Category Archives: Clinical Interviewing

Two Short Suicide and Psychotherapy Video Clips

As a part of my presentations for ACA last week, I prepared a couple of short video clips. These clips are part of a much, much longer, three-volume (7.5 hour) video series produced and published by psychotherapy.net. Victor Yalom of psychotherapy.net gave me permission to occasionally share a few short clips like these. If you’re interested in purchasing the whole video series (or having your library do so), you can check out the series here: https://www.psychotherapy.net/videos/expert/john-sommers-flanagan

IMHO, although the whole video series is excellent and obviously I recommend it, these clips can be used all by themselves to stimulate class discussions. Check them out if you’re interested.

Clip 1: Opening a Session with Kennedy: https://www.youtube.com/watch?v=gR7YU0VrHqw

Kennedy is a 15-year-old cisgender female referred by her parents for suicidal ideation. Although a case could be made for using a family systems approach, this opening is of me working 1-1 with Kennedy. When I show this video, I like to emphasize that I’m using a “Strengths-based Approach” AND I’m also asking a series of questions that pull for Kennedy to talk about her distress. This is because clients generally need to talk about their distress before they can focus on strengths or solutions. Instead of practicing “toxic positivity” this approach emphasizes the need to come alongside and be empathic with client pain and distress.

Clip 2: A Trial Interpretation with Chase: https://www.youtube.com/watch?v=UNBR3bKyE4I

Chase is a 35-year-old cisgender Gay male. In this brief excerpt, I try (somewhat poorly) to use a pattern interpretation to facilitate insight into his history of social relationships. Chase’s response is to dismiss my interpretation. Back in my psychoanalytic days, we talked about and used trial interpretations to gauge whether an abstract-oriented psychodynamic approach was a good fit for clients. Chase’s response is so dismissive that I immediately shift to using a very concrete approach to analyzing his social universe. Then, when Chase isn’t able to identify anyone who is validating, I use a strategy I call “Building hope from the bottom up” to help him start the brainstorming process.

A Visual of Chase’s Social Universe

A big thanks to psychotherapy.net and Victor Yalom for their support of this work.

As always, if you have thoughts or feedback on these clips or life in general, please feel free to share.

John S-F

Resources from my American Counseling Association Conference Presentations

Last week I had the honor of presenting three times at the American Counseling Association meeting in Atlanta. Today, I’m posting the Abstracts and Powerpoints from those presentations, just in case someone might find the information useful.

On Friday, April 8: The way of the humanist: Illuminating the path from suicide to wellness. Invited presentation on behalf of the Association for Humanistic Counseling.

At this moment, counselors are hearing more distress, anxiety, and suicidal ideation than ever before. In response, we are called to resonate with our clients’ distress. On behalf of the Association for Humanistic Counseling, John Sommers-Flanagan will describe how humanistic principles of acceptance and empathy can paradoxically prepare clients to embrace wellness interventions. Participants will learn five evidence-based happiness strategies to use with their clients and with themselves.

Also, on Friday, April 8: Using a strengths-based approach to suicide assessment and treatment in your counseling practice. Invited presentation on behalf of ACA Publications.

Most counselors agree: no clinical task is more stressful than suicide assessment and treatment planning. When working with people who are suicidal, it’s all-too-easy for counselors to over-focus on psychopathology and experience feelings of hopelessness and helplessness. However, framing suicidal ideation as an unparalleled opportunity to help alleviate your client’s deep psychological pain, and embracing a strengths-based orientation, you can relieve some of your own anxiety. This practice-oriented education session includes an overview of strengths-based principles for suicide assessment and treatment.

On Saturday, April 9, Being seen, being heard: Strategies for working with adolescents in the age of Tik Tok. Educational presentation (with Chinwe Williams).

Counseling and connecting with adolescents can be difficult. In this educational session, we will present six strategies for connecting with and facilitating change among adolescents. For each strategy, the co‐presenters, coming from different cultural and generational perspectives, will engage each other and participants in a discussion of challenges likely to emerge when counseling adolescents. Social media influences, self‐disclosure, and handling adolescents’ questions will be emphasized.

Thanks for reading. I hope some of these resources are helpful to you in your work.

