Post-Partum (now Peripartum) Depression: What you should know . . . and some resources to help you know it

Note: This post is provided for individuals interested in learning more about post-partum or peripartum depression. It’s also a supplement for the recent Practically Perfect Parenting Podcast on “Post-Partum Depression.” You can listen to the podcast on iTunes: https://itunes.apple.com/us/podcast/practically-perfect-parenting/id1170841304?mt=2

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For the first time ever on planet Earth, the latest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) includes the diagnosis of Peripartum Depression. Although I’m not usually a fan of labeling or big psychiatry, this is generally good news.

So, why is Peripartum Depression good news?

The truth is that many pregnant women and new moms experience depressive symptoms related to pregnancy and childbirth. These symptoms are beyond the normal and transient “baby blues.” Depressive symptoms can be anywhere from mild to severe and, combined with the rigors of pregnancy, childbirth, and parenting a newborn, these symptoms become very difficult to shake.

But the most important point is that Peripartum Depression is a problem that has been flying under the RADAR for a very long time.

Approximately 20% of pregnant women struggle with depressive symptoms. The official 12-15% estimates of post-partum (after birth) depression in women are thought to be an underestimate. What makes these numbers even worse is the fact that society views childbirth as a dramatically positive life event. This makes it all-the-more difficult for most pregnant women and new moms to speak openly about their emotional pain and misery. And, as you probably know, when people feel they shouldn’t talk about their emotional pain, it makes getting the help they deserve and recovering from depression even more difficult.

Jane Honikman, a post-partum depression survivor and founder of Postpartum Support International has three universal messages for all couples and families. She says:

  • You’re not alone
  • It’s not your fault
  • You will be well

Keep in mind that although peripartum depression is thought to have strong biological roots, the first-line treatment of choice is psychotherapy. This is because many new moms are reluctant to take antidepressant medications, but also because psychotherapy is effective in directly addressing the social and contextual factors, as well as the physiological symptoms. Additionally, as Ms. Honikman emphasizes, support groups for post-partum depression can be transformative.

Below, I’m including links and resources related to peripartum or post-partum depression.

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A very helpful informational post by Dr. Nicola Gray: http://cognitive-psychiatry.com/peripartum-depression/

Books by Jane Honikman can be found at this Amazon link. Her books include: I’m Listening: A Guide to Supporting Postpartum Families.  https://www.amazon.com/s/ref=dp_byline_sr_book_1?ie=UTF8&text=Jane+I.+Honikman&search-alias=books&field-author=Jane+I.+Honikman&sort=relevancerank

Although it’s true that peripartum depression can be debilitating, it’s also true that it can be a source of personal growth. Dr. Walker Karraa shares optimistic stories of post-partum related trauma and growth in her book:

https://www.amazon.com/Walker-Karraa/e/B00QTWH9PW/ref=dp_byline_cont_book_1

 

More Methods for Discussing Suicide with Mental Health Clients

nick-nacksNearly everyone agrees that asking clients directly about suicide is the right thing. However, because every client situation is unique, there are also many different strategies for asking about suicide. In this short excerpt from Clinical Interviewing, we discuss how to bring up suicide using information from outside of the counseling or assessment session.

Using Outside Information to initiate Risk and Protective Factor Assessment

Outside of the formal suicide assessment interview, three main sources of information can be used to initiate a discussion with clients about suicide risk and protective factors:

  1. Client Records
  2. Assessment Instruments
  3. Collateral Informants

Client Records

If available, your client’s previous medical or mental health (med-psych) records are a quick and efficient source for client risk and protective factor information. Many risk factors listed in this chapter won’t be in your client’s records, but you should look closely for factors, such as: (a) previous suicide ideation and attempts; (b) a history of a depression diagnosis; and (c) familial suicide. After your standard intake interviewing opening and rapport building, you can use the records to broach these issues.

I saw in your records that you attempted suicide back in 2012. Could you tell me what was going on in your life back then to trigger that attempt? 

When exploring previous suicide attempts, it’s important to do so in a constructive manner that can contribute to treatment (see Case Example 10.2). Using psychoeducation to explain to clients why you’re asking about the past helps frame and facilitate the process.

The reason I’m asking about your previous suicide attempt is because the latest research indicates that the more we know about the specific stresses that triggered a past attempt, the better we can work together to help you cope with that stress now and in the future. 

