All posts by johnsommersflanagan

Clinical Interviewing

Practicing Humility When Conducting Mental Status Examinations

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Perhaps more than any other assessment task, conducting a balanced mental status examination requires that professionals resist the natural temptation to make sweeping judgments about clients on the basis of appearance, specific behaviors, or single symptoms. For example, in a recently published book titled The mental status examination and brief social history in clinical psychology, Smith {{5681 III 2011;}} stated:

A Fu-Manchu mustache suggests the wearer doesn’t mind being thought of as “bad,” whereas a handlebar mustache tells you the person may be somewhat of a dandy or narcissist. (p. 4)

After reading the preceding excerpt, I decided to conduct a small research study by surveying men in Montana with Fu-Manchu mustaches. Whenever I saw men sporting a Fu-Manchu, I asked them to rate (on a seven-point Likert scale) whether they minded being thought of as “bad.” In contrast to Smith’s (2011) observations, I found that most men with Fu-Manchu’s actually thought they looked good and reported wearing the mustache in an effort to look attractive. Of course I didn’t really conduct this survey, but the fact that I thought about doing it and imagined the results carries approximately the same validity as the wild assumption that a mental status examiner can quickly “get into the head of” all clients with Fu-Manchu (or handlebar) mustaches and interpret their underlying personal beliefs or intentions, or even worse, extrapolate from a physical feature to a personality disorder diagnosis.

Although I’m poking fun at the sweeping generalizations that Smith (2011) made in his text, my intent is to point out how easy it is to grow overconfident when conducting MSEs. Like Smith, I’ve sometimes found myself making wild and highly personalized assumptions about the psychopathological meaning of very specific behaviors (some years ago I had my own personal theory about “tanning” behaviors being linked to narcissism).

The key to dealing with this natural tendency towards overconfidence is to use Stanley Sue’s (2006) concept of scientific mindedness. A single symptom should be viewed as a sign that the sensitive and ethical mental status examiner considers a hypothesis to explore. Another example from Smith (2011) may be helpful as another caution of the dangers of over-interpreting single symptoms. He stated: “If the person is unshaven, this may be a sign of depression, alcoholism, or other poor ability at social adaptation” (p. 4).

Smith may be correct in his hypotheses about unshaven clients. In fact, if a research study were conducted on diagnoses or symptoms commonly associated with unshaven-ness, it might show a small correlation with depressive symptoms, partly because poor hygiene can be a feature of some depressive disorders. However, in the absence of additional confirming evidence, an unshaven client is just an unshaven client. And when it comes to social adaptation, I should note that I know many young men (as well as a variety of movie stars) who consider the unshaven look as either desirable, sexy, or both. This could lead to an equally likely hypothesis that an unshaven client is particularly cool or has an especially high level of social adaptation.

In your own MSE work I encourage you to adopt the following three guidelines to help you avoid what might be called the overconfident clinician syndrome:

  1. When you spot a single symptom or client feature of particular interest, you should begin the scientific mindedness process.
  2. Remember that hypotheses are hypotheses and not conclusions; this is why hypotheses require additional supporting evidence.
  3. Don’t make wild inferential leaps without first consulting with colleagues and/or supervisors; it’s often easier to become overconfident and subsequently make inappropriate judgments when working in isolation.

Keep these preceding guidelines in minds as you conduct mental status examinations. You can find my DVD with a clip of a mental status exam at: http://www.amazon.com/Clinical-Interviewing-Skills-John-Sommers-Flanagan/dp/1118390121

Personal Reflections

Song Lyrics for the Election

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In my own wacky mind I’m thinking it might be a good idea to listen to some social justice lyrics on election day. Here are a few that came to me. Feel free to offer your own.

Ten Top Song Lyrics for Election Day . . .

