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THE PSYCHIATRIC INTERVIEW IN CLINICAL PRACTICE

T H I R D E D I T I O N

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THE PSYCHIATRIC INTERVIEW IN

CLINICAL PRACTICE

T H I R D E D I T I O N

ROGER A MACKINNON, M.D.

Professor Emeritus of Clinical Psychiatry

College of Physicians and Surgeons of Columbia University

New York, New York

ROBERT MICHELS, M.D.

Walsh McDermott University Professor of Medicine and Psychiatry

Weill Medical College of Cornell University

New York, New York

PETER J BUCKLEY, M.D.

Professor of Psychiatry and Behavioral Sciences

Albert Einstein College of Medicine of Yeshiva University

Bronx, New York

Note: The authors have worked to ensure that all information in this book isaccurate at the time of publication and consistent with general psychiatric andmedical standards, and that information concerning drug dosages, schedules,and routes of administration is accurate at the time of publication and consis-tent with standards set by the U.S Food and Drug Administration and the gen-eral medical community As medical research and practice continue to advance,however, therapeutic standards may change Moreover, specific situations mayrequire a specific therapeutic response not included in this book For these rea-sons and because human and mechanical errors sometimes occur, we recom-mend that readers follow the advice of physicians directly involved in their care

or the care of a member of their family

Books published by American Psychiatric Association Publishing represent theviews and opinions of the individual authors and do not necessarily representthe policies and opinions of American Psychiatric Association Publishing or theAmerican Psychiatric Association

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Copyright © 2016 American Psychiatric Association

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Library of Congress Cataloging-in-Publication Data

MacKinnon, Roger A., author

The psychiatric interview in clinical practice / Roger A Mackinnon, RobertMichels, Peter J Buckley ; with contributions by John W Barnhill, Brad Foote,Alessandra Scalmati — Third edition

p ; cm

Includes bibliographical references and index

ISBN 978-1-61537-034-4 (hardcover : alk paper)

I Michels, Robert, author II Buckley, Peter, author III Title

[DNLM: 1 Interview, Psychological—methods 2 Mental nosis 3 Physician-Patient Relations 4 Psychotherapy—methods WM 143]RC480.7

Disorders—diag-616.8914–dc23

2015029338

British Library Cataloguing in Publication Data

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About the Authors ix

Preface xi

Acknowledgments xv

P A R T I General Principles 1 General Principles of the Interview 3

2 General Principles of Psychodynamics 77

P A R T I I Major Clinical Syndromes 3 The Obsessive-Compulsive Patient 105

4 The Histrionic Patient 133

5 The Narcissistic Patient 173

6 The Masochistic Patient 201

7 The Depressed Patient 225

8 The Anxiety Disorder Patient 277

9 The Borderline Patient 311

10 The Traumatized Patient 339

Alessandra Scalmati, M.D., Ph.D.

11 The Dissociative Identity Disorder Patient 373

Brad Foote, M.D 12 The Antisocial Patient 405

13 The Paranoid Patient .437

14 The Psychotic Patient 473

15 The Psychosomatic Patient .499

John W Barnhill, M.D 16 The Cognitively Impaired Patient 513

John W Barnhill, M.D P A R T I I I Special Clinical Situations 17 The Emergency Patient .533

18 The Hospitalized Patient 557

John W Barnhill, M.D 19 The Patient of Different Background 573

P A R T I V Technical Factors Affecting the Interview 20 Note Taking and the Psychiatric Interview .603

21 Telephones, E-Mail, Other Digital Media, and the Psychiatric Interview 611

Afterword 635

Bibliography 637

Index 657

ABOUT THE AUTHORS

Roger A MacKinnon, M.D., is Professor Emeritus of Clinical try in the College of Physicians and Surgeons of Columbia University,and Training and Supervising Analyst at the Columbia University Cen-ter for Psychoanalytic Training and Research, in New York, New York

Psychia-Robert Michels, M.D., is Walsh McDermott University Professor ofMedicine and Psychiatry at Weill Medical College of Cornell University,and Training and Supervising Analyst at the Columbia University Cen-ter for Psychoanalytic Training and Research, in New York, New York

Peter J Buckley, M.D., is Professor of Psychiatry and Behavioral ences at Albert Einstein College of Medicine of Yeshiva University inBronx, New York; and Training and Supervising Analyst at the Colum-bia University Center for Psychoanalytic Training and Research in NewYork, New York

Sci-Contributors

John W Barnhill, M.D., is Professor of Clinical Psychiatry, DeWitt lace Senior Scholar, and Vice Chair for Psychosomatic Medicine in theDepartment of Psychiatry at Weill Medical College of Cornell University;and Chief of the Consultation-Liaison Service at New York-PresbyterianHospital/Weill Cornell Medical Center Hospital for Special Surgery inNew York, New York

Wal-Brad Foote, M.D., is Associate Professor of Clinical Psychiatry and havioral Sciences at Albert Einstein College of Medicine/MontefioreMedical Center in Bronx, New York

Be-Alessandra Scalmati, M.D., Ph.D., is Associate Professor of ClinicalPsychiatry and Behavioral Sciences at Albert Einstein College of Medi-cine/Montefiore Medical Center in Bronx, New York

The authors and contributors have no competing interests to report

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PREFACE

The third edition of this book builds on the second, which was published

in 2006 Unlike the second edition, written 35 years after the first, thechanges in psychiatry, in the intervening 9 years, have been less enormous

or revolutionary In an editorial in the American Journal of Psychiatry in

2006, we delineated and critiqued the radical developments that had curred in the psychiatric landscape between the publication of the firstand second editions These included the refinement of phenomenologicalpsychiatric diagnosis in DSM-III and subsequent revisions, an increasingbiological knowledge base for understanding the somatic origins of men-tal illness and effective pharmacological treatments, the expansion ofpsychodynamic thinking beyond ego psychology to incorporate differingtheoretical perspectives, and a dramatic shift in sociocultural attitudes to-ward the clinician-patient relationship The last-mentioned developmentremains especially relevant and continues to inform the psychiatric inter-view The social relationship between patient and clinician is no longerasymmetric Patients are now better informed, correctly believe that theirbodies and minds belong to them, and wish to be involved in treatmentdecisions The therapeutic alliance between doctor and patient has be-come the foundation of treatment efforts in all of medicine The assertion

oc-of the intrinsic rights oc-of patients has its origins in the cultural changes thatbegan in the 1960s The civil rights movement, the feminist movement, andthe gay liberation movement all provided catalysts for the questioning ofauthoritarian and paternalistic dogma and for the assertion of individualidentities In the past 9 years we note that this progressive developmenthas extended to transgender patients

We now know that the subjective experience of being “different” isuniversal and that psychiatry is enriched by recognizing and exploringthat experience, validating its existence and its universality, and at-tempting to understand how it influences the patient’s life This democ-ratization was anticipated over half a century ago when Anna Freud,commenting on the psychoanalytic situation, wrote:

