Psychiatry 72(4) Winter 2009 382 Intimate Partner Violence Fussell et al. Clinical Perception: A Study of Intimate Partner Violence versus Methamphetamine Use as Presenting Problems Holly Fussell, Janice Haaken, Colleen S. Lewy, and Bentson H. McFarland, MD This study draws on theory by Solomon Asch (1946, 1952) to examine how presenting with intimate partner violence versus methamphetamine use shapes characteristics of substance abuse assessment interviews. When responding to an initial open-ended question from a substance abuse counselor, the methamphetamine user and intimate partner violence survivor may elicit very different reactions from the counselor. We predicted that these differing presenting problems would initiate different trajectories for overall impression formation. To test this hypothesis, 18 substance abuse practitioners interviewed one standardized patient (an actor portraying a substance abuse client) who alternated her presenting problem between a) violence in a domestic setting and b) methamphetamine use. The remainder of her story was identical for counselors in either presenting problem group. Results included differences between the two groups in median length of the interviews and failure of both groups to explore domestic violence as a cooccurring problem. Clinical practices related to substance abuse counseling and intimate partner violence are discussed in light of these findings. Solomon Asch (1946, 1952) pioneered the study of impression formation-how discrete elements or variables shape global assessments of others. Guided by Gestalt theory, with its emphasis on how the mind is organized to seek patterns and to construct whole pictures out of disparate elements, Asch initially demonstrated the potency of first impressions in shaping subsequent perceptions. He later extended this line of inquiry to include a focus on central characteristics. Asch (1946) concluded that “central characteristics, while imposing their direction upon the total impression, were themselves affected by the surrounding characteristics” (p. 62). He demonstrated how the inclusion of items such as warm, cold, or intelligent, for example, on a list of attributes often shaped the subjects’ overall view of a hypothetical person. Holly Fusell, PhD, is affiliated with the Department of Public Health & Preventive Medicine, at Oregon Health & Science University in Portland, Oregon. Janice Haaken, PhD, is with the Department of Psychology at Portland State University. Colleen S. Lewy, PhD, is with the Department of Psychiatry at Oregon Health & Science University and Bentson H. McFarland, MD, PhD, is affiliated with both the Department of Public Health & Preventive Medicine, at Oregon Health & Science University. This research was supported by National Institute on Drug Abuse grant R03 DA 016958 entitled “Standardized Patients as Drug Abuse Treatment Clients.” The authors also thank the standardized patient, Julie Starbird, and the participating counselors. Address correspondence to Holly E. Fussell, PhD, Department of Public Health & Preventive Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd., Mail Code CB-669, Portland, OR 97239-3098; Email: firstname.lastname@example.org Fussell et al. Research demonstrates that first impressions influence how physicians assign medical diagnoses as well as other areas of clinical judgment (see Chapman, Bergus, & Elstein, 1996; Chapman & Chapman, 1969; Chiaramonte & Friend, 2006; Curley, Young, Kingry, & Yates, 1988; Pain & Sharpley, 1989).Most clinical interactions occur, however, under confidential conditions, restricting opportunities for investigating these interactive processes. The use of standardized patients in clinical training, increasingly adopted to assess practitioner skills in eliciting clinical data (see Fussell, Kunkel, Lewy, McFarland & McCarty, 2008), has introduced a new lens for studying clinical interactions by “standardizing” patient responses to specific questions or lines of inquiry (Colliver & Swartz, 1997; Swartz & Colliver, 1996). Standardized patients are actors trained to enact a particular set of symptoms consistently across clinical interactions with multiple practitioners, allowing for cross-clinician comparisons on multiple pre-determined criteria (e.g., diagnosis). Colliver and Swartz (1997) found that on an initial visit physicians are usually unable to distinguish standardized patients from “real” patients. This paper reports on a study that utilized a standardized patient to examine how socially relevant presenting problems, specifically intimate partner violence and methamphetamine use, shape characteristics of clinical interviews in the context of addictions treatment counseling. During assessment interviews drug and alcohol counselors must obtain and integrate a wide range of clinical data to diagnose the client and develop a treatment plan. Often the assessment includes making recommendations that have profound impacts on the life of the client, such as court-mandated treatment or termination of parental rights. This combined focus on clinical intervention and social judgments requires the addictions counselor to process a complex array of social and clinical information. In carrying out the study reported 383 here, we sought to determine how varying the opening lines of the script, with two differing presenting problem statements, would shape subsequent clinical interactions. Methamphetamine and Intimate Partner Violence Methamphetamine use and intimate partner violence commonly co-occur (Cohen, Dickow, Horner, Zweben, Balabis, & Vandersloot, 2003). However, even