  1. It’s a beautiful day; don’t let it get away . . . without voting (Bono)
  2. What kind of father would take his own daughter’s rights away? And what kind of father might hate his own daughter if she were gay? (Pink)
  3. Why am I soft in the middle when the rest of my life is so hard? (Paul Simon)
  4. So often have I wondered where these homeless brothers go, down in some hidden valley where their sorrows cannot show. (Don McLean)
  5. . . . our children are watching us, they put their trust in us, they’re gonna be like us; so let’s learn from our history, and do it differently (Dixie Chicks)
  6. Cause I’m bluffin’ with my muffin; I’m not lying; I’m just stunnin’ with my love-glue-gunning (Lady Gaga)
  7. I’ve been trying to get down to the heart of the matter, but my will gets weak and my thoughts seem to scatter. But I think it’s about forgiveness. (Don Henley)
  8. It’s just a theory. A particular set of assumptions. It’s just a theory; an educated guess, a conclusion not forgone (Tracy Chapman)
  9. After changes upon changes we are more or less the same. After changes we are more or less the same (Paul Simon)
  10. In times like these and in times like those, what will be will be and so it goes . . . and it always goes on and on and on and on and on. On and on and on and on and on it goes, hmm (Jack Johnson)
Personal Reflections, Politics, Writing

Tomorrow’s Election and Confirmation Bias

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Confirmation bias is one of the most ubiquitous psychological phenomena on planet Earth. If you don’t know what it is, you should learn. And if you do know what it is, you should start paying even more attention to it. It’s everywhere and it affects everyone.

I think the all-time best description of confirmation bias is captured by an old Yogi Berra story. One day, when a player on Yogi’s team was called out on a close play at second base in a crucial game, Yogi went charging onto the field to protest the call. The umpire explained that he, unlike Yogi, was an objective observer and that he, unlike Yogi, had been only about 5 feet from the play, while Yogi had been over 100 feet away, seated in the dugout. When Yogi heard the umpire’s logic, he became EVEN MORE ANGRY than before and snapped back, “Listen ump, I wouldn’t have seen it, if I hadn’t believed it” (adapted from Leber, 1991).

There’s little doubt about the relevance of confirmation bias for tomorrow’s election. Liberal bloggers and pollsters see data suggesting an Obama victory while conservative media personalities counter-predict a Romney landslide.

As in the Yogi Berra example, confirmation bias explains why two presumably objective individuals can observe the same incident and draw starkly differing conclusions. After all, it’s impossible to suspend our personal beliefs and rely exclusively on logical data. We all naturally interpret and spin the data. Republicans look at recent economic figures and claim they’re caused by failed economic policies. Democrats look at the same data and note that Obama inherited a dismal economic situation and that we’d be far worse off if he hadn’t provided a stimulus and increased government spending.

The confirmation bias is everywhere all at once. If I were to wake up one morning believing abortion is murder, immigrants are illegals, and gays are sinful—my perceptions and behaviors would follow . . . and I’ll be more inclined to view individuals with darker skin as intruders who threaten my lifestyle, I’ll reject the mainstream media as having a liberal bias, and believe deeply that Fox News offers fair and balanced reporting.

But if somehow a miracle occurs and I wake up the next day believing women have the right to make their own medical choices, that many immigrants are just seeking a better life like my Italian forebears, and that gay-ness is a natural biological disposition—you can imagine how I might feel when I turn on my radio and accidentally listen to the Glen Beck show. It’s likely that I’ll pick a art his statements and question the source and validity of his facts.

My point is not to claim that one side has all the correct answers and if you think that, you’ve been drinking far too much Kool-Aid. Instead, my point is that we should all look at ourselves and question our biases. In fact, as you read this blog your response to the words on the screen will be affected by confirmation bias . . . and to the extent that you find yourself agreeing with or debating my position will likely have more to do with you and your beliefs and personal history than the accuracy or truthfulness of this blog.

As a final example, let’s look at the potential Presidential election outcome tomorrow. If you’re a liberal and Romney is elected you’ll be more likely to wonder if Tagg’s ownership of Ohio voting machines and voter suppression had more to do with the outcome than Romney’s desirability or credibility. On the other hand, if you’re a conservative and Obama wins, you may be inclined to blame it on voter fraud or an ignorant electorate. And if I’m correct and confirmation bias is ubiquitous, you may already be preparing your explanation for tomorrow’s election outcome.

Remember these words: “I wouldn’t have seen it, if I hadn’t believed it” and try your best to cope with tomorrow’s results—either way.

Parenting

Why Dear Abby’s Parenting Advice is so Limited

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In the preceding weeks I’ve been posting about the 4 primary ways parents can influence their children. Today, we look at the application of what we refer to as the “Parent Influence Model.” More information on this model and how to use it to improve parenting strategies is in the book, “How to Listen so Parents will Talk. . .” by two of my favorite authors. The following is an adapted excerpt.

