Why You Should Open with a Focus on the Negative When Using a Strength-Based Suicide Treatment Model

Keno Horse

I’m working on a book manuscript tentatively titled something like: Strength-Based Suicide Assessment and Treatment. As I do more work and professional training in this area, I’m struck by the natural dialectic involved in the whole area of suicide (I’m sure Marsha Linehan discovered this long ago).

One dialectic on my mind today involves the fact that although I’m calling the approach that I’m writing about “Strength-Based,” I often (but not always) advise clinicians to open their sessions with a focus on negative distress. The following excerpt takes a bit of content from my 7.5 hour (3-part) published video with Psychotherapy.net and explains my rationale for opening a session with a focus on negative or painful emotions. You can access the 3-part training video here: https://www.psychotherapy.net/video/suicidal-clients-series

Here’s the case example:

In the following excerpt, I’m working with Kennedy, a 15-year-old girl whose parents referred her to me for suicide ideation (see https://www.psychotherapy.net/video/suicidal-clients-series, Sommers-Flanagan, 2018). Although I might meet with her parents first, or with the whole family, in this case I chose to start therapy with her as an individual. My opening exchange with Kennedy is important because, in contrast to what you might expect from a “strength-based” approach, my focus with her is distinctly negative. Pay close attention to the italicized words and [bracketed explanation].

John:  Kennedy, thank you for meeting with me. Let me just tell you what I know, okay, because I know that you’re not exactly excited to be here. But the thing is that I know that your parents have said you’ve been talking about suicide off and on for a little while, and so they wanted me to talk with you. [I already know that suicide ideation is an issue with Kennedy, so I share that immediately. If I pretend that I don’t already know about her and her situation, it will adversely affect our rapport. This is a basic principle for working with teens, but also true for adults: Lead with a statement of what you know . . . and be clear about what you don’t know.]

And I don’t know exactly what’s happening in your life. I don’t know how you’re feeling. And I would like to be of help. And so I guess if you’re even willing to talk to me, the first thing I’d love to hear would be what’s going on in your life, and what’s making you feel bad or sad or miserable or whatever it is that you’re feeling? [You’ll notice that my opening question has a negative focus. The reason I’m starting with a question that focuses on Kennedy’s negative affect and pulls for what makes her feel bad or sad or miserable is because (a) I want to start with Kennedy’s emotional distress, because that’s what brings her to therapy, and (b) I want to immediately begin linking her emotional distress to situations or experiences that trigger her distress. By doing this, I’m focusing on the presumptive primary treatment goal (according to Shneidman) for all clients who are suicidal, and that is to reduce the perceived intolerable or excruciating emotional distress. In Kennedy’s case, one of my very first treatment targets is to reduce the frequency and intensity of whatever it is that’s triggering Kennedy’s suicide ideation. We’ll get to the positive, strength-based stuff later.]

Kennedy: I think I’m just like really busy every day. I am in volleyball, and I got a lot of homework, and I don’t get a lot of sleep. So, it’s really stressful getting up early, and my parents are always fighting, and sometimes I miss the bus, and they don’t want to drive me. So, I have to call one of my older friends to drive me, and sometimes I’m late, and I just – it’s stressful, and the teachers get mad, but it’s not my fault.

John:   Yeah. So, you’ve got some stress piling up, volleyball, school, sometimes being late, and your parents arguing. Of those, which one adds the most misery into your life? [Again, my focus is purposefully on the negative. I want to know what adds the most misery to Kennedy’s life so that I can work with her and her family or her and her school to decrease the stimulus or trigger for her misery.]

Kennedy: I think being at home is the hardest. In volleyball at least I find some joy. Like I like enjoy being on the court and playing with my team. They’re there to lift me up. But like my parents, I don’t like being at home.

John:  Okay. What do you hate about it? [When Kennedy says, “I don’t like being at home” she’s not providing me with specific information about the trigger for her distress, so I continue with that focus and stay with the negative and use a word (hate) that I think is a good match for how a teenage girl might sometimes feel about being with her family.]

Kennedy: I just – they’re always fighting. Sometimes my dad will leave, and my mom cries, and I’ll cry. And he’s just mean, and she’s mean, and they’re both mean to each other. And I just lock myself in my room.

John:   Yeah. So, even as I listen to you talk, it feels like this is a – just being around them – I don’t know what the feeling is, maybe of just being alone. Like they’re fighting, and you retreat to your room. Any other feelings coming up when that happens? [Although I’m trying to tune into specific feeling words to link to what’s happening for Kennedy, I’m also being tentative and vague and wanting to collaboratively explore the right words to use with Kennedy.]