without methamphetamine use complicating the picture, interpersonal violence alone has been described as “one of the most critical problems facing society” (Ammerman & Hersen, 2000, p. xiii). Assistance for women, in particular those who are living with intimate partner violence, has been described as one of the most significant victories of second-wave feminism (Haaken, Fussell & Mankowski, 2007). Unlike with female methamphetamine users, substantial public effort has been placed on removing blame and focusing on sympathetic efforts to assist females entrapped in violent domestic settings. When responding to the question, “What brings you in today?,” the methamphetamine user and the intimate partner violence survivor may elicit different reactions from the counselor. We predicted that these differing presenting problems would initiate different trajectories for overall impression formation. Nonetheless, impression formation is a dynamic process where other client characteristics and story elements also likely affect interpretations of the presenting problem. The challenge of untangling these interactive effects and assessing their impacts in applied settings is compounded by the enormous variability in how clients present their problems and tell their stories. The standardized patient procedure offers one methodological strategy for reducing some of this variability. 384 Intimate Partner Violence Research Question The findings presented here are part of a larger study that sought to test the authenticity of standardized patients as substance abuse clients. The study consisted of creating four standardized patient scripts, recruiting and training the standardized patients, recruiting addictions treatment clinicians, conducting assessment interviews with standardized patients and clinicians, monitoring and assessing the standardized patients’ performances, and assessing key dimensions of counselors’ performances (see Fussell, Lewy, & McFarland, 2009). The standardized patient script and methods presented here were designed specifically to investigate the following research question: How do presenting problems shape characteristics of clinical interviews in the context of addictions treatment counseling? While this was an open-ended study of how the presenting problem shapes clinical impressions, we began with the prediction that responses to the methamphetamine abuse story would elicit a “colder” response and the domestic violence story a “warmer” response, primarily because media representations of methamphetamine abusers, particularly women, have been harsher and less sympathetic than those of domestic violence survivors. Methods Quantitative and qualitative analyses were conducted in order to gain a broad and rich view of how substance abuse counselors, in particular, develop perceptual frameworks of a client based on two different presenting problems in substance abuse assessment interviews. Individual substance abuse counselors saw one standardized patient and engaged in mock assessment interviews. The standardized patient’s case included an indepth history sufficient for up to a one and a half hour assessment interview. Participants The standardized patient was a professional actor recruited from the theater community in Portland, Oregon. The candidate actor was screened for the ability to portray affect and physical dispositions consistent with presenting problems of substance abuse clients. Training focused solely on script memorization and delivery. The standardized patient was only told that she would be rated for authenticity and that for another aspect of the study she would alternate her presenting problem. The recruitment of substance abuse practitioners to interview the standardized patient occurred primarily in the alcohol and drug counseling community and through the inclusion of recruitment materials at the 2005 Northwest Institute of Addiction Studies conference in Portland. Eighteen participants (72.2% female, n = 13; Mean Age = 42, SD = 11.37) interviewed Debby, who was portrayed by one female Caucasian actor. Counselor ethnicity included ten Caucasians (55.6%), three African Americans (16.7%), two Asian/Pacific Islanders (11.1%), one Hispanic (5.6%), one “other” (5.6%) and one “multiple” (5.6%). Highest level of education completed included some college (n = 2, 11.1%), associate’s degree (n = 5, 27.8%), bachelor’s degree (n = 5, 27.8%), and master’s degree (n = 6, 33.3%). Three of the 18 participants had no clinical experience other than their substance abuse counselor training at the time of the study. Procedures The standardized patient for this study alternated her opening statement between a) “Me and my husband have been fighting a lot lately and this last time the police came and they took my kids,” and b) “I’ve been having some pretty bad problems with meth.” Alternating the standardized patient’s presenting problem between 18 counselors provided Fussell et al. • • • • • • 385 Does this client have one or more problems with substances? Yes/No If yes, what label(s)/diagnosis(es) would you use to describe the problem(s)? Is the client suffering from one or more co-occurring problem(s)/disorder(s)? Yes/No? Label? Reason? Client currently in physical danger? Yes/No Given this client’s overall clinical picture, what are his/her barriers to recovery? What is/are the treatment goal(s) for this client? Figure 1. Post-Interview Questionnaire Topics two data sets (intimate partner violence presenting problem, n = 9; methamphetamine presenting problem, n = 9), allowing comparisons between two groups of counselors on