Many cultures focus excessively on using direct power to get children to comply with parental authority, and our dominant American culture is certainly among them.  This may be in part because of the powerful influence of behavioral psychology and partly due to a historical white-European devaluing of children identified by some authors.  Fortunately, the Parenting Influence Model (PIM) provides parents with effective alternatives to simply using direct power over and over again.

As an American icon, “Dear Abby” regularly provides guidance for parents who face specific parenting challenges. However, for better or worse, Abby usually offers advice based almost exclusively on direct power. While you read through the following summary of a Dear Abby column, consider the PIM. In particular, think about which indirect, problem-solving, and relationship power strategies you might suggest for the parenting dilemma described in this column:

In her February 17, 2009 column, Abby responded to a letter written by a mother described as Tanya of North Lima, Ohio. Tanya described a challenging situation with her nine-year-old son. She reported that he refused or made excuses when asked to take a shower after his wrestling practice and that she was at her “wits’ end.” She noted other personal hygiene problems, including difficulty getting him to brush his teeth and change his underwear. She ended her letter with a plea: “Please give me some advice.”

Abby responded with clear and direct guidance. She instructed Tanya to:

  1. Establish rules and enforce them.
  2. Consider asking the wrestling coach to “impress upon him the importance of personal hygiene.”
  3. Refuse to serve the son dinner until he has showered.
  4. Require him to “brush his teeth before coming to the breakfast table.”
  5. If the problem continues for over six months, consider a consultation with a “child psychologist.”

The problem that Tanya of Ohio presented to Abby was typical. Tanya has an agenda and she wants her child to comply with her agenda. She has tried direct power strategies, failed miserably, but is still unable to think outside the direct-power paradigm. For example, she states: “I tell him to take a shower,” “I have had to personally bathe him,” and “I don’t know what to do to get him . . . .” Each of these phrases articulates at least two things: (1) she has taken on the primary responsibility for her son’s hygiene (and so he is free to not care much at all about hygiene; we refer to this as problem polarization and discuss it at length later); and (2) she is focused, as far as we can tell, exclusively on direct power strategies.

Using the PIM as a guide, in an educational or therapeutic setting, the first step would be for the parenting professional to model an attitude reflected in the short phrase, developed by Linda Braun of Families First Boston: “Get curious, not furious.” The professional would empathize with the parent’s frustration (“It is hard when your nine-year-old smells bad!”) while gently exploring the roots of the problem (“What do you suppose is going on that makes it so your son really doesn’t seem to care about showering and brushing his teeth?”), and gathering concrete information about exactly what the parent has tried and how it has worked. In the end, the professional might provide the parent with a collaboratively generated list of parenting strategies. For Tanya and her son, the list would likely, but not inevitably, include an individualized combination of the following:

  • Mutual problem-solving
  • Solution questions
  • Character feedback
  • Giving choices
  • Asset flooding
  • Expressing anger and disappointment

In contrast, as Abby articulated so well, our popular cultural advice for parents who face problem child behavior is something like:

You need to force that boy to comply with your parental authority.

Abby’s solution advocates parental over-control: She recommended withholding food. She recommended usurping the boy’s privacy by consulting with his wrestling coach (apparently behind the boy’s back). She didn’t seem to understand the powerful force of encouragement—or even positive reinforcement. Although the mom may win this battle using direct power, her withdrawals from her joint emotional bank account with her son may be immense. Their relationship will suffer and their conflicts may continue to grow.  Eventually, the mom’s power-plays may become significantly less effective as he heads into his teenage years.

In contrast to Abby’s approach, many parenting book authors acknowledge the need for parents to have a wide range of skills and strategies for parenting well. As an example, Fields and Brown (2010) described this need for multiple strategies for parents of toddlers:

You can’t make a kid eat, sleep, or poop on the potty. Yes, toddlers have a will all of their own—and if they don’t want to do any of the above, darn it, that’s the way it is. Nope, you have to come well-armed with a series of clever strategies and tricks to work some magic. (p. 6)

Overall, the PIM can help you become more aware of specific influence strategies parents are using in their daily lives. You can then use this awareness to help parents expand their influence repertoire, and hopefully help parents become more successful in really getting what they want: being and becoming a positive and guiding influence in their children’s lives.

