Psychiatric Technique for Diagnostic Interviewing and Therapy: 6 Mantras Every Clinician Should Know

Summary

Psychofarm Podcast — Episode Summary

Episode Title: Psychiatric Technique for Diagnostic Interviewing and Therapy: 6 Mantras Every Clinician Should Know

Date: April 21, 2026
Hosts: Dr. Gregory Malzberg (A), Dr. Fu (B)
Theme: Core “mantras” or guiding slogans for psychiatric interviewing and therapy, focusing on enhancing clinical effectiveness, deepening reflection, and avoiding common pitfalls in patient encounters. Aimed at both clinicians and interested laypeople.

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Episode Overview

In this episode, Dr. Malzberg and Dr. Fu move beyond the technicalities of medication management and diagnosis, highlighting the often-overlooked—but foundational—techniques that underpin effective psychiatric interviewing and psychotherapy. They present and dissect six mantras, or simple guiding phrases, that can immediately improve clinicians’ practice by helping them navigate complex patient relationships, spot deeper problems, and keep sessions meaningful and connected.

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Main Discussion Points and Insights

1. Challenges of Reaching Audiences and the Value of Psychotherapy Skills

• The hosts note lower listener numbers for episodes focused on psychodynamic and psychotherapy techniques, compared to those on medication or diagnosis, reflecting a wider trend in the field.
  • A: “I blame the word psychodynamic. I think it’s a dirty word today, which is a shame.” [01:22]
• Technical skills in interviewing and therapy are compared to the resolution of an MRI: if your approach is poor, your diagnostic information will be “low resolution.” [00:28-00:56]
• Positioning the six mantras as sticky, memorable tools—more useful in-session than rigid frameworks or level systems. [02:24-02:51]

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The Six Mantras for Interviewing and Therapy

1. "Who Is Doing What to Whom?"

[04:12–10:17]

• Meaning: Encourages awareness of the interpersonal dynamics in the room—how patient and clinician influence each other, including conscious and unconscious transference and countertransference.
  • A: “If we’re not aware of that, we’re in trouble.” [04:12]
• Extension: Consider how the patient wants the clinician to feel.
  • B: “…It’s who is doing what to whom and how is the patient trying to get me to feel.” [05:01]
• Clinical example: Novice providers in ER eliciting defensiveness by asking “Any thoughts of hurting yourself?”—transmits coldness, worsens guardedness. [07:49–09:00]
• Caveat: Most of this process is unconscious, not intentional on the patient’s part. [10:17]
• Key Insight: Both clinician and patient can become hyper-focused on one issue at the expense of deeper or parallel problems—a reminder to keep an eye on such dyadic processes.

2. "Make Links and Name Things"

[12:10–18:43]

• Meaning: The practice of connecting symptoms, behaviors, or events with possible causes or consequences, and giving those things a name or conceptual hook.
  • Useful for diagnosis, therapy, and medication management.
• A: “Make links between causes and effects, and put things into some kind of abstract name so that you can refer to it with the patient, regardless of the source.” [12:47]
• Practical example: Noticing a patient’s recurring depression after binge drinking and making that pattern explicit. [12:50–13:58]
• Emphasizes using plain, concrete language (ideally, the patient’s own words) in names and links.
  • B: “So it seems like a big predecessor of making links and naming things is developing a good formulation in a way that captures the patient…” [17:57]
• Key Insight: Making links shouldn’t be limited to diagnosis—also connect emotions with experiences, current patterns with past events, and relationships inside the session with those outside. [18:21–18:42]

3. "Stay Close to the Material"

[18:48–23:52]

• Meaning: Begin with and ground yourself in what the patient actually says and experiences; resist the urge to leap to generalizations, abstractions, or theoretical explanations too quickly.
• Example: Patient reports recent difficulty concentrating; clinician jumps immediately to ADHD differential instead of exploring the change’s context. [18:48–20:10]
• B: “You really need to delve into the experience. And sometimes labels and symptoms are a way of patient and provider colluding not to get into the material.” [22:58–23:52]
• A: “Be experience-near, rather than going to the abstract.” [23:52]

4. "Act Stupider"

[23:52–29:58]

• Meaning: Deliberately approach patient material with a posture of not-knowing; ask seemingly “obvious” or “simple” questions to uncover the patient’s meaning, avoid assumptions, and elicit more depth.
  • A: “Don’t be afraid as a clinician, to ask what seems like very obvious and stupid questions.” [25:15]
• Linked to: The “Columbo approach”—the detective persona of bumbling curiosity that lowers patient defensiveness and encourages their self-explanation. [26:27–26:54]
• B: “It is very rarely through intellectual concepts that help people. A lot of it is being present, being aware, and not being smart.” [28:49]
• Use plain language; beware the expert’s mind (“everything is a nail and we’re the hammer”). [28:00]
• Key Insight: Even experienced clinicians must continually approach each case with curiosity and humility.