particular themes and descriptive characteristics of the interviews After the opening statements, the standardized patient was instructed to respond to probes based on the following scripted story. Debby Patterson is a 24-year-old unemployed woman who, along with her husband, Eric, was arrested one week ago at their home after the police responded to a domestic dispute. The police noted dilapidated conditions (no telephone or electricity) and a small amount of methamphetamine. Debby’s children were subsequently placed in protective custody on grounds of neglect. Debby knows she has a problem with methamphetamine and wants to quit but blames the addiction on Eric. Debby’s husband has increased physically and emotionally violent behavior toward Debby over the past year and more so in the last month. Debby’s story includes being thrown to the floor and kicked in the stomach within the past month. Eric is still incarcerated at the time of the assessment interview with an unknown release date. Debby has no social support. Her children (Tyler, age 4, and Hope, age 2) recently reported to Debby’s mother that Debby and Eric “never pay attention” to them, and this information along with knowledge of Debby’s use of methamphetamine has caused Debby’s mother to stop communicating with her. Debby’s story includes acknowledging that Tyler takes care of Hope most of the time, including changing diapers, feeding, and helping bathe, and that she has been methamphetamine free for one week. She does not know the current location of her children. She has been mandated to a substance abuse assessment interview. All interviews took place in a private room and were videotaped. Counselors were instructed that they had up to one hour and 15 minutes to conduct a typical assessment interview and that they would be asked to offer a diagnosis as well as to respond to additional items assessing various aspects of the client’s overall clinical picture, similar to a real assessment interview. Diagnostic criteria were left to the counselor’s discretion. Counselors were also told that the key purpose of the interviews was to assess the authenticity of the standardized patient. Measures Counselors completed a post-interview questionnaire (see Figure 1 for questionnaire topics reported on for this paper), and interview sessions were video- and audio-recorded. Audio portions of the videotaped interviews were transcribed and sections identified where counselors offered impressions to the standardized patient by a) summarizing their understanding of the situation, b) speculating on what may have happened in the past to cause the problem, c) making predictive statements about the standardized patient’s future, or d) asking a question that carried an implicit interpretation or inference (e.g., “so, you feel sad that you are not with your kids?”). 386 Intimate Partner Violence TABLE 1. Counselor Recognition of Intimate Partner Violence by Presenting Problem Group Analytic Medium and Topic *IPV Group **Meth Group N 9 9 Post-interview questionnaire: Acknowledged IPV as a cooccurring “problem” in diagnosis 0 0 Post-interview questionnaire: Responded affirmatively to question, “Is this patient currently in physical danger?” 0 2 14 of 28 total barriers 5 of 26 total barriers 1 0 Post-interview questionnaire: Listed the husband as an open-ended response to “barrier to recovery.” Interview transcriptions: Obtained information that Debby has been physically assaulted and/or injured by her partner. (issues of safety) Note. *IPV = Intimate partner violence. **Meth = Methamphetamine. Analyses This study employed a three phase analytic framework. While the sample size does not allow for significance testing of differences between groups, analyzing the interviews through multiple methodological approaches, including limited quantitative analyses, provides a multi-layered description of outcomes and processes in the methamphetamine and intimate partner violence presenting problem groups. Phase one included quantitative and qualitative analysis of items on a post-interview questionnaire. The questionnaire was designed to assess both diagnostic outcomes of counselor/standardized patient interviews and the believability of the standardized patient (see Fussell, Lewy, & McFarland, 2009). Phase two enlisted three mental health practitioners to conduct blind ratings of the post-interview questionnaires, each practitioner reading the documents as though they were real-life case reports. The post-interview questionnaires elicited multiple openended responses from participating counselors beyond those specifically analyzed for this study, including treatment plan priorities and reasons for diagnostic responses. Practitioners were asked to rate counselor reactions to Debby as warm, cold, neutral, or ambivalent. Although raters were considered independent, inter-rater reliability was not calculated as a measure of relevance to theoretical testing. This decision was due to two factors: 1) Pre-existing definitions of warm, cold, or ambivalent do not exist. Raters were intentionally using an entirely subjective gauge for their decisions. 