Don’t forget to balance your questioning about previous suicide attempts with a focus on the positive.

Often, after a suicide attempt, people say they discovered some new strengths or resources or specific people who were especially helpful. How about for you? Did you have anything positive you discovered in the time after your suicide attempt.

It may be difficult to identify protective factors in your client’s med-psych records. However, if you find evidence of protective factors or personal strengths, you should bring them up in the appropriate context during a suicide assessment interview. For example, when interviewing a client who’s talking about despair associated with a current depressive episode, you might say something like:

I noticed in your records that you had a similar time a couple years ago when you were feeling very down and discouraged. And, according to your therapist back then, you worked very hard and managed to climb back up out of that depressing place. What worked for you back then?

Strive to use information from your clients’ records collaboratively. As illustrated, you can use the information to broach delicate issues (both positive and negative).

Traditionally, previous suicide attempts are considered one of the strongest predictors of future suicidal behaviors. However, as with all risk factors, previous attempts should be considered within the idiosyncratic context of each individual client. Case example 10.2 provides a glimpse of a case where a previous attempt ends up serving as a protective factor, rather than a risk factor.

Case Example 10.2

Exploring Previous Attempts as a Method for Understanding Client Stressors and Coping Strategies

Exploring previous suicide attempts is an assessment process. It can illuminate past stressors, but it’s equally useful for helping clients articulate past, present, and future coping responses.

Therapist: You wrote on your intake form that you attempted suicide about a year and a half ago. Can you tell me a bit about that?

Client: Right. I shot myself in the head. It’s obvious. You can see the scar right here.

Therapist: What was happening in your life that brought you to that point?

Client: I was getting bullied in school. I hated my step-father. Life was shit, so one day after school I took the pistol out of my mom’s room, aimed at my head and shot.

Therapist: What happened then?

Client: I woke up in the hospital with a bad fucking headache. And then there was rehab. It was a long road, but here I am.

Therapist: Right. Here you are. What do you make of that?

Client: I’m lucky. I’m bad at suicide. I don’t know. I suppose I took it to mean that I’m supposed to be alive.

Therapist: Have you had any thoughts about suicide recently?

Client: Nope. Nada. Not one.

Therapist: I guess from what you said that getting bullied or having family issues could still be hard for you. How do you cope with that now?

Client: I’ve got some friends. I’ve got my sister. I talk to them. You know, after you do what I did, you find out who really cares about you. Now I know.

 

Talking with Clients about Suicidal Thoughts and Feelings

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Spring is coming to the Northern Hemisphere. Along with spring, there will also be a bump in death by suicide. To help prepare counselors and clinicians to talk directly with clients about suicide, I’m posting an excerpt from the Clinical Interviewing text. The purpose is to help everyone be more comfortable talking about suicidal thoughts and feelings because the more comfortable we are, the more likely clients are to openly share their suicidal thoughts and feelings and that gives us a chance to engage them as a collaborative helper.

Here’s a link to the text https://www.amazon.com/Clinical-Interviewing-Video-Resource-Center/dp/1119084237/ref=asap_bc?ie=UTF8

And here’s the excerpt:

Exploring Suicide Ideation

Unlike many other risk factors (e.g., demographic factors), suicide ideation is directly linked to potential suicide behavior. It’s difficult to imagine anyone ever dying by suicide without having first experienced suicide ideation.

Because of this, you may decide to systematically ask every client about suicide ideation during initial clinical interviews. This is a conservative approach and guarantees you won’t face a situation where you should have asked about suicide, but didn’t. Alternatively, you may decide to weave questions about suicide ideation into clinical interviews as appropriate. At least initially, for developing professionals, we recommend using the systematic approach. However, we recognize that this can se0em rote. From our perspective, it is better to learn to ask artfully by doing it over and over than to fail to ask and regret it.

The nonverbal nature of communication has direct implications for how and when you ask about suicide ideation, depressive symptoms, previous attempts, and other emotionally laden issues. For example, it’s possible to ask: “Have you ever thought about suicide?” while nonverbally communicating to the client: “Please, please say no!” Therefore, before you decide how you’ll ask about suicide ideation, you need the right attitude about asking the question.

