The inTerview Process
The core elements of a good interview ... 50 Interaction with a purpose ... 52 Client feedback ... 53
The core elemenTs oF A gooD inTerview
Building on Chapter 2’s discussion of the specific features of a good assessment process, we will now outline the core elements of a good interview. Along the way, we will review some common clinical challenges that counsellors may experience during the process and provide some tips to use in clinical practice.
The core elements of a good interview include such things as: 1. Motivational interviewing principles:
• use counselling strategies that build rapport. • use counselling strategies that reduce resistance. • use counselling strategies that are client-centred. 2. Doing the right thing at the right time:
• use clinical judgment to determine when to use the tools in an interview. • use interventions that are designed for the client’s stage of change. 3. Using an appropriate mix of probing, data gathering and direction.
4. Using your clinical judgement:
• Should the tools be used for this individual? • Should the tools be used at this time?
• Can the tools be used within the interview? Outside of the interview? As homework? 5. Employing “best practices”:
• use clinical standards that respect diversity.
• use clinical standards that are research-based and have clinical utility.
in Chapter 2, you read some clinical tips about things that will help your client feel comfortable with you in the context of a therapeutic relationship. The client needs to understand your role, its limitations and strengths and your relationship with other referral sources. The client also needs to develop an understanding of his or her own role in this equation.
All of the above factors, in conjunction with the style of your interview, the format, the purpose of the interview, and other elements such as the client’s personal circumstances, are the key elements to a positive interview experience.
CHAP TER 3: THE inTERViEW PROCESS
51 Research indicates that “the way in which the therapist interacts with the client appears to be nearly as important as, or more important than, the specific approach or school of thought from which he or she operates. This suggests that therapist style, a variable often ignored in outcome research, is a major determinant of treatment success” (Miller & Rollnick, 1991, p. 4).
This manual will assist you to develop an interview style that promotes client engagement and encourages your client to attend further appointments, if that is appropriate to your role. There is an art to incorporating the use of structured tools into the interview. You have a complex task to build rapport, gather information and enhance client information within the structure of an interview.
Clinical challenge Question: what do i do if my client is high or under the influence of alcohol? Discussion: if your client is under the influence of substances, his impression of you may be coloured by his level of intoxication, as may your impression of him! ensure that the first interview is not conducted while the client is too affected by intoxicants. and how does one define too intoxicated? when should an interview be rebooked, and what are the potential consequences? several factors will need to be considered to answer these questions.
1. The setting in which you work: Your agency may have a policy about how and when staff are to proceed with an interview if the client is under the influence of substances. policies will need to be developed for all substances. training can be accessed about intoxication, about when substance use can interfere with participation, and about how to determine when the client is too intoxicated to proceed. the policies of the the setting in which you work, as well as the work to be accomplished, will determine the answer to this question. some centres may have a policy to use a Breathalyzer on-site for determining alcohol intoxication. in such a case, clients would be required to provide a breath sample and the level of blood alcohol concentration would be a deciding factor in whether the interview proceeded or was rebooked. the level of a client’s impairment would determine whether the application of the tools would be meaningful or not. agencies should focus on the level of impairment rather than on clients’ meeting expectations of “24 hours clean and sober” or “alcohol- and drug-free.”
2. The drug used: clinical settings may have different policies about specific drug use. an agency may have a policy that clients must be abstinent from some drugs but that the assessment may proceed if the client is under the influence of other drugs. for example, medication used as prescribed would be allowed, but medication purchased on the street would be considered inappropriate. keep in mind that a clinician may not realize that a client has taken a mood-altering drug if there are no behavioural or physical indications.
3. The work to be done in the interview: a screening or intake interview at a withdrawal management service would naturally proceed unless there were anticipated medical complications in
withdrawal. in other clinical settings such as residential treatment or support an interview to gather data and other information would most likely be rebooked. an admission interview for any setting that requires abstinence would not normally proceed and the client would be referred to
the withdrawal management service or other appropriate resource.
should the intoxicated client be unable to go ahead with the interview, the focus becomes the safety of the client as well as of the rest of the community. the client may need a referral to a withdrawal management service or emergency department, as appropriate.
4. The client’s ability to abstain or use moderately: some clients may not be able to attend an
appointment while abstinent, in which case some mutually agreeable terms need to be set, so that the client can attend the centre to access services. there are clinical strategies that can assist a client to reduce her use over time so that she eventually, or by some agreed-upon date, can attend appointments while drug-free.
inTerAcTion wiTh A PurPose
The initial interview may have several different priorities. You may need to address the immediate needs of the client and concentrate on building rapport. in addition, collecting assessment information is important, so that referrals can be made. The interview should have structure and be meaningful to the client. The structure of each assessment interview should be consistent from client to client within an agency so that the clinician can develop skill in probing for personal information in an empathetic manner. Both clinician and client need to be clear about the purpose of the interaction. it is to:
• conduct an objective assessment of substance use • collect baseline data to be discussed
• examine the impact of substance use on a variety of life areas • examine the client’s perception of risk, problems and consequences
• give the client an opportunity to clearly compare her substance use patterns and consequences to those of other clients in the clinical population and in the general public. This comparing is called norm referencing and the purpose is to increase the client’s information about what responsible use looks like. The structured assessment interview allows the clinician to ensure that all necessary data is collected so that the client and the clinician can together develop treatment goals and determine next steps.
