Trauma, Suicide, and Motivational Interviewing: A Handout for BYEP Mentors

Sunset

Trauma may be the most common underlying factor contributing to mental disorders. Unfortunately, trauma is often overlooked, partly because it can manifest itself in so many different ways. That said, here are some common definitions. Trauma always involves a stressful trigger that activates a trauma response. Because, like everything, trauma responses are brain-based and involve the body, symptoms affect the whole person.

Old, informal, and useful definitions include:

  • A stressor outside the realm of normal human experience (but sadly, trauma is all-too-common)
  • A betrayal . . . (e.g., something that should not happen)
  • Occurrence of an event that’s emotionally overwhelming

Below I’ve listed the essence of the DSM-5 definition for Post-Traumatic Stress Disorder (note that the whole idea of PTSD centers on the chronic or long-lasting effects of trauma).

Exposure to a traumatic stressor that involves direct personal experience, witnessing, or learning about events involving threatened death, serious injury, or a threat to your physical integrity. The trauma response includes:

  • Intrusion symptoms (recurring unwanted memories, nightmares, flashbacks, and triggered distress)
  • Avoidance of trauma-related thoughts or external cues
  • Negative cognitive alternations (e.g., memory gaps, no joy, etc.)
  • Arousal and reactivity (e.g., irritability, risky behaviors, hypervigilance, insomnia, startle response)

Trauma and trauma responses can be big, medium, and small. Big traumas meet the DSM-5 diagnostic criteria for PTSD or acute stress disorder. Small traumas are usually disturbing and disruptive, but the body and brain adjust to them within 2-3 days. Medium size traumas have lasting effects, but don’t meet formal diagnostic criterial, and are usually referred to as subclinical.

I like to think of Trauma with an uppercase T (like in the DSM) and all other traumas that are difficult, challenging, and require adjustment as traumas with a lowercase t.

What to Say

Sometimes trauma responses or symptoms are visible and obvious. If so, it’s good to say and do some of the following:

  • Listen and show compassion
  • Reassure participants that physical/psychological responses are normal, take up energy & need soothing
  • Note that very effective treatments are available (e.g., This American Life)
  • Brainstorm on what helps
  • Remember: A pill is not a skill
  • Link and universalize (“It’s normal to have pleasant and unpleasant reactions to things we talk about”)
  • Brainstorm on more and less healthy reactions (Using substances is a quick distraction, but not a fix)
  • Share hopeful stories (what skills can be developed?)
  • Self-disclosure can help. But be careful with self-disclosure and remember that it’s not about you

Trauma is a normal and natural human response. You may experience trauma just by listening to people talk about trauma, or you may have your own direct experiences. When in the business of helping others, be sure to take good care of yourself.

Three Suicide Myths

Myth #1: Suicidal thoughts are about death and dying.

Most people assume that suicidal thoughts are about death and dying. On the surface, it seems like a no-brainer: Someone has thoughts about death, therefore, the thoughts must be about death. But the truth isn’t always how it appears from the surface. The human brain is complex. Thoughts about death may not be about death itself.

Myth #2: Suicide and suicidal thinking are signs of mental illness.

Not true. Philosophers and research scientists agree: nearly everyone on the planet thinks about suicide at one time or another—even if briefly. The philosopher Friedrich Nietzsche referred to suicidal thoughts as a coping strategy, writing, “The thought of suicide is a great consolation: by means of it one gets through many a dark night.”

Myth #3: Scientific knowledge about suicide risk factors and warning signs allows for the prediction and prevention of suicide.

Believing in this myth can make surviving family members, friends, and helping professionals experience too much guilt and responsibility. In fact, even the most famous suicidologists say that it’s impossible to consistently and accurately predict suicide.

Tips for Talking about Suicide

We need to be able to talk directly about suicide with courage and calmness. But first, we should listen. Here’s what you should listen for in general

  • Emotional pain
  • A sense of feeling trapped or ashamed
  • Not believing that anything can possibly help to reduce the pain and misery

While listening, show acceptance, empathy, and compassion. Remember: suicidal thoughts are not signs of illness or moral failing; if you judge the person, it will make it harder for the person to be open. Also remember: when people talk with you about their suicidal thoughts, that’s a good thing, because you can’t help unless they’re comfortable enough with you to speak openly about their suicidal thoughts and feelings.

