Note: This is a re-post. I had a chance to drive to Trapper this past week with one of our doc students and I was reminded of the powerful life experiences that happen at Trapper Creek Job Corps.
Sometimes on Thursday or Fridays I drive from Missoula to Trapper Creek Job Corps. Then I drive back the same day. It’s a 140 mile round trip. Sometimes I have interns with me. The company makes the miles go by more quickly. Sometimes the interns are very nervous sitting next to me for the whole drive and consequently compete to see who gets the back seat. This makes me wonder if maybe I shouldn’t quiz them about theories of counseling and psychotherapy as we drive there together. Although I wonder about this . . . I haven’t changed my behavior. Maybe this means I’m trying to scare them all into the…
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The clinical interview is 40% assessment, 40% therapy, 25% relational, and 20% technical. What I’m trying to say (other than I wasn’t a math major) is that, as the headwaters from which all counseling and psychotherapy flow, the clinical interview is a flexible tool that many researchers and practitioners use to achieve many different goals. Although I’m a big fan of the clinical interview as a means through which clinicians interpersonally connect with clients to begin therapeutic collaboration, I also recognize that interviews can be a highly structured procedure for collecting data and establishing mental disorder diagnoses.
Recently, I came across a nice “eight minute” diagnostic interviewing article by Allen Frances. Dr. Frances was deeply involved in the development of DSM-IV. Here’s a link to his excellent article: https://pro.psychcentral.com/14-tips-for-the-diagnostic-interview-of-mental-disorders/
Reading the 14 tips from Dr. Frances reminded me of a similar section in our Clinical Interviewing textbook, and so I’ve pasted it below. As always our emphasis is on making sure that technical tasks during an interview don’t overshadow essential relational components. In fact, as I write this, I’m aware that even using the term “relational components” is bad form. It’s bad form because it misses the deep human connection, the non-verbal signals, the first impressions, and the whole interpersonal dance that is de rigueur in every unique clinical encounter. Words cannot adequately express what can and does happen during a clinical interview. Nevertheless, here are a few words from the Clinical Interviewing text anyway. We start with short lists of the advantages and disadvantages of structured diagnostic interviews and then move on to a less structure diagnostic interviewing model. Here’s a link to the 6th edition of Clinical Interviewing on Amazon: https://www.amazon.com/Clinical-Interviewing-John-Sommers-Flanagan/dp/1119215587/ref=sr_1_1?ie=UTF8&qid=1519745757&sr=8-1&keywords=clinical+interviewing+sommers-flanagan
Advantages Associated with Structured Diagnostic Interviewing
Advantages associated with structured diagnostic interviewing include the following:
- Structured diagnostic interview schedules are standardized. Therapists systematically ask clients a menu of diagnostically relevant questions.
- Diagnostic interview schedules generally produce a diagnosis, consequently relieving clinicians of subjectively weighing many alternative diagnoses.
- Diagnostic interview schedules show better diagnostic reliability and validity than less structured methods.
- Diagnostic interviews are well suited for scientific research. Valid and reliable diagnoses support research on the nature, course, prognosis, and treatment responsiveness of particular disorders.
Structured and semi-structured diagnostic interviews are a part of the scientific foundation of psychology and counseling. Current systems are always in revision; realistically, progress (not a perfect system) is the goal. The diagnostic criteria from DSM-III and -IV and ICD-9 and -10 were improvements on previous versions, and there’s hope that the DSM-5 and ICD-11 will show further improvements in reliability, validity, and clinical utility (Keeley et al., 2016).
Disadvantages Associated with Structured Diagnostic Interviewing
There are also disadvantages associated with structured diagnostic interviewing:
- Many diagnostic interviews require considerable time for administration. For example, the Schedule for Affective Disorders and Schizophrenia for School-Age Children (Puig-Antich, Chambers, & Tabrizi, 1983) may take one to four hours to administer, depending on whether both parent and child are interviewed.
- Diagnostic interviews don’t allow experienced diagnosticians to take shortcuts. This is cumbersome because experts in psychiatric diagnosis might require less information to accurately diagnose clients than would beginning therapists.
- Some clinicians complain that diagnostic interviews are too structured and rigid, de-emphasizing rapport building and basic interpersonal communication between client and therapist. Extensive structure may not be acceptable for practitioners who prefer using intuition and who emphasize relationship development.
- Although structured diagnostic interviews have demonstrated reliability, some clinicians question their validity. All diagnostic interviews are limited and leave out important information about clients’ personal history, personality style, and other contextual variables. As noted earlier, two different therapists may administer the same interview schedule and consistently come up with the same incorrect diagnosis.
Given their time-intensive requirements in combination with the need of mental health providers for time-efficient evaluation, it’s not surprising that diagnostic interviewing procedures are underutilized and sometimes unutilized in clinical practice. Critics contend that even the diagnostic criteria themselves are more oriented toward researchers than clinicians (Phillips et al., 2012):
It is difficult to avoid the conclusion that the diagnostic criteria are mainly useful for researchers, who are obligated to insure a uniform research population. (p. 2)
Researchers and academics are far and away the primary users of contemporary structured diagnostic interviewing procedures.