JSF

Evaluating Interpersonal Dynamics in the Initial Clinical Interview

As we begin the revision process for Clinical Interviewing, I’m discovering content here and there that I want to share. Below is a short excerpt from the Intake Interviewing chapter where we’re discussing the process of evaluating clients’ interpersonal behavior patterns. Please email me your reactions and recommendations if you have some.

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Evaluating Interpersonal Behavior

Interpersonal behavior is central in the development and maintenance of client problems. Some theorists claim that all client problems have their roots in relationship problems (Glasser, 1998). Evaluating client interpersonal behavior is an essential part of an intake interview.

Intake interviewers have five potential data sources pertaining to client interpersonal behavior.

  1. Client self-report. This includes self-report of (a) past relationship interactions (e.g., childhood) and (b) contemporary relationship interactions.
  2. Clinician observations of client interpersonal behavior during the interview.
  3. Formal psychological assessment data.
  4. Information from past psychological records/reports.
  5. Information from collateral informants.

Although some behaviorists and in-home family therapists also observe clients outside the office (e.g., in school, home, and work environments), it’s unusual to have those data available prior to an intake.

Evaluating interpersonal behavior is difficult. Each of the preceding data sources can be suspect. For example, client self-report may be distorted or biased; often clients cast their interpersonal behaviors in a favorable light, or they may excessively blame themselves for negative interpersonal experiences. Clinician observations are also subjective. When you’re evaluating client interpersonal behavior, it’s wise to use several basic assessment principles to temper your conclusions:

  1. Single observations are often unreliable. This is partly because interpersonal behavior can shift dramatically from situation to situation. Multiple observations of behavior patterns (e.g., interpersonal aggression or interpersonal isolation) are more reliable.
  2. Just as construct validity is established through multimethod, multitrait assessments (Campbell & Fiske, 1959), interpersonal assessments are more valid when you have converging data from more than one source (e.g., self-report plus clinician observation).
  3. The literature is replete with theory-based models for interpersonal assessment. When clinicians hold strong theoretical beliefs, confirmation bias is more likely (in other words, you will make observations that confirm your theoretical stance or hypothesis). Therefore, you should regularly question conclusions about client interpersonal behavior based on your preexisting ideas.

One of the most popular models for conceptualizing interpersonal behavior is attachment theory. Adherents to this perspective believe that early caregiver-child relationship interactions create internal working models about how relationships work. Essentially, this leaves clients with consistent (and sometimes rigid) interpersonal expectations and reactions. For example, clients with insecure attachment styles may expect or anticipate rejection or abandonment, while clients with ambivalent attachment styles alternate between pushing others away and clinging to them. Typically, maladaptive components of client internal working models are activated during the early stages of new relationships or during times of significant stress, when support and reassurance are needed (O’Shea, Spence, & Donovan, 2014).

Interpersonal assessment based on attachment theory is a psychodynamic approach and involves a depth-oriented assessment process. However, the idea that individuals have internal working models that guide their interpersonal behaviors is consistent across many different theoretical perspectives. Specifically,

  • Cognitive therapists emphasize client schema or schemata that shape what clients expect in interpersonal relationships (Young, Klosko, & Weishaar, 2003).
  • Adlerian therapists use the term lifestyle assessment to refer to the evaluation of client expectations about the self, the world, and others (Carlson, Watts, & Maniacci, 2006).
  • Psychoanalytic therapists refer to the client’s core conflictual relational theme (CCRT) as a target for treatment (Luborsky, 1984).
  • The whole emphasis of the empirically supported interpersonal psychotherapy for depression is based on addressing problematic interpersonal relationship dynamics (Markowitz & Weissman, 2012).

It’s always advisable to attend to feelings and reactions that clients elicit in you (Teyber & McClure, 2011). For example, some clients may trigger boredom, arousal, sadness, or annoyance. These personal and emotional reactions can be viewed as countertransference (Luborsky & Barrett, 2006). However, if there’s convergent evidence that reactions the client is evoking in you are also evoked in others, it’s likely that the client’s interpersonal behavior is the culprit. If your reactions are unique, then your countertransference reaction may be more about you and less about the client.