Individuals who have suicidal thoughts can be extremely sensitive to social judgment. They may have avoided sharing suicidal thoughts out of fear of being judged as “insane” or some other stigma. They’re likely monitoring you closely and gauging whether you’re someone to trust with this deeply intimate information. To pass this unspoken test of trust, it’s important to endorse, and directly or indirectly communicate the following beliefs:

  • Suicide ideation is normal and natural and counseling is a good place for clients to share those thoughts.
  • I can be of better help to clients if they tell me their emotional pain, distress, and suicidal thoughts.
  • I want my clients to share their suicidal thoughts.
  • If my clients share their suicidal thoughts and plans, I can handle it!

If you don’t embrace these beliefs, clients experiencing suicide ideation may choose to be less open.

Asking Directly about Suicide Ideation

Asking about suicide ideation may feel awkward. Learning to ask difficult questions in a deliberate, compassionate, professional, and calm manner requires practice. It also may help to know that, in a study by Hahn and Marks (1996), 97% of previously suicidal clients were either receptive or neutral about discussing suicide with their therapists during intake sessions. It also may help to know that you’re about to learn the three most effective approaches to asking about suicide that exist on this planet.

Use a normalizing frame. Most modern prevention and intervention programs recommend directly asking clients something like, “Have you been thinking about suicide recently?” This is an adequate approach if you’re in a situation with someone you know well and from whom you can expect an honest response.

A more nuanced approach is to ask about suicide along with a normalizing or universalizing statement about suicide ideation. Here’s the classic example:

Well, I asked this question since almost all people at one time or another during their lives have thought about suicide. There is nothing abnormal about the thought. In fact it is very normal when one feels so down in the dumps. The thought itself is not harmful. (Wollersheim, 1974, p. 223)

Three more examples of using a normalizing frame follow:

  • I’ve read that up to 50% of teenagers have thought about suicide. Is that true for you?
  • Sometimes when people are down or feeling miserable, they think about suicide and reject the idea or they think about suicide as a solution. Have you had either of these thoughts about suicide?
  • I have a practice of asking everyone I meet with about suicide and so I’m going to ask you: Have you had thoughts about death or suicide?

A common fear is that asking about suicide will put suicidal ideas in clients’ heads. There’s no evidence to support this  (Jobes, 2006). More likely, your invitation to share suicidal thoughts will reassure clients that you’re comfortable with the subject, in control of the situation, and capable of dealing with the problem.

Use gentle assumption. Based on over two decades of clinical experience with suicide assessment Shawn Shea (2002/ 2004/2015) recommends using a framing strategy referred to as gentle assumption. To use gentle assumption, the interviewer presumes that certain illegal or embarrassing behaviors are already occurring in the client’s life, and gently structures questions accordingly. For example, instead of asking “Have you been thinking about suicide?” you would ask:

When was the last time when you had thoughts about suicide?

Gentle assumption can make it easier for clients to disclose suicide ideation.

Use mood ratings with a suicidal floor. It can be helpful to ask about suicide in the context of a mood assessment (as in a mental status examination). Scaling questions such as those that follow can be used to empathically assess mood levels.

  1. Is it okay if I ask some questions about your mood? (This is an invitation for collaboration; clients can say “no,” but rarely do.)
  2. Please rate your mood right now, using a zero to 10 scale. Zero is the worst mood possible. In fact, zero would mean you’re totally depressed and so you’re just going to kill yourself. At the top, 10 is your best possible mood. A 10 would mean you’re as happy as you could possibly be. Maybe you would be dancing or singing or doing whatever you do when you’re extremely happy. Using that zero to 10 scale, what rating would you give your mood right now? (Each end of the scale must be anchored for mutual understanding.)
  3. What’s happening now that makes you give your mood that rating? (This links the mood rating to the external situation.)
  4. What’s the worst or lowest mood rating you’ve ever had? (This informs the interviewer about the lowest lows.)
  5. What was happening back then to make you feel so down? (This links the lowest rating to the external situation and may lead to discussing previous attempts.)
  6. For you, what would be a normal mood rating on a normal day? (Clients define their normal.)
  7. Now tell me, what’s the best mood rating you think you’ve ever had? (The process ends with a positive mood rating.)
  8. What was happening that helped you have such a high mood rating? (The positive rating is linked to an external situation.)