Traditional warning signs in particular

Although it’s good to know these warning signs, there’s not much research supporting the idea that anything predicts suicide.

  • Active suicidal thinking that includes planning and talk about wanting to die
  • Preparation and rehearsal behaviors (stockpiling pills, giving away belongings, etc.)
  • Hopelessness related to feeling that the excruciating distress will never end
  • Recklessness, impulsivity, dramatic mood changes
  • Anger, anxiety, and agitation
  • Feeling trapped
  • No reasons for living, no purpose in life, broken relationships
  • Increased alcohol or substance abuse
  • Immense shame or self-hatred

How should I ask about suicide?

The answer to this is always, “Ask directly.” But we can do even better than that. We need to de-shame suicidal thoughts and talk. Before asking, communicate that you know suicidal thoughts are a normal and natural response to emotional pain and disturbing situations. For example, you could ask it this way, “I know that it’s not unusual for people to think about suicide. Have you had any thoughts about suicide?”

What should I say if someone admits to thinking about suicide? You can say things like,

  • Thanks for telling me.
  • It sounds like things have been terribly hard.
  • Thanks for being so honest, that takes courage.
  • I know I can’t instantly make everything better, but I want you to live and I want to help.
  • How can I best support you right now?
  • What can we do together that would help?
  • When you want to give up, tell yourself to hold off for one more day, hour, minute—whatever you can.
  • Or . . . use your good listening skills and reflect back the feelings and thoughts that the person shared.

Resources for Help

  • National Suicide Prevention Lifeline: Call 800-273-TALK (800-273-8255)
  • Crisis Text Line: Text HOME to 741741
  • Bozeman Help Center – 24-Hour Crisis Line: (406) 586-3333

What is Motivational Interviewing?

Motivational interviewing (MI) is an evidence-based approach to treating substance problems, health concerns, and other mental health issues. MI is “person-centered” and based on the foundational principle that clients should be the ones who make the case for change in their lives. MI:

  • Focuses on the common problem of ambivalence about change.
  • Relies on four central listening skills (OARS): open questions, affirming, reflecting, and summarizing.
  • Helps clients transition from less healthy to more healthy behaviors

Four overlapping components combine to create the spirit of MI:

  • Collaboration (partnership; dancing, not wrestling)
  • Acceptance (UPR, accurate empathy, autonomy, affirmation)
  • Compassion (honoring the client’s best interest)
  • Evocation (tapping the client’s well of wisdom)

MI is a specific treatment approach that requires professional training. However, operating on a few basic MI principles can improve nearly anyone’s approach to helping others. For more information, see the book: Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change. New York, NY: Guilford Press.

This handout is from a mentor workshop for the Big Sky Youth Empowerment Program. These ideas are based on research and collected from professionals who have experience working with people who are feeling suicidal. These guidelines should not be considered medical advice and are no substitute for getting an appointment with a licensed health or mental health professional. See: johnsommersflanagan.com for more information.

The End of Suicide Prevention Week

Chair

The September 12 edition of the New York Times included an opinion piece titled “What Lies in Suicide’s Wake” by Peggy Wehmeyer. Ms. Wehmeyer previously worked as a correspondent on ABC’s “World News Tonight.” In the opinion piece, Ms. Wehmeyer shared experiences following her husband’s death by suicide in 2008.

Wehmeyer’s account of widowhood by suicide grabs you by the throat and brings you to your knees. If you’re a suicide survivor, read it with caution, because it will bring you anger, sadness, pain, and guilt.

Wehmeyer’s story also made me want to take action. I wanted to do to her what Robin Williams did to Matt Damon in his role of the therapist in Good Will Hunting. Williams looked at a file on Damon’s history of abuse, and then stood in front of him, saying,

“All this shit. This is not your fault. Look at me son. It’s not your fault.” Then Williams repeated “It’s not your fault” until Damon collapsed crying in his arms.

Some burdens are too big. I want to take Ms. Wehmeyer in my arms and tell her she’s taking on too much. Her former husband chose suicide. That’s a tragedy. But it’s not her fault.