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But—and this seems important to me—so far as the patient has a healthypart of his personality, his real relationship to the analyst is never whollysubmerged With due respect for the necessary strictest handling and in-terpretation of the transference, I feel still that we should leave roomsomewhere for the realization that analyst and patient are also two realpeople, of equal adult status, in a real personal relationship to each other

We strongly believe that this credo applies to the psychiatric interviewand the interchange between patient and clinician in all its manifesta-tions and vicissitudes

Alterations in the psychiatric landscape in the past 9 years have beenincremental We have brought this new edition of our book into align-ment with DSM-5, which was published in 2013, although we retain some

of the criticism of DSM classification that we expressed in our previousedition As we noted in our second edition, DSM, in its successive edi-tions, has emphasized descriptive phenomenological approaches to psy-chopathology and, unfortunately, continues to encourage psychiatricinterviewing that is overly focused on describing symptoms and estab-lishing diagnoses rather than on learning about the patient, his problems,his illnesses, and his life As an example, while advances in biological psy-chiatry have definitively established that schizophrenia is a “brain dis-ease” and neurodevelopmental disorder, there persists an unfortunatediminution in the attention given to the subjective experience of individ-ual psychotic patients Since psychosis can be expressed only through thepersonality of the individual patient, that person’s personal history andcharacter structure determine many aspects of the psychotic “experience”and should be recognized and addressed in the clinical engagement

DSM-5 acknowledged controversy in the conceptualization of sonality disorders by providing an essentially unchanged version of the

per-criteria found in DSM-IV-TR in Section II of the text and an alternativemodel in Section III that emphasizes impairments in personality func-

tioning and pathological personality traits Personality disorders are a central part of the major clinical syndromes component of our book, and

we find the original model in Section II more compatible with our ical approach Hence, we have maintained these definitions in our cur-

clin-rent text Basically we concur with an editorial in the American Journal of Psychiatry published in 2010, which argued that the primary unit of diag- nosis should be a personality syndrome that encompasses cognition, af-

fectivity, interpersonal functioning, behavior, coping, and the defensesand that trait-based systems are less useful in clinical practice

The advances in biological psychiatry—genetics, cognitive science, psychopharmacology, brain imaging, and the neurosciences ingeneral—continue apace, inform the culture of psychiatry, and provide

neuro-growing insight into the provenance of mental illnesses We continue tosubscribe to the view enunciated by Glen Gabbard that “virtually all ma-jor psychiatric disorders are complex amalgams of genetic diatheses andenvironmental influences Genes and environment are inextricably con-nected in shaping human behavior.”

The psychiatric interview engages the clinician in a spoken dialoguewith the patient In that sense it is about “voice” and its interplay—the vo-calist and the response and interpretation of the listener We hope that

in this current edition we have maintained an appreciation for the reader

of the complex music involved

Peter J Buckley, M.D Robert Michels, M.D Roger A MacKinnon, M.D.

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ACKNOWLEDGMENTS

A s always, we are grateful to our students, colleagues, and patients, all

of whom continue to teach and enlighten us More specifically, we wish

to thank John Barnhill, M.D., Brad Foote, M.D., and Alessandra Scalmati,M.D., Ph.D., for their original contributions to this edition

John McDuffie, Greg Kuny, and Tammy Cordova at American atric Association Publishing have been superb facilitators for the creation

Psychi-of this new edition Bessie Jones has provided critical administrativesupport Bob Hales is the gentle accoucheur who brought this new edi-tion to life

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GENERAL PRINCIPLES

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We believe that it takes years for a beginning student to become askilled interviewer However, time in itself does not create an experiencedpsychiatric interviewer Training in the basic sciences of psychodynam-ics and psychopathology is essential, along with skillful clinical teach-ers who themselves interview patients in the presence of the studentsand also observe and discuss interviews conducted by the students.Freud provided a foundation for our current knowledge of psycho-dynamics, although others have broadened and extended his concepts.

We have included contributions from ego psychology, object relationstheory, behavioral psychology, self psychology, relational psychology,and intersubjective psychology, although not always identified as such.Any systematic attempt to integrate these theories is well beyond thescope of this book They are addressed briefly in Chapter 2, “GeneralPrinciples of Psychodynamics,” along with biological influences on be-havior We favor an eclectic or pluralistic theoretical orientation.After the two introductory chapters, the next part addresses majorclinical syndromes and personality types These syndromes and per-sonality styles are major determinants of the unfolding of the interviewand of later problems in treatment Each of these clinical chapters be-

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gins with a discussion of the psychopathology, clinical findings, and apsychodynamic formulation They then discuss characteristic interviewbehavior and offer advice concerning the management of the interviewwith each type of patient Clinical vignettes throughout the book havebeen drawn largely from our clinical practice or teaching experience.This approach is not meant to imply that these are the “correct” tech-niques or that one can learn to interview by memorizing them Our inter-viewing style will neither appeal to nor be equally suited to all readers.However, there are students who have little opportunity to observe theinterviews of experienced clinicians or to be observed themselves Al-though this book cannot substitute for good clinical teaching, it can pro-vide some useful glimpses of how experienced clinicians conductinterviews

A second reason for providing specific clinical responses stems fromthe common misinterpretations of abstract principles of interviewing Forexample, one supervisor, who suggested that a student “interpret the pa-tient’s resistance,” later learned that the inexperienced therapist had toldhis patient, “You are being resistant.” It was only after the patient reactednegatively and the student shared this with his supervisor that the studentrecognized his error After the supervisor pointed out the patient’s sensi-tivity to criticism and the need for tact, the resident rephrased his interpre-tation and instead said, “You seem to feel that this is not a problem for apsychiatrist” or “Have some of my questions seemed irrelevant?”Part III concerns interview situations that offer special problems oftheir own These can involve patients with any syndrome or illness.Here the emphasis shifts from the specific type of psychopathology tofactors inherent in the clinical setting that may take precedence in deter-mining the conduct of the interview The consultation on the ward of ageneral hospital or the patient of different background are examples.The final part is reserved for special technical issues that influencethe psychiatric interview, such as note taking and e-mail, the role of thetelephone, including the patient’s cellular phone or pager, and issues re-lated to other digital media