The preceding protocol assumes clients are minimally cooperative. More advanced interviewing procedures can be added when clients are resistant (see Chapter 12). The process facilitates a deeper understanding of life events linked to negative moods and suicide ideation. This can lead to formal counseling or psychotherapy, as well as safety planning.

Responding to Suicide Ideation

Let’s say you broach the question and your client openly discloses the presence of suicide ideation. What next?

First, remember that hearing about your client’s suicide ideation is good news. It reflects trust. Also remember that depressive and suicidal symptoms are part of a normal response to distress. Validate and normalize:

Given the stress you’re experiencing, it’s not unusual for you to sometimes think about suicide. It sounds like things have been really hard lately.

This validation is important because many suicidal individuals feel socially disconnected, emotionally invalidated, and as if they’re a social burden (Joiner, 2005). Your empathic reflection may be more or less specific, depending on how much detailed information your client has given you.

As you continue the assessment, collaboratively explore the frequency, triggers, duration, and intensity of your client’s suicidal thoughts.

  • Frequency: How often do you find yourself thinking about suicide?
  • Triggers: What seems to trigger your suicidal thoughts? What gets them started?
  • Duration: How long do these thoughts stay with you once they start?
  • Intensity: How intense are your thoughts about suicide? Do they gently pop into your head or do they have lots of power and sort of smack you down?

As you explore the suicide ideation, strive to emanate calmness, and curiosity, rather than judgment. Instead of thinking, “We need to get rid of these thoughts,” engage in collaborative and empathic exploration.

Some clients will deny suicidal thoughts. If this happens, and it feels genuine, acknowledge and accept the denial, while noting that you were just using your standard practice.

Okay. Thanks. Asking about suicidal thoughts is just something I think is important to do with everyone.

On the other hand, if the denial seems forced, or is combined with depressive symptoms or other risk factors, you’ll still want to use acknowledgement and acceptance, but then find a way to return to the topic later in the session.

 

The White Privilege Piece for the Montana Psychological Association

Reblogging this in response to Michael Smerconish’s feature on CNN today.

John Sommers-Flanagan

Michael Smerconish did a feature on White Privilege today on CNN. It was excellent and reminded me of this piece I’d written on White Privilege about 4 years ago. Check it out if you like this sort of thing.

A White, Male Psychologist Reflects on White Privilege

I’m a white male writing about white privilege. This irony makes the task all the more challenging.

Gyda Swaney asked if I would write this piece. This brings me mixed feelings. I am honored. I met Gyda in 1981 and I like and respect her as a person and as a Native American leader in Montana. But the fact that she thinks I might have something useful to say to psychologists about white privilege is humbling. Rarely have I been asked to write about something I know so well and understand so little.

On Invisibility

The challenge begins with the definition. White privilege…

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State Leadership in Education: A Missoulian Op-Ed Piece

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Hi All.

I just had another op-ed piece published in the Missoulian Newspaper this morning. It’s about early childhood education. It may come as a surprise to you, but, along with John Adams, our second president, I’m a supporter of early childhood education.

If you’re interested in what John Adams and I think (we’re time-traveling buddies) about education, here’s the link: http://missoulian.com/news/opinion/columnists/state-leadership-in-education-our-children-deserve-better/article_fc8aeea4-7670-5a39-a7f5-bbb1c0875043.html

If you read it and like it, please pass on the link, especially to others in Montana and on Facebook and Twitter and all that.

Thanks . . . I’ll be getting back to the more normal counseling and psychology stuff soon.

John

The Missoula CASA Keynote

There are a number of problems associated with being asked to do a keynote speech for a local non-profit. Maybe this is all just me, but the pressure feels very big. Keynotes are supposed to be informative and inspiring and funny. Right? Well, to be perfectly honest, although I love to think of myself as able to be informative, inspiring, and funny, to actually have expectations to be informative, inspiring, and funny is miserable. That might be why, 15 minutes before stepping up to the microphone at the Doubletree banquet room in Missoula, I had a case of the complete BLANK MIND. I seriously had no idea what I had planned to say. Two days before the event I was sure I could memorize my 25 minute speech. Now, I looked at my notebook and words were there, but they seemed stupid and boring and not funny and I couldn’t help but wonder, “Who wrote this crap?” I suppose that’s an example of an unfriendly dissociation.