Parenting

Relationship Power as a Strategy for Influencing Children

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For the past several weeks I’ve been posting about different strategies parents can use to exert a positive influence on their children. Today’s focus is on the grandaddy or grandmommy of all forms of parental influence–we refer to this as RELATIONSHIP POWER!

Relationship power is the foundation of all parental power. Having a high-quality, respectful parent–child relationship is the fuel that naturally drives children to want to please their parents.  However, there is a serious problem associated with creating and sustaining relationship power.

In the 21st century, perhaps more than previously, parents have tended to overemphasize the “friendship” dimension between parents and children (Grosshans & Burton, 2008). The worst consequence of this friendship-oriented parent–child relationship is that sometimes parents hesitate to set limits on their children’s behavior, fearing they’ll not be “liked” by their children. Although wanting our children to like us is a perfectly natural impulse, it can become problematic if parents become frozen and unable or unwilling to set limits due to fears of rejection. When this happens, a very destructive pattern can emerge. This pattern is characterized by an imbalance of parent–child power. Unfortunately, often the consequence of this pattern is a child who is too free and too much in charge and a parent who feels impotent and disrespected. In extreme situations, the parent–child power relationship and the roles associated with that relationship are so twisted that the parent may begin inappropriately involving his or her child or children in adult matters, adult relationships, and even adult partying, including exposure to many adult issues and problems (e.g., sexual information or relationships and/or substance use).

The parent–child relationship that works best is characterized by respect, interest, caring, love, and kindness. It is not an egalitarian relationship between peers, but it is a central and all-encompassing relationship that entails love, sacrifice, and the willingness to be there, no matter what. Call us idealists, but we believe this is the foundation upon which parental authority and influence should be built.

Stephen Covey articulated the foundational quality of relationship when he discussed the relationship bank account, both in his book, Seven Habits of Highly Effective People (Covey, 1990), and online. In the following excerpt from his homepage, he discussed the concept of the emotional bank account as a means of rebuilding trust—and rebuilding trust can be especially relevant for parents of teenagers. The concept is equally important with regard to building and maintaining trust and respect. Here’s what Covey says on his website:

Examine your Emotional Bank Account with this person; it’s most likely strained because of withdrawals. Make a commitment to start making deposits that matter most to that person, and do it. Little by little, even with small deposits, you will find that the account will grow. It may take time. But over time you will find the cumulative effect of the deposits. Slowly, depending on the severity of the broken trust, you can find trust being rebuilt and restored, and a new relationship will be born. Of course, this also depends on the other person, but you can choose to do your part regardless of the other person—to focus on your circle of influence. And you will find some peace, knowing that you’ve done your part. (http://www.stephencovey.com/blog/?tag=emotional-bank-account; accessed February 18, 2009)

Like modeling, relationship power is part of the 24/7 parenting role. Consequently, relationship power activities can and should be integrated into the parent–child relationship on a daily basis. Tomorrow or on Tuesday I’ll be posting a story or example of relationship power. In the meantime, you can always check out the “How to Listen so Parents will Talk” book at: http://www.amazon.com/How-Listen-Parents-Will-Talk/dp/1118012968/ref=cm_cr_pr_pb_i

Here’s what a recent spontaneous reviewer just posted about the book on Amazon “This book is an informative, easy-to-read guide to the specific intricacies involved in counseling parents. It is useful for both trainees and seasoned clinicians.” Cool.

 

Parenting

How Parents Can Use Problem-Solving Power

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Problem-solving power refers to a group of parent influence strategies designed to activate, within children or teenagers, a problem-solving or solution-focused mental state. This strategy is best illustrated with an example:

Sonya is busy at her laptop reading an online newspaper while her 6-year-old son plays in the living room. She notices her son working hard on a small puzzle and after he gets a piece into place, she says: “How did you figure out where that piece went?” Her son looks up and replies, “I don’t know. It just fit there.”

This interaction may seem trivial, but the mother, whether she knows it or not, is using problem-solving power to encourage her son to reflect on how he’s getting his puzzle together. This particular approach is based on constructive or solution-focused principles. The underlying belief is that the more we can get our children thinking about how to solve problems, the better they’ll become at problem-solving.  Further we are helping them become more optimistic, focusing on solutions and successes instead of pessimistically focusing on failures and problems.