5. "Rewind the Tape"

[29:59–33:51]

• Meaning: Return to—and re-examine—moments or details the patient or the session has glossed over or shifted away from. Interrupt if needed to revisit clinically important content.
  • A: “Don’t be afraid to rewind the tape, lead the discussion and go back to something before. It can feel awkward….but don’t be afraid.” [31:03]
• Useful in both diagnostic interviews and therapy (especially with rapid or tangential narrators, or highly emotional/multitopic sessions).
• A: “It really bothers me when I see venting being documented as a psychotherapy intervention. Venting is not the operating procedure that actually helps people." [32:59]
• Key Insight: Good clinicians don’t just listen—they shape and direct sessions, even if it feels uncomfortable.

6. "Observe and Confront"

[33:54–39:25]

• Meaning: Go beyond passive listening—make explicit observations about the patient’s behavior, affect, or contradictions, and gently confront discrepancies between their actions, thoughts, and feelings.
  • A: “Make an observation out loud to the patient about what you’re seeing….For confront, that sounds aggressive. That might be better described as…explicitly [name] contradiction.” [33:54]
• Example: Pointing out a patient’s hopeful statements in previous sessions when they now claim complete hopelessness.
• Linked to motivational interviewing and the importance of highlighting ambivalence or internal contradiction.
• B: “You have to have faith that sometimes…their response after I brought it up was not a positive one. But…there’s a part of them that hears the message.” [36:29]
• A: “You don’t know when something you do is really going to bear fruit later… Nothing is going to grow unless you actually sow regularly.” [37:25]
• Key Insight: Change happens slowly—repeated, well-timed observations can produce long-term effects, even without an immediate positive response.

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Notable Quotes & Memorable Moments

• A: "Your interviewing and therapy technique...it’s kind of like, how good is your MRI? If your interviewing...isn’t good, then your MRI is going to be very low resolution." [00:28]
• A: "I blame the word psychodynamic. I think it’s a dirty word today, which is a shame." [01:22]
• B: “Process over content…what’s going on underneath can sometimes contain the actual information…” [05:25]
• A: “Act stupider. Don’t be afraid as a clinician, to ask what seems like very obvious and stupid questions.” [25:15]
• B: “It is very rarely through intellectual concepts that help people… A lot of it is being present, being aware, and not being smart.” [28:49]
• A: “Venting itself is not actually helpful. It really bothers me when I see venting being documented as a psychotherapy intervention.” [32:59]
• A: “You don’t know when something you do is really going to bear fruit later… Nothing is going to grow unless you actually sow regularly.” [37:25]

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Timestamps for Important Segments

• Intro and Framing: [00:00–02:51]
• Mantra 1: Who is doing what to whom: [04:12–10:17]
• Mantra 2: Make links and name things: [12:10–18:43]
• Mantra 3: Stay close to the material: [18:48–23:52]
• Mantra 4: Act stupider: [23:52–29:58]
• Mantra 5: Rewind the tape: [29:59–33:51]
• Mantra 6: Observe and confront: [33:54–39:25]
• Reflections on outcome-focus and change: [39:25–44:58]

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Episode Tone & Style

• Warm, skeptical, irreverent, and practical.
• Frequent acknowledgment of audience experience—clinicians in training, seasoned therapists, and laypeople.
• Leaned into humility (“act stupider”), emphasizing real-world imperfection and the importance of continual self-correction.

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Closing Reflection

The hosts wrap by emphasizing that effective psychiatric care is not measured solely by immediate outcomes but by the consistent, conscious practice of these core techniques—“mantras”—in every session. They urge listeners to focus first on process, presence, and integration, trusting that improvements in patient care will follow in their own unpredictable ways.

“If you do the job right, regardless of the outcome, you’ve done the right thing. That should be the ultimate guideline.” – Dr. Malzberg [43:31]

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For full episodes, resources, and Dr. Malzberg’s practical guide to treating depression:
psychofarm.substack.com

Transcript

[A]

Foreign. Doctor Mousburg, good morning.

[B]

How you doing?

[A]

Well, I suppose I'm feeling a little unheard today. I'm not sure how many people are actually listening to this series, but I think we better press on.

[B]

I. I want to contain you, but I also. I'm upset that we're not being heard,

[A]

whereas I normally expect the med management stuff and diagnostic stuff is way more popular. But it is a shame because I do think that this material is of utmost importance in the diagnostic process. You know, readying and guiding patients during interview is pretty much the key to you getting any kind of diagnostic data. And it's. It's kind of like, how good is your mri? Right. If your interviewing and therapy technique isn't good, then your MRI is going to be very low resolution. Yeah.

[B]

And I don't think we're being dramatic. We have less than 1500 views on our last episode. In. In my head, I think sometimes I'm like, oh, our podcast has a big reach. And then sometimes I look at our views and it's like it's less than a thousand.

[A]

Well, I blame the word psychodynamic. I think it's a dirty word today, which is a shame.

[B]

A dirty word.

[A]

It's a dirty word. I'm going to put out an edict. I'm going to say, no psychodynamic in this episode title. Let's see if it has an effect.