THE CLINICAL INTERVIEW

A professional interview differs from other types of interviews in thatone individual is consulting another who has been defined as an expert.The “professional” is expected to provide some form of help, whether

he is a lawyer, accountant, architect, psychologist, social worker, orphysician In the medical interview, typically, one person is suffering

and desires relief; the other is expected to provide this relief The hope

of obtaining help to alleviate his suffering motivates the patient to pose himself and to “tell all.” This process is facilitated by the confiden-tiality of the clinician–patient relationship As long as the patient viewsthe clinician as a potential source of help, he will communicate more orless freely any material that he feels may be pertinent to his difficulty.Therefore, it is frequently possible to obtain a considerable amount of in-formation about the patient and his suffering merely by listening

ex-The Psychiatric Interview

The psychiatric interview differs from the general clinical interview in

a number of respects As Sullivan pointed out, the psychiatrist is sidered an expert in the field of interpersonal relations, and accordinglythe patient expects to find more than a sympathetic listener Any personseeking psychological help justifiably expects expert handling in theinterview The clinician demonstrates his expertise by the questions heboth asks and does not ask and by certain other activities, which areelaborated later The usual clinical interview is sought voluntarily, andthe patient’s cooperation is generally assumed Although this is also thecase in many psychiatric interviews, there are occasions when the per-son being interviewed has not voluntarily consulted the mental healthspecialist These interviews are discussed separately later in this book(see Chapter 14, “The Psychotic Patient”; Chapter 15, “The Psychoso-matic Patient”; and Chapter 18, “The Hospitalized Patient”)

con-Interviews in nonpsychiatric branches of medicine generally size medical history taking, the purpose of which is to obtain facts thatwill facilitate the establishment of a correct diagnosis and the institution

empha-of appropriate treatment That interview is organized around the ent illness, the past history, the family history, and the review of systems.Data concerning the personal life of the patient are considered important

pres-if they have possible bearing on the present illness For example, pres-if a tient describes unsafe sex practices, the interviewer will ask if the patienthas ever had a venereal disease or been tested for HIV However, if thepatient’s concern for the privacy of the written record is in doubt, suchinformation can remain unwritten The psychiatrist is also interested inthe patient’s symptoms, their dates of onset, and significant factors inthe patient’s life that may be related However, psychiatric diagnosis andtreatment are based as much on the total life history of the patient as onthe present illness This includes the patient’s lifestyle, self-appraisal,traditional coping patterns, and relationships with others

pa-6 • T H E P S Y C H I A T R I C I N T E R V I E W I N C L I N I C A L P R A C T I C E

The medical patient believes that his symptoms will help the doctor

to understand his illness and to provide effective treatment He is usuallywilling to tell the doctor anything that he thinks may be related to hisillness Many psychiatric symptoms, on the other hand, involve the de-fensive functions of the ego and represent unconscious psychologicalconflicts (see Chapter 2, “General Principles of Psychodynamics”) To theextent that the patient defends himself from awareness of these conflicts,

he will also conceal them from the interviewer Therefore, although thepsychiatric patient is motivated to reveal himself in order to gain relieffrom his suffering, he is also motivated to conceal his innermost feelingsand the fundamental causes of his psychological disturbance

The patient’s fear of looking beneath his defenses is not the only basisfor concealment in the interview Every person is concerned with the im-pression he makes on others The clinician, as a figure of authority, oftensymbolically represents the patient’s parents, and consequently his orher reactions are particularly important to the patient Most often the pa-tient wishes to obtain the clinician’s love or respect, but other patternsoccur If the patient suspects that some of the less admirable aspects ofhis personality are involved in his illness, he may be unwilling to disclosesuch material until he is certain that he will not lose the interviewer’s re-spect as he exposes himself

Diagnostic and Therapeutic Interviews

An artificial distinction between diagnostic and therapeutic interviews isfrequently made The interview that is oriented only toward establishing

a diagnosis gives the patient the feeling that he is a specimen of pathologybeing examined, and therefore actually inhibits him from revealing hisproblems If there is any single mark of a successful interview, it is the de-gree to which the patient and clinician develop a shared feeling of under-standing The beginner frequently misinterprets this statement as advice

to provide reassurance or approval As an example, statements that begin

“Don’t worry” or “That’s perfectly normal” are reassuring but not standing Remarks such as “I can see how badly you feel about ,” orthose that pinpoint the circumstances in which the patient became “up-set,” are understanding An interview that is centered on understandingthe patient provides more valuable diagnostic information than one thatseeks to elicit psychopathology Even though the interviewer may see apatient only once, a truly therapeutic interaction is possible

under-Initial and Later Interviews

At first glance, the initial interview might logically be defined as thepatient’s first interview with a professional, but in one sense such a def-inition is inaccurate Every adult has had prior contact with a clinicianand has a characteristic mode of relating in this setting The first contactwith a mental health professional is only the most recent in a series ofinterviews with health professionals The situation is further compli-cated by the patient who has had prior psychotherapy or has studiedpsychology, thereby arriving, before his initial psychiatric interview, at

a point of self-understanding that would require several months oftreatment for another person There is also the question of time: Howlong is the initial interview? One hour, 2 hours, or 5 hours? Certainlythere are issues that differentiate initial from later interviews; however,these often prevail for more than one session Topics that may be dis-cussed with one patient in the first or second interview might not bediscussed with another patient until the second year of treatment Weprovide advice from time to time regarding those issues that should bediscussed in the first few sessions and those that are better left for laterstages of treatment Greater precision would require discussion of spe-cific sessions with specific patients Examples from our own consultationrooms are provided throughout the book

This book discusses the consultation and initial phase of therapy,which may last a few hours, a few months, or even longer The inter-viewer uses the same basic principles in the first few interviews as inmore prolonged treatment

Data of the Interview

Content and Process

The content of an interview refers both to the factual information

pro-vided by the patient and to the specific interventions of the interviewer.Much of the content can be transmitted verbally, although both partiesalso communicate through nonverbal behavior Often the verbal con-tent may be unrelated to the real message of the interview Some com-mon examples are the patient who tears a piece of paper into small pieces

or sits with a rigid posture and clenched fists or the seductive womanwho exposes her thighs and elicits a guilty nonverbal peek from the in-terviewer Content involves more than the dictionary meanings of the pa-

8 • T H E P S Y C H I A T R I C I N T E R V I E W I N C L I N I C A L P R A C T I C E

tient’s words For example, it also concerns his language style—his use

of the active or passive verb forms, technical jargon, colloquialisms, orfrequent injunctives

The process of the interview refers to the developing relationship

be-tween interviewer and patient It is particularly concerned with the plicit meaning of the communications The patient has varying degrees

im-of awareness im-of the process, experienced chiefly in the form im-of his tasies about the doctor and a sense of confidence and trust in him Somepatients analyze the clinician, speculating on why he says particularthings at particular times The interviewer strives for a continuing aware-ness of the process aspects of the interview He asks himself questionsthat illuminate this process, such as “Why did I phrase my remark inthose words?” or “Why did the patient interrupt me at this time?”Process includes the manner in which the patient relates to the inter-viewer Is he isolated, seductive, ingratiating, charming, arrogant, orevasive? His mode of relating may be fixed, or it may change frequentlyduring the interview The interviewer learns to become aware of his ownemotional responses to the patient If he examines these in the light ofwhat the patient has just said or done, he may broaden his understanding

fan-of the interaction For example, he may begin to have difficulty trating on the dissertation of an obsessive-compulsive patient, therebyrecognizing that the patient is using words in order to avoid contact ratherthan to communicate In another situation, the clinician’s own emotionalresponse may help him recognize a patient’s underlying depression orthat the patient is quite narcissistic or borderline

concen-Introspective and Inspective Data

The data communicated in the psychiatric interview are both

introspec-tive and inspecintrospec-tive Introspecintrospec-tive data include the patient’s report of his

feelings and experiences This material is usually expressed verbally

Inspective data involve the nonverbal behavior of the patient and the

interviewer The patient is largely unaware of the significance of hisnonverbal communications and their timing in relation to verbal con-tent Common nonverbal communications involve the patient’s emo-tional responses, such as crying, laughing, blushing, and being restless