To top all that off, every speaker who offered introductions and who spoke before me was smooth and articulate . . . and I had decided to drink a cup of herbal tea which led to my bladder was telling me that I HAD to get to the bathroom right away. But I wasn’t sure how long I had before being called up as the highly acclaimed keynote speaker whose name was in big bold letters on the program. Mostly, I felt like crawling under the Crowley and Fleck sponsored keynote table or escaping to the bathroom. Neither of these options seemed realistic.

So I told my bladder to wait its turn and listened to Eden Atwood sing along with a group of fabulously talented and cute young girls. A man at the front table started crying. That’s what happens when you’re at an event celebrating and funding an organization that works with abused and neglected children. It was around then that Eden Atwood and her group (called the MOB) distracted me from my anxiety, calmed me out of my dissociative episode, and inspired me to go ahead and sing and dance around the stage as part of the ending of my keynote.

Just in case you missed it, the whole darn event was awesome. The best part was to be right in the middle of the generosity of so many people who help make Missoula a better and healthier and safer place.

And just in case you’re interested, I managed to deliver most my planned speech and people laughed and afterward offered big compliments. But I’m not certain how well I stuck to the script because at some point I remember saying “Of course, I’m lying about that” which I followed with, “But I understand that lying is popular right now.” I also recall, after one particular non-sequitur, saying something about the fact that because I was a university professor, I could say whatever I wanted and didn’t really have to make any logical sense. None of these comments were in the transcript to my speech. Obviously, I went way off script.

It might be surprising, but my plan to start singing and dancing actually was in the script. However, partway through the song my blank mind returned and I forgot the lyrics. The good news is that I’m fairly sure that everyone, including me, was greatly relieved when I stopped singing.

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Today, I am Captain America

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Today, I am Captain America

John Sommers-Flanagan

One of the hardest things about being a superhero is maintaining a secret identity. Sometimes I get so far undercover that even the Marvel Comics people don’t know who I am. This pretty much drives them nuts. But they deal with it, because, after all, I am Captain America.

I was born with the name John Sommers. This might be confusing to those of you who thought Steve Rogers was the original Captain America. That’s a myth Marvel and I perpetuated to help keep my identity secret. To further the deception, in 1985, I changed my name to John Sommers-Flanagan. This addressed the dual objectives of expressing an equal partnership with my wife and further obfuscating my identity.

Hyphenating my last name was a strategy similar to how my friend Superman is able to maintain his secret Clark Kent identity just by wearing nerdy glasses. Obviously, if you wear nerdy glasses, nobody will think you could possibly be Superman. Well, I wear nerdy glasses AND I have a hyphenated last name. Nobody in their right mind could possibly think I’m Captain America. Think about it. One time a guy I know asked me, “What sort of man hyphenates his last name?” I didn’t tell him because I was maintaining the secret identity thing, but the answer was and is: “Captain America.” #perfectdisguise.

I told Superman I was coming out of the secret identity closet and he asked me, “John, why are you choosing, at this moment in history, to give up your perfect disguise?” I said, “Hey Clark. . . ” (we’re on a first name basis because it always feels awkward when people call me Captain), “. . . radical times call for radical measures.” He just nodded thoughtfully. He’s like that.

The thing is, while growing up as Captain America, I realized early on that women were competent and I wanted to work alongside them, as equal partners. This eventually led me to be against the objectification of women and in favor of women’s rights to make their own healthcare decisions.

Being Captain American has also helped me clarify other values. I’m a big fan of the phrase “All men are created equal” but I’m inclined to substitute “people” for “men.” It seems only right that Captain America would support statements that Thomas Jefferson wrote in the Declaration of Independence. Over the years I’ve had Gay and Lesbian and Transgender friends and family and colleagues, and you know what, I found that they’re kind and competent and respectful and loving and safe people to have in my life who are equal to everyone else. I’m also pretty big on liberty and the pursuit of happiness for all people, and that includes Muslims and Mexicans and Native Americans who have sacred lands threatened by oil pipelines and other minorities, including sexual minorities and persons with disabilities.