[B]

All right. We already used it, though.

[A]

I know, I know. Okay, so last time, we left off on talking about containment. Today, I know we talked about going over the rest of the levels and all, but I actually thought before we do that, we're going to do a little divergence, and we're going to discuss a few things that I kind of call the mantras of therapy. Psychodynamic psychotherapy, because they're things that I think if you kind of repeat them in your head as you reflect on what you do in interviews, it helps you do them better and more often. So they're just little slogans, essentially.

[B]

Yeah. And I think this is. I think this is more appropriate than the levels right now because the slogans are a lot stickier. It's not like a psychodynamic therapist is going like, oh, what level is the most appropriate thing now? And I think the mantras is probably an easier thing to integrate, especially if you're not listening as a therapist. If you are listening as a therapist, great. But for people doing a wide array of psychiatric treatments, these mantras can be helpful.

[A]

Now, keep in mind the level system. Again, I do not recommend you do it in session. Don't think about the levels when you're in the session. It's for retrospective analysis only. You can use process notes, you can use video, but just. Or you can just use your memory. Note down moments that stood out to you in any kind of interview or session, and then ask yourself, what level was I operating at? It's purely for retrospective analysis. And if you're a supervisor, I think it's a great way to work with technique when you supervise someone doing a therapy.

[B]

Yeah, great point. But these mantras you can think about in the session.

[A]

Oh, yeah, all the time. So the first one, I think, is familiar to many people. And at the outset here, I should say that these are not my originals, except for maybe one or two. I think most of these I got over time from interviewing experienced psychiatrists, analysts and psychologists. And some of these are taken verbatim from somebody, and I don't remember who it was, but it's kind of timeless wisdom anyway, so I'm not sure it can be attributed to anybody in particular. Awesome. Let's. The first one, though. Oh, go on.

[B]

No, no, jump. Let's jump in.

[A]

Okay. The first one, though, it's certainly from the object relations crew, I would say, or the interpersonal therapy crew. But it's so important to medication management and diagnostic interviewing because it's essentially about countertransference transference phenomena. Right. We all have baggage. Patients have baggage, clinicians have baggage. We bring it into the room and it's going to alter how we perceive or notice or act clinically. And so if we're not aware of that, we're in trouble. So the mantra is who is doing what to whom? Okay. Who is doing what to whom? Any first impressions on that?

[B]

Yeah, actually, if I were to extend it a little bit more, I would say it's who is doing what to whom and how is the patient trying to get me to feel. If we're. I mean, I guess that kind of removes the. Your. The relational.

[A]

Well, I think you're being more. You're explaining it more. We have a little quick, pithy one to keep it in your head, but yeah, you're explaining it, basically. Say more about that.

[B]

Yeah, I think patient. You know, a lot of times you get put in these. These crazy situations, and if you don't take the time to reflect, if you just kind of stay on the surface level of what's occurring, you might be missing what's under underlying it. I think another pithy thing, that phrase that you use Is is process over content in that what's going on underneath can sometimes contain the actual information as to what's going on, rather than the superficial level experience of the provider or the patient.

[A]

Yeah. And then the who was doing what to whom mantra basically reminds us to consider that there's some kind of specifically interpersonal process too, some kind of exchange process between any parties involved in a group situation where a document double situation. Right. And that you, the clinician, can be inducing some kind of effect in the patient. For example, maybe you're interviewing a patient with schizophrenia and something that you have no control over is making that patient have a particular paranoid idea about you. Okay. And then because of that, they withhold information. Right. This is a pretty common. But it's also going in the other direction and it can be happening simultaneously as you doing something to the patient. Right. That patient may then project or rather attribute their paranoia, fear, aggression to you. They may start acting in a way that's maybe a little dicey or maybe even overtly aggressive, maybe yelling or being very oppositional. And that may make you start to feel unkind, unhappy, or negative towards the patient. And then maybe because of that, you say, oh, let's, let's up the medications. I know they don't like them, but, you know, what's the point of talking about it? Or you might say, this is, this is pointless. There's no point talking to or listening to this person. Let's get them out of here. Right. All kinds of things can be happening, and if we're not attentive to that, you can miss it.

[B]

