizing Psychotic Process Induced by Street Drugs Recognizing Medication-Induced Psychosis Effectively Interviewing and Collaborating With Law Enforcement Officers Differential Diagnosis on Mr. Williams and Summary of Key Interviewing Tips Clinical Presentation #2: Mr. Walker Discussion of Mr. Walker Spotting Disturbances of Affect as Seen in Schizophrenia Diagnostic Significance of the Presence of Delusions: Delineating Schizophrenia From Delusional Disorders Negative (Deficit) Symptoms of Schizophrenia The Importance of Family Members in Uncovering Psychotic Process Differential Diagnosis Between Schizophrenia and Mood Disorders With Psychotic Features Schizoaffective Disorder and the Schizo–Bipolar Continuum Differential Diagnosis on Mr. Walker and Summary of Key Interviewing Tips Clinical Presentation #3: Ms. Hastings Discussion of Ms. Hastings Types of Delusional Disorders Paranoid Delusions: Techniques for Uncovering Potential Dangerousness Delusions in the Elderly and Paraphrenia Differential Diagnosis on Ms. Hastings and Summary of Key Interviewing Tips Clinical Presentation #4: Ms. Fay Discussion of Ms. Fay The Life Cycle of a Psychosis Delusional Mood Delusional Perception The Emergence of Concrete Delusional Ideation Soft Signs of Psychosis: How to Spot Hidden Psychotic Process Helping Patients to Share Delusional Material Tapping Intense Affect Tapping Odd Language, Illogical Thought, and Idiosyncratic Phrasing Indirect Techniques for Exploring Delusional Material Examples Illustrative Dialogue How to Respond When a Delusional Patient Asks, “Do You Believe Me?” Hallucinations and Other “Hard Signs of Psychosis” in the Normal Population Auditory and Visual Hallucinations in the Normal Population Cultural Competence: Its Importance in Distinguishing True Psychotic Symptoms From Culturally Accepted Behaviors The Interface Between Cultural Phenomena and the Life Cycle of a Psychosis Back to Ms. Fay: An Illustration of How to Tap a Piece of Illogical Thought for Underlying Delusional Material Differential Diagnosis on Ms. Fay and Summary of Key Interviewing Tips Clinical Presentation #5: Mr. Lawrence Discussion of Mr. Lawrence A Deadly Trap: Missing Deliria in Patients With Illnesses Such as Schizophrenia Practical Tips for Spotting a Delirium: The Nature of the Beast Four Cognitive Tests Useful for Recognizing a Subtle Delirium Differential Diagnosis on Mr. Lawrence and Summary of Key Interviewing Tips Clinical Presentation #6: Kate Discussion of Kate Spotting Non-Delirial Psychoses Caused by Underlying Medical Conditions When to Refer for a Physical Exam and What to Do If You Can Perform One Differential Diagnosis on Kate and Summary of Key Interviewing Tips Clinical Presentation #7: Ms. Flagstone Discussion of Ms. Flagstone “Micropsychotic Episodes” Seen in People Coping With Personality Disorders Psychotic Processes With a Rapid Onset/Offset Differential Diagnosis on Ms. Flagstone and Summary of Key Interviewing Tips Recognizing Psychotic Process Triggered by Seizure Disorders References 12 Interviewing Techniques for Understanding the Person Beneath the Psychosis The Pain Beneath Psychotic Process Fields of Interaction I. The Biological Wing of the Matrix Sleep Disturbances in Psychosis Psychotic Disruption of the “Sensation of the Physical Boundaries of the Body” and the Concept of a “Porous Ego” Schneiderian First-Rank Symptoms of Psychosis Exploring Somatic Passivity and “Made Feelings”: The World of the Porous Ego Thought Withdrawal and Thought Insertion Thought Broadcasting (Unintentional and Intentional) Spotting Medication-Induced Akathisia Establishing an Alliance With a Patient Experiencing Catatonia II. The Psychological Wing of the Matrix Auditory Hallucinations: Their Nature, Phenomenology, and Exploration The Directional Location of Auditory Hallucinations The Reality of Auditory Hallucinations to the Patient Distinction Between Auditory Hallucinations and Auditory Illusions The Uniqueness of Auditory Hallucinations Schneiderian Symptoms Related to Auditory Hallucinations The Relationship Between the Patient and the Patient’s Voices Uncovering and Sensitively Exploring Auditory Hallucinations Sensitively Raising the Topic of Auditory Hallucinations Sensitively Exploring the Phenomenology of Auditory Hallucinations Once Raised Illustrative Transcript of a Clinician Exploring Auditory Hallucinations Exploring Command Hallucinations Exploring the Content of Command Hallucinations Exploring the Auditory Quality of Command Hallucinations Exploring the Degree to Which a Patient Feels Able to Resist a Command Hallucination