A very important way in which the patient communicates feelings isthrough the physical qualities of his voice The interviewer also observesthe patient’s motor behavior in order to infer more specific thought pro-cesses that have not been verbalized For example, the patient who playswith his wedding ring or looks at his watch has communicated morethan diffuse anxiety

Affect and Thought

The patient’s decision to consult a mental health expert is usually rienced with some ambivalence, even when the patient has had priorexperience with that situation It is scary to open oneself up to a stranger.This is particularly true if the stranger does little to put the patient atease or feels ill at ease himself The patient fears embarrassment, or pre-mature or critical judgments on the part of the interviewer Inexperi-enced interviewers are more apt to feel anxious when meeting a patientfor the first time The patient is anxious about his illness and about thepractical problems of psychiatric treatment Many people find the idea

expe-of consulting a mental health prexpe-ofessional extremely upsetting, whichfurther complicates the situation The clinician’s anxiety usually centers

on his new patient’s reaction to him as well as on his ability to providehelp If the interviewer is also a student, the opinions of his teachers will

be of great importance

The patient may express other affects, such as sadness, anger, guilt,shame, pride, or joy The interviewer should ask the patient what he feelsand what he thinks elicited that feeling If the emotion is obvious, the in-terviewer need not ask what the patient is feeling but rather what has led

to this emotion now If the patient denies the emotion named by the viewer but uses a synonym, the interviewer accepts the correction andasks what stimulated that feeling instead of arguing with the patient Somepatients are quite open about their emotional responses, whereas othersconceal them even from themselves Although the patient’s thoughts areimportant, his emotional responses are the key to understanding the inter-view For instance, one patient who was describing details of her currentlife situation fought back her tears when she mentioned her mother-in-law The interviewer might remark, “This seems to be an upsetting topic”

inter-or “Are you fighting back tears?”

The patient’s thought processes can be observed in terms of quantity,rate of production, content, and organization Is his thinking constricted?

If so, to what topics does he limit himself? Are his ideas organized andcoherently expressed? Gross disturbances in the pattern of associations,rate of production, and total quantity of thought are easily recognized

The Patient

Psychopathology. Psychopathology refers to the phenomenology of

emotional disorders It includes neurotic or psychotic symptoms as well

as behavioral or characterological disturbances In the latter categoriesare defects in the patient’s capacities for functioning in the areas of love,sex, work, play, socialization, family life, and physiological regulation

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Psychopathology also deals with the effectiveness of defense nisms, the interrelationships between them, and their overall integra-tion into the personality

mecha-Psychodynamics. Psychodynamics is a science that attempts to explain

the patient’s total psychic development Not only are his symptoms andcharacter pathology explained but also his strengths and personalityassets The patient’s reactions to internal and external stimuli over the en-tire course of his lifetime provide the data for psychodynamic explana-tions These topics are discussed in detail in Chapter 2 as well as in specificapplications in the various clinical chapters in Part II In recent years, neu-roscientific research has provided useful understanding of brain function.For example, in the case of posttraumatic stress disorder, brain imagingtechniques identify areas of the brain that are damaged as a result of severepsychological stress This does not negate the psychological meaning of theexperience for the patient The lone survivor of a company wiped out bythe enemy in battle suffers more than just witnessing the death of hisfriends and companions He wonders why he was spared and what hecould have done differently to help his comrades Guilt is an essential com-ponent of the human psychic apparatus, and the patient can usually find aconscious or unconscious reason to blame himself for his suffering

Personality strengths. Frequently, a patient comes to the consultationwith the expectation that the interviewer is only concerned with symp-toms and deficiencies of character It can be reassuring when the clini-cian expresses interest in assets, talents, and personality strengths Withsome patients such information is volunteered, but with others the in-terviewer may have to inquire, “Can you tell me some things you likeabout yourself or of which you are the most proud?” Often the patient’smost important assets can be discovered through his reactions duringthe interview The interviewer can help the patient to reveal his health-ier attributes It is normal to be tense, anxious, embarrassed, or guiltywhen revealing shortcomings to a stranger There is little likelihood thatthe patient will demonstrate his capacity for joy and pride if, just after hehas tearfully revealed some painful material, he is asked, “What do you

do for fun?” It is often necessary to lead the patient away from ting topics gently, allowing him the opportunity for a transition period,before exploring more pleasant areas

upset-In this area, more than any other, the nonreactive interviewer willmiss important data For example, if a patient asks, “Would you like tosee a picture of my children?” and the interviewer appears neutral, thepatient will experience this as indifference If the clinician looks at the

pictures and returns them without comment, it is unlikely that the tient will show his full capacity for warm feelings Usually the picturesprovide clues to appropriate remarks that will be responsive and willhelp to put the patient at ease The interviewer could comment on thefamily resemblances or what feelings are apparent in the picture, indi-cating that he takes the patient’s offering sincerely He could also ask thepatient to name the persons in the picture.

pa-Transference. Transference is a process whereby the patient

uncon-sciously displaces onto individuals in his current life those patterns of havior and emotional reactions that originated with significant figuresfrom his childhood The relative anonymity of the interviewer and hisrole of parent-surrogate facilitate this displacement to him These trans-ference themes are integrated with the patient’s realistic and appropri-ate reactions to the interview and together form the total relationship.Many psychoanalysts believe that all responses in human relationsare transferentially based Others make a distinction between transfer-

be-ence and the therapeutic alliance, which is the real relationship between the

interviewer’s professional persona and the healthy, observing, rationalcomponent of the patient The realistic cooperative therapeutic alliancealso has its origin during infancy and is based on the bond of real trust

between the child and his mother Positive transference is often employed

loosely to refer to all of the patient’s positive emotional responses to thetherapist, but strictly speaking the term should be limited to responsesthat are truly transference—that is, attitudes or feelings that are displacedfrom childhood relationships and are unrealistic in the therapeutic set-ting An example is the delegated omnipotence with which the therapist

is commonly endowed A stronger therapeutic alliance is desirable fortreatment so that the patient will place his trust and confidence in the cli-nician—a process that is mistakenly referred to as “maintaining a positivetransference.” The beginner may misconstrue such advice to mean thatthe patient should be encouraged to love him or to express only positivefeelings This leads to “courting” behavior on the part of the interviewer.Certain patients, such as one who is paranoid, are more comfortable, par-ticularly early in treatment, if they maintain a moderately negative trans-ference exemplified in suspiciousness For other patients, such as manywith psychosomatic or depressive disorders, negative transference must

be recognized and resolved promptly or the patient will flee treatment

Transference neurosis refers to the development of a new dynamic

constellation during intensive psychotherapy The therapist becomesthe central character in a dramatization of the emotional conflicts thatbegan in the patient’s childhood Whereas transference involves frag-