It might surprise you to find out that I really love music. I’m not that much of a dancer—although I’ve cut a rug or two in my time. Now that I’m older, I’m more into lyrics than swinging my hips. Like that phrase in the Star Spangled Banner about America being “the land of the free and the home of the brave.” To me and most Americans, I think the meaning of those words is simple. We have freedom of religion, freedom of speech, freedom of the press, freedom to marry whomever we like, and we’ve got the courage to accept and embrace the goodness inherent in all this freedom and diversity. We also have the freedom to hate, although most people end up feeling so good about living in America that they usually find they prefer loving over hating.

Another musical reference that gives me tingles is the part of America the Beautiful where it goes: “May all success be nobleness and every gain divine.” That’s massively deep stuff, but right now it doesn’t feel like Wall Street, income inequality, and tax breaks for the wealthy fit with the idea of success being noble and divine. What would Jesus think? Well, along with Superman, he’s one of my besties and so I asked him. Wouldn’t you know, he got all analogy on me. He said something about rich people getting to heaven being as likely as a camel getting through the eye of a needle. My follow up question was about whether that meant it would be easier for Ant Man to get to heaven? At that point Jesus said, “Sure, Ant Man gets in, along with everyone else who makes himself or herself or their-self small and is interested in serving others instead of trying too hard to be bigly.” Then he giggled for almost a whole minute. Sometimes I’m not sure I get Jesus’s humor, but He thinks he’s funny, so that’s good enough for me.

Here’s another thing freedom means to me. Freedom means that we don’t have to register ourselves or be profiled or be put on watch lists because of believing in a particular God or because of having a particular color skin. It also means we’ve got the freedom to vote. And that means registering to vote should be pretty darn easy for all Americans and that voting lines should be equally short in poor and rich neighborhoods. Mostly we should be registering cars and college students, and, because I’m a superhero, I’m also in favor of registering guns. My reasoning is that in the real world it’s not as easy to sort out the good guys from the bad guys as it is in comic books and on television. What helps me is that I wear an easily recognizable spandex red white and blue outfit.  So I figure if you’re planning to carry firearms, you should register them and then at least have the decency to make it clear that you’re one of the good guys and if that involves putting on some spandex, so be it. That’s what my friend Thor would say. He always likes to say “So be it” in his loud, thunderous voice. He can be pretty convincing.

Here’s one last point on the gun thing. You may have noticed, I only carry a shield. Make of that what you will. I believe in the right to bear arms, but I believe even harder in gun safety.

Growing up, I went to public schools all my life. I even went to public universities. And as I’ve made clear, I ended up becoming Captain America. That’s not to say public schools are perfect, but Damn, American public school teachers are fucking amazing (I think that’s how my friend Pink would say it). Do you know how hard teachers work? Do you know how little they get paid? Did you know that John Adams, the 2nd President of the United States said something like (paraphrasing here), “there’s no way you can spend too much money on education for poor people.” Now, if you studied some proper history in a public school, you’d know that during his time, John Adams was just about the smartest and most persistent dude on the planet . . . and you’d also probably know the difference between educational measurements of proficiency and growth. Just saying.

I should confess right now that I’ve thought long and hard about whether to support the new president of the United States. The disrespect he’s shown for anyone he considers beneath him and who didn’t donate to his campaign make it difficult for me to endorse anything about him. But then I had an epiphany. I realized, “Wait, I’m Captain America, and that means I’m all about supporting values and not people.” This epiphany (BTW, “Thank-you Jesus”) helped me see and understand that I’m not a republican or a democrat and that I don’t support specific politicians. Therefore, whenever our new president upholds the values of equality for everyone, freedom for everyone, health insurance for everyone, gun safety, and better education for everyone—I’ll support him acting on those values. Also, whenever he sacrifices his own wealth and ego and treats women, minorities, the disabled, LGBTQ people, and everyone else with the respect they deserve, I’ll support those actions too.  However, to the extent that he advocates unequal treatment of individuals, restricts religious and other freedoms, meddles with women’s health decisions, or interferes with the common person’s pursuit of happiness, I’ll be opposing him along with my friends Jesus, Superman, and Pink.

That’s because I’m Captain America.

And you can be too.

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John Sommers-Flanagan is a clinical psychologist, a professor of counselor education at the University of Montana, the author of eight books, co-host of the Practically Perfect Parenting Podcast, and Captain America.

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Author, Speaker, University of Montana Professor