After a suicide, shame and guilt spread like warm butter on hot toast, seeping into crevices, muscles, joints, and neurons. Guilt stabs you in the heart and then pummels your brain with the most obvious, most painful, most important, and most impossible question, “Why?”

Why . . . is a stupid, impenetrable, devious, and unhelpful question. But suicide survivors can’t stop themselves from painfully ruminating on, Why did this happen? If I were the god of suicide recovery, I’d cancel that question from the genetic blueprint. After a suicide, the question Why is pointless and unanswerable.

I’m a psychologist and a counselor. I’ve got plenty of friends in the mental health professions. Many of my friends, being of the post-modern or existential ilk, like to exclaim, usually with intellectual delight and breathless discovery, that “Humans are meaning makers!!” Well, duh.

Of course humans are meaning makers. Basically, that’s all we do. We make up shit all the time in an effort to explain our existence and our experiences. Let’s say your romantic partner breaks up with you, if you’re like most humans, you’ll wonder “Why?” And then you’ll painfully exfoliate your soul until you corner yourself with some irrational bullshit like, “I must be unlovable” or “I’m defective” or “I’m undesirable.” Or, if you’re inclined the other direction, you’ll quickly conclude, “He was an asshole” or “She’s defective” or “I hope my ex gets hit by a train.” And there are the new-age explainers who repeatedly wax philosophical, saying, “It wasn’t meant to be” or “The universe is telling me that it’s not my time for a romantic relationship.”

Asking why shit happens (and then answering yourself) is simply not helpful; it’s not helpful because you will, being human, come up with dozens of stupid, irrational, and unhelpful explanations for terrible things that happen. In the aftermath of suicide, if you’re like Ms. Wehmeyer, and many of us are, most of your stupid, irrational, and unhelpful explanations will involve blaming yourself. You’ll think things like, “I should have loved him better” or, you’ll embrace the ultimate piece of bullshit, that, somehow, as Ms. Wehmeyer wrote, “I missed those [suicide] signs until it was too late.”

No she didn’t. Wehmeyer didn’t miss the signs. And neither did you. Predicting suicide is impossible for even the best suicide researchers on the planet. Like Robin Williams said: It’s not your fault. You’re not the god of suicide prevention. Things happen. Shit happens. People kill themselves. Suicide started eons before you were born and it will continue for eons after.

Accepting tragedy sucks. It sucks more than nearly anything else we can think of. But tragedy strikes. And most of the time, tragedies are outside our control. Does that mean you should stop trying to prevent suicide and save lives? Of course not. Do what you can when you can. Does it mean you should stop blaming yourself for actions and choices that other people make and that are beyond your control? Hell yes!

In case you missed it, National Suicide Prevention Week is just ending. All week we’ve been encouraged to watch for warning signs, to follow up on our concerns by directly asking friends, family, and colleagues how they’re doing, and if they’ve been thinking about suicide. All this is great stuff. But, along with the many educational messages we’ve heard, somebody has to point out the cold, hard truth.

Sometimes you track the warning signs, you ask all the right questions, and you love people with all your heart, and they’ll still die by suicide. If that happens, it doesn’t mean you missed the signs or that you weren’t lovable enough. If suicide happens, you need to take care of yourself; you need to talk about your sadness, pain, and regrets. But you need to add one more thing. You need to listen to Robin Williams (who also died by suicide) and forgive yourself, because . . . All this shit. This is not your fault. . . . It’s not your fault.

****************************

Resources for help

  • National Suicide Prevention Lifeline: Call 800-273-TALK (800-273-8255)
  • Crisis Text Line: Text HOME to 741741
  • Bozeman Help Center – 24-Hour Crisis Line: (406) 586-3333

 

Eight Tips for Coping with Writing Rejections

SheepWriting is hard. I know you already know that.

Reading is hard too, especially if you have to read bad writers, which is why I hope you haven’t already started thinking, “Reading this blog is hard. . .”

My point is that putting words on a page and hoping they pile up and turn into clear, coherent, and meaningful prose (or poetry) is so difficult that it creates self-consciousness and worry and other neurotic thoughts and emotions linked to being judged and rejected. And just in case you feel tempted, you don’t have to tell me that good writers never write, “My point is. . .” because my other point is that I’ve been getting lots of rejections lately.