12 • T H E P S Y C H I A T R I C I N T E R V I E W I N C L I N I C A L P R A C T I C E

mentary reproductions of attitudes from the past, the transference rosis is a constant and pervasive theme of the patient’s life His fantasiesand dreams center on the clinician

neu-Realistic factors concerning the clinician can be starting points forthe initial transference Age, sex, personal manner, and social and ethnicbackground all influence the rapidity and direction of the patient’s re-sponses The female clinician is likely to elicit competitive reactionsfrom female patients and erotic responses from male patients If the cli-nician’s youth and appearance indicate that she is a trainee or a student,these factors also influence the initial transference With male cliniciansthe reverse holds true Transference is not simply positive or negativebut rather a re-creation of the various stages of the patient’s emotionaldevelopment or a reflection of his complex attitudes toward key figures

of importance in his life In terms of clinical phenomenology, some mon patterns of transference can be recognized

com-Desire for affection, respect, and the gratification of dependentneeds is the most widespread form of transference The patient seeksevidence that the interviewer can, does, or will love him Requestingspecial time or financial considerations, borrowing a magazine from thewaiting room, and asking for a glass of water can be common examples

of the symbolic expressions of transference wishes The inexperiencedinterviewer tries to differentiate “legitimate,” realistic requests from “ir-rational” transference demands and then to respond to the former whilefrustrating and interpreting the latter As a result, many errors are made

in the management of such episodes The problem could be simplified

if it is assumed that all requests include unconscious transference ing The question then becomes the appropriate mixture of gratificationand interpretation The decision depends on the timing of the request,its content, the type of patient, the nature of the treatment, and the real-ity of the situation One is wise not to make most transference interpre-tations until a therapeutic alliance has been firmly established

mean-For example, at their first meeting a new patient might greet theinterviewer saying, “Do you have a tissue?” This patient begins his rela-tionship by making a request The clinician should simply respond to thisrequest, since refusals or interpretations would be premature and quicklyalienate the patient However, once an initial relationship has been estab-lished, the patient might ask for a tissue and add parenthetically, “I think Ihave one somewhere, but I’d have to look for it.” If the interviewer chose

to explore this behavior, he could simply raise his eyebrows and wait ally the patient will search for his own while commenting, “You probablyattribute some significance to this!” “Such as?” the interviewer might reply.This provides an opportunity for further inquiry into the patient’s motives

Usu-The interviewer who has provided tissues on several occasions mightcomment, “I notice that you often ask me for tissues.” The discussion willthen explore whether this request reflects a general practice or occursonly in the therapist’s office In either event, the dialogue can progress tothe patient’s attitude toward self-reliance and dependency on others.

On occasion, early transference feelings may appear in the form of aquestion, such as “How can you stand to listen to people complain allday?” The patient is trying to dissociate himself from aspects of his per-sonality that he holds in contempt and that he fears will not be accepted

by the clinician The interviewer might reply, “Perhaps you are cerned about my reaction to you?” or “Patients do other things besidescomplain,” thereby opening the topic of how the treatment time can beutilized

con-Omnipotent transference feelings are revealed by remarks such as “Iknow you can help me!”; “You must know the answer”; or “What does

my dream mean?” Hollywood has worn out the standard gambit of

“What do you think?” Instead, the interviewer can reply, “You feel that

I know the answers?” or “Do you feel that I am withholding?” A moredifficult manifestation of this problem is seen in the younger patient whoconsistently refers to the interviewer with an ingratiating manner as

“Ma’am” or “Doctor.” The interviewer meets great resistance if he tempts to interpret this behavior prematurely, particularly if the patientgrew up in an environment where this was the polite tradition

at-Questions about the interviewer’s personal life may involve severaldifferent types of transference However, they most often reveal con-cern about his experience or his ability to understand the patient Suchquestions include “Are you married?”; “Do you have children?”; “Howold are you?”; “Are you Jewish?”; or “Do you live in the city?” The expe-rienced interviewer often knows the meaning of the question from priorexperience and his knowledge of the patient and might intuitively rec-ognize when it is preferable to answer the question directly For the mostpart, the beginner is best advised to inquire, “What did you have in mind?”

or “What leads to your question?” The patient’s reply may reveal ference feelings At that point, the interviewer could interpret the mean-ing of the patient’s question by stating, “Perhaps you ask about my agebecause you’re not sure if I am experienced enough to help you?” or

trans-“Your question about my having children sounds as if it means, am I able

to understand what it is like to be a parent?” On other occasions thesequestions signify the patient’s desire to become a social friend rather than

a patient, since he dislikes the asymmetry of the patient role and believesthat a symmetrical friendship will provide the contact that he craves.Here the interviewer can explore the subject of the patient’s friendships

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and inquire whether he has attempted to discuss his problems withfriends and whether they were helpful If this had helped sufficiently,the patient would not be in the clinician’s office

Later in the process, the therapist often becomes an ego-ideal for thepatient This type of positive transference is often not interpreted Thepatient may imitate the mannerisms, speech, or dress of the therapist,usually without conscious awareness Some patients openly admire theclinician’s clothing, furniture, or pictures Questions such as “Where didyou buy that chair?” can be answered with “What leads to your ques-tion?” The patient usually replies that he admires the item and wants toobtain one for himself If the therapist wishes to foster this transference,

he may provide the information; if he wants to interpret it, he will explorethe patient’s desire to emulate him With increasing experience the in-terviewer is more comfortable occasionally answering such questions,first because he grows more at ease in his therapist role and second be-cause he is more likely to find an opportunity to refer to the episode in

an interpretation later in the session or in a subsequent session after hehas accumulated additional similar material

Competitive feelings stemming from earlier relations with parents

or siblings can be expressed in the transference An illustration occurredwith a young man who regularly arrived for morning appointmentsearlier than the therapist One day he uncharacteristically arrived a fewminutes late and remarked, “Well, you beat me today.” He experiencedeverything as a competitive struggle The therapist replied, “I didn’trealize that we were having a race,” thereby calling attention to the pa-tient’s construction of the event and connecting it with a theme that hadbeen discussed in the past

Other common manifestations of competitive transferences includedisparaging remarks about the therapist’s office, manners, and dress; dog-matic, challenging pronouncements; or attempts to assess the clinician’smemory, his vocabulary, or his fund of knowledge Belittling attitudesmay also appear in other forms, such as referring to a clinician as “Doc” orconstantly interrupting him Other examples include using the therapist’sfirst name without invitation or talking down to the interviewer The cli-nician can directly approach the underlying feeling by asking, “Do youfeel there is something demeaning about talking to me?” In general, com-petitive behavior is usually best ignored in the initial interview becausethe patient is vulnerable to what will be experienced as a criticism.Male patients show interest in the male clinician’s power, status, oreconomic success; with a female clinician they are more concerned withher motherliness, her seduceability, and how she is able to have a careerand a family Female patients are concerned about a male therapist’s

attitude concerning the role of women, whether he can be seduced,what sort of father he is, and what his wife is like The female patient isinterested in a female therapist’s career and in her adequacy as a womanand mother She may ask, “How do you manage it all?” or “How do youmake the difficult choices?”