Clinical challenge
Question: does using tools diminish the ability of the client and counsellor to establish rapport? Discussion: there is a time and a place for the use of tools, and once you are comfortable with the
administration of the tool and have enough practice, you will find you can maintain rapport during the administration of the tool.
CHAP TER 3: THE inTERViEW PROCESS 53 remember to: • introduce the tool • explain its purpose • explain what it measures and what the two of you will do with the information! make sure that you have enough space to administer the tools and spread out the paperwork. it is a good idea to have a small table where you can lay out the materials and where you and your client can either look at the tools together or where the client can sit to complete the tools himself. Clinical tip
It is a good idea to practise administering the tools with a colleague or with your supervisor to develop a comfort level with the materials. It takes practice to handle the forms and explain them with ease, and to score and interpret them. Again, it’s important that you can fully explain the tools to the client, including why you are using them and why investing his time to carefully assess the issues will be helpful to the client.
if you are not yet convinced about why the tools can assist you then you will not be able to engage the client and explain to him why the tools are helpful. A good assessor understands and believes in the process of assessment and is able to convey to the client the value in the process.
clienT FeeDBAck
The purpose of the assessment is to gather data so that you can give the client individualized feedback. You will share the results of the assessment with the client using a motivational framework, counselling strategies appropriate to her stage of change and with a view to reinforcing the responsibility of the client to decide upon next steps.
The client receives personalized information and sees the scores and interpretations of the assessment tools. This can be a very motivating experience for the client. You may share personalized feedback during the assessment or in a later session, depending on the setting in which the assessment takes place.
When feedback is individualized, it is more meaningful to the client because it is clinically relevant to the client personally. it is current information about her own patterns of use. Remember that clients may not be used to thinking about their use patterns in this way. They may be surprised to see the total scores. Clients who present in various stages of change are helped differentially by personalized feedback.
See Appendix B, “The importance of motivational interviewing,” for more on building an interview style using motivational interviewing approaches and about how personalized feedback helps a client stage by stage.
Clinical tip
During the interview:
• Take your time when sharing feedback. • Speak clearly and do not use clinical jargon.
• Give the client a copy of the feedback or results to follow along with and explain how the session will go.
• Tell them they can stop and ask questions.
• Do not set yourself up as the expert. After each tool is explained, ask the client if they understand, have questions or wish to pause and reflect on how they are reacting. • Watch body language and other non-verbal cues for signs of resistance, distress or relief.
Use motivation-enhancing techniques such as probing, reflection and amplified reflection to elicit the client’s own reactions.
• Remember that your interpretation of the results will not be as important, relevant or powerful as tthe client’s own!
General information about other substance users, research, or your clinical experiences can only go so far to engage the client in decision-making. The other very important piece in this equation is to relate the client’s personal feedback and scores to relevant norms. Comparisons to other non-problem users, the population that your agency serves, or the system’s alumni can be very helpful ways to allow the client to process their use compared to others. Telling the client that they drink too much may not be as helpful as saying “your total number of drinks per week is about the average that the other clients of the addiction treatment system report.” This confirms to the client that they are in the right place for help.
Clinical challenge You may wonder, “how can i be sure that my client is telling the truth?” clients will give accurate information if they feel safe. a client may decide not to give you “all” the information at this time, but he may wish to share more at a later time. at the beginning of an assessment interview it is wise to cover this by saying, “i hope you can be as honest as possible when answering questions. this is your process and it will be more helpful for you if you can give more information. i realize that it takes time to develop trust and that you may feel you have a lot at stake. if you wish to change or add any information later, please feel free to do so.” research shows that a self-report is generally valid as long as the client does not have a positive blood alcohol level at the time of the interview and has nothing to lose by telling the truth.
CHAP TER 3: THE inTERViEW PROCESS 55 Clinical challenge Question: “how do i encourage mandated clients to tell the truth when the truth could result in the loss of children, liberty, employment or welfare?” clients will need to be fully informed of the limits of confidentiality. Discussion: inform clients fully of your obligation to report to family and children’s services. inform them of their rights to confidentiality, informed consent and protection or advocacy. it may be helpful to do a decisional balance so that they may decide the benefits and costs of telling you the whole story as opposed to bits and pieces. a decisional balance is an exercise where you and the client map out the costs and benefits of both sides of an issue. it is important to explain the importance of their input and how it is reflected in the results and interpretations. some clients will be encouraged in knowing that an accurate assessment may show that they are drinking within acceptable standards or minimally beyond responsible use standards. the assessment may show that they do not actually have as much of a problem as they feared! sometimes referral sources are mistaken in their interpretation that a client is substance-dependent. sometimes the client has a history of bad decision-making or inappropriate lifestyle choices and it is assumed that a previous history of substance abuse or dependence means she is a drug abuser now. You may be able to convince the client that it is in her interest in the long run to participate fully. encourage your client to see that you cannot advocate on her behalf if you are not fully apprised of the situation.