As our young clients often remind us, you don’t have to know much to realize that interacting with children and teens is often strikingly different from interacting with adults. In this chapter, we provide practical recommendations for interviewing young clients. After reading this chapter, you will know:

• Several special considerations for interviewing children and adolescents.

• How you can modify your interactions-and sometimes even your clothing-

to make a good ?rst impression with young clients.

• How to discuss con?dentiality, informed consent, referral information, and assessment and therapy procedures with youth.

• A speci?c technique for talking with young clients about therapy goals.

• User friendly assessment and information gathering strategies.

• Methods for reassuring, supporting, and empowering youth.

• Important issues to address when ending sessions with young clients.

CHAPTER OBJECTIVESSPECIAL CONSIDERATIONS IN WORKING WITH CHILDREN When working with children, it can be hard to stay balanced and objective. For example, there is an unfortunate tendency for adults to view each individual child as primarily a “good kid” or “bad kid.” If interviewers succumb to this tendency, it often results in dreading the arrival of some child clients, while celebrating the arrival of other child clients.

Similarly, interviewers, teachers, and other adults frequently either overidentify or underidentify with children. Some adults see themselves as fully capable of understanding children because of a strong belief, “I was a kid once and so I know what it’s like.” Adults suffering from this overidenti?cation may fail to set appropriate boundaries when necessary, project their own childhood con?icts onto children, and/or be unable to appreciate unique aspects of children with whom they work. Other adults who underidentify with children may experience children as alien beings-not yet fully part of the human race. Adults suffering from underidenti?cation may talk about a child who is sitting three feet away, as if the child were not even in the room. They also might become condescending, rigid, out of touch with issues children face, and/or unrealistic in their fears or expectations.

In case we have not made our biases and values clear, consider this: Even with respect to diagnosis and treatment planning, mental health work is about human relationships. If, in the process of diagnosing or formulating, planning, and goal setting, we lose contact with our clients as unique human beings, we risk missing their real needs and causing damage. If, in this same process, we lose contact with ourselves as unique, complex human beings as well as professionals, we diminish our work and the potential of our profession.

300 Structuring and AssessmentDiagnosis and Treatment Planning Cultural Issues in Treatment Planning: A Case Example Often, client cultural issues take center stage in treatment planning. The following very brief example is adapted and summarized from “The Case of Dolores” .

Dolores, a 43 year old American Indian woman, came to counseling because she was suffering from sadness, inability to concentrate, insomnia, and anhedonia. These depressive symptoms were associated with two major concerns. First, Dolores was very upset because her husband of 23 years, Gabe, was suffering from a serious gambling addiction but was refusing to go to treatment. Second, Dolores was worried that, because of her diminished functioning and her husband’s gambling, she might lose custody of her adopted daughter, Sage.

Even with the minimal information provided in this example, several cultural issues rise to the fore. Speci?cally, because Dolores’s major concerns center around family issues, it is important to explore the onset and duration of her concerns in the context of familism-as Dolores’s symptoms might be more directly associated with her family identity than with her “self.” Additionally, it could be that the decision to come to counseling was producing nearly as much stress as her family situation because some American Indian tribes consider it disloyal to say negative things about other family members. Consequently, Dolores’s feelings about counseling and what it says about her Indian identity may be a major focus of treatment-especially if she is seeing a counselor from the dominant culture.

PROFESSIONAL ISSUES When working with suicidal clients, it is your responsibility to be a competent and caring professional who lives up to professional standards of practice. Meeting pro266 Structuring and Assessmentfessional standards makes your practice more effective and helps protect you if one of your clients actually completes a suicide .

Many important professional issues are associated with suicide assessment. Some of these issues are personal; others emphasize professional or legal issues. It is sometimes dif?cult to disentangle the personal from the professional legal. These issues are discussed brie?y in the following section.

Can You Work with Suicidal Clients? Some interviewers are not well suited to working with suicidal clients. Depressed and suicidal clients are often angry and hostile toward those who try to help them. However, it remains your responsibility to maintain rapport and not become too irritated, even with hostile clients. Avoid taking the comments of irate or suicidal clients personally.