Less Structured Diagnostic Clinical Interviews
If your goal is to conduct a state-of-the-science diagnostic clinical interview, then you’ll use a structured or semi-structured format. But not all clinicians choose that approach. The features of a less structured approach include the following:
- An introduction to the assessment process (aka role induction) characterized by culturally sensitive warmth and active listening. Depending on the situation and clinician preference, clinicians may employ culturally appropriate standardized questionnaires and intake/referral information (for example, MMPI-2-RC; BDI-2; OQ-45).
- An extensive review of client problems and associated goals, and a detailed analysis of the client’s primary problem and goal. This could include questions about the client’s symptoms using the ICD-10-CM or DSM-5 as a guide, or a circumscribed, symptom-oriented diagnostic interview protocol (the HAM-D, for example).
- A brief discussion of experiences (personal history) relevant to the client’s primary problem, including a history of the presenting problem if such a history hasn’t already been conducted.
- If appropriate, a brief mental status examination could be included, but more likely you’ll review the client’s current situation, including his or her social support network, coping skills, physical health, and personal strengths.
Introduction and Role Induction
The goal of developing a diagnosis and treatment plan shouldn’t change the therapist’s interest in the client as a unique individual. After reviewing confidentiality limits, you should introduce diagnostic interviews to clients using a statement similar to the following:
Today, we’ll be working together to try to understand what has been troubling you. This means I want you to talk freely with me, but also, I’ll be asking lots of questions to clarify as precisely as possible what you’ve been experiencing. If we can identify your main concerns, we’ll be able to come up with a plan for resolving them. Does that sound OK to you?
This statement emphasizes collaboration and de-emphasizes pathology. The language “try to understand” and “main concerns” are client-friendly ways of talking about diagnostic issues. This statement is a role induction that educates clients about the interview process.
Beginning therapists often become too structured, excluding client spontaneity, or too unstructured, allowing clients to ramble. Remember to integrate active listening and diagnostic questioning throughout your diagnostic interview.
Reviewing Client Problems
While reviewing client problems, consider the following.
Respect Your Client’s Perspective, but Don’t Automatically Accept Your Client’s Self-Diagnosis as Valid
Diagnostic information is available to the general public. This leads many clients to offer their own diagnosis at the beginning of interviews:
- I’m so depressed. It’s really getting to me.
- I think my child has ADHD.
- I took an online quiz and found out that I’m bipolar.
- I have a problem with compulsive behavior.
- My main problem is panic. Whenever I’m in public, I just freeze.
Some diagnostic terminology has been so popularized that its specificity has been lost. This is especially true with the term depression. Many people use the word depression to describe sadness. The astute diagnostician recognizes that depression is a syndrome and not a mood state. When clients report “being depressed,” further questioning about sleep dysfunction, appetite or weight changes, and concentration problems are necessary. Research has shown that using the single question “Are you depressed?” isn’t an adequate substitute for an appropriate diagnostic interview (Kawase et al., 2006; Vahter, Kreegipuu, Talvik, & Gross-Paju, 2007).
Similarly, the lay public overuses the terms compulsive, panic, hyperactive, and bipolar. In diagnostic circles, compulsive behavior generally alerts the clinician to symptoms associated with either obsessive-compulsive disorder or obsessive-compulsive personality disorder. In contrast, many individuals with eating disorders and substance abuse disorders refer to their behaviors as compulsive. Similarly, panic disorder is a specific syndrome in the ICD-10-CM and DSM-5. However, many individuals with social phobias, agoraphobia, or public speaking anxiety refer to panic. Therefore, when clients say they have panic, it should alert you to gather additional information about a range of different anxiety disorders. Finally, diagnostic rates of bipolar disorder in both youth and adults have skyrocketed (Blader & Carlson, 2007; Moreno et al., 2007). As a result, the lay public (and some mental health professionals) quickly attribute irritability and/or mood swings to bipolar disorder. Nevertheless, we recommend using established diagnostic criteria.
Keep Diagnostic Checklists Available
When questioning clients about problems, keep diagnostic criteria in mind, but don’t expect to have perfectly memorized diagnostic criteria from the ICD or DSM systems. Using checklists to aid in recalling specific diagnostic criteria helps. But don’t reduce your diagnostic musing to a simple checklist.
Don’t Expect to Accurately Diagnose Clients after a Single Interview
It’s good to have lofty goals, but in many cases, you won’t be able to assign an accurate diagnosis to a client after a single interview. In fact, you may leave the first interview more confused than when you began. Fear not. The ICD-10-CM and DSM-5 provide practitioners with procedures for handling diagnostic uncertainty. These include the following:
V codes (DSM-5) and Z codes (ICD-10-CM): V codes and Z codes are used to indicate that treatment is focusing on a problem that doesn’t meet diagnostic criteria for a mental disorder.
F99: This code refers to Unspecified Mental Disorder. It’s used when the clinician determines that symptoms are present, but full criteria for a specific mental disorder are not met. Also, the clinician doesn’t specify why the criteria aren’t met.
Provisional diagnosis: When a specific diagnosis is followed by the word provisional in parentheses, it communicates a degree of uncertainty. A provisional diagnosis is a working diagnosis, indicating that additional information may modify the diagnosis. The ICD-10-CM also allows for using the word tentative, meaning there is uncertainty but that “more information is unlikely to become available” (p. 8)
Being uncertain about your client’s diagnosis after an intake interview should be an excellent stimulus for you to do some extra reading before meeting for a second appointment.