Competitive themes may reflect sibling rivalry as well as oedipalconflicts The patient’s competitive feelings may become manifest when

he responds to the therapist’s other patients as though they were lings Spontaneous disparaging remarks such as “How could you treatsomeone like that?” or “I hate the smell of cheap perfume” are commonexamples In initial interviews no response is preferable

sib-Older patients may treat a young interviewer as a child Maternalfemale patients may bring a therapist food or caution him about hishealth, working too hard, and so on Paternal male patients may offerfatherly advice about investments, insurance, automobiles, and so on.Early attention to either the ingratiating or the patronizing dimensions

of these comments would be disruptive to the developing relationship.These transference attitudes can also occur with younger patients Suchadvice is well intentioned at the conscious level and is indicative of pos-itive conscious feelings It is therefore often not interpreted, particularly

in the first few interviews Older interviewers with younger patientsoften elicit parental transferences If the patient has a positive relation-ship with his parents, he may develop an early positive transference,deferring to the interviewer’s wisdom and experience or seeking advice

in a specific situation Older patients usually prefer older clinicians, andhigh-status patients generally seek high-status professionals Older men

of importance are particularly prone to address the male interviewerearly on by his first name, sometimes asking or stating, “I hope that youdon’t mind that I call you John!” This situation can be handled with a re-ply such as “Whatever you prefer.” This is unlikely to happen with a fe-male patient unless it is with a female interviewer

Some therapists use first names with their patients This is neitherinherently good nor inherently bad, but it always means something,and that meaning should be understood Symbols used in the relation-ship should reflect mutual respect and comfortable social forms Gener-ally, therapists call children or adolescents by first name, as do otheradults Patients who would expect to be on a first-name basis with thetherapist outside the therapeutic situation may prefer to use first names

in the professional setting, and there is no reason not to do so However,this should always be symmetrical The patient who wants to be called

by his or her first name but calls the therapist “Dr ——” is expressing adesire for an asymmetric relationship that has important transference

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meaning that should be explored but not enacted by the therapist Itusually suggests the patient’s offer to submit to the therapist, with thesubmission entailing authority or social, racial, generational, sexual, orother power The therapist who accepts such an invitation not onlyabuses the patient but also misses an important therapeutic opportu-nity Conversely, the therapist who, uninvited, has the impulse to call anadult patient by his or her first name should explore that impulse forcountertransference significance This occurs most commonly with pa-tients of perceived lower status—socially, economically, or because ofpathology or great age Understanding the temptation can help thepatient; acting on it is destructive

In general, transference is not discussed early in treatment except inthe context of resistance This does not mean that only negative transfer-ence is discussed; positive transference can also become a powerful re-sistance For example, if the patient discusses only affection for theclinician, the interviewer can remark, “You spend much more time dis-cussing your feelings about me than talking about yourself or your prob-lems.” Other patients avoid mentioning anything that is related to theinterviewer In this case, one waits until the patient seems to suppress

or avoid a conscious thought and then inquires, “You seemed to hesitatefor a moment Did you avoid some thought?” When a patient who hasspoken freely suddenly becomes silent, it is usually because of thoughts

or feelings about the clinician The patient may remark, “I have run out

of things to talk about.” If the silence persists, the interviewer couldcomment, “Perhaps there is something you are uncomfortable talkingabout?”

Resistance. Resistance is any attitude on the part of the patient that

opposes the objectives of the treatment Insight-oriented psychotherapynecessitates the exploration of symptoms and behavior patterns, andthis leads to anxiety Therefore the patient is motivated to resist the ther-apy in order to maintain repression, ward off insight, and avoid anxiety.The concept of resistance is one of the cornerstones of all dynamic psy-chotherapy

Resistance can develop from any of the transference attitudes ously described Each of the major types of transference is at times used

previ-as a resistance The patient attempts to elicit evidence of the clinician’slove or expects a magical cure through his omnipotent power Ratherthan resolving his basic conflicts, the patient may merely attempt anidentification with the therapist, or he may adopt an attitude of compe-tition with the therapist instead of working together with him Theseprocesses may assume subtle forms—for example, the patient may pre-

sent material that he thinks is of particular interest to the clinician ply to please him Just as transference can be used as a resistance, so toocan it serve as a motivating factor for the patient to work together with theclinician.

sim-For example, a resident came to one of us for analysis Soon the patientwas informing the therapist (who held an important administrativeposition in the program) of the misbehavior of other residents Attempts

to explore the meaning of the tattling were useful, but the behavior tinued Finally, the therapist suggested that the patient omit the names

con-of the other residents This was after exploring the obvious fantasy thatthe analyst received gratification from this private source of informa-tion The patient replied angrily, “Aren’t I supposed to say whatevercomes to mind?” The therapist replied, “You can continue to discuss theincidents and their meanings to you, but I don’t need to have the names.”