Kennedy: I don’t know. Just sometimes I don’t feel like – I don’t feel like I have a home, or my family is not there for me, and sometimes I just don’t feel like living anymore. [Kennedy uses the term “feel like” which often is a signal that she’s talking about a cognition and not an emotion. For example, “I don’t feel like I have a home” is likely more of a cognition that leaves her with an emotion like sadness. But it’s too soon to be that emotionally nuanced with Kennedy and the important part of what she’s saying is that there’s a pattern that’s something like this: her parents’ fighting triggers a cognition, that triggers an unspecified emotion, and that triggers the cognition of “I just don’t feel like living anymore.”]

John:   Yeah. So, there are times when the family stuff feels so bad, that’s when you start to think about suicide?

Kennedy: Yeah.

Using Shneidman’s (1980) model to guide my initial interactions with Kennedy leads me to focus on her immediate emotional distress and the triggers for her distress. Exploring her distress and the triggers takes me to an early treatment plan (that will likely be revised and refined).

  1. I will focus on Kennedy’s immediate distress and collaboratively work with her on a plan to reduce her distress and create more positive affect.
  2. I will focus on specific situational variables that trigger Kennedy’s suicide ideation. Part of the treatment plan is likely to involve her parents and to try to get them to stop their intense “fighting” in her presence.
  3. As I aim toward distress reduction and reducing or eliminating the distress trigger, I will keep in mind that—like most teenagers—it may be very difficult for me to get Kennedy to agree to let me work directly with her parents on their fighting. Getting Kennedy on board for an intervention with her parents will test my therapeutic and relational skills.

While I’m working on this next book, I’ll be posting excerpts like this. As always, I would love your feedback and input on this content. Please post comments here, or email me directly at: john.sf@mso.umt.edu.

Numbers, Men and Suicide in Montana, Liz Plank, and My 42 Seconds of Fame

220px-Elizabeth_Plank

Last month in Bozeman, I took a lunch break from a 6.5 hour suicide assessment and treatment workshop for professionals, walked out of the #IwontcallitGianforte Auditorium on the campus of Montana State University where #Idonotteach, up two flights of stairs, where I met Liz Plank and the amazing video recording and production team for the Vox news show Consider It.

Despite being in the middle of a wardrobe malfunction, I was fascinatingly anxiety-free. After talking about suicide for three hours nothing else really matters much.

Liz Plank is a big deal and a fantastic dresser. All that fits fabulously with her being a fourth wave feminist and 2018 Webby award winner. I was super happy to meet her then, and now, after having met her and done a couple Tick-Tock stunts with her (watch this 9 seconds: https://www.tiktok.com/share/video/6692077388945165573?langCountry=en), I’m still super happy to have met her.

Andy Warhol said we get 15 minutes of fame and Marilyn Manson sang about 15 minutes of shame. What I got in the final Consider It episode was somewhere around 42 seconds of a mix of the two (I’m estimating here because I haven’t timed it). But here’s the good news . . . and there’s lots of good news.

  1. The Consider It episode is now available for public viewing and it’s EXCELLENT. The title: What’s Behind Montana’s Suicide Epidemic? Obviously an incredibly important topic and other than my 42 seconds of fame/shame, very thoughtfully and artfully done (first person to post a comment that accurately identifies my exact wardrobe malfunction on the Consider It site will get a free JSF book of your choice). Yes, you can watch the best ever Consider It episode right here: https://www.facebook.com/consideritshow/videos/1395971993875811/
  2. When Liz Plank got her 2018 Webby, she did a 5 word speech. Listen for her 5 words here: https://www.youtube.com/watch?v=i4pTOQ2YY5Y
  3. Wonder what the heck Liz Plank was talking about in her 5 word speech, find out here (spoiler alert, this video makes fun of Donald Trump): https://www.facebook.com/feministabulous/videos/140217433363072/
  4. If you want Liz to have John S-F back on her show to answer the question of why people vote for Trump against their own best interests, start using the hashtag, #JSFknowstheanswer EVERYWHERE and especially here: https://www.facebook.com/consideritshow/?epa=SEARCH_BOX
  5. For me to get my 15 minutes, all you have to do is watch the Consider It episode 22.5 times. https://www.facebook.com/consideritshow/videos/1395971993875811/

As always, thanks for reading and have a fabulous weekend!

John S-F

 

What Is a Strength-Based Approach to Suicide Prevention?

Sommers FB 44

Suicide—as a thought, word, or action—usually triggers fear and judgment. Even though suicidal thoughts are common and suicidal behaviors have been part of humanity from as far back as anyone can recall, to think or talk of suicide is saturated with shame and judgment. A strength-based model for suicide prevention is about shifting attitudes toward suicide from negative judgment to compassion and lovingkindness.