If you are prone to depression and suicidal thoughts yourself, it is wise to avoid regular work with suicidal clients. Working with suicidal clients may trigger your depressive thoughts and add to your tendency to become depressed and/or suicidal.

Strong values about suicide, too, can be an important professional consideration.

Some people strongly believe that suicide is a viable life choice and that clients should not be prevented from committing suicide if they truly want to : All this points toward the desirability of according suicide the status of a basic human right . I do not mean that killing oneself is always good or praiseworthy; I mean only that the power of the state should not be legitimately invoked or deployed to prohibit or prevent persons from killing themselves.

Mr. Smith sees himself as ordinarily having numerous personal strengths, although he needed prompting to elaborate on his positive qualities. For example, he considers himself an honest man, a hard worker, and a devoted husband and father. He further believes he is a good buddy to several friends and fun to be around . In terms of intelligence, Mr. Smith claimed he is “no dummy” but that he is having some trouble concentrating and “remembering anything” lately. When asked about personal weaknesses, Mr. Smith stated, “I hope you got lotsa ink left in that pen of yours, Doc,” but primarily focused on his current state of mind, which he described as “being a problem of not having the guts to get back on that horse that bucked me off.” Despite his poor hygiene and general lack of productiveness, Mr. Smith seems capable of adequately performing most activities of daily living. He reported occasionally cooking dinner, ?xing the lawnmower, and taking care of other household and maintenance tasks.

His perception, and it may be accurate, is that he is less ef?cient with most tasks because of distractibility and intermittent forgetfulness. His interpersonal functioning appears somewhat limited, as he described relatively few current outside involvements.

Diagnostic Impressions

For good reason, students are often reluctant to assign a diagnosis to clients. Nonetheless, most intake reports should include some discussion of diagnostic issues, even if you discuss only broad diagnostic categories, such as depression, anxiety, substance use, eating disorders, and so on. Although simply listing your diagnostic considerations is acceptable in some circumstances and including only a multiaxial diagnosis is preferred by managed care companies, our preference is for a brief discussion of diagnostic issues followed by a DSM multiaxial diagnosis. The brief discussion orients the reader to how you conceptualized your diagnosis, and it can even include an explanation of why you chose one particular diagnostic label over another. In the following description, we use Morrison’s guidelines of assigning the least severe label that adequately explains the symptom pattern.

____ 12. After the initial session, write up a treatment plan that clients can sign at the outset of the second session.THE INTAKE REPORT Report writing constitutes a unique challenge to clinicians. You must consider at least ?ve dimensions: Determining your audience.

Choosing the structure and content of your report.

Writing clearly and concisely.

Keeping your report con?dential.

Sharing the report with your client.

Before discussing these dimensions, it should be emphasized that interviewers have a responsibility to keep and maintain client records. Although this responsibility varies depending on your professional af?liation and theoretical orientation, failure to maintain appropriate records is unethical and, in some cases, illegal. The American Psychological Association’s ethical code states: 198 Structuring and Assessment Prompting Clients to Stick With Essential Information

About Themselves

Using the managed care intake interviewing checklist provided in Table 7.2, work with a partner from class to streamline your intake interviewing skills. Interviewers working in a managed care environment must stay focused and goaldirected throughout the intake interview. To maintain this crucial focus, it may be helpful to: Inform your client in advance that you have only a limited amount of time and therefore must stick to essential issues or key factors.

If your client drifts into some less essential area, gently redirect him or her by saying something such as: “You know, I’d like to hear more about what your mother thinks about environmentalism , but because our time is limited, I’m going to ask you a different set of questions. Between this meeting and our next meeting, I want you to write me an autobiography-maybe a couple of pages about your personal history and experiences that have shaped your life. If you want, you can include some information about your mom in your autobiography and get it to me before our next session.” Often, clients are willing to talk about particular issues at great length, but when asked to write about those issues, they are much more succinct.