Exploring the Emotional Impact of Command Hallucinations on a Patient Psychotic Disruptions in Cognition, Logic, and Communication How to Safely Interact With an Illogical, Agitated Psychotic Patient Unobtrusively Screening for Paranoid Process, Delusions, and Other Psychotic Process Understanding the Demoralization and Self-Denigration Spurred by Psychotic Process III. The Dyadic Wing of the Matrix Uncovering Social Withdrawal and Recognizing Social Inappropriateness The Impact of Psychotic Process on the Interviewer’s Emotions and Behaviors The Impact of the Interviewer’s Behaviors on Psychotic Process IV. The Familial, Cultural, and Societal Wing of the Matrix Understanding the Exquisite Pain of Family Members Practical Techniques for Engaging Family Members in the Initial Interview Opening the Conversation in an Initial Encounter With a Family Member Tips for Initial Interviews With Family Members on Inpatient Units Talking With Patients About Involving Their Family Members in Assessment and Treatment Cultural and Societal Impacts on Psychotic Process Encountering Culture-Bound Syndromes and Behaviors Missing Culturally Specific Psychotic Process Mistaking Culturally Normal Phenomena for Psychotic Process Redux The Community Mental Health Center as a Subculture Language and Culture: Potential Roadblocks When Uncovering Psychotic Process V. The Wing of the Matrix Encompassing Worldview and Spirituality Psychotic Destruction of the Patient’s Religious Worldview The Personalized Meaning of Psychotic Symptoms to Patients References 13 Personality Disorders Introduction The Mystery of Personality Disorders Revealed: Core Principles and Definitions In Search of a Definition The Gestalt of Personality Dysfunction DSM-5 Definitions of a Personality Disorder Personality Disorders as Reflections of the Social History The Nature of Personality Diagnoses: Abuses and Uses A Cautionary Note The Beneficial Uses of Personality Diagnoses A Useful Metaphor The Etiology of Personality Disorders References 14 Personality Disorders Introduction Section I: A Survey of the DSM-5 Personality Disorders Goals and Limitations of the Survey 1. Anxiety-Prone Disorders Obsessive–Compulsive Personality Disorder Dependent Personality Disorder Avoidant Personality Disorder 2. Poorly Empathic Disorders Schizoid Personality Disorder Antisocial Personality Disorder Histrionic Personality Disorder Narcissistic Personality Disorder 3. Psychotic-Prone Disorders Borderline Personality Disorder Schizotypal Personality Disorder Paranoid Personality Disorder Section II: Common Problems Encountered When Diagnosing Personality Disorders Premature Diagnosis: “Label Slapping” Mistaking Behaviors Shown in the Interview as Personality Traits Problems With Countertransference Inappropriate Hesitation to Make a Personality Diagnosis Section III: Using the DSM-5 to Arrive at a Personality Diagnosis Step #1: Limiting the Field of Diagnostic Choices Passively Scouting for Clues to Personality Dysfunction Signal Signs Signal Symptoms Actively Limiting the Diagnostic Field With Probe Questions Illustration of a Clinician Limiting the Field of Diagnostic Possibilities Step #2: Actively Expanding the Diagnostic Criteria for a Specific Diagnosis Illustration of a Clinician Expanding the Diagnostic Criteria of a Specific Diagnosis Verifying the Validity of Patient-Reported Diagnostic Traits Enhancing Validity by Maintaining Engagement Techniques for Verifying Historical Persistency Techniques for Ruling Out State Dependency Verifying Pathological Severity Tapping for Epiphenomena Section IV: Future Diagnostic Systems of Personality Dysfunction and the Usefulness of Dimensionality Today Dimensionality: A Note of Caution The Power of Dimensionality in the Initial Interview Entrance Questions for Exploring Personality Traits Differential Diagnosis of Personality Disorders: A Glimpse Into the Future Building Upon the DSM-5 Categorical System Conclusion References 15 Understanding and Effectively Engaging People With Difficult Personality Disorders Introduction to Object Relations and Self Psychology Goals of This Chapter and Core Definitions Defining Object Relations and Self Psychology What Propels the Development of the Self? The Four Developmental Stages of the Self and Their Clinical Applications Developmental Stage #1: Discovering the Boundaries of the Body Developmental Stage #2: Seeking Safety by Merging With Others Winnicott, Merger Objects, and Transitional Objects Signal Signs Arising From Merger Dynamics Signal Symptoms Arising From Merger Dynamics Enhancing Engagement as Related to Merger