Most people who think about suicide are sensitive, intelligent, and self-critical. Typically, they’re judging themselves in negative ways; sometimes they experience self-hatred. All this adds up to the main proposition underlying a strength-based approach to suicide prevention: Because individuals who feel suicidal are already burying themselves in harsh judgments and negativity, what they need from others is empathy for their pain, reassurance that suicidal thoughts are a nearly universal part of human experience, compassion, help for coping with their excruciating psychological distress, and a more or less relentless focus on the positive.

No More Mental Illness and No More Moral Shaming

In 1973, Edwin Shneidman, wrote the Encyclopedia Britannica’s definition of suicide: “Suicide is not a disease (although there are those who think so); it is not, in the view of the most detached observers, an immorality.” Shneidman—often referred to as the father of suicidology (the study of suicide)—capture two harsh judgments popularly linked to suicide: Mental or moral illness. As advocates for suicide prevention, we need to doggedly follow Shneidman’s lead, and show acceptance of the mental and moral condition of people experiencing suicidality.

I like this next quotation from Nanea Hoffman. I’m not sure it fits here, but because this post is about being strength-based when thinking and talking about suicide, and this is my blog and I can include what I want, here it is:

“None of us are getting out of here alive . . . so please stop treating yourself like an afterthought. Eat the delicious food. Walk in the sunshine. Jump in the ocean. Say the truth you’re carrying in your heart like hidden treasure. Be silly. Be kind. Be weird. There’s no time for anything else.” – Nanea Hoffman

Shame surrounding suicide has a long history. By 1000 B.C. most ancient city-states had criminalized suicide. People who died from suicide were sometimes dragged through the streets to enhance their shame and possibly as deterrence for others. Around 400 A.D., Saint Augustine declared suicide an unrepentable sin. I’m not quite sure how that works because I’m guessing that Christian theology would hold up God as the authority on what’s repentable and what’s not repentable.

Contemporary suicide-related policies continue to link shame and suicide. When students die from suicide, many U.S. schools follow a “no memorializing” policy. In New Zealand, the media is prohibited from using the word suicide when reporting on suicide deaths. Most families, when struggling to write obituaries for family members who died by suicide, replace the word suicide with “died suddenly” or some other vague explanation. In an online article, Charlotte Maya wrote of the first time she was able to speak of her husband’s suicide:

“The first time I spoke publicly was about a year and a half after Sam’s death. In many ways, I think Sam would have been appalled. After all, he did not speak a word of his struggles out loud – not to a therapist, not to his friends, not to me. There is so much shame.”

Charlotte is right; there is so much shame. To avoid shame, many people, institutions, and nations have decided that—like Lord Voldemort in the Harry Potter series—suicide is the thing that must not be named.

But it should be named; if we don’t talk about it, the shame linked to suicide grows more powerful, more frightening, and less well understood. It should be named because, hundreds of thousands of people around the world are dying by suicide every year, perhaps dying in shame, perhaps dying unnecessarily, and always leaving loved ones behind who pick up on the theme of shame and begin experiencing it themselves. If we don’t talk openly about suicide, we cannot address it effectively.

Shaming people for thinking about suicide, or for making a suicide attempt, or for completing suicide, magnifies the problem. Shaming people for their suicidal thoughts only makes them less likely to speak openly about their thoughts. And, as in the case of Charlotte Maya’s husband, remaining quiet about emotional pain is linked to tragic outcomes. When people who are suicidal shutter themselves in their private worlds, the suicidal pain and distress doesn’t diminish or evaporate; instead, being alone with suicidal thoughts usually deepens hopelessness and grows desperation, both of which contribute directly to death by suicide.

Shaming individuals who are suicidal is like pouring fuel on an open fire. Suicidal people already feel immense shame. There’s no need to add more. Besides, shaming isn’t an effective deterrent. Further, as I’ll elaborate on later, suicidal thoughts aren’t primarily about death anyway. If our goal is to save lives, there’s a different and more useful emotion to link with suicide.

Instead of shame, the word suicide should evoke compassion—compassion for people who were or are so distressed that they have contemplated or completed suicide; compassion for people who lost someone they loved to suicide; compassion for ourselves, during times when we’re in psychological pain and naturally have thoughts about suicide.