Just a small plug to leave a review if you can. Leaving a review will help other clinicians find our show and will let us keep making it. If you're on Apple podcasts, open the show page, scroll to ratings and review. If you like us, tap five stars. If you're not sure what to put for the review, just say, hi, Dr. Fu. And if you're on Reddit or YouTube, leave a comment. Dr. Fu reads absolutely every single one. Let's get back to the show. Yeah, I'm glad that you brought in that it's bidirectional. One example I'm thinking of is, as a provider, I've seen a lot of novice providers go up to patients, especially in the emergency room, and go, any thoughts are hurting yourself or hurting other people. And the person obviously is going to get defensive and blocked down and not actually answer in an appropriate way. And what it is, is it's reminding them of probably priority providers who didn't actually listen to them and channels their defensive guarded mode. And whereas asking in a different way maybe won't channel that previous experience with uncaring providers. I actually have another thing that it kind of made me think of and it might be relevant for medication management. There was. I had a supervisee and I'm going to change the details here. Come and say the patient came and they were on Cymbalta and Abilify and Gabapentin and they were having what they were reporting as increasing OCD symptoms of intrusive suicidal thoughts. And the provider was so anxious because she had never made the switch from Cymbalta to Luvox, then the Luvox was going to increase the levels of all the other medications. And it was like this big. She was like this psychopharmacologically is so scary to me. And when we actually unpack things slowly, I explained to her that I've almost, it's been a handful of times that I've made such a complicated psychopharmacological switch. And we thought together of maybe it's something else going on other than OCD type symptoms. And that this patient is putting us in this crazy situation of making this really complicated psychopharmacolo pharmacological switch. And when we, when we unpacked it, we were able to kind of see a lot more of the patient's history and the influence that her emotional dysregulation was having rather than just screening things through OCD type symptoms like the patient had wanted us to. Yeah.

[A]

For the laypeople listening, this isn't to suggest that any patient is vanishingly rare. That this is ever the case is that a patient is doing this knowingly and consciously of parsing their symptoms through a particular lens in order to have an effect on a clinician. That's not the process that we're imagining here. What happens is that there's just automatic ways that we think, feel and decide about things in our lives, but particularly ourselves. And we can manifest that through talking about some symptoms to the detriment of ignoring other ones.

[B]

Right.

[A]

And so if we hyper focus on that as a patient to a clinician, that can start creating a level of distress, urgency or anxiety about those specific symptoms. And then both the clinician and the patient then become very energetically mentally focused on that specifically, and then it kind of buries the rest.

[B]

Right.

[A]

You could call that repression. You could call that selective attention. Call it whatever you want. The fact is, it's possible for both on the clinician end and on the patient end to hyper focus, hyper energize on one topic or particular problem and in a way that obscures another, maybe deeper or at least parallel and important problem. And parallel an important solution.

[B]

Absolutely. And if you just look at the surface level of things, you really miss what's going on between the patient and the provider in a way that it reflects the patient's life and what the patient experiences, not just in medication management or therapy, but in her day to day.

[A]

Yeah. And I think that leads us to the next mantra, which is make links and name things. I think this specific form of it is from Marty Horowitz, but make links, that's very beyondian, actually. And name things. We're actually already always doing this today. Maybe a little too much, in a way. The process of making a diagnosis in the medical model is a form of making links from symptoms and impairments to a disease process and naming it, giving that syndrome a name. But you don't want to limit yourself to only viewing things within the model of diagnoses. When you do any kind of work, whether that's medication management or therapy, you want to make links between causes and effects and put things into some kind of abstract name so that you can refer to it with the patient, regardless of the source. It could be a social stressor, it could be a psychological process. It might be a patient's tendency to just subvert themselves in some way when they're doing better. You know, let's say the patient who, when they start doing a little better at school, they start to think, you know, I don't really deserve this. But on a more conscious level, they think, I deserve to party, I deserve to let go. And they go binge drinking and they become very depressed. Notice that more than twice in a row, you better name it, let the patient name it, and make a link between that and their ongoing problems with depression, dysfunction.

[B]

Right.

[A]

Or it could be kind of what you mentioned in the last episode, again, just part of the diagnostic process. Right. This problem of concentration. You have this problem focusing and not being able to get the schoolwork done. I'm not so sure it's adhd. It really does seem like that. It's your high level of obsessions, compulsions and related anxiety and fear that are just exhausting you and keeping you from being able to focus. Right. Using a diagnostic label to explain or encompass certain impairments or symptoms, Making links and naming things important both in the therapy and in medication management.

[B]

This one's a tough one for me to understand. Just on the Surface. Because last time you talked about containment, and I think a big part of containment is putting words to things and we're going to get to the levels, but some of the other levels also. Part of it is naming things, but possibly in a different sense. So I'm wondering, because sometimes to me, this is a vague thing that it's hard to put into practice in terms of what you mean in terms of when should we be making links? Is this something that should be constantly happening? There's different, like, you know, there's different levels of depth for links. You know, there's linking, like you said, feeling like. Like crap for a week. And it turned out that they were really hungover on Monday and that carried over versus a link such as. Have you ever noticed that it's around your mother's passing that you get depressed? I guess. Can you give us a little bit more depth into what you mean by this pithy statement?