Evaluating a client’s personal history and interpersonal behaviors is a formidable task that could easily take several sessions. Expecting that you should have a precise sense of your client’s interpersonal style after a single interview is unrealistic. A better goal is to have a few working hypotheses about your client’s interpersonal behavior patterns (see Case Example 8.2).

CASE EXAMPLE 8.2: DESCRIBING INTERPERSONAL OBSERVATIONS

The following intake note focuses on interpersonal observations and, consistent with a collaborative/therapeutic assessment model, uses a descriptive rather than a labeling approach.

Miriam, a 36-year-old White, married female, described herself as suffering from tension and stress in her marital relationship. She reported, “My husband always calls me controlling, and I hate that, but sometimes he’s right.” During our session, Miriam repeatedly (about five times) asked for more information, complaining that she “really needed” to understand exactly what counseling was about before she could be sure she wanted to proceed. As we discussed her husband’s comments in greater detail, Miriam noted that she believed her “need for control” was related to anxiety. Together we identified several triggers that elicit anxiety and are then followed by self-identified controlling behaviors. These comprised (a) new situations (like counseling), (b) her husband leaving the house without telling her his plans, and (c) when she feels neglected by her husband. Overall, these triggers may be related to an internal working model where Miriam’s sense of relational security is threatened. Consequently, one of our first therapy tasks is for Miriam to engage in a self-monitoring homework assignment to help further refine our understanding of the interpersonal triggers that activate her “controlling” behaviors.

Send Me Your Feedback and Ideas for the 7th Edition of Clinical Interviewing

And the beat goes on. . .

Rita and I are signing a contract with John Wiley & Sons to update our Clinical Interviewing text to the 7th edition. Clinical Interviewing was first published in 1993 under the title, Foundations of Therapeutic Interviewing with Allyn & Bacon publishers. As one of my academic friends once said, it was a good book, but it fell apart in the end. I was instantly worried that we hadn’t handled the final chapter very well. Turns out, he was referring to the binding.

After Allyn & Bacon let go of the copyright in 1996, we shopped the book and got great offers from Norton, Guilford, and Wiley. We went with Wiley, received excellent editorial guidance, and Clinical Interviewing was born; the text has been very popular in the graduate textbook market in psychology, counseling, and social work.

Along with the great news that we’re headed for another edition comes a rather large chunk of planning and work.

First, the planning . . .

Clinical Interviewing became popular and has remained popular because it’s a practical and accessible text that focuses on clinician competencies. We will continue that focus—we want students to not only read the text, but to return to it, keep it, and use it to remind themselves of the foundations that underlie the clinical encounter.

Another reason the book has been popular is because of the fabulous feedback and ideas we’ve gotten from people like you. We want to continue that emphasis too. If you’re familiar with Clinical Interviewing—as a professor or as a student—I’d love to hear your ideas about what we should change or add. Please, email me with any and all your ideas: john.sf@mso.umt.edu. We’ve already have some feedback, including:

  • Update the text to sync with DSM-5-TR
  • Add more content, and a video demonstration, of online (remote) interviewing (tele-mental health)
  • Add more specific content pertaining to interviewing special populations in general, and working across cultures and sexualities in particular
  • Add more (and updated) video demonstrations
  • Consider stronger and more traditional diagnostic assessment content (I’m mixed on this)

Second, the work . . .

During the past two revisions, I asked people to volunteer to read and review specific chapters. This is extra work for you, but it’s also a good academic process. Everyone who provides a chapter review will be listed in the acknowledgements. And so, if any of you would like to review a chapter (or more) and provide us with feedback and guidance for the 7th edition, please email me at john.sf@mso.umt.edu

As always, thanks for reading this and thanks for considering the opportunity to share your clinical interviewing expertise.

Love, Sex, Racism, Suicide, Goal-Setting, Awards, Stories, Burnout, Flexibility, and the Whole Genome at the Psychotherapy Networker Symposium Conference

The View from the Corner

As I type, Steven Hayes, the creator of acceptance and commitment therapy (ACT), is talking in a variety of voices about mindful acceptance. Earlier, he mentioned something about the whole human genome. In case you don’t already know, Steve is an older white guy. His writing about psychotherapy is fantastic. I really like his Ted talk. I’ve found his question, “What shall we do with our difficult thoughts?” an excellent prompt to reflect on.