I’ll be writing more about this in the future and so I’ll summarize here. What people who are suicidal need from others includes:

  • Empathy for their pain
  • Reassurance that suicidal thoughts are a nearly universal part of human experience
  • Compassion
  • Help for coping with their excruciating psychological distress
  • A more or less relentless focus on the positive (to help counter their feelings of hopelessness)

Last night I had a chance to engage in a delightful discussion of the strength-based approach with a small group of amazing people at Big Sky, Montana. Thanks to Robin and Jacque for setting that up. As a part of our time together, I flipped through a set of powerpoints. Here are the powerpoints, in case you’re interested: Big Sky Public Lecture 2019

Check out a new “Strengths-Based Suicide Assessment” continuing education course

From M 2019 Spring

This past month I worked on revising our Suicide Assessment chapter from our Clinical Interviewing (6th edition, 2017) textbook so it could function as a stand-alone continuing education course. The continuing education course is finished and now available online.

The Learning Objectives include:

Learning Objectives

This is a beginning to intermediate level course. After completing this course, you will be able to:

  • Explore your own personal reactions to suicide and identify four clinician self-care strategies.
  • Discuss and debunk four common and unhelpful myths about suicide.
  • Describe evidence-based risk/protective factors, warning signs, and cultural issues and how they can be used to deepen empathic understanding of suicidal clients.
  • Identify components of suicide theory that contribute to and guide suicide assessment.
  • Provide a comprehensive suicide assessment interview based on a social constructionist model.
  • Engage in decision-making with suicidal clients.

If you’re interested, here’s a link to the list of courses on ContinuingEdCourses.Net, with the Suicide Assessment course at the top of the list: http://www.continuingedcourses.net/active/courses/courses.php

And here’s a link that takes you deeper . . . all the way to the brand new 3 hour course, go here (I think you can read it for free and only have to pay to take the quiz and get CE credits): Suicide Assessment For Clinicians: A Strength-Based Model

Of course, if you’re interested in a three-part (7.5 hours total) continuing education video experience, here’s your link to Psychotherapy.net: https://www.psychotherapy.net/video/suicidal-clients-series

Have a great day . . . and keep on learning!

 

Please Support Trapper Creek Job Corps and the Other Job Corps Designated as Civilian Conservation Corps

Hi All.

I’m asking for help. All of the Job Corps designated as Civilian Conservation Corps are slated to be cut.

Below, I’m pasting information about Trapper Creek Job Corps. I’m also providing a link to a form letter with talking points, as well as an Excel sheet with contact info for various Senate Offices.

Thanks in advance for your help. Job Corps was started as part of LBJ’s war on poverty. It’s a program that gives youth and young adults ages 16-24 a chance to learn a trade and become a taxpayer who contributes to our country in positive ways.

I hope you will spread this message far and wide!

Here’s the letter:

Dear Friend of Job Corps.

This is not a drill. This is 911.

The media is out there; Secretary Acosta (Department of Labor) and Secretary Purdue (USDA) have made the agreement to eliminate the USDA’s role in the Job Corps Program. This means that Trapper Creek (as well as the other 24 Forest Service Centers, or CCCs) will be transferred to DOL, and Trapper Creek will be more or less eliminated as we know it. Our students will no longer be served by this program. Our communities will no longer be served by the extensive support of our amazing students. Our 55 hard working staff at Trapper Creek (and over 1,200 Nation-wide) who have dedicated their professional lives to helping disadvantaged youth will lose their jobs. It is clear this is an assault on our youth, our communities and our people.

My understanding is as such: the decision is to eliminate operations of the CCCs by September 30, 2019. This is not an arbitrary date: it is the last day of the fiscal year. Should this movement take place successfully, the contingent will have won; Trapper and the CCCs are over and done for. We lose our jobs and the thousands of young people served by the CCCs ever year will be without services. However, Congress was just notified today of this decision and, frankly, are not happy. The Forest Service Job Corps program has always had huge support from both sides of Congress; Democrats believe in the humanitarian component while Republicans believe in the fiscal responsibility of training young adults in poverty to learn the hard skills to get a living wage job and the soft skills to stay employed.

WHAT I NEED YOU TO DO: below are two documents.  The spreadsheet attached has contact information for Congressional folks in your states. Please make as many contacts as you can to them as well as to local political folks; mayors, city council, etc. We need as many calls and emails as possible from as many folks as possible. Democrats are already putting things in writing; Republicans are on board but all together too quiet. These folks need to hear of your displeasure of this decision.

Also attached is a form letter (5.23.19 CCC Agency Letter), talking points if you will, to use when visiting with these folks.

Please forward this message to all parties you know that care about our youth, our communities, our staff and the program at large. Facebook is a great tool to move information as well.

FEDERAL EMPLOYEES: do not use government time, equipment or material to move this information. You are welcome to use Facebook if you do not identify yourself as a Federal Employee.

