How Therapy Works: The Role of Basic Interview Techniques
Therapy is, in part, an ongoing interview.
Posted Feb 13, 2020
An interview is essentially a structured conversation where one participant asks questions and the other provides answers. Therapy, therefore, can be viewed as involving an ongoing interview process. Indeed, therapists regularly use interview techniques to gather useful information that will, in turn, help them better understand the client’s difficulties, implement proper interventions, assess progress, and overcome obstacles in therapy.
Therapists use interview techniques both to collect useful data and to help build and maintain client-therapist rapport. Thus, certain strategies that may work in other interview contexts, such as ‘gotcha’ techniques, hostile attacks, or sycophantic pandering, are ill-suited for psychotherapy.
Below are a few of the basic interview techniques that therapists may beneficially use in the course of therapy:
1. Reflection: A staple of Carl Rogers’ person-centered therapy approach, this technique is foundational to psychotherapy. It involves 'verbal mirroring' of the client's communications, by which the therapist restates what the client has said (usually in a summarized, paraphrased form). Reflection appears simple-minded, but it is in fact quite far-reaching in its effects. For one, in order to reflect you have to listen. Thus, reflecting back to the client what they said implicitly communicates that you are, in fact, paying attention. People like to be acknowledged and attended to, and the experience is not common in the outside world, so reflection aids in building trust and therapeutic rapport.
Second, reflection is a self-correcting communicative mechanism. If you reflect erroneously, the client has a chance to correct you. In this way, reflection helps make sure that what you understood matches what the client was attempting to convey. Reflection helps clarify communications, and thus allows the therapist to understand the client’s experience.
Moreover, reflection over time allows for the detection of specific patterns in the client’s communications. For example, if the therapist repeatedly fails to accurately reflect a client’s intent, then perhaps (assuming the therapist is competent) the client’s communication style is unclear, which may help explain some of the client’s difficulties out in the world.
Reflection involves both content (fact) and process (feeling). In other words, if a client says, “I just can't seem to get anywhere in my life,” the therapist may simply restate the content: “So you feel like you’re not achieving your life goals." Or, alternately, the therapist may reflect the client’s conveyed emotions: “You seem frustrated, and perhaps fatigued, due to your lack of progress.”
2. Pinpointing: In this technique, the therapist seeks to clarify or ‘pin down’ the client’s specific meaning regarding some event or interaction. This is important because people come to therapy with different systems of meaning and points of reference. So, for example, if the client says “I came back home late from the bar last night and my wife went crazy on me,” pinpointing would sound something like: “What do you mean by ‘went crazy'? What did she actually do?”
Pinpointing can be also used in the service of exploration, looking to map out the client’s behavioral and emotional terrain in detail. For example, if a client says, “My father used to beat me,” the therapist may respond with several pinpointing questions: “How often did he beat you? How? Where?” This is important because a failure to pinpoint adequately, particularly with difficult topics, may be experienced by the client as timidity or lack of care on part of the therapist. Pinpointing specific painful aspects of the client’s experience legitimizes a difficult conversation, conveys courage, determination, and real caring, all of which aid rapport and help create a ‘therapy milieu’ in which we approach and inspect difficult things rather than avoid and cover them up.
3. Open-ended questions: This is the complement to pinpointing. An open-ended question is one that cannot be answered with a simple yes or no or another short, laconic reply. Thus, it invites the client to reflect on their experience, elaborate, and provide further context and data. A closed question is: “Did you enjoy the date?” An open-ended question would be: “Let’s hear more about your date.” Similarly, instead of asking “Are you happy at work?” the therapist may say: “Tell me more about your experience at work.”
4. Confrontation: This technique is used to point out discrepancies between what the client states and what is being observed. It may highlight inconsistencies in the client’s story and help the client face the facts, and actual consequences, of their behavior. Confrontation is a risky strategy, but often a high-reward one, particularly when the rapport is strong and the client is invested. Confrontation in therapy is most useful when it involves the presentation of objective facts and when done in search of truth, not of judgment. So, for example, if a client says, “Yeah, I drink to excess sometimes,” the therapist may point to the record and say, “In fact, you’ve spent half your income on booze last month, and had three DWIs as well; and you’re drinking every morning just to steady your nerves. Are we not more accurate to say that you are dependent on alcohol?”
5. Self-disclosure: Disclosing an aspect of the therapist’s experience is another technique that may be used to establish rapport, support the client emotionally, and show empathy. However, this should be deployed judiciously, since a therapist who talks about him or herself may convey a lack of client-focus, and may appear (or be) preoccupied with their own issues. Different schools of therapy have different approaches to self-disclosure, and different clients will benefit from different levels of disclosure, yet a good rule of thumb may be to approach the issue on a case-by-case basis and to weigh the benefits against the risks carefully, given the specific issues, and people, involved.
For example, if the client says: “People think I’m stupid because I can’t read well, but I’m actually dyslexic,” the therapist may say: “I am dyslexic as well. I had similar experiences in school.” The risk is that the client may interpret this as bragging or a putdown, (as in, ‘I am dyslexic and I made it, so why are you complaining?’); the hope is that the client will see in the therapist a true ally who understands their struggle as well as an example of success, which could inspire the client to disclose more freely and to strive to achieve their own goals despite obstacles.
6. Silence: Miles Davis once said, "It’s not the note you play, it’s the note you don’t play" that matters. A silence can be pregnant with meaning. In therapy, pauses in conversation may create a space for self-reflection, in which thoughts and emotions may become clearer and reach awareness. They may also convey a comfort with silence, which is a sign of healthy intimacy.
In this way, silence, expertly employed, is both an interview technique and a therapeutic intervention, providing the client with the opportunity to process and understand what is being said, thus promoting introspection and allowing them to re-integrate emotions. For example, if a client says, “I get so mad I feel like hitting her,” the therapist may remain silent. After a pause, the client may add: “And then I immediately feel guilty and beat myself up for being a lousy husband.” The silence here has allowed for a fuller picture to emerge.
7. Reframing: This technique shows up in many types of psychotherapy and involves, in essence, seeing old problems or events with new eyes. We know today, in part through Tversky and Kahneman’s groundbreaking research, that how a problem is framed (presented, viewed) affects how it is appraised and addressed. For example, doctors presented with a new drug labeled 70% effective will have a much more positive attitude about prescribing it than those presented with a new drug that has 30% failure rate. (Do the math: It’s the same drug.) Likewise, unhappy workers who frame their trouble as having a lousy boss will choose a different set of behaviors than those who frame their problem as having a boss in the first place. The former will seek to work for someone else. The latter will seek to work for themselves. Relatedly, if a client says, “I’m nervous about my job interview,” the therapist may reframe this by saying, “That’s a good thing. It means you care.”
8. Focusing: This technique is used to ensure that the therapeutic encounter remains just that—focused on the work of therapy. At times, clients may seek to branch out into side conversations or tangents that, while perhaps interesting in and of themselves, do not serve to advance the main narrative of the therapy. The reasons for that may vary. Some clients may just be meandering storytellers. Some may not yet have been socialized into the focused culture of the therapy process. Others may seek to avoid a painful topic they know is about to be approached in session and use small talk as a form of resistance. Still others may be under the impression of an event that had just transpired before they came in, and feel the need to share or unload. In all these cases, a gentle focusing comment may help re-center the conversation and re-direct attention to the work at hand.
So, for example, if a client embarks on a long tangent about her daughter’s achievements, the therapist may say, "Your daughter sounds like a wonderful, accomplished person; that must be very satisfying for you. Now, let’s pick up our conversation from last week. We were looking into your recent difficulties with your mother-in-law…”