I’d rather not admit anything about my writing rejection rate; I’d rather have you think that everything I write gets published. There have been thousands of pages, eight books, and 100+ professional articles—all published, but that’s NOT the point (I also know that using ALL CAPS is bad form, like shouting while writing, and that no one but Dave Barry, former humor columnist, GETS AWAY WITH ALL CAPS).

This summer, not unlike last summer and the summer before that, and other ad nauseam summers of my life, was a summer of writing rejections. I like to say, “There were a plethora of rejections” because I like the word plethora. But let’s not go into the details because one year I tried to count up all my rejections and it was like counting cloudy days and I got depressed and I vowed to never count rejections and instead to only count acceptances and publications and successes and smiles and sunshine, and I also vowed to write long sentences if I feel like writing long sentences, because as far as I can tell, that’s what Sigmund Freud did, and he got a couple things published.

Instead of numbering the rejections, let me share just one.

This summer I wrote a proposal for a trade book on Suicide in American. It was supposed to be a proposal for a trade book on Suicide in America. But the first version of the proposal managed to include an extra “n.” How that typo slipped in there after 43 readings, including my traditional oral reading before submitting—I cannot say.

Anyway, just remember this, Suicide in America is not the most fun topic, but it’s even a worse topic when you make a typo in the first line. After experiencing the horror of seeing the typo and correcting it, I sent the proposal out to a dozen or so agents and got a dozen or so rejections. Not the most fun outcome. However, not to be deterred, I stole some of my sample chapter material and used it in a continuing education course that I DID GET PUBLISHED (notice the ALL CAPS, BECAUSE, YES, I AM YELLING).

I thought about sending all the agents who rejected my book proposal a copy of my first check from the CE company, along with a photo of my finger, but that belongs on this list of tips and sage advice for all you writers who will inevitably need to cope with rejection.

  1. Even though you want to, don’t write a snarky email or letter back to the person who rejected your wonderful work. No doubt, the snarky email will feel good in the moment, but you could regret it later. I speak from experience. Being at conferences with people who have received photos of my finger is awkward. Instead, vent to your friends and colleagues, and thank the person who rejected you for considering your work.
  2. Listen—sometimes. Lots of trade book agents and publishers tell you in advance that they plan to ghost you, so sometimes there’s nothing to hear. But on occasion, there’s this thing that happens called feedback. You can take it or leave it, but if you want to develop your writing skills, take it—or at least take some of it sometimes. The corollary to this is that reviewers can be nasty. This is especially true of academic reviewers, many of whom have come to believe that it’s their responsibility to shame fledgling writers. My advice on that is simple: Ignore the reviewer’s tone because he/she/they likely have poor social skills and are compensating for their loneliness by trying to make you feel bad, or something like that. Ignore the tone, but listen to the content.
  3. Go Big or Go Home. Being that you’re an amazing person with fantastic ideas, don’t, as former President George W. Bush might say, misunderestimate yourself. Feel free to submit pieces to the New Yorker or the New England Journal of Medicine or other fancy publications that begin with the word New. Then, get ready to be ghosted, rejected, and humiliated. If—odds are low here—you get something accepted, you’ll be like Rocket Man.
  4. Find a Small Pond. Going big or going home is a broken philosophy, unless you finish the guidance with go home and find a small pond where you can submit your work, become a big fish, and find the positive reinforcement you crave. Publishing a short comment in your neighborhood newsletter is better than having nothing published. Look at me. I’ve got a blog. I publish here all the time. The best part of the deal is my publisher loves my work.
  5. Turn it Around. Rita and I have an academic friend who says we academics should live by the turn it around in 24 hours rule. He says that as soon as he receives a rejection letter/email from a professional journal, he starts his timer and submits the manuscript to a different journal in 24 hours or less. Never having achieved that, Rita and I try to live by something more like a 24 day rule. Either way, push yourself to revise and resubmit to someone, like my blog publisher, who’s likely to love your work and publish you yesterday.
  6. Mingle. If you’re sitting around feeling sorry for yourself, you need to get out more because, duh, you’re not alone. If you find them, you’ll discover that most writers are mostly sitting around feeling sorry for themselves most of the time. So mingle. Share your sorrows. Maybe form a writing group or a book club or a knitting clutch. Embrace the Hegelian dialectic that, although you’re plenty special, you’re also simultaneously not really all that special.
  7. Write More. There comes a time when you need to get right back on that bus that bucked you off. Nobody becomes a better writer without writing. Visualization is good for golf and relaxation, but not so much for writing. Reading is good for writing, but only if you’re also putting fingers to keyboards and digits on screens. Somebody said this already: Read, write, repeat.
  8. Practice CBT on Your Neurotic Writer-Self. Albert Ellis liked to say, “Don’t be a love slob.” What he meant was to not be too needy. He would ask his clients things like, “What the holy Hell are you thinking?” He drove home the idea that you can perform badly at lots of things, get rejected, fail, and still have, what he called, “Unconditional Self-Acceptance.” In other words (which is another phrase my editor hates), Ellis is saying you shouldn’t confuse your performance with your SELF. Let’s say you get rejected. You’ll likely feel sad and disappointed. That’s normal and healthy. But don’t use your Vita to measure your SELF.