Client Personal History
Even when time is limited, social-developmental history information helps ensure accurate diagnosis. For example, the DSM-5 lists numerous disorders that have depressive symptoms as one of their primary features, including (1) persistent depressive disorder, (2) major depressive disorder, (3) various adjustment disorders, (4) bipolar I disorder, (5) bipolar II disorder, and (6) cyclothymic disorder. Many other disorders include depressive symptoms or symptoms that are comorbid with one of the previously listed depressive disorders. Among others, these include (1) posttraumatic stress disorder, (2) generalized anxiety disorder, (3) anorexia nervosa, (4) bulimia nervosa, and (5) conduct disorder. The question is not whether depressive symptoms exist in a particular client but rather which depressive symptoms exist, in what context, and for how long. Without adequate historical information, you can’t discriminate between various depressive disorders and comorbid conditions.
In some cases, accurate diagnosis is directly linked to client history. For example, a panic disorder diagnosis requires information about previous panic attacks. Similarly, posttraumatic stress disorder, by definition, requires a trauma history; and for AD/HD (in DSM-5) and hyperkinetic disorders (in ICD-10-CM), the diagnosis can’t be given unless there is evidence that symptoms existed prior to age twelve (DSM) or age six (ICD-10-CM).
Obtaining information about a client’s current functioning is a standard part of the intake interview. A few significant issues should be reviewed and emphasized.
A detailed review of your client’s current situation includes an evaluation of his or her typical day, social support network, coping skills, physical health (if this area hasn’t been covered during a medical history), and personal strengths. Each of these areas can provide information crucial to the diagnostic process.
The Usual or Typical Day
Yalom (2002) has written that he believes an inquiry into the “patient’s daily schedule” is especially revealing. He wrote:
In recent initial interviews this inquiry allowed me to learn of activities I might not otherwise have known for months: two hours a day of computer solitaire; three hours a night in Internet sex chat rooms under a different identity; massive procrastination at work and ensuing shame; a daily schedule so demanding that I was exhausted listening to it; a middle-aged woman’s extended daily (sometimes hourly) phone calls with her father; a gay woman’s long daily phone conversations with an ex-lover whom she disliked but from whom she felt unable to separate. (pp. 208–209)
Asking about the client’s typical day can open up a cache of diagnostically rich data that moves you toward identifying appropriate treatment goals and an associated treatment plan.
Client Social Support Network
In some cases, it can be critical to obtain diagnostic information from people other than the client, especially when interviewing young clients. Parents are often interviewed as part of the diagnostic work-up (see Chapter 13). However, even when interviewing adults, you may need outside information:
Adults can also be unaware of their family histories or details about their own development. Patients with psychosis or personality disorder may not have enough perspective to judge accurately many of their own symptoms. In any of these situations, the history you obtain from people who know your patient well may strongly influence your diagnosis. (Morrison, 2007, p. 203)
Whether you need to interview a collateral informant to obtain diagnostic information should be determined on a case-by-case basis.
Assessment of Client Coping Skills
Client coping skills may be related to diagnosis and can facilitate treatment planning. For example, clients with anxiety disorders frequently use avoidance strategies to reduce anxiety (people with agoraphobia don’t leave their homes; individuals with claustrophobia stay away from enclosed spaces). It’s important to examine whether clients are coping with their problems and moving toward mastery or reacting to problems and exacerbating symptoms and/or restricting themselves from social or vocational activities.
Coping skills also may be assessed by using projective techniques or behavior observation. You might try having clients imagine an especially stressful scenario (sometimes referred to as a simulation) and describe how they would handle it. Behavioral observations may be collected either in an office or in an outside setting (school, home, workplace). Collateral informants also may provide information regarding how clients cope when outside your office.
Often, a conclusive mental disorder diagnosis can’t be achieved without a medical examination. When interviewing new clients, therapists should inquire about the most recent physical examination results. Some therapists ask for this information on their intake form and discuss it with clients.
Physical and mental states can have powerful and reciprocal influences on each other. For instance, a long-term illness or serious injury can contribute to anxiety and depression. Consider the following options when completing a diagnostic assessment:
- Gather information about physical examination results.
- Consult with the client’s primary care physician.
- Refer clients for a physical examination.
Making sure that potential medical or physical causes or contributors to mental disorders are considered and noted is an ethical mandate.
Clients who come for professional assistance may have lost sight of their personal strengths and positive qualities. Further, after experiencing an hour-long diagnostic interview, clients may feel even more sad or demoralized. As we’ve mentioned before, especially within the context of suicide assessment interviewing, it’s important to ask clients to identify and elaborate on positive personal qualities throughout the interview, but especially toward the end of an assessment/diagnostic process. For example:
I appreciate your telling me about your problems and symptoms. But I’d also like to hear more about your positive qualities. Like how you’ve managed to be a single parent and go to school and fight off those depressive feelings you’ve been talking about.