[A]

I think it's a reminder that needs to exist because it's very, very easy for two people to get carried away and to think that they're doing treatment when they're doing other things. That's all. I don't know if it is an exaggeration to say that it is something you are doing all the time. It doesn't mean that you're constantly talking. That's not what I mean. I mean that even if you're not intervening by saying something in an interview or a session, you, the clinician, are always trying to come up with some kind of a link or explanation. That's the fundamental work of mental health treatment. It's basically conceptualizing things into words in a way that makes sense and produces causes and effects and therefore solutions. Right. So it's not any kind of specific thing, but we have to remember to do it. Because, for example, maybe instead of making links or naming things, we get sucked into the emotional whirlwind of the crisis of the week, for example. Right. Maybe instead we get very intellectual and we spend the majority of the time talking about the research evidence and risks and benefits of lamotrigine. Right. When what may be more important is specifically noting this problem you're having with concentration, these issues that you're having with sleep. That's what I'm medically calling a bipolar 2 disorder. And I'm expecting that with this medication we're going to see improvements on both of those major issues that have been problems for you. I don't know if that makes sense, but to me that's what the mantra means. In a general treatment standpoint. But of course, in psychotherapy, you're going to want to be making links between emotions and other things and also early experiences and current patterns.

[B]

So it seems like a big predecessor of making links and naming things is developing a good formulation in a way that captures the patient. And then also, like you said, they're

[A]

like one and the same thing to me.

[B]

Yeah, yeah, yeah. And as you said, the links between emotions and past experiences, not just links in general. All right.

[A]

Yeah. It's frankly just an integrationalist attitude. Right. We're trying to integrate. We're trying to fight to disassociation. We're trying to get people to make connections. And the connections aren't only conceptual. In the mind, the connections are between you and the patient, and the connections are between the patient and other people in the world.

[B]

Right.

[A]

We're making links and we're naming things.

[B]

All right, what's our next one?

[A]

Okay, the next one is stay close to the material. Okay. Stay close to the material. Well, what does this mean? In short, I would say that it's natural for a clinician to have their own questions, curiosity and interests. Let's say, when presented with something that the patient brings up. This is true across all kinds of sessions. It's sometimes a good thing. But I think that not staying close to the patient's material can lead you astray. Let me give you an example. Patient comes in and says, you know, in the last few weeks, I've just been having a lot of problems with concentrating. Okay? And then if the clinician thinks concentration. Top of the differential diagnosis of concentration is adhd, tell me about what you were like as a child. Did you have problems with attention or concentrating? Then that's going pretty far afield from the material. It may be specifically about concentration, but you didn't take the whole element of what the patient is talking about. For example, in the last two or three weeks, right. If you stay close to the patient's material, you need to stay close to exactly what they told you or how they told it to you. And you might say, this is basic medical interviewing. Two or three weeks ago, what's happened? What's different? Right. Staying close to material that's in a diagnostic interviewing sense. But this is also true in talk therapy. Let's say. Let's say somebody comes in and they talk about how, you know, they found out that their friend likes to collect violent movies. Okay? They're into collecting gore films, and that's changed how they see that person. Now, this is a Therapy session. Okay. If you begin to ask. Someone, learning something about someone and then changing your mind about them, is that something that happened to you when you were younger? That's pretty far off from what the patient brought in and immediately started talking about. It may be useful, it may yield fruit. But properly, the best thing to start with is, what are your thoughts and feelings about these kinds of movies? What does it mean about a person? What. How did you change your mind? Right. Staying close to the patient's material.

[B]

This is. This is a really interesting one because it's a very. It takes a lot of concentration and a lot of intuition because, you know, it superficially sounds like you're staying close to the material. When you say, does that remind you someone from the past? Because it's like, someone could argue, it's like, oh, that's the. That I'm just making a connection. But. But you're not paying attention to the person's internal experience and understanding what their experience was before delving into that connection that you think you saw.

[A]

Yeah.

[B]

In another point that you brought in, you mentioned, like, the focus on concentration, and I see this a lot, is the patient and the provider can in some way both work to not pay attention to the important stuff. They collude in some sense by. By focusing on symptoms rather than the patient's experience. And so many times with patients, they'll come in and say, like, I've had an increase in anxiety. And if I were to stop there and say, you know, just. Just focus on the anxiety and the.

[A]

Yeah. And in many cases, people focus on generalized anxiety disorder, but go on.

[B]

Then I'll not actually know what the patient meant because anxiety is such a vague term. So staying with the material says, and I do this a lot with patients, especially on an intake. I go, let's try our best to not use clinical terms because it can mean different things to different people. When you say you had an increased anxiety, what did you experience? What are you referring to? And you'll hear an insane spectrum of different things. For some people, it's a very specific event, like, oh, whenever I have to do a talk, my heart rate increases. For other people, it's this vague thing of, whenever I'm super hungover, I kind of feel uncomfortable. So you really need to delve into the experience. And sometimes labels and symptoms are a way of patient and provider colluding not to get into the material.