I’m hoping you find this list of tips for handling rejection helpful. If it’s not, feel free to let me know. I’ll be sad and disappointed But I’ll get over it. I plan to keep writing anyway. I hope you do too.

Want to Learn More about Suicide Interventions and Treatment Planning? Here’s a link to a brand new CE course

John and Max SeattleOver the past several months I’ve been busy writing a 2-part continuing education course on a strength-based approach to suicide assessment, interventions, and treatment planning. As you may recall, Part One of this course was published last May (see: http://www.continuingedcourses.net/active/courses/course114.php ).

Today, I’m announcing that Part Two, titled, Suicide Interventions and Treatment Planning for Clinicians: A Strength-Based Model, is now available. To check it out, go to: http://www.continuingedcourses.net/active/courses/course115.php

Just in case you’d rather watch a CE video on this topic, last year I also did a cool three-part (7.5 hours total) continuing education video on suicide assessment and treatment.with Victor Yalom and Psychotherapy.net. Here’s a link to that resource: Psychotherapy.net: https://www.psychotherapy.net/video/suicidal-clients-series

Happy Labor Day!

John SF

 

Wanted: A Conservative Candidate for President

John Prof 2018Not long ago, on This American Life, Bill Kristol, conservative journalist and #NeverTrumper (not to be confused with the comedian Billy Crystal), touted the benefits of having a legitimate contender in the republican primaries. He acknowledged former Massachusetts Governor Bill Weld’s candidacy, but I’m guessing Mr. Kristol was hoping for someone with more firepower, and maybe someone not named Bill. Naturally, after engaging in self-reflection, I immediately concluded that Bill Kristol must be thinking of me.

But why me?

Because watching me dance around Donald “Old Man” Trump in a debate, would be a #NeverTrumper’s fantasy. I’d be floating like helium and stinging like a scorpion. Because I’m a shrink, it would take me an estimated microsecond to get under Trump’s microscopically thin orange skin to reveal his huge—never seen bigger—INSECURITIES.

I’m already practicing a coughing routine; at this point, I automatically cough whenever I hear his voice. Just ask Mick Mulvaney how much Trump likes people coughing while he’s talking. I can see Trump responding to my coughing fit like an old man with uncontrollable tremors.

Speaking of Trump being an old man, I’d casually and repeatedly make note of the fact that I’m younger, stronger, fitter, and a better golfer than he is. Me being a better golfer than Trump might be a lie, but I’d still challenge him to a televised round of golf (if only to have America watch him cheat). I’d also challenge him and his sagging body to be video recorded as we meet with his physician to undergo simultaneous physical exams.

Although it’s probably unnecessary, I’d show off how much BIGGER my IQ score is, first by pointing out that anybody who knows anything about IQs, never says IQ, they always say “IQ score.” Duh, Donald! Then I’d challenge him to a spelling bee, wherein the first word would be “conservative” and the dunce that is the Donald won’t even be able to spell it, let alone act like one. Just in case he’s lucky and gets it right, the second word would be “unprecedented.”

