Counseling Today, Member Insights

Client suggestibility: A beginner’s guide for mental health professionals

By Jerrod Brown, Amanda Fenrich, Jeffrey Haun and Megan N. Carter August 12, 2019

In the context of mental health treatment, suggestibility refers to a client’s vulnerability to accepting information provided by a third party as true, regardless of its veracity. This can result in the client providing inaccurate guesses or statements in a verbal, nonverbal or narrative format. Influenced by a range of individual, psychosocial and contextual factors, the client may be convinced that events unfolded differently than they actually did or that events that never took place actually occurred.

Such behavior is often encountered when clients are uncertain about what happened or what is true, lack confidence in their own memories or ability to understand, or are unable to discriminate between what is real and what is not. As such, suggestibility can profoundly limit a client’s capacity to navigate the various stages of the mental health system.

Suggestibility is a complex and multifaceted phenomenon that mental health treatment specialists rarely take into consideration, largely because of the lack of research on it and the limited availability of training opportunities on the topic specifically tailored for these professionals. The research that has been conducted is largely circumscribed to the fields of criminal justice, forensics and the law, where it is well-established that clients who are more suggestible are more likely to provide unreliable eyewitness accounts, spurious alibis or even false confessions to crimes.

Across mental health treatment settings, suggestibility may result in inaccurate diagnoses and ineffective or problematic goal and treatment plans. Given the importance of this topic, we aim to briefly describe the phenomenon of suggestibility within the context of clinical interviewing, assessment and treatment planning. We will also suggest future directions that may assist mental health professionals in addressing this threat to effective clinical decision-making.

Minimizing suggestibility risk in clinical interviews

Certain forms of questioning can increase the likelihood of suggestibility. A suggestive question is one that implies a certain answer, regardless of the client’s actual perspective. Such questions intentionally or unintentionally seek to be persuasive, often by using wording that excludes other possible answers. For example, asking “Where did your father hit you?” instead of “What happened with your father when you got home?” is leading. It promotes a response that would affirm the interviewer’s hypothesis that a physical assault took place and largely excludes the possibility that no altercation occurred.

Questions framed in a negative manner also can have a suggestible impact and are confusing to the client. For example, asking “Didn’t you want to run away?” rather than “Did you want to run away?” is biased in that it may make the client feel guilty for not saying that he or she wanted to run away.

To avoid asking suggestive questions and to lessen the likelihood of receiving false responses from clients, consider using the following strategies:

1) Use open-ended questions while avoiding or minimizing the use of forced-choice and either-or questions.

2) Allow the client to speak in his or her own words, and avoid interrupting the client.

3) Do not assume that you know what the client is trying to say when he or she is unable to fully convey his or her ideas.

4) Accept “I don’t know” responses as potentially valid.

To further illustrate this point of decreasing suggestibility within the context of clinical interviewing, mental health professionals should try to avoid the following approaches when questioning clients:

  • Use of closed-ended questions
  • Giving an impression that implies the client is providing the wrong answer
  • Implying that a certain answer is needed or required
  • Leading questions
  • Misleading questions
  • Negatively worded statements
  • Persuading the client to change his or her response
  • Pressing the client for a response
  • Rapid-fire questioning
  • Repeated lines of questioning
  • Biased statements
  • Subtle prompts

How often questions are asked may also have a suggestive impact. Clients may perceive repeated questioning as a sign that they have not responded in a manner that the counselor deems “correct” or acceptable. Indeed, repetitive lines of questioning in which the client is asked about details of events that either did not happen or that the client does not remember well may result in the unintentional formation of false memories or confabulation (i.e., filling in memory gaps with fabricated memories or experiences).

Asking more general questions about an incident (e.g., “Tell me about what happened at the park”) and then later following up with related questions (e.g., “How often do you go to the park?”) has been found to be a useful method for verifying or clarifying information that might appear to be inconsistent or illogical. Regardless of the questioning style, however, it is advisable to allow clients as much time as they need to respond to questions and to verbally reinforce that they can take their time when answering questions.