Exploring client strengths provides important diagnostic information. Clients who are more depressed and demoralized may not be able to identify their strengths. Nonetheless, be sure to provide support, reassurance, and positive feedback. In addition, as solution-oriented theorists emphasize, don’t forget that diagnosis and assessment procedures can—and should—include a consistent orientation toward the positive. Bertolino and O’Hanlon (2002) stated:
Formal assessment procedures are often viewed solely as a means of uncovering and discovering deficiencies and deviancies with clients and their lives. However, as we’ve learned, they can assist with learning about clients’ abilities, strength, and resources, and in searching for exceptions and differences. (p. 79)
Effective diagnostic interviewing isn’t exclusively a fact-finding process. Throughout the interview, skilled diagnosticians express compassion and support for a fellow human being in distress. The purpose of diagnostic interviewing goes beyond establishing a diagnosis or “pigeonhole” for clients. Instead, it’s an initial step in developing an individualized treatment plan.
Coming up in March and April, I’ve got two, two-day professional workshops scheduled at the University of Montana. Together, these workshops can earn you 2-credits through the U of M . . . or you can enroll for continuing education credit (one workshop = 2 days = 13 CE hours). Whatever you decide, coming to Missoula in early March and early April is pretty fabulous. We’ve scheduled these workshops for the first Friday and Saturday in Missoula to coincide with the First Friday Art Walk. That way you can workshop during the day and walk around downtown Missoula and check out fantastic Montana art Friday evening.
The workshops and their descriptions are below:
March 2 and 3, 8:30am to 4:30pm: Working with Challenging Youth and Parents . . . and Loving It
Counseling difficult youth and challenging parents can be immensely frustrating or splendidly gratifying. The truth of this statement is so obvious that the supportive reference, at least according to many teenagers is, “Duh!” Using storytelling, video clips, live demonstrations, group discussion, and skill-building break-out sessions, John will present essential evidence-based principles and over 20 specific techniques for influencing “tough” clients or students. Techniques for working with youth will include, but are not limited to: (a) the affect bridge, (b) what’s good about you?, (c) empowered storytelling, (d) generating behavioral alternatives, (e) the three-step emotional change technique, and many more. Dr. Sara Polanchek will join John for the parenting portion of the workshop. They will describe essential principles for working effectively with parents, how to conduct brief parenting consultations using a positive, solution-focused model, and strategies for providing parents with specific suggestions and advice to parents. Issues related to ethics and culture will be highlighted and discussed throughout this two-day workshop.
Here’s a link to the registration form for both workshops. Registration Form for JSF Workshops 2018
If you want to call for more information: Call 406-243-5252 and leave a message if our administrative person is away. Or you can always email me: firstname.lastname@example.org
April 6 and 7, 8:30am to 4:30pm: Variations on the Clinical Interview: Collaborative Approaches to Mental Status Examinations, Suicide Assessment, and Suicide Interventions
The clinical interview is the headwaters from which all mental health assessment and interventions flow. In this workshop, following an overview of clinical interviewing principles and practice, skills training for conducting the mental status examination (MSE) and suicide assessment interviews will be provided. Participants will learn MSE terminology, common symptom clusters and presentations, and strategies through which the MSE can be more collaborative and user-friendly. Additionally, participants will learn a flexible model for conducting suicide assessments. This model features eight core suicide dimensions and techniques for directly and collaboratively questioning clients about suicide ideations, previous attempts, hopelessness, and more. Five suicide interventions will be featured: alternatives to suicide; separating suicide intent from the self; interpersonal re-connection; neodissociation; and safety-planning.
One last note: On Wednesday, February 14, I’ll be doing my annual 1/2 day workshop on Tough Kids, Cool Counseling in the Schools at the annual meeting of the National Association of School Psychologists (NASP). We’re in Chicago this year. So if you happen to be in Chicago, check out the NASP conference. https://www.nasponline.org/professional-development/nasp-2018-annual-convention
Many professionals and media sources have proclaimed that suicide is a 100% preventable problem. Although I completely disagree with that message—and find it terribly offensive—I also believe that we should do what we can to prevent suicide.
Recently I was asked to write a journal article summarizing the conditions or dimensions that commonly contribute to suicide. To give you a flavor of these dimensions, below I’ve included brief descriptions of each one. However, I also want to emphasize that suicidologists and suicide researchers agree that death by suicide is nearly always unpredictable. Suicide is unpredictable despite the fact that, afterwards, many people and professionals will feel as though they should have “seen the signs” and done something more to prevent the death.
Knowing the following eight dimensions is useful when they’re used to enhance your compassion and capacity to collaborate with individual clients and persons. They’re not designed to be used as suicide risk factors or predictors.
Here are the eight dimensions.
Unbearable Psychological/Emotional Distress (Shneidman’s Psychache)
Shneidman (1985) originally identified “psychache” as the central psychological force leading to suicide. He defined psychache as negative emotions and psychological pain, referring to it as “the dark heart of suicide; no psychache, no suicide” (p. 200). In more modern patient-oriented language, psychache is aptly described as unbearable emotional distress. Unbearable distress can involve many factors, or center around one main trauma, loss, or other psychologically activating experiences; it may be accompanied by distinct cognitive, emotional, or physical symptoms.
Problem-Solving Impairment (Shneidman’s Mental Constriction)
Depression or low mood is commonly associated with problem-solving impairments. Originally, Shneidman called these impairments mental constriction, and defined them as “a pathological narrowing of the mind’s focus . . . which takes the form of seeing only two choices: either something painfully unsatisfactory or cessation” (1984, pp. 320–321). Researchers have reported support for Shneidman’s original ideas about mental constriction (Ghahramanlou-Holloway et al., 2012; Lau, Haigh, Christensen, Segal, & Taube-Schiff, 2012).