2) Each rater was left to subjectively determine criteria for definitions of warm versus cold. Therefore, it was determined that overall number of warm and cold ratings should dictate agreement or disagreement with Asch’s (1946) theoretical constructs. Phase three involved accessing dominant themes and overarching story lines that emerged in narrative transcriptions of nodal points in the videotaped interactions between counselors and Debby. As opposed to a coding system in which words and phrases are examined individually based on one coding scheme, this study followed a narrative analytic framework available in A Listening Guide (Gilligan, Spencer, Weinberg, & Bertsch, 2003). This framework includes analyzing narrative on multiple dimensions, including a) the primary, overarching theme; b) a closer examination of how the protagonist’s (Debby’s) story emerges differently in respective presenting problem groups; and c) how the former relate to the guiding research question. Fussell et al. 387 TABLE 2. Clinician Blind Ratings of Substance Abuse Counselor Impressions of Debby as Warm or Cold by Presenting Problem Group Rating *IPV Group **Meth Group Total Ratings Across Groups Warm 13 (68%) 6 (32%) 19 Warm/Neutral 2 (33%) 4 (67%) 6 Neutral 5 (50%) 5 (50%) 10 Ambivalent 6 (62%) 4 (38%) 10 0 1 (100%) 1 4 Ambivalent/Cold Cold/Neutral 1 (25%) 3 (75%) Cold 0 4 (100%) 4 Total 27 27 54 Note. *IPV = Intimate partner violence. **Meth = Methamphetamine Results Results provide insights on how counselors ascertain information about the standardized patient’s problems with intimate partner violence across all three phases of data analysis. Guiding theoretical premises of this study included that the social saliency of intimate partner violence should inform the development of a different perceptual trajectory for the intimate partner violence group than the methamphetamine group. In addition, issues of patient safety in situations of intimate partner violence support understanding the more direct impact of the presenting problem on counselor diagnoses and behavior. See Table 1 for ways counselors ascertained and responded to the standardized patient’s scripted involvement in intimate partner violence by presenting problem group. Notice that few counselors in either group identified intimate partner violence. Neither the intimate partner violence nor the methamphetamine group emphasized or ascertained concerns over the standardized patient’s scripted experiences of intimate partner violence with her husband. However, systematic differences between the two presenting problem groups did appear. Table 2 reports on between-group differences identified in clinicians’ blind ratings of substance abuse counselor responses to Debby as warm or cold as derived by blind ratings of the post-interview questionnaires. Three clinicians were asked to act as blind raters of post-interview questionnaires. Instructions to clinicians included rating the counselors’ interpretation of the client as warm, cold, neutral, or ambivalent. Although response options of warm, cold, neutral, and ambivalent were provided a priori, as Table 2 illustrates, clinicians created categories due to feeling the additional categories better reflected their actual judgment of the impression the substance abuse counselors had of the standardized patient. In addition to differences in warmer and colder ratings of counselor perceptions of Debby, substantial differences in duration of interviews occurred as well (see Table 3 for interviews lengths by group). Additional differences between presenting problem groups are found in the numbers of questions or statements in the interview transcriptions reflective of uncertainty for Debby’s future (i.e., “what if” comments or questions). Counselors in the intimate partner violence group overwhelmingly expressed less certainty about Debby’s future than did the counselors for the methamphetamine group. The intimate partner violence group transcripts included 36 comments or questions challenging Debby to consider possibilities that could result in less than ideal outcomes, with a particular em- 388 Intimate Partner Violence TABLE 3. Interview Duration Data Points by Group IPV* (median 40 minutes) Meth** (median 18 minutes) 20 16 25 16 28 18 30 18 40 18 46 30 50 50 64 53 70 65 Note. *IPV = Intimate partner violence. **Meth = Methamphetamine. phasis on her husband. Three of nine intimate partner violence group transcripts did not include any “what if” questions or comments. Those three narratives were characterized by extreme and unrealistic optimism. When Debby offered that problems with methamphetamine brought her to the session, counselors asked only seven “what if” questions. For example, one counselor asked, “If your husband comes back and starts using again, is that a situation you can feel comfortable with?” This closed-ended question characterized many of the questions in the transcripts from the methamphetamine group. As opposed to open-ended questions, such as the “what’s gonna happen?” query in the intimate partner violence group, the predominately closed-ended questions in the methamphetamine group did not leave room for further exploration of possible problems. Table 4 provides additional differences between the intimate partner violence and methamphetamine presenting problem groups on responses to the post-interview questionnaire. One unanticipated overarching theme emerged in the narrative analysis--a consistent emphasis on Debby’s maternal status (a woman whose children had been forcibly removed into protective custody). In particular, the transcripts from both presenting problem groups included statements indicative of a strong desire by the counselors to believe that Debby was a good mother in a bad situation, despite direct statements that she was not able to care for her children. For example, Debby stated that four-year-old Tyler bathes and feeds his two-year-old sister; that the children are sent to their room while she and her husband stay high on methamphetamine for days at a time; that upon entry to the house, after