In addition to questioning style, the counselor’s nonverbal behaviors, including facial affect, gestural affect and intonation, both before and during the interview, may increase the likelihood of suggestibility and threaten the validity of the information elicited. An example of facial affect could be smiling when a client is providing certain answers but not others. A gestural affect might include leaning forward when a client is providing certain answers but not others. Intonation as a means of nonverbal communication could be providing feedback using upward inflection when a client provides certain answers but downward inflection when he or she provides others. These nonverbal, and often unintended, means of communication are forms of both positive and negative feedback that can shape a person’s responses and increase the risk of suggestibility.

The context of the interview can also affect the likelihood of suggestibility. For example, false reports are more likely if an interview is conducted in a stressful situation (e.g., having an appointment with a therapist immediately following a family conflict). Environmental factors (e.g., a small room without windows or air conditioning on a hot summer afternoon) can also be influential. Providing clients with frequent breaks and avoiding very long clinical interviews is encouraged, when possible. The time between the occurrence of an event and the interview that focuses on the event can also influence suggestibility because clients can become more confident in the accuracy of their false accounts over time. Context within the realm of a clinical interview can include any of the following either prior to and during the actual interviewing process:

  • Body language of the counselor
  • Duration of eye contact from the counselor
  • Environmental distractions (lighting, noise, temperature, etc.)
  • Length of the interview
  • Pace of the interview
  • Tone of the counselor’s voice

Mental health professionals should also take into consideration personality and social characteristics that can influence suggestibility. These may include tendencies toward confabulation, acquiescence, memory distrust, low confidence, desire to please, extreme shyness and social anxiety, avoidant-based coping strategies, fear of negative evaluation, lack of assertiveness, attachment disruptions, fantasy proneness, and psychosocial immaturity (e.g., irresponsibility and temperament). Professionals should also consider cognitive factors, including executive function and memory-related problems (e.g., short-term, long-term and working memory), intellectual limitations, diminished language abilities, and deficits in theory of mind (the ability to understand mental states in oneself and in others).

Preparing for and debriefing from the interview

Understandably, many of these characteristics initially present as invisible, meaning that clients who are highly suggestible may not overtly appear as impaired or vulnerable. Clinicians would benefit from screening for such traits in the initial interview with new clients to determine the prevalence of traits that are likely to contribute to suggestibility. Specific screening tools for suggestibility, such as the Gudjonsson Suggestibility Scale, can help clinicians in determining a person’s level of suggestibility. This will also assist clinicians in understanding how best to proceed as it relates to interviewing techniques and treatment planning to account for an individual’s level of suggestibility.

False or misleading information can have a negative impact on diagnostic accuracy and treatment outcomes. Accordingly, it is important that mental health professionals not only conduct interviews properly but also prepare for and debrief from them properly. Prior to beginning an interview, counselors are encouraged to review client records (psychological testing, mental health records, criminal justice records, etc.) that may reveal a behavioral pattern of suggestibility and provide a resource for corroborating a client’s statements. Cross-referencing this information with information obtained from collateral informants is also recommended when appropriate. The importance of awareness of one’s self throughout the interview is an important factor for reducing the risk of suggestibility. This includes monitoring one’s verbal and nonverbal communication that could provide feedback to the client regarding potentially desirable versus undesirable responses.

It’s worth noting that some special situations may require clinicians to be more aware of their questioning style and require adaptations and flexibility on the part of the clinician to minimize suggestibility. For instance, those working in correctional and jail settings should consider how suggestibility presents among incarcerated populations, to include those with mental health needs and low intellectual functioning. Substance use is another variable that can have adverse effects on the accuracy of the information obtained during a clinical interview. Furthermore, when interviewing children or adults with neurocognitive and neurodevelopmental disorders, extra precautions may be necessary to reduce the risk of suggestibility. Finally, it is important to note that individuals with exposure to negative life events (e.g., the death of a parent or sibling, exposure to physical violence) may be more susceptible to suggestibility.

Conclusion

Given the importance of collecting accurate information, it is essential that mental health professionals acquaint themselves with the phenomenon of suggestibility. Unfortunately, many mental health providers lack the necessary awareness and training related to the detection and screening of suggestibility among clients.