The polar opposite of problem-solving power occurs when parents, in frustration, ask their child something like, “What’s wrong with you?” or after a sequence of misbehavior, “What were you thinking!?” When parents ask these problem-oriented questions, it encourages children to focus on their failures, what’s wrong with them, or on their negative thoughts and behaviors.

Just like solution-focused therapy, problem-solving power is indirect and leading (Murphy, 2008; Steenbarger, 2004). It’s also something we have to train ourselves to do.  For some reason, it seems more natural to ignore our children when they are behaving, and to give them attention when they are not.  Many parents remain silent and even detached while children play quietly (savoring the silence). This, of course, is the equivalent of ignoring good behavior, which we know from our basic behavioral principles is a great way to extinguish behavior.

The most common forms of problem-solving power are listed in the “How to Listen so Parents will Talk book (see: http://www.amazon.com/How-Listen-Parents-Will-Talk/dp/1118012968/ref=la_B0030LK6NM_1_5?ie=UTF8&qid=1351053762&sr=1-5)

Here’s one example of a problem-solving power strategy.

Child-Generated Rules

As noted in the “How to Listen. . .” book, parent-generated family rules are an example of direct power. In contrast, when using problem-solving power, parents try to hook their children into generating rules themselves. Interestingly, as family members discuss what they want for themselves and for the family, children often become motivated to contribute to very positive and reasonable family rules. Many authors have written about family meetings or the family council (Croake, 1983; Dreikurs, Gould, & Corsini, 1974).

Problem-solving power is an excellent way to help children reflect on and contribute to family solutions. It’s a method for helping children learn solutions and rules from the inside out—instead of the external or outside-in behavioral approach. Problem-solving power can be used liberally but sometimes parents need to take charge and solve family problems themselves. This is especially true with younger children. As family therapist Carl Whitaker once said (we’re paraphrasing), “Two-year-olds cannot take over leadership within a family unless they’re standing on the shoulders of a parent.” In the end, things go better if parents are the primary leaders in the home who not only allow their children to voice opinions, but also engage their children in the family problem-solving process.

Parenting

Indirect Power

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Indirect power involves a strategy or process whereby parents obtain compliance through an indirect means. In contrast to direct power, this particular strategy generally doesn’t activate rebellion and therefore power struggles are minimized. Indirect power strategies include some of the most important parenting strategies of all time, as well as a few strategies that are somewhat playful and, some might say, manipulative.

The most important indirect parenting strategy is modeling. If parents don’t want their children to swear, they should avoid swearing (at least in their children’s presence). Children are strongly inclined to model their behavior after their parents’ behavior, especially if they respect their parents. There is scientific truth in the old saying, “Imitation is the sincerest form of flattery” (Bandura, Ross, & Ross, 1963; Bandura & Walters, 1963).

Modeling highlights the perpetual 24/7 aspect of parenting. If you tell your child, “Don’t lie,” but then you call in sick so you can go skiing instead of going to work, or sit home on a night when you turned down a social invitation because you were “too busy,” you’re role-modeling the opposite of what you’re preaching. In essence, you’re asking your children to do as you say, but not as you do. And we all know how well that works! Parental behavior is often closely scrutinized by children, even when they don’t let on that they’re watching.

John recalls a particularly uncomfortable situation with his younger daughter when she was four years old. As he hurried on his drive home with her beside him in a child’s seat, they were forced to stop at a railroad crossing. Frustrated, John muttered under his breath a particular four-letter word generally associated with fecal matter. Much to his horror, his sweet 4-year-old instantly picked up the beat, repeatedly letting fly with the dung word until, finally, John came up with the bright idea of correcting her by compounding his mistake: “Oh no sweetheart, you’ve got that wrong. What Daddy really said was, ‘shoot!’ Try saying that, ‘shoot.’” When his daughter finally was able to satisfactorily mutter “shoot” under her breath, John felt a mixed gratification. He had lied to his daughter to stop her from using profanity:). Clearly, this was only a marginal parenting success and one that illustrates the complex burden of parental modeling:(.