At that point the patient stopped tattling on colleagues

Another example of resistance is reflected by the patient’s ingness to relinquish the secondary benefits that accompany his illness.Thus the patient with a conversion symptom of back pain is legiti-mately unable to carry out her unwanted household tasks as long as she

unwill-is sick, and at the same time she receives attention and sympathy

A different resistance is manifested by the patient’s unconsciousneed for punishment The patient’s symptoms inflict suffering on him-self that he is reluctant to relinquish This is particularly prominent inthe treatment of depressed patients or patients who feel intensely guiltywhen they encounter critical feelings toward a loved one

It is a valid clinical observation that patients maintain fixed adaptive patterns of behavior despite insight and the undoing of re-pression Neuroscientists explain this phenomenon in terms of thepersistence of established patterns of neurocircuitry This means thatthe therapist and patient must learn to accept that which cannot changedespite multiple repetitions of alternate patterns.1

mal-Clinical examples of resistance mal-Clinical examples of resistance are

overdetermined and represent mixtures of several mechanisms Theyare classified in terms of their manifestations during the interview ratherthan according to hypothetical underlying psychodynamics

1Sandor Rado was decades ahead of his time with his belief in a cal basis for resistance to change and that the patient had to actively change hisbehavior before he could develop new responses to old situations

neurobiologi-18 • T H E P S Y C H I A T R I C I N T E R V I E W I N C L I N I C A L P R A C T I C E

First are the resistances that are expressed by patterns of cation during the session The one that is most easily recognized andmost uncomfortable for many interviewers is silence The patient mayexplain, “Nothing comes to my mind” or “I don’t have anything to talkabout.” Once the initial phase of therapy is past, the doctor may sit qui-etly and wait for the patient Such an approach is rarely helpful in thefirst few interviews

communi-The interviewer indicates his interest in the patient’s silence Hemight comment, “You’re silent What does that mean?” or “Tell me aboutyour silence” if that is not successful Depending on the emotional tone

of the silence, as revealed by nonverbal communication, the clinician maydecide on a tentative meaning and then remark accordingly For example,

he could say, “Shame makes people hide” or “Perhaps there is somethingthat is difficult for you to discuss.” If the patient seems to feel helpless and

is floundering for direction, the interviewer might interpret, “You seem

to feel lost.” The patient might respond, “Could you ask me some tions?” The interviewer’s goal is to teach the patient how to participatewithout provoking the feeling that his performance thus far has been in-adequate One possible response is, “It is often helpful to find out justwhat was on your mind when it went blank The last thing we were talk-ing about was your children What were you thinking then?”

ques-If the silence is more a manifestation of the patient’s defiance or tive obstinacy, an appropriate remark would be, “You may resent having

reten-to expose your problems reten-to me” or “You seem reten-to feel like holding back.”Beginning interviewers often unwittingly provoke silences by as-suming a disproportionate responsibility for keeping the interview go-ing Asking the patient questions that can be answered “yes” or “no” orproviding the patient with multiple-choice answers for a question dis-courages his sense of responsibility for the interview Such questionslimit the patient’s spontaneity and constrict the flow of ideas The patientretreats to passivity while the interviewer struggles for the right ques-tion that will “open the patient up.”

The patient who speaks garrulously may use words as a means ofavoiding engagement with the interviewer as well as of warding off hisown emotions If the interviewer is unable to get a word in edgewise,

he can interrupt the patient and comment, “I find it difficult to say thing without interrupting you.” The literal-minded patient may reply,

any-“Oh, did you want to say something?” A suitable response would be, “Iwas wondering what makes it so difficult for us to talk together?”Censoring or editing thoughts is universal Clues to this include in-terruptions in the free flow of speech and abrupt changes of subject,facial expressions, and other motor behavior These are usually not

interpreted directly, but the interviewer sometimes remarks, “You don’tseem free to say everything that comes to your mind”; “What was it thatinterrupted your thought?”; or “It seems that you’re screening yourthoughts.” These comments emphasize the process of editing ratherthan the content Another form of editing occurs when the patientcomes to the appointment with a prepared agenda, thereby making cer-tain that spontaneous behavior during the interview will be at a mini-mum This resistance is not to be interpreted in the first few interviews,since the patient will be unable to accept that it is a resistance until later.Further discussion of this issue appears in Chapter 2.

The patient who brings notes to the interview may utilize them as away of controlling the interview or of avoiding interaction with the in-terviewer However, bringing notes to the interview is not always a man-ifestation of resistance For example, a disorganized patient may use thenotes to help organize himself, or an older patient may use them to com-pensate for memory impairment

Intellectualization is a form of resistance encouraged by the fact that

psychotherapy is a “talking” therapy that utilizes intellectual constructs.Beginning interviewers have particular difficulty in recognizing the de-fensive use of the patient’s intellect except when it occurs in obsessive

or schizophrenic patients, in whom the absence of affect is an obviousclue However, in the case of the histrionic patient who speaks in alively manner, often with more “emotion” than the interviewer, the pro-cess may go undetected If the patient offers some insight into his behav-ior and then asks the interviewer, “Is that right?” resistance is operatingregardless of how much affect was present Although the insight may

be valid, the side comment reveals the patient’s concern with the viewer’s concurrence or approval It is the use of intellectualization towin the therapist’s emotional support that demonstrates the patient’sresistance The patient is simultaneously opening issues related to thetherapeutic alliance as he attempts to collaborate with the clinician inlearning the therapist’s “language” and concepts for the purpose ofwinning the therapist’s approval The interviewer can address the trans-ference resistance while supporting the therapeutic alliance He mightsay to the patient, “Finding answers that are meaningful to you not onlyhelps you understand yourself, but it also builds your self-confidence.”The patient might not accept this answer and might respond with “But

inter-I need you to tell me whether inter-I’m right or not.” This is one of the mostcommon problems in psychotherapy, and one that will be analyzed re-peatedly in a variety of different contexts The therapist, by recognizingand accepting the patient’s need for reassurance and guidance, offerssome emotional support without infantilizing the patient

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There are several ways in which the interviewer can discourage tellectualization First, he can avoid asking the patient questions thatbegin with “Why?” The patient usually does not know why he becamesick at this time or in this particular way, or even why he feels as hedoes The clinician wants to learn why, but in order to do so he must findways to encourage the patient to reveal more about himself When

in-“Why?” comes to the clinician’s mind, he could ask the patient to rate or provide more details Asking “Exactly what happened?” or “Howdid this come about?” is more likely to elicit an answer to a “why” ques-tion than asking “Why?” “Why” questions also tend to place the patient

elabo-in a defensive position

Any question that suggests the “right” answer will invite alization Furthermore, it will give the patient the idea that the inter-viewer is not interested in his true feelings but is attempting to fit himinto a textbook category The use of professional jargon or technical termssuch as “Oedipus complex,” “resistance,” or “masochistic” also encour-ages intellectualized discussions

intellectu-Patients who use rhetorical questions for the effect that they produce

on the interviewer invite intellectualization For example, a patientsays, “Why do you suppose I get so angry whenever Jane brings up thesubject of money?” Any attempt to deal with the manifest question en-sures intellectualization If the interviewer remains quiet, the patientusually continues to speak The experienced interviewer may see this as

an opportunity to find out the details and asks, “Would you give me arecent example?” The meaning of a pattern is hidden in the details ofparticular episodes The interviewer, on the other hand, may strategi-cally utilize rhetorical questions on occasion when he wishes to stimu-late the patient’s curiosity or leave him with something to ponder Forinstance, “I wonder if there is any pattern to your anxiety attacks?”Reading about psychotherapy and psychodynamics is at times used

as an intellectual resistance or a desire to please the therapist It alsomay be a manifestation of a competitive or dependent transference Thepatient may be attempting to keep “one up” on the clinician or may belooking for the “additional help.” Some therapists used to give the pa-tient injunctions against reading Usually this avoided the issue Thepopular literature is now filled with information for patients, as are Websites, and a generation of people are trained to look things up If the pa-tient finds it helpful, go with the flow If it largely has a transferentialmessage, let it emerge