Mental health professionals should seek to establish routine procedures to better identify clients who are at an increased risk of susceptibility to suggestibility before proceeding with the interviewing process. Such a procedure could include a validated suggestibility screening tool and a checklist of variables that research has found to increase risk of suggestibility among certain mental health treatment populations. We encourage mental health professionals to be aware of the various personality, social and cognitive factors that may influence some clients to be suggestible.

Suggestibility can have a negative impact on the various components of mental health treatment, including intake, screening, assessment, psychological testing, treatment planning, medication compliance, perceived understanding of treatment concepts, and discharge planning. For this reason, we urge mental health professionals to gain an increased awareness and understanding of this complex and multifaceted phenomenon.

One suggested step for moving the field forward is for mental health professionals to engage in self-study and continuing education via in-person and online training courses that focus on the evidence-based assessment and management of suggestibility. It is also important for mental health professionals interested in understanding suggestibility and its implications to review key research findings on at least a quarterly basis and to consult with recognized subject matter experts. Clinical interviews should be conducted through developmentally sensitive and suggestibility-informed approaches that consider the client’s psychiatric, neurocognitive, social and trauma history. By taking such steps, the potential negative impact of suggestibility can be minimized, thus paving the way for positive outcomes.

 

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Jerrod Brown is an assistant professor, program director and lead developer for the master’s degree in human services with an emphasis in forensic behavioral health for Concordia University in St. Paul, Minnesota. He has also been employed with Pathways Counseling Center for the past 15 years and is the founder and CEO of the American Institute for the Advancement of Forensic Studies. Contact him at jerrod01234brown@live.com.

Amanda Fenrich obtained her master’s degree in human services with an emphasis in forensic mental health from Concordia University. She is currently completing her doctoral degree in the advanced studies of human behavior from Capella University and is employed as a psychology associate for the Washington State Department of Corrections Sex Offender Treatment and Assessment Program.

Jeffrey Haun is employed as a forensic psychologist for the Minnesota Department of Human Services, where he conducts a variety of forensic evaluations and offers consultation, supervision and training in forensic psychology. He is an adjunct assistant professor in the Department of Psychiatry at the University of Minnesota and an adjunct instructor at Concordia University. He is board certified in forensic psychology.

Megan N. Carter is board certified in forensic psychology and has received the designation of fellow from the Association for the Treatment of Sexual Abusers. She has worked as a forensic evaluator at the Special Commitment Center, Washington state’s sexually violent predator facility, since 2008. She also maintains a small private practice focusing on forensic evaluations and child welfare issues.

 

Letters to the editor:ct@counseling.org

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

40 Comments

  1. Kathryn Helland

    This is a great read and highlights such an important piece of our job as mental health providers. We must ask questions in a purposeful, strategic way in order to obtain the most accurate information from the client. Thank you!

    Reply
  2. Jennifer Cady

    Suggestibility is so important to know and understand and this article does a great of job of highlighting this.

    Reply
  3. Bob Ludgate

    This is an outstanding topic about suggestibility with clients. This is such an important part of our jobs as mental health professionals. Thank you!

    Reply
  4. Nicole Kimberley-Staeheli

    An excellent and thought provoking introduction to the topic! Suggestibility informed approaches with non-voluntary clients in particular would also serve to reduce potential negativity, bias, and mistrust on the behalf of clients and create an atmosphere of mutuality and collaboration allowing for the sharing and receiving of more accurate and honest information.

    Reply
  5. Don Porth

    This is a very important consideration. In my field of work with youth, criminal implications are sometimes a consideration. The line between investigation and intervention can become blurred and influence outcomes through suggestibility. This article helps with understanding the implications of suggestibility.

    Reply
  6. Dr. Heather Grammatico

    Extremely useful information. Suggestibility is such an important area to understand when working with clients in a Human Services setting. This article is great for those working at all levels of interactions with clients. From the intake coordinator to the clinician, understanding how suggestibility can impact interactions is vital.

    Reply
  7. Joel Sheagren

    Great job at explaining this complex topic of suggestibility and practical ways for working with such a vulnerable population.

    Reply
  8. Mandy

    This is such an important topic! I plan to share this with my colleagues to create an awareness how suggestibility impacts clinical interviews.

    Reply
  9. Kristy Donaldson

    Suggestibility is an important consideration when counseling those who are susceptible. Thank you for shedding light on an important element of sound therapeutic processes.