Steve and I have a history. I’m glad to say that I’ve mindfully accepted that he missed his supervision appointment with me at AABT (now ABCT) back in 1987 in Los Angeles. Really. I’ve let go Steve standing me up, not because I’m all that good at forgiveness, but because him skipping out on our chance to meet makes for a better story. In fact, in this mindful moment, I’ve accepted him missing our meeting so completely that I have no urge to try to meet him today.

This is my first Networker “Symposium.” I hadn’t realized it was quite the distinctive thing. They’ve got numbers you can put on your badges to represent how many times you’ve attended the Symposium. Although it’s just a conference, it does have a particular flair and feel. From the beginning, there was movement, talk about love and sex-tech, dancing, singing, and learning. The breadth of content and diversity of attendees has been marvelous.

I started the first day with a workshop on Love and the Therapeutic relationship with Sabrina N’Diaye. Later, I took in a workshop on Tech-Sex with Tammy Nelson, author of Getting the Sex you Want. Nelson basically blew my mind. Did you know there are “devices” you can use to remotely vibrate your romantic partner’s genitalia? I didn’t . . . and maybe I didn’t want to. Did you know someone commented in the session that “Dominants” use that vibrating device to issue “commands?” I was sitting next to a professional cuddler and sexual surrogate. She was delightful. Steve Hayes (and Ram Dass) would be proud of the fact that I managed my difficult thoughts by staying in the here and now instead of trying to imagine her work or think about what the dominatrix had shared. Just saying. My mind remained as pure as the water of the Stillwater River.

There’s been lots of talk about racism at the Symposium. That’s a good thing. I’m better for it. The more we can all be less racist or anti-racist and aware of our biases, the better. Of course, while I’m typing this, my almost erstwhile buddy Steve continues to talk (and sometimes mumble). I’m aware (somewhat painfully) that I’m more “like” him in age and gender and ethnicity and can’t help but lament that (sorry Steve). Being an old white guy brings privilege (or advantage, as our first keynote speaker preferred). At the same time, looking in the mirror and seeing myself as just another old white guy also brings along gut-level unpleasantness.

Yesterday’s highlights were listening to Ester Perel (very smart, very articulate, very impressive) and learning more about Susan Johnson and her personal history of growing up in a Pub. We also listened to three young women talk about the couple therapy experiences that changed them. Fabulous.

One of my (many) take-aways from the past two days is for me to NOT be THAT old WHITE guy. I want to be a different white guy. How does that work? Among other things, I will try not to think too much of myself . . . or mumble.

Steve is now trying to get us all to love ourselves. That’s a nice idea. Someday, Steve, I hope to get there. But, to channel our Saturday morning Symposium keynote speaker, Emily Nagoski, most of the time, things just don’t fucking work.

Wait. I know that sounds negative. Among many of her excellent points about coping with burnout, Emily played a cool song (of her twin sister’s), a song liberally infused with the F-word. If you’ve ever experienced technology frustration (which I suppose even happens with sex-tech), you should listen. Here’s the link: https://www.youtube.com/watch?v=eottd9Lw8l4 If you listen, don’t think about sex-tech at the same time. There’s no need to thank me for this great advice.

I’ve now abandoned Steve, in favor of one of the darling presenters of the Symposium and PESI. Sorry Steve . . . but I know you’ll mindfully accept your experience of me abandoning you. . . partly because you’ve never acknowledged my existence anyway (see, I’m totally over that 1987 incident).

There’s a woman talking . . . softly . . . without the changing voice routines of Steve Hayes. As she drones on, she mentions that therapy and therapists can be triggering. . . which is interesting given that I can’t find any affect in her voice. I’ve taken a seat on the floor in the back corner of the room and quickly recognized she’s right. She’s right because she instantly triggered me as I walked in the door with her monotone statement that talk therapy doesn’t work for trauma (what about CPT . . . or?). She continued to trigger me with her statement that PTSD was only identified in the 1970s (what about the diagnosis of war neurosis or battle fatigue or the many other earlier versions of PTSD?). And she finished triggering me with her laudatory comments on narrative therapy (does she NOT think of narrative therapy as “talk therapy?”).