The Talking Points letter is here: 5.23.19 CCC Agency Form Letter with Talking Points

The Excel spreadsheet with contact info is here: Copy of CCC Contact Sheet

 

 

 

The Whole Truth and Nothing But the Truth

One Wipe Charlies

This post includes psychology and politics. If you don’t like psychology or you don’t like politics, you can stop reading. If you continue reading, you should know that I’m not focusing on political ideology; I’m focusing on the corrosive effect of lies on trust, relationships, history, and the social contract between government and the people.

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I thought I was having a very bad dream.

Donald J. Trump was speaking. He said,

“Well, it turns out I’m the most — and I think most of you would agree to this — I’m the most transparent president, probably in the history of this country.” 

That was two days ago.

Yesterday, Trump summoned his staff, claimed (again) to be a stable genius (who even makes up bullshit like that?). Then he called on people to speak out in support of him in his temperamental tiff with Nancy Pelosi. Shortly thereafter he posted a spliced video designed to make Pelosi look bad.

Sadly, none of what I experienced had anything to do with an altered mental state. I was listening to the radio when Trump’s fictitious words floated into my brain. This is a big problem, not just for me. There are far too many fictitious words floating around, and far too many people having them drift into their brains, which brings me to my central point: Even though most of us would readily agree that saying or thinking or writing something doesn’t make it so, sometimes, over time and with help from others (e.g., Fox news and spliced videos), and this is the dangerous part, saying something can—and often does—make it so.

My non-dream left me with two powerful insights.

  1. Never before, probably in the history of this country, have I been more of a social constructionist.
  2. Now I know the EXACT strategy for beating Donald Trump in the upcoming presidential election.

Some of you may wonder what being a social constructionist means. Let me quote some experts:

“There are two main branches of constructive theory . . . both perspectives hold firmly to the postmodern idea that knowledge and reality is subjective. Constructivists . . . believe knowledge and reality are constructed within individuals. In contrast, social constructionists . . . believe knowledge and reality are constructed through discourse or conversation. . . . social constructionists focus on what’s happening between people as they join together to create realities (Sommers-Flanagan & Sommers-Flanagan, 2018, pp. 283-284).

Right now, as I type and as you read, we’re in the midst of a dangerous social deconstruction and reconstruction. Every morning, we awaken to new savage attacks on conventional truth. We’re facing the most chronic and pathological liar probably in the history of this country.

George Orwell might put it this way:

. . . if all others accepted the lie which the [Trump] imposed – if all records told the same tale—then the lie passed into history and became truth. ‘Who controls the past’ ran the [Trump] slogan, ‘controls the future: who controls the present controls the past’ (from the novel, 1984).

Lies corrode trust. Lies destroy relationships. Lies re-write history and shape the future. We all know this from our direct personal experiences.

But there’s a method to Trump’s madness; the method is all about using social constructionism to divide and conquer. Trump is a master at creating new realities through conversation. He’s a master at using dishonesty and the misrepresentation of facts to destroy trust, incite hatred, and gain power. Trump has a nearly reflexive capacity for steering conversations away from conventional reality and toward his subjective perspective.

Trump is engaging us all in a re-write of past, present, and future realities to meet his own narcissistic perceptions. He can’t do it alone, but he has many proponents who support his views. Big money can do that. Sometimes the mainstream media contributes too, albeit inadvertently. For example, when Rachel Martin on NPR’s Morning Edition interviewed Kristen Gillibrand, she referred to Trump as “formidable.” Her words contribute to Trump being perceived as formidable, as if that’s a constructed reality. In fact, Trump is something far less than formidable, which leads me to the recipe for Trump’s defeat.

Trump’s Achilles’ heel is his deep fear of weakness and his compensating wishes for strength, power, and ultimate authority. What this means is that Trump’s so-called strengths are also his weaknesses. To defeat Trump, we must relentlessly target his lies, his weakness, and his inadequacy.

Everything he says should be viewed through the lens of weakness. He wants to drop the mother of all bombs, mostly to compensate for his inner terrpr over being seen as weak. He insists on complete obedience from his administration because he’s too weak to cope with hearing dissent. He’s deeply afraid of being discovered as a fraud, and so he cannot share his tax returns. He must fight to resist the Mueller probe and legal efforts to get at his personal finances, because he’s not man enough to be open, honest, and forthright about who he is and how he does business. He pays off porn stars because he wants to maintain his delusion and a false cover up of who he really is . . . a man who has to pay a porn star for sex and then has to pay for her silence.