Agitation or Arousal (Shneidman’s Perturbation)
Agitation or arousal is consistently associated with death by suicide (Ribeiro, Silva, & Joiner, 2014). Shneidman (1985) originally used the term perturbation to refer to internal agitation that moves patients toward suicidal acts. When combined with high psychological distress and impaired problem-solving, agitation or arousal seems to push patients toward acting on suicide as a solution to their distress. Trauma, insomnia, drug use (including starting on a trial of serotonin-reuptake inhibitors), and many other factors can elevate agitation (Healy, 2009).
Thwarted Belongingness and Perceived Burdensomeness
Joiner (2005) developed an interpersonal theory of suicide. Part of his theory includes thwarted belongingness and perceived burdensomeness as contextual interpersonal factors linked to suicide. Thwarted belongingness involves unmet wishes for social connection. Perceived burdensomeness occurs when patients see themselves as flawed in ways that make them a burden to others.
Hopelessness is a broad cognitive variable related to problem-solving impairment and linked to elevated suicide risk (Hagan, Podlogar, Chu, & Joiner, 2015; Strosahl, Chiles, & Linehan, 1992). Hopelessness is the belief that whatever distressing life conditions might be present will never improve. In many cases, patients hold a hopeless view—even when a rational justification for hope exists.
Joiner (2005) and Klonsky and May (2015) have described how fear of death or aversion to physical pain is a natural suicide deterrent present in most individuals. However, at least two situations or patterns can desensitize patients to suicide and reduce natural suicide deterrence. First, some patients may be predisposed to high pain tolerance. This predisposition is likely biogenetic, as in blood-injury phobias (Klonsky & May, 2015). Second, patients may acquire, through desensitization, a numbness that reduces natural fears of pain and suicide. Chronic pain, self-mutilation, and other experiences can be desensitizing.
Suicide Plan or Intent
In and of itself, suicide ideation is a poor predictor of suicide. Nevertheless, ideation is an important marker to explore with patients; exploring ideation can lead to asking directly about whether patients have a suicide plan. Suicide plans may or may not be associated with suicide intent. Some patients will keep a potential suicide plan on reserve, just in case their psychological pain grows unbearable. These patients do not intend to die by suicide, but they want the option and sometimes they have thought through the method(s) they might employ.
Access to a lethal means is a situational dimension that substantially contributes to suicide risk. Firearms are far and away the most lethal suicide method. Specifically, Swanson, Bonnie, and Appelbaum (2015) reported that firearms result in an 84% case fatality rate. Although firearms can quickly become a politicized issue in the U.S., researchers have repeatedly found that access to firearms greatly magnifies suicide risk (Anestis & Houtsma, 2017).
At first, conducting a mental status examination (MSE) can feel “different” and daunting to non-medical mental health professionals. However, even though the MSE is a modernist medical-psychiatric assessment tool, it’s also possible to conduct MSEs more collaboratively.
To help address a recent listserv request, below, I’ve pasted some Tables from the MSE chapter in Clinical Interviewing. These Tables are not comprehensive, but along with other resources provide relatively good coverage of how and when to administer an MSE and some useful vocabulary words.
In addition to the Tables below, Dr. Thom Field from City University of Seattle has a set of training videos. You can find them here: http://www.thomfield.com/mental-status-exam-training.html
Also, there are several other resources posted on this blog. In fact, the most viewed of all posts on this blog is titled “Two Sample Mental Status Examination Reports” https://johnsommersflanagan.com/2012/08/10/two-sample-mental-status-examination-reports/
In addition, there is a nifty (IMHO) MSE protocol here: https://johnsommersflanagan.com/mental%20status/
And another sample MSE report: https://johnsommersflanagan.com/2012/11/23/another-sample-mental-status-examination-report/
And an interesting post on “Psychic Communications . . . and Cultural Differences in Mental Status” https://johnsommersflanagan.com/2013/01/02/psychic-communications-and-cultural-differences-in-mental-status/
And a short MSE video clip: https://johnsommersflanagan.com/2013/02/28/mental-status-examination-video-clip/
Okay. Enough tangential speech from me. The Tables are below:
|Table 8.1. Descriptors of Client Attitude Toward the Examiner|
|Aggressive: The client attacks the examiner physically or verbally or through grimaces and gestures. The client may “flip off” the examiner or simply say to an examiner something like, “That’s a stupid question” or “Of course I’m feeling angry, can’t you do anything but mimic back to me what I’ve already said?”|
|Cooperative: The client responds directly to interviewer comments or questions. There is a clear effort to work with the interviewer to gather data or solve problems. Frequent head nods and receptive body posture are common.|
|Guarded: The client is reluctant to share information about himself. When clients are mildly suspicious they may appear guarded in terms of personal disclosure or affective expression.|
|Hostile: The client is indirectly nasty or biting. Sarcasm, rolling of the eyes in response to an interviewer comment or question, or staring off into space may represent subtle, or not so subtle, hostility. This behavior pattern can be more common among young clients.|
|Impatient: The client is on the edge of his seat. The client is not very tolerant of pauses or of times when interviewer speech becomes deliberate. She may make statements about wanting an answer to concerns immediately. There may be associated hostility and competitiveness.|
|Indifferent: The client’s appearance and movements suggest lack of concern or interest in the interview. The client may yawn, drum fingers, or become distracted by irrelevant details. The client could also be described as apathetic.|
|Ingratiating: The client is overly solicitous of approval and interviewer reinforcement. He may try to present in an overly positive manner, or may agree with everything the interviewer says. There may be excessive head nodding, eye contact, and smiles.|