neighbors called the police over their fighting, the officers noted dilapidated conditions, such as no electricity; and that the children had reported to their grandmother that she and Eric never pay attention to them. After learning of these circumstances, one counselor concluded the topic of Debby’s relationship with her children by stating, “So, you would say, overall, that they’re happy, pretty balanced kids.” In focusing on Debby’s maternal status, including reshaping the story to conclude that Debby is a good parent, the counselors in both groups repeatedly suggested that Debby’s ultimate goal was taking care of her family. Although the standardized patient was scripted to state that “she just wants her kids back” in response to any questions of motivation for sobriety, this aim of becoming a better parent was not scripted. Indeed, the overemphasis on her desire to retrieve her children was scripted as indicative of a lack of motivation toward sobriety, given a lack of insight into any other reason to avoid methamphetamine. Fussell et al. 389 TABLE 4. Differences Between Presenting Problem Groups on Responses to Items on the Post-Interview Questionnaire *IPV Group **Meth Group 100% ; 7 of 7 “yes” responses 50%; 4 of 8 “yes” responses 44%; 7 of 16 total reasons 11%; 2 of 16 total reasons 33%; 3 of 9 counselors 0%; 0 of 9 counselors Questionnaire Topic Mental health related co-occurring problem Psychological reason for listed co-occurring problem Mental health evaluation listed as a treatment goal Note. *IPV = Intimate partner violence. **Meth = Methamphetamine Discussion These findings suggest differing trends in substance abuse assessment interviews when the same standardized patient-“Debby”--equipped with one clinical story presented with intimate partner violence versus problems with methamphetamine. Unexpectedly, however, findings also reveal an overall paucity of clinical emphasis on the client’s involvement in a dangerous relationship as well as her immediate safety. Regardless of their presenting problem group, counselors failed to obtain information on the severity of the standardized patient’s situation. The script required the standardized patient to reveal further information upon counselor probing. For the most part, this probing did not occur. When clinical discussion did turn to possibilities that Debby may be in a violent relationship, the standardized patient was to state initially that “I hit him too” and that “he’s just been dealing with a lot lately.” In all but one interview that broached this topic, the counselors immediately changed the subject. In addition, in both presenting problem groups, an inordinate emphasis was placed on the client’s maternal status, including over-confidence in the client as a “good” mother in a bad situation, despite evidence to the contrary. None of the 18 counselors reported intimate partner violence as a co-occurring problem or disorder. Although the standardized patient’s script was identical for both counseling groups, including level of intimate partner violence, the finding that no counselors emphasized problems with vio- lence is particular noteworthy given that nine counselors heard Debby state that “Me and my husband have been fighting a lot lately, and this last time the police came and they took my kids” as the presenting problem. One potential explanation for the omission concerns the post-interview questionnaire; did the questionnaire afford counselors clear opportunity for reporting intimate partner violence as a co-occurring problem? Practitioners could have interpreted the question, “if (the client is suffering from one or more co-occurring problem(s)/disorder(s), what labels/diagnoses would you use to describe the problem,” as inquiring specifically whether the client had a mental health disorder. However, the term “co-occurring problem” was intentionally inserted in this question in order to broaden response options. Also, and crucially, only two of 18 counselors reported that the client was in physical danger. Duration of the intimate partner violence sessions was twice as long as that of the methamphetamine group. Although a plausible explanation for this time difference could be that the intimate partner violence group spent more time struggling with how to deal with the topic of violence, this did not occur. Rather, transcripts and responses on the post-interview questionnaire pointed to the interpersonal violence group shifting the emphasis away from violence and toward explorations of psychological processes. Additionally, the methamphetamine group transcripts included only seven “what if” type inquiries, while the intimate partner violence group included 36 such questions and/or statements indicative of uncertainty in the outcome of the client’s story. This 390 combination of findings suggests that the intimate partner violence presenting problem elicited a more concerned response followed by more detailed interviews. However, the content analytic finding that only one of 18 counselors obtained information that the standardized patient had been physically injured by her domestic partner reinforces concerns about omitting that critical component of the standardized patient’s story. Acknowledging a problem with methamphetamine, particularly as the patient’s description of the presenting problem, could lead counselors to believe that the standardized patient was highly motivated to change. This belief could, in turn, have foreclosed therapeutic exploration of other aspects of the client’s story. This tendency toward clinical closure quite likely contributed