[A]

Exactly. Being experience near rather than going to the abstract. Right. Extremely important. It sounds almost like a contradiction between making links and naming things but when I say name things, I recommend that you be as concrete as possible and use the patient's own language. And this point that you brought up leads us to the next mantra very naturally. So well done. This one is of my own invention. Okay? It's act stupider. Act stupider. I'm going to use that example about the anxiety. A patient comes in and they have some kind of a complaint or they report some kind of event in their lives happening. I've been feeling a lot of anxiety. My friend called me a bum, so I became very irate. Okay? Don't allow your intellectual capacities, which almost every clinician has very vast intellectual capacities. If they've made it that far into grad school and been able to pass all those tests and learn all this stuff, don't let your intellectual capacities keep you from staying close to the patient's material. Okay? What do I mean? If you immediately assume that you understand what the patient means by anxiety, let's say, or you go directly to an intellectual framework of generalized anxiety disorder or state anxiety versus trait anxiety, if you immediately begin to do that, you're going to close off the opportunity to get a more detailed understanding of the patient's internal experiences and how they describe things. Right. So you need to act stupider. You need to say, I don't know what you mean. Can you say more about that? Explain anxiety to me. What does that mean to you? Right. Or, for example, you might think, well, anyone might get angry if someone called them a bum. But I don't want that to be enough. That's obvious. That's obvious to anyone. Why is this moment important to the patient? Okay. And you might say, well, it sounds that being called upon may be quite angry. Could you explain more about that to me? What specifically about that ticked you off? Annoyed you? Act stupider. Don't be afraid as a clinician, to ask what seems like very obvious and stupid questions. And I'm an advocate of simply apologizing. If you feel uncomfortable with this, say, you know, I'm. I'm afraid this may sound like a stupid question. It may be obvious, but I think it's important to hear it from you. What exactly happened there that made you so angry? What is it about that that bothers you? Okay, act stupider.

[B]

I'm sure you've heard of the Columbo approach. Is that. Yeah, that's right. I've had. Almost every single therapy supervisor I've had has brought this up. Columbo. I'm sure that most people have probably heard this.

[A]

I Don't know, it's kind of old now. You better explain a little.

[B]

Yeah, I feel like everyone's had a. Probably supervisor's brought up, but Columbo was this investigator that essentially how he would operate, I've actually never seen it, but my understanding is tv.

[A]

TV detective.

[B]

He would go in and hear the patient, the criminal story and agree with it. And then he'd be like, oh, I guess we have everything. And then he would walk out and then he would come back. He goes, you know what? Actually, wait just one second. Listen, I know I'm sure you have a good reason for this, but you mentioned that you were in New Jersey a week ago and then you were in New York five days ago. And listen, I'm sure you have a great explanation, but if you could just kind of go into a little bit more detail. So the gist is essentially you feign, in some sense, ignorance and curiosity. And the goal is to help the patient not be defensive. It fosters trust and like, reduces the defensiveness and encourages self reflection by not having a potential for like the therapist or the psychiatrist is seeing me and seeing the problems that I can't see, but it makes the person feel a little bit more comfortable and helps them to talk out their own inconsistencies.

[A]

Yeah, exactly. And even beyond that, I think what I mean by this mantra is that you should let go of your own sense of mastery of the patient's material or who the patient is. And this may be even more important for the experienced clinician because we begin to see the same case over and over. And then we start to think everything is a nail and we're the hammer. But you gotta look at things with fresh eyes. You can't assume that you truly understand what someone is telling you until they've discussed it in more detail. So act stupider, be stupider. Go back and talk about the details, get the details and ask stupid questions. You may find that you're going to uncover some material or some information diagnostically that you would not have if you simply assumed and then went directly to some kind of a diagnostic framework.

[B]

Bingo.

[A]

This is also related then to. I just want to say what you just mentioned.

[B]

I'll let you finish, but I will say I've never, through intelligence, through like a very smart interpretation or a very intellectual biological understanding, ever really help the patient through. It's very rarely through intellectual concepts that help people. A lot of it is being present, being aware and not being smart.

[A]

Yeah, I mean, if intellectualization really helped, people don't get Me wrong. Having lower functioning is generally worse for mental health outcomes. But being intellectual alone is no solution. If it was very smart people would be living brilliant and very happy lives all the time simply by having a library card. Okay, this is not the case for a reason. Act stupider. Don't worry about the intellectual so much. And honestly, that's also important in case formulation. When people try to formulate a case, they try to get all these high minded concepts. Listen, if you can explain this patient's problems in a way that a completely uneducated person will understand, that's better. Because that's how you should formulate with the patient. In plain language.

[B]

Absolutely.

[A]

Yeah. Okay, so what you just described in terms of going back, that relates just to the next mantra as well actually, which is rewind the tape. I believe this is one of mine and I basically thought of it literally because you know, do require video recording of supervisees and we would literally rewind the tape to review a moment. But in the session with some patients, I think it is quite common that people will move past an important point without noticing it. This is extremely common in diagnostic interviewing, in medication, treatment or in talk therapy. It might be mentioned, it might be talked about briefly, but then that might remind someone of another point, or it might take the narrative somewhere along very quickly and then soon you'll find yourself talking about something else. For example, someone might come in and they might say, oh, you know, I've actually been feeling pretty sick and I've got a new rash in, in the last couple weeks. Oh, but you know, I also want to bring up that, you know, last week my husband left me and then they start talking about all that stuff. Right now you don't necessarily know which element is more important, but especially if you have noticed that something rather important to the treatment was brought up and then suddenly you're talking about something perhaps less important or that it's well trodden ground, then you may need to rewind the tape. Don't be afraid to interrupt. Say, hold on, this thing that you're telling me about right now, you know, that sounds really stressful, awful and like it's really been occupying a lot of time. But I have to go back. If you're willing. You mentioned earlier about that rash, that's actually pretty important. We better talk about that some more first. Don't be afraid to rewind the tape, lead the discussion and go back to something before it can feel awkward. Especially for the clinicians who don't like to upset patients or hurt patients. In Their mind, they may be a little more timid about this, but don't be afraid. Redirect, rewind the tape.