|Intense: The client’s eye contact is constant, or nearly so; the client’s body leans forward and listens closely to the interviewer’s every word. Client voice volume may be loud and voice tone forceful. The client is the opposite of indifferent.|
|Manipulative: The client tries to use the examiner for his or her own purpose. Examiner statements may be twisted to represent the client’s best interests. Statements such as “His behavior isn’t fair, is it Doctor?” are efforts to solicit agreement and may represent manipulation.|
|Negativistic: The client opposes virtually everything the examiner says. The client may disagree with reflections, paraphrases, or summaries that appear accurate. The client may refuse to answer questions or be completely silent. This behavior is also called oppositional.|
|Open: The client openly discusses problems and concerns. The client may also have a positive response to examiner ideas or interpretations.|
|Passive: The client offers little or no active opposition or participation in the interview. The client may say things like, “Whatever you think.” He may simply sit passively until told what to do or say.|
|Seductive: The client may move in seductive or suggestive ways. He or she may expose skin or make efforts to be “too close” to or to touch the examiner. The client may make flirtatious and suggestive verbal comments.|
|Suspicious: The client may repeatedly look around the room (e.g., checking for hidden microphones). Squinting or looking out of the corner of one’s eyes also may be interpreted as suspiciousness. Questions about the examiner’s notes or about why such information is needed may signal suspiciousness.|
|Table 8.2. Thought Process Descriptors|
|Blocking: Sudden cessation of speech in the midst of a stream of talk. There is no clear reason for the client to stop talking and little explanation. Blocking may indicate that the client was about to associate to an uncomfortable topic. It also can indicate intrusion of delusional thoughts or hallucinations.|
|Circumstantiality: Excessive and unnecessary detail provided by the client. Very intellectual people (e.g., college professors) can become circumstantial; they eventually make their point, but don’t do so directly and efficiently. Circumstantiality or overelaboration may be a sign of defensiveness and can be associated with paranoid thinking styles. (It can also simply be a sign the professor was not well-prepared for the lecture.)|
|Clang Associations: Combining unrelated words or phrases because they have similar sounds. Usually, this is manifest through rhyming or alliteration; for example: “I’m slime, dime, do some mime” or “When I think of my dad, rad, mad, pad, lad, sad.” Some clients who clang are also perseverating (see below). Clanging usually occurs among very disturbed clients (e.g., schizophrenics). As with all psychiatric symptoms, cultural norms may prompt the behavior (e.g., clang associations among rappers is normal).|
|Flight of Ideas: Speech in which the client’s ideas are fragmented. Usually, an idea is stimulated by either a previous idea or an external event, but the relationship among ideas or ideas and events is weak. In contrast to loose associations (see below), there are logical connections in the client’s thinking. However, unlike circumstantiality (see above), the client never gets to the point. Clients who exhibit flight of ideas often appear over-active or overstimulated (e.g., mania or hypomania). Many normal people exhibit flight of ideas after excessive caffeine intake—including one of the authors.|
|Loose Associations: Minimal logical connections between thoughts. The thinking process is nearly, but not completely random; for example: “I love you. Bread is the staff of life. Haven’t I seen you in church? I think incest is horrible.” In this example, the client thinks of attraction and love, then of God’s love as expressed through communion, then of church, and then of an incest presentation he heard in church. It may take effort to track the links. Loose associations may indicate schizotypal personality disorder, schizophrenia, or other psychotic or pre-psychotic disorders. Extremely creative people also regularly exhibit loosening of associations, but are able to find a socially acceptable vehicle through which to express their ideas.|
|Mutism: Virtually total unexpressiveness. There may be signs the client is in contact with others, but these are usually limited. Mutism can indicate autism or schizophrenia, catatonic subtype. Mutism may also be selective in that young clients will be able to speak freely at home, but become mute and apparently unable to speak at school or with professionals (see DSM-5, **).|
|Neologisms: Client-invented words. They’re often spontaneously and unintentionally created and associated with psychotic disorders; they’re products of the moment rather than of a thoughtful creative process. We’ve heard words such as “slibber” and “temperaturific.” It’s important to check with the client with regard to word meaning and origin. Unusual words may be taken from popular songs, television shows, or a product of combining languages.|
|Perseveration: Involuntary repetition of a single response or idea. The concept of perseveration applies to speech and/or movement. Perseveration is often associated with brain damage and psychotic disorders. After being told no, teenagers often engage in this behavior, although normal teenagers are being persistent rather than perseverative; that is, if properly motivated, they’re able to stop themselves voluntarily.|
|Tangential speech: Tangential speech is similar to loose associations, but connections between ideas are even less clear. Tangential speech is different from flight of ideas because flight of ideas involves pressured speech.|
|Word Salad: A series of unrelated words. Word salad indicates extremely disorganized thinking. Clients who exhibit word salad are incoherent. (See the second half of the preceding “Dear Bill” letter for an example of word salad.)|
|Table 8.3. Characteristics of Different Perceptual Disturbances|
|Definition||False sensory experiences||Perceptual distortions||Sudden and vivid sensory-laden recollections of previous experiences|
|Diagnostic Relevance||Auditory hallucinations are most common and usually associated with schizophrenia, bipolar disorder, or a severe depressive episode||Illusions are more common among clients who have vivid imaginations, who believe in the occult, or have other schizotypal personality disorder symptoms||Flashbacks are most common among clients with post-traumatic stress disorder|
|Useful Questions||Do you ever hear or see things that other people can’t see or hear?