    Reply
  10. Joseph Arvidson

    The phenomenon of suggestibility is one that needs to be explored and discussed not just in the arena of mental health, but also in the field of criminal justice. In Corrections, there is a heavy reliance in structured interviews for the purpose of assessment and interventions. This article highlights the urgent need to educate practitioners as to the impact that suggestibility can have on these routine yet extremely important job functions. This article is a must read for Correctional administrators. Kudos to the authors for advancement of this issue.

    Reply
  11. Cheryl Arndt, PhD

    Given that incorrect information from clients can impact diagnosis, treatment goals, and treatment outcomes, suggestibility is an important factor for clinicians to consider. This brief article does a great job of considering factors related to the clinician (such as types of questions, non-verbal expressing, and clinical setting) as well as those related to the client (including personality, cognitive functioning, and legal status). One thing I would add is a consideration of culture. For example, clinicians may wish to consider the perception of authority figures in the client’s culture and how that perception might influence the clinical relationship. Readers who want more information on effective client interviewing may wish to review Dr. Dian Williams’ 2019 book: The Winning Edge: The Art and Science of the Interview.

    Reply
  12. Diane Harr

    Thank you for a great discussion on maintaining awareness of suggestibility with clients and focusing on evidence-based practices in our work. Your provision of contextual considerations when interacting with clients is beneficial and worthy of implementation.

    Reply
  13. Brittany Miskowiec

    Suggestibility isn’t something that mental health providers frequently talk about. I appreciate that the authors brought this topic to light. The strategies to reduce the likelihood of suggestibility that the authors presented will be great to use with my students and supervisees. Thanks for the great read!

    Reply
  14. Hal Piickett, Psy.D., LP, ABPP

    Though the topic has been around for sometime, the absolute importance of this topic is now coming to the forefront of many aspects of mental health interviewing. Though it can be a complex topic to understand, it should be a staple of basic education of all mental health providers. For interviewing children, vulnerable adults and forensic cases, not being aware of this important topic area can lead to many errors in reporting and possibly increased risk to the client of inappropriate diagnosis, treatments and disposition. Great article, timely and a staple for all mental health providers

    Reply
  15. Dr. Chris Caulkins

    This article is well-written and is an important conversation to have. I find the insights of the authors applicable to not only mental health professionals, but to investigators of all ilks, researchers, and clinicians in the general medical community.

    Reply
  16. Lucas Volini, DMFT, LMFT

    I applaud the authors’ efforts in bringing attention to this often overlooked aspect of clinical practice. Too many times, clients have come to me tormented by a ‘suggestion’ implanted by another healthcare provider in their premature effort to clarify and make sense of current struggles. This seems to be most common in cases where clients present a series of symptoms congruent with the literature on responses to childhood sexual abuse. Instead of openly and unbiasedly assessing a history of sexual abuse, clinician’s have been known to say “well these symptoms are what we see when children were abused by an adult growing up. Are you sure no one in your family or community abused you?”

    Therapy clients are particularly vulnerable to ‘suggestibility’ given their desire to make sense of their current state of suffering. Compound this with an inexperienced clinician eager to earn self-esteem by feeling competent in their interpretations, and its an environment capable of inflicting further harm if the professional isn’t attuned to these dynamics. Much of it comes down to the intolerance for ambiguity (i.e., not knowing) that can be as mutually difficult for the therapist as it is the client. The lower our tolerance for ambiguity. the more inclined we become to clinging unfounded certainties to create an illusion of ‘knowing’ (i.e., mastery over the experience).

    A recommendation by Ron Siegel in his book ‘Wisdom and Compassion in Psychotherapy’ has engrained itself into the foundation of my clinical practice: “The right interpretation at the wrong time is the WRONG interpretation.” Be wise out there, folks; and always remember the ethical practice of protecting each client’s autonomy over bringing meaning to their experiences.

    Reply
  17. Jeremiah Schimp, PhD, CPRP

    Thank you for covering an important topic in clinical interviewing and therapeutic work. As someone who regularly conducts client interviews and coaches mental health staff in a residential treatment setting, I found this article to offer many practical ideas on a topic we do not talk about often enough. I appreciate the connection to helping clients develop goals and creating effective treatment plans. This article provides an excellent guide to how suggestibility can impact clinical assessment and client care. I plan on sharing this article with staff and colleagues. Thank you for a valuable article!