to missing the crucial intimate partner violence component of the client’s story and/or moving too hastily to treatment issues. The counselors’ emphasis on Debby’s maternal status, to the point of all but ignoring information presented that countered the idea that she was simply a “good mother in a bad situation,” may register countertransference anxiety on the part of clinicians. This redemptive script may operate as an unconscious effort to compensate for the historical tendency toward “mother-blaming” in situations of domestic abuse. But clinicians also may feel ill-equipped to explore the difficult terrain where problems of drug abuse and intimate partner violence converge, and where clinicians are caught between competing conventional discourses on women and social problems. The study included the prediction that intimate partner violence would be interpreted more sympathetically than methamphetamine use, a premise tested directly through external, blind ratings of post-interview questionnaires. Clinicians were asked to include comments explaining the reasons for their ratings. Interestingly, two of the blind raters’ evaluations made use of Debby’s maternal status discrepantly in explaining criteria for warm versus cold perceptions. Com- Intimate Partner Violence ments from the first rater’s warm assessments included items such as, “states positive traits of client--honesty, determination, love for her children, willing to follow directions … despite low awareness of addiction clinician perceives client ‘wants’ her kids … addresses client’s self-esteem and self-confidence and desires as clinician to support client’s goal (to get kids back) ... points to children as assets in recovery, client values kids.” This clinician’s comments point to an emphasis on substance abuse counselors ascertaining Debby’s “love” for her children and the “value” she places on them as a sign of a warm perception. The second clinician elaborated on her rating criteria by stating that including getting kids back as a priority goal indicates a lack of attentiveness and depth of exploration into Debby’s scenario--concepts associated with a cold perception. Both clinicians viewed the children as indicative of a warm perception if care was taken by the substance abuse counselor to make use of the information in a way consistent with developing what the third rater described as a therapeutic alliance. Due to the higher number of female counselors (n = 13) than male (n = 5) that participated in the study, one possible conclusion is that females tended toward warm perceptions of the standardized patient and males tended toward cold perceptions. However, closer analysis of which counselors were rated as having warmer versus colder perceptions of Debby shows that of the five males only one received two “cold/neutral” ratings. Of the remaining 13 ratings of the five males, seven were interpreted as having a warm perception of Debby and six as having a neutral or ambivalent perception. Although the numbers of questionnaires rated warm, cold, and so forth, were similar, raters did not always agree on which questionnaires fell into particular categories. For example, one counselor was rated ambivalent, warm, and cold. Rather than lending doubt to Asch’s (1946) theory, the discrepancies in ratings for counselors’ perceptions of Debby actually substantiate the key premise Fussell et al. 391 that even dynamic interactions between multiple characteristics of an individual demonstrate relatively predictable interpersonal patterns in impression formation. Regardless of individual criteria and subjectivity, aggregate outcomes nonetheless demonstrate more warm perceptions related to a problem eliciting sympathy and more cold perceptions of a problem eliciting distance. Implications Assisting patients with co-occurring problems of intimate partner violence and substance abuse is not limited to addictions counseling. Possibilities for inadvertent and inordinate attention to presenting problems in clinical interviews exist across multiple clinical domains. In conceptualizing interventions in intimate partner violence as a social priority, substance abuse treatment is an opportune location for identifying the problem and providing information on assistance and/or referrals. While reducing problems specific to substance abuse remain the priority for counselors in the field, educating practitioners on how to broach intimate partner violence could go some distance in attempts to alleviate both problems. This study began with the recognition that clinical exploration of interpersonal processes poses specific methodological challenges. Standardized patients address some of these challenges by controlling for the content of client responses to therapeutic inquiry. Use of standardized patients in clinical settings has vastly increased over the past decade as have studies investigating their utility and limitations. The larger study that provided the context for the findings reported here offers preliminary evidence that standardized patients can authentically portray complex client cases, such as those including intimate partner violence and substance abuse, supporting future use of standardized patient technology to understand clinical processes with critical consequences for individuals dealing with intimate partner violence and substance abuse. Findings from this study suggest that practitioners from a range of counseling fields may benefit from increased awareness of how particular presenting problems influence clinical interaction. 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