When and where do you usually see or hear these things (checking for hypnogogic or hypnopompic experiences)?
Does the radio or television ever speak directly to you?
Has anyone been trying to steal your thoughts or read your mind?
|What was happening in your surroundings when you saw (or experienced) what you saw (or experienced)?
Did the vision (or image or sounds) come out of nowhere, or was there something happening?
|Have you had any similar experiences before in your life?
Sometimes when people have had very hard or bad things happen to them, they keep having those memories come back to them. Does that happen to you?
Was there anything happening that triggered this memory or flashback to the past?
|Table 8.4. Mental Status Examination Checklist|
|Attitude Toward Examiner|
|Affect and Mood|
|Speech and Thought|
|Orientation and Consciousness|
|Memory and Intelligence|
|Judgment, Reliability and Insight|
From 13 Reasons Why, to Chris Cornell’s recent death, issues pertaining to suicide have been in our face this month. This is no surprise. May (late spring in the Northern hemisphere) is nearly always the month with the highest suicide rates.
That’s why right now is an excellent time for some straight talk about suicide.
Suicide is an emotionally triggering topic that’s notoriously difficult to talk or write about. Most of us know people who have been suicidal. Some of us know people who have died by suicide. Still others who read this may be having suicidal thoughts in this moment, or may have made suicide attempts in the past. Talking and writing about suicide is unpleasant, but necessary.
Because suicide is difficult to talk about, myths and misconceptions flourish. Not talking (or writing) about suicide also makes it harder to keep tabs on the latest research. Sometimes, leading professional journals neglect publishing new articles on suicide for a decade or more. This brings me to my purpose. To bust a few stubborn suicide-related myths and provide a glimpse at recent research on suicide prevention.
Let’s begin with now.
It’s a beautiful green spring in Montana with brilliant white snow in the mountains. Despite this beauty and brilliance, suicide rates rise in the spring and early summer and drop in fall and winter. Most people think the opposite is true, but every year, late spring and early summer bring the highest rates. Why? There are theories, but unfortunately, “we don’t know” is the answer to this and many questions related to suicide. I’m starting with this misconception to illustrate how easy it is to get the even the simplest facts related to suicide completely wrong.
One of the most insidious and unhealthy myths about suicide is the promotion of the idea that suicidal thoughts and impulses represent deviance or indicate the presence of a mental disorder. Once again, although many think it so, this idea is also untrue. Suicidal thoughts are a normal and natural response to psychological distress and misery. Social disconnection (relationship break-ups, death of a loved one, or other relationship problems) also can trigger suicidal thoughts in so-called “normal” people.
Our entire culture needs to stop classifying suicidal thoughts as automatic deviance. At one point or another, most people contemplate suicide, at least briefly. That fact pretty much blows the whole idea of suicidal thoughts as deviance right out of the metaphorical water.
Suicidal thoughts can be associated with specific mental disorders, but they are not, in and of themselves, signs of a mental disorder. In a recent large scale study, it was reported that mental disorders and suicidal thoughts weren’t useful in determining which individuals would eventually make suicide attempts.
Believing that suicidal thoughts represent a mental disorder isn’t just untrue, it’s also unhelpful. People who are suicidal, don’t need the public or professionals to make them feel worse by implying that their suicidal thoughts represent some form of illness.
Another surprising research finding is that, in general, suicide warning signs and suicide risk factors are unhelpful. This is true despite the fact that following a death by suicide, one of the first messages you’ll hear in the media is how important it is to watch for specific suicide warning signs. Unfortunately, like many things related to suicide, this is both good and bad advice. It’s good advice in that it’s always important to notice when friends, family, coworkers, and strangers are in distress and to do what we can to be comforting. But it’s also bad advice. Pointing the public or professionals toward warning signs implies that scientifically-based warning signs exist. They don’t.
There’s no science that supports the usefulness of warning signs or risk factors. This may seem discouraging, but it shouldn’t, because it leads to ONE BIG EXCELLENT CONCLUSION. That is, we should all try to offer support, empathy, and compassion to everyone. The take-home message is, don’t wait to encounter a suicidal person to unleash your kind and compassionate side. You should be leading with that. All. The. Time.
Chew on this idea for a moment. We’re stuck. If we’re interested in suicide prevention (or in having healthy relationships), our best default response is to treat everyone with kindness, respect, and empathy. I understand that’s impossible and I understand that you may think there are some exceptions to universal compassion. But we should try to lead with kindness, respect, and empathy anyway.
A good thing about having a general philosophy of kindness and compassion is that it helps suicidal people trust you. It will be harder for them to conclude, “This person is just being nice because I’m suicidal.” Instead, you’ll be treating everyone with kindness and empathy simply because that’s the sort of world you’re creating around you.