    Reply
  18. john Von eschen

    A lot of great information and it has given me a lot to think about.

    I will certainly reflect about some of my interviewing techniques.

    Reply
  19. Megan Puckett

    A well-rounded and highly informative article that provides excellent advice and insight on an often overlooked topic. The focus on the conveyance of verbal and nonverbal cues and their effects is invaluable.

    Reply
  20. Rachel Tiede

    Suggestibility is a very important and often misunderstood topic. Thanks for the detailed information. It will be helpful for many!

    Reply
  21. Steve Breitbarth, M. Div., LMFT, CISM

    The message of this article is so important to remember and to use especially when working with people who have been victimized or have ben involved in a Critical Incident. It is important to remember that it takes time for people involved in a critical incident to sort out the facts. The trust that a person places in the therapist can be so powerful in swaying a person in sorting out and possibly distorting the facts.

    Reply
  22. Paul Novotny, PsyD, LP, LPCC

    This is a wonderful read that helps increase understanding and awareness to such an important topic.

    Reply
  23. Darian Buel

    As a professional in the Criminal Justice System, the importance of self-awareness and accountability when it comes to this topic can’t be overstated. Very thought-provoking and well-written article!

    Reply
  24. Forensic Researcher

    Suggestibility is a complex and complicated topic. When examining this topic, it is also important to consider the possibility of confabulation during the intake, screening, and treatment planning process.

    Reply
  25. Mario L Hesse, PhD

    Brown et al. have written, summarized and applied extremely useful information. I concur with many of the previous comments that suggestibility an important area to understand when working with clients in any interview-based setting. Yes, this article is an important and necessary read for those interacting with clients across all levels.

    Reply
  26. Andrew Freeberg

    Excellent article! Very accessible and practical. The authors do a great job of highlighting an important topic that may not get enough attention. I echo previous comments about the importance in the corrections arena. With limited resources for services, interventions based on valid and accurate assessment are critical so they effectively match criminogenic needs. Great work.

    Reply
  27. Vanessa

    A very important topic that has wide reaching implications for individuals, professionals and the wider community. Even though it should be at the forefront of every interview or interaction with a person, particularly in the criminal justice setting it is often forgotten or comes as an afterthought. A very interesting and thought provoking read.

    Reply
  28. Manfred Tatzmann

    A necessary check-in topic for professionals willing to up their skillset. This is a very important topic, especially in the areas of forensic interviewing. Please, more from these authors.

    Reply
  29. Erv Weinkauf

    This article identifies the importance of educating and training mental health and criminal justice practitioners in the skills of properly interviewing witnesses and interrogating suspects. It is a must read for criminal justice administrators to ensure every patrol officer and investigator is adequately trained on suggestibility to avoid false or misleading information that can have a negative impact on statement accuracy and investigation outcomes.

    Reply
  30. Criminal Justice Researcher

    This topic is useful for anyone who interacts with someone prone to suggestibility. I am looking forward to more information about this topic. Thank you!

    Reply
  31. Leslie Barfknecht

    This is a great topic to help increase self-awareness in ourselves and our affects on the relationship and outcomes in working with persons in the mental health field. Thanks for bringing attention to it!

    Reply
  32. Lisa

    This is a great article and reminder of the influence that, if unchecked, professionals can have on their clients. Something that I want to learn more about.

    Reply
  33. Amber Owens

    This is very practical and helpful for information for the practicing therapist. It truly is often overlooked in sessions (individual and group), as well as in graduate level classes. As a therapist, this is something I will work on and try to keep in check, so as not to unduly influence my patients’ answers. I believe this might also have a closer relationship with transference than we might originally think, and I hope that more research will be done on the topic.

    Reply
  34. William Ward

    Excellent article and insight on suggestibility. Training on this area should be a must for stakeholders in the criminal court arena. Arrested individuals are too often scared, bewildered and without the means to counter “interview” techniques employed by the police. Once in the system, interacting with other professionals may also have the same effect. All of us need to be cognizant of this critical issue.

    Reply

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