The press consistently refers to Trump as an unconventional politician. Other than his lack of political experience, governing experience, and foreign policy experience, I can’t figure out what they mean. Trump is a political caricature. He lies with abandon, buys himself out of trouble, and takes on the persona of an attack dog who attacks people whom he sees as beneath him, principally because he’s scared shitless that his inner weakling-fraud will be exposed.

A small sampling of his lies helps capture his focus.

In the beginning he mocked people with disabilities (is that what strong people do?). He was caught on tape degrading and debasing women (more strength; so much strength). He called Hillary “Crooked,” when his most dominant trait is all about being crooked. His lies are mostly about his desperation to appear strong. Often, they’re obvious projections. Projection happens when a behavior or trait of someone else stirs an impulse in you, so you end up accusing others of something that’s really about you. For example, when Trump claims Nancy Pelosi is “mess” or “crazy” what he’s really saying is “I’m a mess” and “I’m crazy.” Projection is an old-fashioned Freudian defense mechanism that thrives on oversensitivity to criticism, combined with an inability to restrain impulses to say whatever comes to mind. A simpler way of thinking about projection is that the traits of others that really disturb you, may often be your own. And so when Trump refers to little Marco Rubio and little Bob Corker and little Adam Schiff, he’s speaking of his preoccupation with their smallness of stature, but he’s also speaking of his unrestrained preoccupation with and fear of being small and weak. In every one of the preceding scenarios, Trump’s purpose was to put down individuals or groups. Think about the people you know in your life who compulsively put everyone down. Are they the strong people?

That Trump would accuse the media of being fake is another in his legion of lies and projections. Who’s fake? Let’s see, there was the fake Trump University, the fake marriages, the fake condolences that he offered to school shooting victims, the fake losses on his tax returns, the fake claims about his wealth, his fake foundation with fake and unsubstantiated charitable giving, and his fake claims of being “completely exonerated.” There are so many fake things, including his skin color, his physical examination reports, his bone spurs, and his claims of being a stable genius that it’s hard to know what’s underneath. There’s also his fake courage, the fake 91 billion in aid to Puerto Rico, fake statements about Democrats executing babies “after birth,” fake promises about Mexico paying for a border wall, fake claims that Democrats want “open borders,” fake announcements that U.S. Steel is building six new steel mills, fake claims that opioid deaths are down, and, as you know, I could go on and on into his thousands of lies.

To defeat Trump, we must attack two things.

We must attack his compulsive and manipulative dishonesty and his fake news about himself and the world. Every word he and his staff utters should be scrutinized and laid side-by-side with the truth.

We must also attack the perception that he’s anything other than a weak, pathetic, inadequate man who has to pay porn stars to get laid. We cannot ever, for the sake of truth, exonerate him for his lies. We need to pierce his armor of narcissism with the whole truth and nothing but the truth over and over again. In this defense of truth, we must not waver.

 

What is Motivational Interviewing? A brief description and demonstration video

The following content is adapted from Clinical Interviewing (6th ed., 2017).

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In their 2013 edition of Motivational Interviewing, Miller and Rollnick offer “Layperson’s,” Practitioner’s,” and “Technical” definitions of MI.  For practitioners, Motivational interviewing is:

. . . a person-centered counseling style for addressing the common problem of ambivalence about change. (p. 29)

As a person-centered approach to therapy, MI relies substantially on four central listening skills, referred to as OARS (open questions, affirming, reflecting, and summarizing). MI is designed to help clients change from less healthy to more healthy behavior patterns. However, consistent with PCT, MI practitioners don’t interpret, confront, or pressure clients in any way. Instead, they use listening skills to encourage clients to talk about reasons for engaging in healthy or positive behaviors.

Moving Away From Confrontation and Education

In his research with problem drinkers, William R. Miller was studying the efficacy of behavioral self-control techniques. To his surprise, he found that structured behavioral treatments were no more effective than an encouragement-based control group. When he explored the data for an explanation, he found that regardless of treatment protocol, therapist empathy ratings were the strongest predictors of positive outcomes at 6 months (r = .82), 12 months (r = .71), and 2 years (r = .51; W. R. Miller, 1978; W. R. Miller & Taylor, 1980). Consequently, he concluded that positive treatment outcomes with problem drinkers were less related to behavioral treatment and more related to reflective listening and empathy. He also found that active confrontation and education generally triggered client resistance. These discoveries led him to develop motivational interviewing (MI).

Miller met Stephen Rollnick while on sabbatical in Australia in 1989. Rollnick was enthused about MI and its popularity in the UK. Miller and Rollnick began collaborating and subsequently published the first edition of Motivational Interviewing in 1991. Rollnick is credited with identifying client ambivalence as a central focus for change (Jones-Smith, 2016, p. 320).