Another common suicide myth is that asking about suicide might somehow put the idea of suicide into someone’s head. Not true. Most people who are suicidal feel relieved and appreciative if you ask them about it in a nonjudgmental way. And, if you ask someone and they aren’t suicidal, well, the point is that people are highly resilient. They’re not so fragile that posing a short inquiry about suicide suddenly becomes life threatening. The other point is that you should ask with kindness and compassion. Even better, you should normalize the question by saying something like, “It’s not unusual for someone in your situation to have thoughts about suicide. I’m wondering if you’ve been having suicidal thoughts?” Making a statement that normalizes (rather than pathologizes) suicidal thoughts can make it easier to for people to talk more openly . . . and when people who are suicidal are talking openly, it will be easier for you to be helpful.
As if it weren’t already hard enough, another thing that’s especially complex is that when people are contemplating suicide, they often have strong negative reactions to infringements on their personal freedoms. This is partly why telling someone, you shouldn’t or can’t choose suicide, is a bad idea. Well-meaning helpers who push people too hard away from suicidal thoughts and toward embracing life can come across as “not understanding.” This could trigger an oppositional response. The person you want to help might either stop talking about it (but keep thinking about it) or feel an urge to oppose all suicide prevention or intervention efforts.
It’s not unusual for suicidal people to feel interpersonally isolated, disconnected, or as if they’re a burden to family, friends, and society. This makes connecting with them all the more important. It’s unfortunate, but people experiencing depression can be rather irritable or unappreciative of your efforts to listen and help. When you express concern, they might say something nasty in response. If so, let go of your needs for feeling appreciated; listen and be supportive anyway.
People who are suicidal can have difficulty problem-solving in a way that reflects hopefulness. Who wouldn’t have trouble being optimistic after experiencing repeated misery? This is why it’s important to problem-solve WITH people who are suicidal. Don’t usurp their control; lend another perspective. Part of this perspective might be the simple message that suicide is always an alternative, but that it’s important to wait and try as many other alternatives as possible.
Often, the response to your problem-solving efforts will be something like, “I’ve tried everything and nothing helps.” Again, we need to understand that when someone is suicidal, this is how it feels! At this point, acknowledge that right now it feels like nothing could possibly help. But at the same time, it’s okay to say things like, “I want you to live.”
If you’re problem-solving with someone who is suicidal, it’s also important to be persistent. Try saying something like, “Let’s make a list of everything you’ve tried, starting with whatever was the worst and most unhelpful idea ever.” Starting with what was unhelpful can resonate with the person’s pessimistic mood and help you identify something that’s at least not the worst option on the planet.
Chris Cornell’s recent death by suicide is a reminder of how specific medications can sometimes increase an individual’s agitation and/or suicidal thoughts. He was taking Ativan (Lorazepam). Ativan is a benzodiazepine (like Xanax and Valium). IMHO (and the science supports this), benzos are very bad medications to use for anything other than very short-term treatment. The bottom line is that sometimes (not always) psychiatric medications are not a part of the suicide solution and can become part of the suicide problem.
Among other things, Thirteen Reasons Why is a reminder of how easy it is for people to feel tremendously guilty when someone dies by suicide. Twenty-six years later, I still feel guilt over the death of a boy with whom I was working. Was it my fault? Absolutely not. Do I still feel bad? Absolutely yes.
Death by suicide is a tragedy. I’m tempted to say that it’s always a tragedy, but I recognize that when it comes to humans and humanity, using the terms always and never is dicey.
Some individuals are living with what they experience as intolerable physical, psychological, or emotional suffering. For their loved ones it’s likely still a tragedy when they die by suicide, but is it a tragedy for them? It’s hard to rule out the possibility that death by suicide may represent solace for them.
Suicide is a very personal option on the palette of human choice. For example, I want people to live. I want to help them reduce their psychological pain, make positive relationship connections, and re-engage in activities they find meaningful. But even so, sometimes suicide happens anyway. This is deeply painful and the guilt can be enormous. If someone close to you dies by suicide or you’re feeling affected by any suicide-related event, please find someone to talk with. One of my former clients once said, “The mind is a terrible place . . . to go alone.” Find someone you can trust and share any dark thoughts you might be having. Deal with it. Don’t let your guilt and angst simmer.
To summarize, suicide rates are highest right now. Does that mean we can relax later? Of course not. Suicide risk factors and warning signs are mostly useless and so we should treat people with respect and compassion all the time. When needed, we should ask the suicide question directly and with a spirit of non-judgmental normality. When possible, we should help people with suicidal thoughts identify options that might move them toward feeling better, while acknowledging that suicide is an option. We need to remember that sometimes medications can make suicidality worse. Perfect prevention is impossible. Suicide may happen despite our best efforts. Dealing with guilt over a suicide takes time and requires support.
No one will be completely happy with the ideas I’ve written here. That’s good. Individual reactions to suicide issues are unique. If you want to argue with or improve on these ideas, feel free to engage in the conversation. Using an attitude of kindness and respect, let’s keep talking about suicide. Right now, that’s the best solution we have to our suicide problem. In fact, it may be the best solution we’ll ever have.
To check out my recent professional journal article in Professional Psychology, click here: SF and Shaw Suicide 2017