The most common forms of indirect power are listed and described in our book, “How to Listen so Parents will Talk and Talk so Parents will Listen.” They include the following:

Table 3.3 Indirect Power Strategies

Modeling

Encouragement

Character feedback

Giving choices

Storytelling

Wagering, racing, and giving audience

And here’s a description of one of these indirect power strategies:

Wagering, Racing, and Giving Audience

These indirect strategies are usually playful. For example, parents might say, “I bet I can eat up my broccoli before you do” (wagering) or “Let’s race and see who can get dressed and ready to go out to the car and to school the fastest” (racing) or “I heard you’re really good at your times tables. How about if you do a set for me and I just watch and listen?” (giving audience).

To be honest, wagering, racing, and giving audience are manipulative ploys. They involve enticing children into compliance using techniques framed as fun and competitive. As a consequence, some parents don’t like these particular parenting strategies.

Nevertheless, these techniques can be useful and are often employed effectively by some parents. For example, as described previously, with children who are slow at dressing themselves, an indirect intervention might involve a competition or race:

Okay, sweetheart, let’s see who can get ready the fastest. I’ll run to my bedroom and see if I can get dressed and ready to go before you’re all dressed. I think I’m the fastest, but you might be. I don’t know. Are you ready? Ready, set, go!

The problem with this form of indirect power is not so much that it’s manipulative (almost everything is manipulative in one way or another), but that it can begin to feel manipulative to children. Consequently, although parents should use positive role-modeling whenever possible, these more playful and manipulative indirect approaches should be used only occasionally.

Parenting

Grandma’s Rule: An Example of Using Direct Parenting Power and Influence

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Direct power is one way parents try to have power and influence. Direct power is simple and straightforward. It involves directly informing children what to do and what not to do. It’s bossy and often manipulative but not necessarily tyrannical. As we all know, it’s possible to have a benevolent boss, someone to look up to as a respected authority. Alternatively, many of us know or have experienced a tyrannical boss. For many reasons, well-established through parenting research and child development, when direct power is needed, parents should enact that power in a wise and benevolent manner—rather than behaving as a controlling tyrant (Baumrind, 1975). A parent we once worked with articulated this practical principle when she told us her philosophy of parenting. She said, “Rules without relationship equals rebellion.”

Direct power can be communicated through voice tone (that extremely firm or even snarling voice), voice loudness (a raised level, even yelling), body posture (standing and pointing), eye contact and facial expression (a hard stare, serious face, or even an unpleasant grimace), and other physical means. Spanking, hitting, and all physical approaches to discipline are classic efforts at exerting direct power. Similarly, when parents use threatening words or verbal abuse with their child, usually they’re trying—somewhat desperately—to directly influence their child’s emotional state or behavior.  When things get desperate, verbal efforts to influence children often end up sounding rather absurd. For example, we’ve heard parents saying things like,

  • “I’ll give you something to cry about.”
  • “I brought you into this world and I can take you out.”

Obviously, yelling, hitting, and verbal abuse are threatening and extreme means of trying to exert parental influence or control and we don’t advice using these approaches.

Grandma’s Rule is an example of a reasonable and relatively effective direct power and influence parenting strategy. This strategy is a language-based intervention that clearly spells out the sequence of desired or required behaviors and optional or reinforcing behaviors. Grandma’s Rule always follows a “When you/then you” format. For example, a parent might say to her child, “When you finish the dishes, then you can call your friends.” Using Grandma’s Rule is a clear and concise way to communicate parental authority by letting the child know exactly what he or she needs to do before engaging in a fun and positively rewarding activity. If you’d like to experience how Grandma’s Rule feels, try this out on yourself: “When you finish reading this blog, then you can check your Facebook account.”

When working with parents who sometimes use ambiguous language with their children, or with parents who are ambivalent about exerting authority, Grandma’s Rule can be very helpful. In particular, parents may need to be coached on avoiding the use of if instead of when.  For example, parents who say, “If you do the dishes, then you can call your friends,” convey a sense of uncertainty as to whether their children really will be doing the dishes. Children who have oppositional or defiant tendencies will quickly latch onto the if and begin a debate over whether that behavior will ever occur. Grandma’s Rule always involves using “When you/then you” language.

In the next day or two I’ll be posting a short description of Indirect Power and Influence strategies. All of this material is excerpted or adapted from our book, “How to Listen so Parents will Talk and Talk so Parents will Listen.” You can find it on Amazon at: http://www.amazon.com/How-Listen-Parents-Will-Talk/dp/1118012968