Client Ambivalence

Client ambivalence is a primary target of MI. Miller and Rollnick (2013) have consistently noted that ambivalence is a natural part of individual decision-making. They wrote: “Ambivalence is simultaneously wanting and not wanting something, or wanting both of two incompatible things. It has been human nature since the dawn of time” (2013, p. 6).

Although MI has been used as an intervention for a variety of problems and integrated into many different treatment protocols, it was originally a treatment approach for addictions and later became popular for influencing other health-related behaviors. This focus is important because ambivalence is especially prevalent among individuals who are contemplating their personal health. Smokers, problem drinkers, and sedentary individuals often recognize they could choose more healthy behaviors, but they also want to keep smoking, drinking, or being sedentary. This is the essence of ambivalence as it relates to health behaviors. When faced with clients who are ambivalent about whether to make changes, it’s not unusual for professional helpers to be tempted to push those clients toward health. Miller and Rollnick (2013) call this the “righting reflex” (p. 10). They described what happens when well-meaning helping professionals try to nudge clients toward healthy behaviors (note that this description is an apt rationale for a person-centered approach, but that it’s also consistent with the Gestalt therapy ideas of polarizing forces within individuals):

[The therapist] then proceeds to advise, teach, persuade, counsel or argue for this particular resolution to [the client’s] ambivalence. One does not need a doctorate in psychology to anticipate [how clients are likely to respond] in this situation. By virtue of ambivalence, [clients are] apt to argue the opposite, or at least point out problems and shortcomings of the proposed solution. It is natural for [clients] to do so, because [they] feels at least two ways about this or almost any prescribed solution. It is the very nature of ambivalence. (2002, pp. 20–21)

The ubiquity of ambivalence leads to Miller and Rollnick’s (2013) foundational person-centered principle of treatment:

Ideally, the client should be voicing the reasons for change (p. 9).

MI is both a set of techniques and a person-centered philosophy. The philosophical MI perspective emphasizes that motivation for change is not something therapists should impose on clients. Change must be drawn out from clients, gently, and with careful timing. Motivational interviewers do not use direct persuasion.

The Spirit of MI

The “underlying spirit” of MI “lies squarely within the long-standing tradition of person-centered care” (Miller & Rollnick, 2013, p. 22). They identified four overlapping components that the spirit of MI “emerges” from. These include:

  • Collaboration
  • Acceptance
  • Compassion
  • Evocation

MI involves partnership or collaboration. It’s described as dancing, not wrestling. Your goal is not to “pin” the client; in fact, you should even avoid stepping on their toes. This is consistent with the first principle of person-centered therapy. The counselor and client make contact, and in that contact there’s an inherent or implied partnership to work together on behalf of the client.

Person centered (and MI) counselors de-emphasize their expertness. Miller and Rollnick refer to this as avoiding the expert trap. Expert traps occur when you communicate “that, based on your professional expertise, you have the answer to the person’s dilemma” (p. 16). In writing about collaboration, Miller and Rollnick (2013) sound very much like Carl Rogers, “Your purpose is to understand the life before you, to see the world through this person’s eyes rather than superimposing your own vision” (p.16).

Consistent with Rogerian philosophy, MI counselors hold an “attitude of profound acceptance of what the client brings” (p. 16). This profound acceptance includes four parts:

  1. Absolute Worth: This is Rogerian unconditional positive regard
  2. Accurate Empathy: This is pure Rogerian.
  3. Autonomy Support: This part of acceptance involves honoring each person’s “irrevocable right and capacity of self-direction” (p. 17)
  4. Affirmation: This involves an active search or focus on what’s right with people instead of what’s wrong or pathological about people.

In the third edition of Motivational Interviewing, Miller and Rollnick added compassion to their previous list of the three elements of MI spirit. Why? Their reasoning was that it was possible for practitioners to adopt the other three elements, but still be operating from a place of self-interest. In other words, practitioners could use collaboration, acceptance, and evocation to further their self-interest to get clients to change. By adding compassion and defining it as “a deliberate commitment to pursue the welfare and best interests of the other” Miller and Rollnick are protecting against practitioners confusing self-interest with the client’s best interests.

Evocation is somewhat unique, but also consistent with person-centered theory. Miller and Rollnick contend that clients have already explored both sides of their natural ambivalence. As a consequence, they know the arguments in both directions and know their own positive motivations for change. Additionally, they note, “From an MI perspective, the assumption is that there is a deep well of wisdom and experience within the person from which the counselor can draw” (p. 21). It’s the counselor’s job to use evocation to draw out (or evoke) client strengths so these strengths can be used to initiate and maintain change.