[B]

Yeah. And I think that's something you get better at. I think I often, early on, felt like I had to be this, like, amazing listener that heard absolutely everything, the patient and supported them and all these things. And that's not helpful for. It's helpful in some instances. But overall, you can't just be a passive person who's perfectly good at listening and perfectly supportive. So you have to practice doing things that might not come natural to you. Because I think most therapists or psychiatrists want to be good listeners in their personal life. They let their friends kind of vent and all those things, and you have to practice doing things that maybe you're not good at or that doesn't come natural to you. Yeah.

[A]

Going back to the first episode, venting itself is not actually helpful. It really bothers me when I see venting being documented as a psychotherapy intervention. The venting is not the operating procedure that actually helps people. It's the reflections you do. It's the technical containment where you have actually received the vent, have organized it, slowed it down, and brought it back in a way that a patient can understand that someone else has persistent perceive their inner experiences. Right. And similarly, it doesn't matter. Think of a manic patient. A manic patient telling you two hours worth of history in one hour because of how quickly they're talking if you don't interrupt them is not going to help you get closer to either a diagnosis or a treatment plan. Because at some point, you're going to have to slow things down, go back to certain points, get more details, and then organize it. So rewind the test.

[B]

All right, what's our next. One

[A]

final mantra for today is observe and confront. Observe and confront. That actually is a little bit more related to the levels of intervention, levels 1, 2, 3, and 4 that we had actually mentioned in the last episode. But we'll go into more detail about that later. But this one is a little bit trickier, I think. But I would say that generally speaking, most people probably don't do enough of this. It's again, that there may be too much passive listening in terms of simply receiving information, which, again, is most of what you do. But when you notice a pattern or you notice the problem, it is your job as the clinician to stop the narrative, at least temporarily. Make an observation out loud to the patient about what you're seeing. I notice that you're quite upset as you Talk about this. This seems to be something that's really important to you, or wow, you haven't been sleeping for three or four days in a row every month. Now that's pretty important. How long has that been going on? You need to actually make a explicit observation of the thing that you're noticing that is clinically salient for confront. That sounds aggressive. That might be a little bit more better described as make an observation of it explicitly in a way that shows contradiction. That is actually something that I would say is very fundamental to motivational interviewing. When you notice discrepancies in the narrative or between the patient's behaviors, thoughts, feelings, or values of things that, you know, the patient have, it's important to confront it. You know, today you're telling me that you don't want to get better, and you don't think that you things can get better. But I've been working with you in the last few months before you started binge drinking again, you were talking about how much hope you had with school, with your life, and that you could get better. You know, it seems to me that there is a large part of you that does want to be better and is trying hard. And all that I'm seeing today is the despair. Do you notice that you're showing the parts that are opposed or contradictory that the patient may not have access to in that moment? That's one version of confrontation.

[B]

Yeah. And one thing I want to say is in terms of oftentimes the response, like the example you provided, you'll get a response that feels discouraging, or the patient won't hear what you say. But I don't think that's actually that. You kind of have to have faith that oftentimes when I've seen patients make change, their response after I brought it up was not a positive one. But in some sense, I have a faith that there's a part of them that hears the message that I'm saying. I don't know if that makes sense, but like, oftentimes I'll have a patient will push back or fight with me in the moment, and then the next month, I'll see the positive change happen. So in some sense, you have to have faith that what you're doing is the right thing, even if you get discouraging feedback on the way back. I don't know if that made sense.

[A]

No, that makes sense to me. I mean, it's. It's a common issue where I think you can fall into complacency or nihilism by saying hey, you know, I point things out all the time. I explain things all the time to patients and you know, a lot of them don't change or a lot of them disagree with me. And you're not going to agree anyway, if I bring this up, this person has schizophrenia. They're not going to agree with me that the hallucination are a problem. You know, you won't know until you try. And I think this is a example of where it's very important to be non outcome focused. Just hold yourself to a standard of practice and do it. And you don't know when something you do is really going to bear fruit later. There's that parable right of sowing seeds and then some of them are going to land in a spot where they grow and some of them are going to land on hard rock and they're not going to grow. But you won't know and nothing is going to grow unless you actually sow regularly.