Objects Kernberg, Splitting, and the Move Towards Mobility Signal Signs Arising From Splitting Defenses Signal Symptoms Arising From Splitting Defenses Enhancing Engagement as Related to Splitting Defenses Developmental Stage #3: Securing the Self Through Grandiosity and Idealization Kohut, the Bipolar Self, and the Search for Independent Functioning Signal Signs Arising From the Psychodynamics of the Bipolar Self Signal Symptoms Arising From the Psychodynamics of the Bipolar Self Enhancing Engagement Via an Understanding of the Bipolar Self Complementary Shifts Countertransference: Short-Circuiting a Clinical Gremlin Accepting Idealization Developmental Stage #4: Achieving a Stable Self and the Advent of Empathy Concluding Comments: on the Utility of Mirrors References 16 The Mental Status Introduction The Impact Status The Mental Status General Characteristics of the Mental Status: What Is It? Documenting the Mental Status Components of the Mental Status 1. Appearance and Behavior 2. Speech Characteristics and Thought Process 3. Thought Content Ruminations Obsessions Compulsions Delusions Thought Concerning Dangerousness to Self and Others 4. Perception 5. Mood and Affect 6. Sensorium, Cognitive Functioning, and Insight References 17 Exploring Suicidal Ideation Introduction Section 1: Risk Factors, Warning Signs, and Protective Factors: Their Role in the Clinical Formulation of Risk Important Distinctions and Critical Limitations Risk Factors Versus Risk Predictors (Warning Signs) Static Versus Dynamic Risk Factors Protective Factors Uncovering and Weighing Risk Factors and Warning Signs: The State of the Art Clinical Illustrations Clinical Illustration #1: Michael Clinical Illustration #2: Mrs. Kelly Risk Factors and Warning Signs: Summary and Effective Utilization Useful Mnemonics Loose Ends and a New Mnemonic Differentiating Between Concerns of Chronic Suicide Risk Versus More Immediate Risk The Tetrad of Lethality: Four Common Indicators That Hospitalization May Be Required Section 2: the Elicitation of Suicidal Ideation, Planning, Behaviors, and Intent 1. Before the Interview Begins: Secrets, Countertransference, and Problematic Myths 2. The Importance of Uncovering Suicidal Ideation and Why It Is Hard to Do So Roadblocks to Sharing Suicidal Ideation Reflected Intent: One of the Master Keys to Unlocking Real Intent Pitfalls of an Incomplete Elicitation of Suicidal Ideation Premature Crisis Resolution Lost Data for the Receiving Clinician The Power of a Thorough Elicitation of Suicidal Ideation, Behavior, and Intent to Save a Life The Issue of Credibility Reaching for Life 3. Setting the Platform for the Suicide Inquiry The “Elicitation of Suicidal Ideation Triad” Step 1 of the Elicitation Triad: Enhancing Engagement With a Potentially Suicidal Patient Step 2 of the Elicitation Triad: Helping the Potentially Suicidal Patient to Share Highly Charged Emotional States Three Gateways to Suicidal Ideation Step 3 of the Elicitation Triad: The Patient Hints at Suicide or Raises the Topic Spontaneously 4. Eliciting Suicidal Ideation, Planning, and Intent Using the Chronological Assessment of Suicide Events (CASE Approach) Background, Rationale, and Limitations The Question of Validity: Its Central Role in the CASE Approach Two Validity Techniques for Sensitively Raising the Topic of Suicide Normalization Shame Attenuation A Note on Word Choice: “Killing Yourself” Versus “Committing Suicide” Five Validity Techniques Used to Explore the Extent of Suicidal Ideation Behavioral Incident Gentle Assumption Denial of the Specific Catch-All Question Symptom Amplification The Macrostructure of the CASE Approach: Avoiding Errors of Omission The Microstructure of the CASE Approach: Exploring the Four Specific Timeframes Step 1: The Exploration of Presenting Suicide Events The Concept of Creating a Verbal Video More Tips on Making a Verbal Video With Behavioral Incidents Uncovering the Patient’s Apparent and Not-so-Apparent Motivations for Suicide Clinical Illustration of Step 1: Exploring the Region of Presenting Suicide Events Step 2: The Exploration of Recent Suicide Events Clinical Illustration of Step 2: Exploring the Region of Recent Events Step 3: The Exploration of Past Suicide Events Clinical Illustration of Step 3: Exploring the Region of Past Events Step 4: The Exploration of Immediate Suicide Events Clinical Illustration of Step 4: Exploring the Region of Immediate Events Concluding Comments References 18 Exploring Violent and Homicidal Ideation Introduction Background Characterizing Violence: Three Practical Domains for Clinicians The Orga