A Sampling of MI Techniques

One distinction between MI and classical PCT is that Miller and Rollnick (2013) identify techniques that practitioners can and should use. These techniques are generally designed to operate within the spirit of MI and to help clients engage in change talk instead of sustain talk. Change talk is defined as client talk that focuses on their desire, ability, reason, and need to change their behavior, as well as their commitment to change.  Sustain talk is the opposite; clients may be talking about lack of desire, ability, reason, and need to change. Overall, researchers have shown that clients who engage in more MI change talk are more likely to make efforts to enact positive change.

MI appears simple, but it’s a complicated approach and challenging to learn (Atkinson & Woods, 2017). Miller and Rollnick (2013) have noted that having a solid foundation of person-centered listening skills makes learning MI much easier. The following content is only a sampling of MI techniques.

MI practitioners use techniques from the OARS listening skills. In particular, there’s a strong emphasis on skillful and intentional use of reflections, instead of questions or directives. Here are examples.

Simple reflections stick very closely to what the client said.

Client: I’ve just been pretty anxious lately.

Simple Reflection: Seems like you’ve been feeling anxious.

 

Client: Being sober sucks.

Simple Reflection: You don’t like being sober.

Simple reflections have two primary functions. First, they convey to clients that you’ve heard what they said. This usually enhances rapport and interpersonal connection. Second, as you provide a simple reflection, it lets clients hear what they’ve said. Hearing their words back—from the outside in—can be illuminating for clients.

Complex reflections add meaning, focus, or a particular emphasis to what the client said.

Client: I haven’t had an HIV test for quite a while.

Complex reflection: Getting an HIV test has been on your mind.

 

Client: I only had a couple drinks. Even when I got pulled over, I didn’t think I was over the limit.

Complex reflection: That was a surprise to you. You might have assumed “I can tell when I’m over the limit” but in this case you couldn’t really tell.

Complex reflections go beyond the surface and make educated guesses about what clients are thinking, feeling, or doing. Clients tend to talk more and get deeper into their issues when MI therapists use complex reflections effectively. Also, if your complex reflection is correct, it’s likely to deepen rapport and might evoke change talk.

An amplified reflection involves an intentional overstatement of the client’s main message. Generally, when therapists overstate, clients make an effort to correct the reflection.

Client: I’m pissed at my roommate. She won’t pick up her clothes or do the dishes or anything.

Interviewer: You’d like to fire her as a roommate.

Client: No. Not that. There are lots of things I like about her, but her messiness really annoys me. (from Sommers-Flanagan & Sommers-Flanagan, 2017, p. 440)

 

Client: My child has a serious disability and so I have to be home for him.

Interviewer: You really need to be home 24/7 and have to turn off any needs you have to get out and take a break.

Client: Actually, that’s not totally true. Sometimes, I think I need to take some breaks so I can do a better job when I am home. (from Sommers-Flanagan & Sommers-Flanagan, 2017, p. 441)

Sometimes MI practitioners accidentally amplify a reflection. Other times amplification is intentional. When intentionally amplifying reflections, it’s important to be careful because it can feel manipulative.

The opposite of amplified reflection is undershooting. Undershooting involves intentionally understating what your client is saying.

Client: I can’t stand it when my mom criticizes my friends right in front of me.

Therapist: You find that a little annoying.

Client: It’s way more than annoying. It pisses me off.

Therapist: What is it that pisses you off when your mom criticizes your friends?

Client: It’s because she doesn’t trust me and my judgment. (from Sommers-Flanagan & Sommers-Flanagan, 2017, p. 441)

In this example, the therapist undershoots the client’s emotion and then follows with an open question. Clients often elaborate when therapists undershoot.

As noted, the preceding content is a small taste of MI technical strategies; if you want to become a competent MI practitioner, advanced training is needed (see Atkinson & Woods, 2017; Miller & Rollnick, 2013).

Now that you’ve read a brief summary of MI, check out the following video link. In this link, John S-F is using a few MI techniques/strategies with a client who has a history of excessive alcohol use. The video is part of our published video package accompanying our Clinical Interviewing textbook, and includes me weaving in a few more traditional clinical interviewing questions (e.g., the CAGE) along with the MI content. There’s also light commentary by Rita and me, as well as a short clip in the middle of me interviewing a Licensed Addictions Counselor on the topic of how to handle clients who are probably lying. Here’s the link to the approximately 22 minute video: https://youtu.be/rtN7kEk0Sv4

If you have questions, comments, praise, or constructive feedback on this blog or the video, I’d love to hear from you. You can post here, on Youtube, or email me directly at john.sf@mso.umt.edu.

Happy Tuesday.

John S-F

 

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