[B]

Yeah, beautifully put. And I'm glad you brought up the not focusing on outcome because what I do see is if you, like you said, there can be. It can be very discouraging of like, oh, no, I point out these things all the time to patients and oftentimes it takes. It's not the first time you point it out. It's not the fifth time you point it out. It'S the tenth time, a year and a half into treatment that finally something clicked. And you did everything perfect in that maybe each time you brought it up, it's not like you, you failed and you didn't bring it up properly or the patient didn't hear it, maybe it took. The patient wasn't ready to receive that information. And the 10th time that you brought it up, a year and a half in a treatment, the person was in a place that they could. So when you focus too much on outcomes, oftentimes you can sabotage the treatment. Because this change is a process. It's not something you go to talk to someone for 45 minutes, you get a piece of advice, and change occurs.

[A]

Yeah, you can see some surprising things. I'm reminded of a case with a trainee where they thought that their therapy really wasn't accomplishing much. You know, all they had really been able to do was kind of get the patient to slow down slightly in their narrative during the sessions, to occasionally talk about affect. The defense of intellectualization and preparation of material was still really at the forefront every single session and could barely get the patient to stop for a moment and reflect before they would move on to Other material. Okay. But then I said, hold on. Let's take a look globally at what's changed about this patient's life just in the last eight months. Okay. This was someone, you know, she was completely isolated before she started the therapy. She was in no contact with all of her family and friends. Actually, she was feeling depressed, and she was in total denial about her attraction to other woman. Just in the last year, this patient has started thinking about dating again and is now back in contact with a lot of friends and kind of navigating those relationships and feeling things about them. You know, we. We could say that's a coincidence, but really, there's no medication on board, and this is the only thing that's changed the therapy. So, you know, we may not fully understand how things improve, but by remaining within our professional practice parameters, that's what we can rely upon.

[B]

Yeah. And I. I almost want to make don't be too outcome focused. One of the mantras. The. Well, while you were telling that story,

[A]

I was thinking of, well, that's like a mindfulness thing. That's, like, key. But that's beyond therapy and clinical treatment. That's like broader life issue.

[B]

I see this all the time in addiction treatment, when patients either start the process of change or start the process of no longer using alcohol or some addiction. And at first things get worse because all this stuff that they were medicating against, they have to start addressing. And if you focus month to month on feeling better, you're not going to go through the process of. Of building a new life, which is part and parcel of any sort of major change. So, I mean, talking about alcohol, it's like, you stop the alcohol, and now you have to actually address all those things that you are numbing yourself to, and it brings up all those negative emotions. I feel like there's such a lack of appreciation that oftentimes in therapy or change, there's things get worse before they get better, because there's a period where now you don't have your coping skill and you have to face all those things. And it takes a period of destabilization to rebuild something new. And I. I worry. I see it all the time. People who, who focus on getting better at a particular time and how damaging that is to an overall process that isn't instant. And that takes time.

[A]

Yeah, things can get better. Things can get worse, and they are going to get better and worse over time, even if your overall trajectory is better. I do tell patients about that. You know, I say if they're better I say, hey, by the way, don't be surprised if things get worse again in the future. That's life. But at this point, you've picked yourself up out of this and you know what to do next time, or, you know, you have to look at the long term. They might say, hey, you know, it's been three weeks and I'm hardly feeling any better. And I actually think I'm feeling worse. Hey, listen, I'm sorry, that's awful. I know you're telling me about all these problems you're having, but we're not looking at just these next two months, right? We want to pick something out for you and figure something out for you that's going to be working for you in two, three, four years for the rest of your life.

[B]

I think that is the end of our mantras.

[A]

I think so. I also wanted to mention, I suppose it's belaboring the point at this last don't be outcome focused lesson, but there was just a recent post, I think, on the medicine subreddit where it was a early career rheumatologist who talked about having to deal with basically a rare negative outcome to a standard treatment that he had prescribed. You know, we have to remember that we are often working with some of the most severe or, you know, suffering people out there. Right? That's who we are as physicians, especially specialist physicians. If you have a job where you're seeing more bread and butter, that's great, that's fine. People need to do that. But often there's a selection. You're working with a troubled group of people and if all you care about is remission, you're not going to be very happy with yourself. And I don't think your patients are going to be very happy either. Right. I think that you're going to actually get a lot more remission, a lot more help to people if what you focus on is your professional practice and staying within a professional framework. If you do the job right, regardless of the outcome, you've done the right thing. That should be the ultimate guideline.

[B]

Beautifully put.

[A]

Well, I think we're at about time. We completely did not deliver on the four levels of interventions, but maybe we'll save that for next time. Hopefully people like this one.

[B]

Sounds good. All right, have a good one. See you. Thanks for listening. If you want to support the show, check out my very practical antidepressant course. If you want to check that out, go to Psycho Farm. Farm. If you prefer to read, you can go to Amazon.com you can just search for my name. Gregory G R E G O R Y Malzberg. M A L Z B E R G and the book is Psychoform's guide to Treating Depression. It's a nice, easy, readable, practical guide to medications for depression.