Generalization is a resistance in which the patient describes his life

and reactions in general terms but avoids the specific details of eachsituation When this occurs, the interviewer can ask the patient to give

additional details or to be more specific Occasionally, it may be sary to pin the patient down to a “yes” or “no” answer to a particularquestion If the patient continues to generalize despite repeated re-quests to be specific, the therapist interprets the resistant aspect of thepatient’s behavior That does not mean telling the patient, “This is a re-sistance” or “You are being resistant.” Such comments are experiencedonly as criticisms and will not be helpful Instead, the clinician couldsay, “You speak in generalities when discussing your husband Perhapsthere are details concerning the relationship that you have trouble tell-ing me.” Such a comment, because it is specific, illustrates one of themost important principles in coping with generalization The inter-viewer who makes vague interpretations such as “Perhaps you general-ize in order to avoid upsetting details” will encourage the very resistance

Concentrating on trivial details while avoiding the important topics is

a frequent resistance with obsessive patients If the interviewer ments on this behavior, the patient insists that the material is pertinentand that he must include such information for “background.” One pa-tient, for instance, reported, “I had a dream last night, but first I must tellyou some background.” Left to his own devices, the patient spoke most

com-of the session before telling his dream The interviewer can make the tient more aware of this resistance if he replies, “Tell me the dream first.”

pa-In psychoanalysis, the patient might be permitted to discover for himselfthat he never allowed enough time to explore his dreams

Affective display may serve as a resistance to meaningful cation Hyperemotionality is common in histrionic patients; affects such

communi-as boredom are more likely in obsessive-compulsive patients The trionic patient uses one emotion to ward off deeper painful affects; forexample, constant anger may be used to defend against injured pride.Frequent “happy sessions” indicate resistance in that the patient ob-tains sufficient emotional gratification during the session to ward offdepression or anxiety This can be dealt with by exploring the processwith the patient and by no longer providing such gratification

his-22 • T H E P S Y C H I A T R I C I N T E R V I E W I N C L I N I C A L P R A C T I C E

In addition to resistances that involve patterns of communication,

there is a second major group of resistances called acting out These

involve behavior that has meaning in relation to the therapist and thetreatment process It does not necessarily occur during the session, butthe clinician is directly involved in the phenomenon, although he may

be unaware of its significance An enactment is a little drama in which

the patient’s transference fantasy is played out rather than verbalized oreven consciously recognized by the patient Examples would be the pa-tient who answers his cell phone during the session to dramatize hisown importance compared with that of the therapist or the woman whohas her secretary call to check the time of the next appointment, whichshe was too preoccupied to write in her appointment book

Acting out is a form of resistance in which feelings or drives ing to treatment or to the clinician are unconsciously displaced to a per-son or situation outside the therapy The patient’s behavior is usuallyego-syntonic, and it involves the acting out of emotions instead of expe-riencing them as part of the therapeutic process Genetically, these feelingsinvolve the reenactment of childhood experiences that are now re-created

pertain-in the transference relationship and then displaced pertain-into the outside world.Two common examples involve patients who discuss their problemswith persons other than the therapist and patients who displace nega-tive transference feeling to other figures of authority and become angrywith them rather than with the therapist This resistance usually is notapparent during the first few hours of treatment, but when the oppor-tunity presents itself, the interviewer may explore the patient’s motivesfor the behavior In most cases the patient will change, but at times theclinician may have to point out the patient’s inability to give up the be-havior despite his recognition that it is irrational

Requests to change the time of the appointment may be a resistance.The patient may communicate his unconscious priorities by saying, “Can

we change Thursday’s appointment? My wife can’t pick up the kids atschool that day.” To interpret this simply as resistance can miss an op-portunity to help the patient recognize that he is saying that he is moreafraid of his wife than of his therapist One patient may look for an ex-cuse to miss the appointment altogether, whereas another may becomeinvolved in a competitive power struggle with the clinician, saying, ineffect, “We will meet when it is convenient for me.” A third patient mayview the clinician’s willingness to change the time as proof that he re-ally wants to see the patient and therefore will be a loving, indulgentparent Before interpreting such requests, the clinician needs to under-

stand the deeper motivation The clinician may indicate that he is willing to grant such a request The claim that he is unable to grant them

un-often reveals a fear of displeasing the patient Special problems exist forthe patient whose job demands change abruptly so that absence onshort notice occurs Keeping one’s job is more important than pleasingthe therapist The clinician’s best response is empathy for the situation.The use of minor physical symptoms as an excuse in missing sessions

is a common resistance in narcissistic, phobic, histrionic, and tion disorder patients Frequently, the patient telephones the clinicianprior to the interview to report a minor illness and to ask if he shouldcome This behavior is discussed in Chapter 15, “The Psychosomatic Pa-tient.” When the patient returns, the clinician explores how the patientfelt about missing the meeting before he interprets the resistance.Arriving late and forgetting appointments altogether are obviousmanifestations of resistance Early attempts at interpretation will be metwith statements such as “I’m sorry I missed the appointment, but it hadnothing to do with you”; “I’m late for everything; it has no bearing onhow I feel about treatment”; “I’ve always been absentminded about ap-pointments”; or “How can you expect me to be on time? Punctuality isone of my problems.” If the interviewer does not extend the length of theappointment, the lateness will become a real problem that the patientmust face It will often become clear that the patient who arrives late ex-pects to see the clinician the moment he arrives It is not appropriate forthe interviewer to retaliate, but it is not expected that he sit idly, waitingfor the patient’s arrival If the clinician has engaged in some activity andthe patient has to wait for a few minutes when arriving late, additionalinformation concerning the meaning of the lateness will emerge In gen-eral, the motive for lateness involves either fear or anger

somatiza-Failing or forgetting to pay the clinician’s bill is another reflection

of both resistance and transference This topic is considered in greaterdetail later in this chapter (see “Fees”)

Second-guessing or getting “one up” on the clinician is a manifestation

of a competitive transference and resistance The patient triumphantly

an-nounces, “I bet I know what you are going to say next” or “You said thesame thing last week.” The interviewer can simply remain silent, or hecan ask, “What will I say?” If the patient has already verbalized his the-ory, the clinician might comment, “Why should I think that?” It is gener-ally not a good idea to tell the patient if he was correct in second-guessingthe interviewer, but as with every rule, there are exceptions

Seductive behavior is designed either to please and gratify the

inter-viewer, thereby winning his love and magical protection, or to disarmhim and obtain power over him Further illustrations are such questions

as “Would you like to hear a dream?” or “Are you interested in a problem

I have with sex?” The interviewer might reply, “I am interested in