My conservative street cred dwarfs Donald’s. He’s a weak old man who knows more about bankruptcy than he does about balancing budgets. That’s not conservative. During the debate, just before dropping the mic, I’d drop the fact that I’ve never declared bankruptcy, that I don’t live on debt, and that I’ve proportionately made way more money than he has (and I’m way younger than he is and so I’ll just keep on making money and paying taxes for far longer than he’ll be making money and not paying taxes).

Sadly, Trump puts his mental weakness on display daily. That’s not a conservative quality. He can’t resist lashing out at anyone who doesn’t worship his beautiful bleach-blonde hair. Trump insults everyone from Gold Star families to porn stars to people who suffer from mental disabilities. Strong people don’t do that. Real conservatives don’t do that. He’s. Not. Even. Close. To. Conservative.

Growing up I learned of conservative principles of integrity and self-discipline. Conservative people have excellent self-control, and lead by example.

Lead by example? Trump is every parents’ nightmare role model. Can you imagine having an Uncle Donald Trump? You’d be hiding the kids when he came to visit. Who wants to raise a weak-minded bully who cheats on his wife and whose buddies are mostly criminals? Trump’s whole behavioral palette is the antithesis of traditional conservative values. Anybody want to argue that one? Anybody? Kristol?

How about me?

I’m an old-fashioned conservative. I believe in practical solutions to personal, national, and world problems.

I live by conservative values, including honesty, respect for others’ freedoms, and a commitment to fairness and the rule of law. I want a level playing field for everyone, recognizing that for too long the field has been tilted in favor of white, wealthy, and the politically connected. Speaking of playing fields BTW, I played college football, the sport of conservatives. What sport has Trump ever played, besides golf on the taxpayer’s dime?

I’m all about Christian, Jewish, and Eastern religious values. I attend church more often than Donald. My favorite Christian value is “Love thy neighbor as thyself” . . . which is clearly NOT Trump’s favorite Christian value; he doesn’t believe in loving thy neighbor, unless the neighbor happens to be a playboy bunny or porn star.

To the best of my knowledge, which, during our debate, I would quickly point out is better than the best of Donald’s knowledge, Jesus said something about treating children with great care and compassion. Maybe Trump didn’t get the memo about Jesus loving the poor or the story about the Good Samaritan? Maybe he never listened to the voice mail Jesus left for him about not separating children from their parents and putting them in cages. In case the debate audience didn’t get the point, I’d make it clear: cages aren’t Christian, and cages aren’t conservative.

Unlike Trump, I’ve got a plan to reduce abortion rates (hint: it involves education, career opportunities, and libertarian values, not degradation of women and their personal freedoms).

Unlike Trump, I’ve got an environmental plan for an economic stimulus. Even Ronald Reagan knew you couldn’t tax cut the country to prosperity. Believe me, my economic policies would be more sophisticated than giving tax breaks to the wealthy, slapping on tariffs to raise prices for Americans, and pissing off our allies.

Unlike Trump, I’m pro-education. I wouldn’t appoint a wealthy, dull donor who hates education and has never stepped into a public school as my Secretary of Education. I’d follow the guidance of John Adams, a white, Christian, who also happened to be the second U.S. President. President Adams said that when it comes to the education of low income youth, “no expense for this purpose would be thought extravagant.”

Unlike Trump, I’m not racist, I don’t call countries “shitholes” or Tweet weird statements about “pig’s blood” or pitch my tent in white supremacist territory. I think most Americans and conservatives would appreciate a straight-up conversation about racism. We’re not a racist nation, and I’d make that point, and then make it again, and then I’d make it again.

Unlike Trump, I’ve got a foreign policy that involves something other than slumming with dictators. That alone should be a relief to bona fide conservatives. Because I’ll be taking a conservative approach, photo ops in North Korea and off-the-books meetings with Putin will not be part of my presidential foreign policy agenda.

In conclusion, let me say:

“Hey Bill Kristol, if you’re reading this, give me a call. I’m ready to be Trump’s biggest nightmare (next to you, of course). I’m happy to volunteer; it’s an easy job, especially because Trump is so old, weak, feeble, and liberal.”

The place to click if you want to learn about psychotherapy, counseling, or whatever John SF is thinking about.