Transference is characterized by inappropriateness; the client responds to the interviewer by acting, thinking, or feeling in an inappropriate manner. S. Freud stated that transference “exceeds anything that could be justi?ed on sensible or rational grounds” . Sometimes, but not always, intense and obvious transference issues can come to the surface early in an interview or early in the therapeutic process. For example, an angry, confused young man had an especially negative reaction to his female counselor. He became verbally violent during an initial screening interview, stating repeatedly, “Women. You [expletives deleted] women can’t understand where I’m coming from. No way. Women just don’t get me. Like you. You don’t get me.” Because the counselor had not behaved in a manner that warranted such a strong reaction, it is likely this client was displacing “feelings, attitudes, and behaviors” based on previous interactions he had experienced with females .

More commonly, like many relationship variables, transference is abstract, vague, and elusive. To notice it, you have to pay attention to idiosyncratic transactions clients initiate with you; for example, clients respond to you in ways that are more emotional than the situation warrants, they make assumptions about you that have little basis in reality, and they express unfounded and unrealistic expectations regarding you or therapy.

A fairly common old map on new terrain is the client’s unspoken belief that you, too, will evaluate him, ?nd him lacking, and reject him. An example is a client who expressed evaluation anxiety regarding her performance on a psychological test and cognitive behavioral homework assignment. She stated tentatively, “You know, some of those things the test says about me don’t seem accurate. I must have done something wrong when I took the test.” This comment is revealing because when clients are provided with inaccurate psychological test feedback, they often begin questioning the test’s validity, rather than their own performance. Similarly, she stated, “I did the assignment, but I’m not sure I had the right idea.” Again, she made this statement when, in fact, she turned in a very thorough homework assignment. She did exactly as instructed, but her self doubt was triggered because she viewed her therapist as an authority ?gure who might evaluate her negatively. Her expectation of criticism suggests, based on the psychoanalytic perspective, that she had been harshly, and perhaps inap114 Listening and Relationship Developmentpropriately, criticized before. In this sense, her reaction is similar to the child who ?inches when approached by an adult whose arm is extended. The child ?inches because of previous physical abuse; the ?inch may be an automatic and unconscious response. Similarly, clients who have been exposed to excessive criticism have an automatic and unconscious tendency to prepare themselves when exposed to evaluative situations. This is an example of transference.

We have one ?nal observation about taping. When you have conducted your best interview ever, you will inevitably discover there was a minor problem with the equipment and, consequently, your session either did not record properly or did not record at all.

On the other hand, when you’ve conducted a session you’d rather forget, the equipment always seems to work perfectly and the session turns out to be the one your supervisor wants to examine closely. Because of this particular variation of Murphy’s Law, we recommend that you carefully test the recording equipment before all your sessions.

PROFESSIONAL AND ETHICAL ISSUES Before conducting real or practice interviews, interviewers should consider numerous professional and ethical issues. Beginning interviewers often struggle with dressing professionally, presenting themselves and their credentials comfortably, handling time boundaries, and discussing con?dentiality. The remainder of this chapter focuses on how to deal with professional and ethical issues comfortably and effectively.

Self Presentation

You are your own primary instrument for a successful interview. Your appearance and the manner in which you present yourself to clients are important components of professional clinical interviewing.

Grooming and Attire

Deciding how to dress for your ?rst clinical interviews can be dif?cult. Some students ignore the issue; others obsess about wearing just the right out?t. The question of how to dress may re?ect a larger developmental issue: How seriously do you take yourself as a professional? Is it time to take off the Salvation Army sweats, or stop trying to capture the title of Most Likely to Be on the Cover of Seventeen? Is it time to don the dreaded three piece suit and come out to do battle with mature reality, as your parents 36 Becoming a Mental Health Professionalor friends may have suggested? Don’t worry. We are not interested in telling you how you should dress. Our point again involves self awareness. Be aware of how your clothes may affect others. Even if you ignore this issue, your clients-and your supervisor-will not. Your choice of clothing and grooming communicates a great deal to clients and can be a source of con?ict between you and your supervisor.