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Clinicians of all experience levels, particularly trainees, may struggle when interviewing an individual experiencing psychosis. Many clinicians feel unsure what to say when a patient expresses fixed beliefs that are not amenable to change despite conflicting evidence, or worry about inadvertently affirming these beliefs. Supporting and empathizing with a person experiencing psychosis while avoiding reinforcing delusional beliefs is an important skillset for clinicians to have. While there is no single “correct” approach to interviewing individuals with psychosis, key principles include:
1. Do not begin by challenging delusions
People experiencing delusions often feel strongly about the validity of their beliefs and find evidence to support them. Directly challenging these beliefs from the beginning may alienate them. Instead, explore with neutral questioning: “Can you tell me more about X?” “What did you notice that made you believe Y?” Later, when rapport is established, it may be appropriate to explore discrepancies that provide insight into their delusions, a technique used in cognitive-behavioral therapy for psychosis.
2. Validate the emotion, not the psychosis
Many interviewers worry that talking about a patient’s delusions or voices will inadvertently reinforce them. Instead of agreeing with the content, listen for and empathize with the emotion (which is often fear): “That sounds frightening.” If the emotion is unclear, ask: “How did you feel when that happened?” When unsure what to say, sometimes a neutral “mmm” conveys listening without reinforcing the psychosis.
3. Explicitly state emotions and intentions
People with psychosis may have difficulty processing others’ emotions and facial expressions.1 We recommend using verbal cues to assist them in recognizing emotions and intentions: “It makes me sad to hear how alone you felt,” or “I’m here to help you.” The interviewer may mildly “amplify” their facial expressions so that the person experiencing psychosis can more clearly identify the expressed emotion, though not all individuals with psychosis respond well to this.
4. Reflect the patient’s own words
We recommend using the patient’s exact (typically nonclinical) words in referring to their experiences to build rapport and a shared understanding of their subjective experience.2 Avoid introducing clinical jargon, such as “delusion” or “hallucination.” For example, the interviewer might follow a patient’s explanation of their experiences by asking: “You heard voices in the walls—what did they say?” If the patient uses clinical jargon, the interviewer should clarify their meaning: “When you say ‘paranoid,’ what does that mean to you?”
5. Be intentional with gestures and positioning
People with schizophrenia-spectrum disorders may have difficulty interpreting gestures and are more likely to perceive gestures as self-referential.1 We recommend minimizing gestures or using simple, neutral-to-positive movements appropriate to cultural context. For example, in the United States, hands with palms up in front of the body generally convey openness, whereas arms crossed over the chest may convey anger. We recommend that to avoid appearing confrontational, interviewers do not position themselves directly in front of the patient, instead positioning themselves at an angle. Consider mirroring patients’ gestures or postures to convey empathy and build rapport.3
1. Chapellier V, Pavlidou A, Maderthaner L, et al. The impact of poor nonverbal social perception on functional capacity in schizophrenia. Front Psychol. 2022;13:804093. doi:10.3389/fpsyg.2022.804093
2. Olson M, Seikkula J, Ziedonis D. The key elements of dialogic practice in Open Dialogue: fidelity criteria. University of Massachusetts Medical School. Published September 2, 2014. Accessed August 16, 2023. https://www.umassmed.edu/globalassets/psychiatry/open-dialogue/keyelementsv1.109022014.pdf
3. Raffard S, Salesse RN, Bortolon C, et al. Using mimicry of body movements by a virtual agent to increase synchronization behavior and rapport in individuals with schizophrenia. Sci Rep. 2018;8(1):17356. doi:10.1038/s41598-018-35813-6
Clinicians of all experience levels, particularly trainees, may struggle when interviewing an individual experiencing psychosis. Many clinicians feel unsure what to say when a patient expresses fixed beliefs that are not amenable to change despite conflicting evidence, or worry about inadvertently affirming these beliefs. Supporting and empathizing with a person experiencing psychosis while avoiding reinforcing delusional beliefs is an important skillset for clinicians to have. While there is no single “correct” approach to interviewing individuals with psychosis, key principles include:
1. Do not begin by challenging delusions
People experiencing delusions often feel strongly about the validity of their beliefs and find evidence to support them. Directly challenging these beliefs from the beginning may alienate them. Instead, explore with neutral questioning: “Can you tell me more about X?” “What did you notice that made you believe Y?” Later, when rapport is established, it may be appropriate to explore discrepancies that provide insight into their delusions, a technique used in cognitive-behavioral therapy for psychosis.
2. Validate the emotion, not the psychosis
Many interviewers worry that talking about a patient’s delusions or voices will inadvertently reinforce them. Instead of agreeing with the content, listen for and empathize with the emotion (which is often fear): “That sounds frightening.” If the emotion is unclear, ask: “How did you feel when that happened?” When unsure what to say, sometimes a neutral “mmm” conveys listening without reinforcing the psychosis.
3. Explicitly state emotions and intentions
People with psychosis may have difficulty processing others’ emotions and facial expressions.1 We recommend using verbal cues to assist them in recognizing emotions and intentions: “It makes me sad to hear how alone you felt,” or “I’m here to help you.” The interviewer may mildly “amplify” their facial expressions so that the person experiencing psychosis can more clearly identify the expressed emotion, though not all individuals with psychosis respond well to this.
4. Reflect the patient’s own words
We recommend using the patient’s exact (typically nonclinical) words in referring to their experiences to build rapport and a shared understanding of their subjective experience.2 Avoid introducing clinical jargon, such as “delusion” or “hallucination.” For example, the interviewer might follow a patient’s explanation of their experiences by asking: “You heard voices in the walls—what did they say?” If the patient uses clinical jargon, the interviewer should clarify their meaning: “When you say ‘paranoid,’ what does that mean to you?”
5. Be intentional with gestures and positioning
People with schizophrenia-spectrum disorders may have difficulty interpreting gestures and are more likely to perceive gestures as self-referential.1 We recommend minimizing gestures or using simple, neutral-to-positive movements appropriate to cultural context. For example, in the United States, hands with palms up in front of the body generally convey openness, whereas arms crossed over the chest may convey anger. We recommend that to avoid appearing confrontational, interviewers do not position themselves directly in front of the patient, instead positioning themselves at an angle. Consider mirroring patients’ gestures or postures to convey empathy and build rapport.3
Clinicians of all experience levels, particularly trainees, may struggle when interviewing an individual experiencing psychosis. Many clinicians feel unsure what to say when a patient expresses fixed beliefs that are not amenable to change despite conflicting evidence, or worry about inadvertently affirming these beliefs. Supporting and empathizing with a person experiencing psychosis while avoiding reinforcing delusional beliefs is an important skillset for clinicians to have. While there is no single “correct” approach to interviewing individuals with psychosis, key principles include:
1. Do not begin by challenging delusions
People experiencing delusions often feel strongly about the validity of their beliefs and find evidence to support them. Directly challenging these beliefs from the beginning may alienate them. Instead, explore with neutral questioning: “Can you tell me more about X?” “What did you notice that made you believe Y?” Later, when rapport is established, it may be appropriate to explore discrepancies that provide insight into their delusions, a technique used in cognitive-behavioral therapy for psychosis.
2. Validate the emotion, not the psychosis
Many interviewers worry that talking about a patient’s delusions or voices will inadvertently reinforce them. Instead of agreeing with the content, listen for and empathize with the emotion (which is often fear): “That sounds frightening.” If the emotion is unclear, ask: “How did you feel when that happened?” When unsure what to say, sometimes a neutral “mmm” conveys listening without reinforcing the psychosis.
3. Explicitly state emotions and intentions
People with psychosis may have difficulty processing others’ emotions and facial expressions.1 We recommend using verbal cues to assist them in recognizing emotions and intentions: “It makes me sad to hear how alone you felt,” or “I’m here to help you.” The interviewer may mildly “amplify” their facial expressions so that the person experiencing psychosis can more clearly identify the expressed emotion, though not all individuals with psychosis respond well to this.
4. Reflect the patient’s own words
We recommend using the patient’s exact (typically nonclinical) words in referring to their experiences to build rapport and a shared understanding of their subjective experience.2 Avoid introducing clinical jargon, such as “delusion” or “hallucination.” For example, the interviewer might follow a patient’s explanation of their experiences by asking: “You heard voices in the walls—what did they say?” If the patient uses clinical jargon, the interviewer should clarify their meaning: “When you say ‘paranoid,’ what does that mean to you?”
5. Be intentional with gestures and positioning
People with schizophrenia-spectrum disorders may have difficulty interpreting gestures and are more likely to perceive gestures as self-referential.1 We recommend minimizing gestures or using simple, neutral-to-positive movements appropriate to cultural context. For example, in the United States, hands with palms up in front of the body generally convey openness, whereas arms crossed over the chest may convey anger. We recommend that to avoid appearing confrontational, interviewers do not position themselves directly in front of the patient, instead positioning themselves at an angle. Consider mirroring patients’ gestures or postures to convey empathy and build rapport.3
1. Chapellier V, Pavlidou A, Maderthaner L, et al. The impact of poor nonverbal social perception on functional capacity in schizophrenia. Front Psychol. 2022;13:804093. doi:10.3389/fpsyg.2022.804093
2. Olson M, Seikkula J, Ziedonis D. The key elements of dialogic practice in Open Dialogue: fidelity criteria. University of Massachusetts Medical School. Published September 2, 2014. Accessed August 16, 2023. https://www.umassmed.edu/globalassets/psychiatry/open-dialogue/keyelementsv1.109022014.pdf
3. Raffard S, Salesse RN, Bortolon C, et al. Using mimicry of body movements by a virtual agent to increase synchronization behavior and rapport in individuals with schizophrenia. Sci Rep. 2018;8(1):17356. doi:10.1038/s41598-018-35813-6
1. Chapellier V, Pavlidou A, Maderthaner L, et al. The impact of poor nonverbal social perception on functional capacity in schizophrenia. Front Psychol. 2022;13:804093. doi:10.3389/fpsyg.2022.804093
2. Olson M, Seikkula J, Ziedonis D. The key elements of dialogic practice in Open Dialogue: fidelity criteria. University of Massachusetts Medical School. Published September 2, 2014. Accessed August 16, 2023. https://www.umassmed.edu/globalassets/psychiatry/open-dialogue/keyelementsv1.109022014.pdf
3. Raffard S, Salesse RN, Bortolon C, et al. Using mimicry of body movements by a virtual agent to increase synchronization behavior and rapport in individuals with schizophrenia. Sci Rep. 2018;8(1):17356. doi:10.1038/s41598-018-35813-6