I know my job here. Mindful acceptance. Learn what I can. Maybe the learning is about my own triggers or my own internal lament over being an increasingly irrelevant old white guy. Maybe the learning is about how to stay calm and embrace both ends of the constant dialectics and polarities of life.

On the whole, I’m so glad to be here at the Symposium, with Rita, and so grateful to continue learning. The fact that the conference has stimulated some of what Steve would call “difficult thoughts” is a blessing to be mindfully accepted. How else do we learn? How else do we grow? Should we expect to be constantly confronted with easy, comfortable, and affirming thoughts?

I think not. And I accept that . . . in my whole human genome.

The Foreword to The 15-Minute Case Conceptualization

Jon Sperry asked if I could write the foreword for a book he and his dad wrote with Oxford University Press.

Because the truth will set me free, I should admit, I’d never written a foreword before. More truth . . . I went ahead and said “Yes” to Jon because (a) I was honored and didn’t want the opportunity to write my first foreword slip away, (b) the book was (is) cool (it’s “The 15-Minute Case Conceptualization”), and (c) Jon Sperry is one of the nicest guys on the planet.

The book arrived in my mailbox yesterday. You too, can get a copy through your favorite bookseller. For more information, here’s the link to the book on the publisher’s website: https://global.oup.com/academic/product/the-15-minute-case-conceptualization-9780197517987?cc=us&lang=en&#

And for even more information about this excellent book, my first-ever foreword is below.

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I’ve needed this book for 30 years.

Just last month (before reading this book), I was standing in front of a Zoom camera, trying to teach the basics of case conceptualization to a group of 23 master’s and doctoral students. All of my fine-grained case conceptualization wisdom was being channeled into a single visual and verbal performance.

“My left hand,” I said, “is the client’s problem.” Pausing briefly for dramatic effect, I then continued, “and my right hand is the client’s goal.”

My new-found nonverbal gestures are mostly a function of seeing myself onscreen, and therefore wanting to avoid seeing myself (and being seen by the class) as boring. To add spice to my case conceptualization gesturing. “Case conceptualization is simple,” I said. “All it is, is the path we take to help clients move from their problem state . . . toward their goal state (I finished with a flourish, by wiggling the fingers on my raised right hand).”

But boiled down truths are always partly lies. Despite my fabulous mix of the verbal and nonverbal, I was lying to my students. At the time, I had thought of it as a little white lie, all for the higher purpose of simplification. And although I still like what I said and still believe in the rough truth of my visual case conceptualization description, after reading Len and Jon Sperry’s illuminating work on case conceptualization, I better understand what I should have said.

Case conceptualization is not simple. As the Sperry’s describe in this book, case conceptualization—even when summarized well—includes multiple dimensions of human behavior along with clinician perception, judgment, and decision-making. I needed much more than a few wiggly fingers to communicate the detailed nuances of case conceptualization.

What these authors have done in this book is the gracious service that great writers do so well: They have done our homework for us. They’ve read extensively, taken notes, and gifted us with elegant summaries of dense and complex concepts. They’ve made it easy for us to understand and apply the principles and practices of case conceptualization.

What I might like best is how they transformed a bulky and inconsistent literature into simple, therapist-friendly principles. They emphasize the explanatory, tailoring, and predictive powers of case conceptualization. I’ve never organized case conceptualizations using those “powers” but doing so was like switching on a light-bulb. Of course, case conceptualizations should explain the relationships between client problems and client goals and shine a bright light along the path, but rarely do theorists or writers make this linkage so efficiently. Their second principle, “tailoring” case conceptualizations to individual and diverse clients, is an essential, idiographic, Adlerian idea. The whole idea of tailoring counters the all-too-frequent cook-book approach to case conceptualization. Tailoring breathes life into creating client-specific case conceptualizations. And of course, case conceptualizations need predictive power; Len and Jon equip us with enough foundational predictive language to improve how we evaluate our own work.

Many other examples of how elegantly the authors have done our homework are sprinkled throughout this book. Here’s another of my favorite examples.

In chapter 2, they take us (in a few succinct paragraphs) from what Theodore Millon described as eight evolutionarily-driven personality disorders to eight crisply described behavioral patterns. What I love about this is that Len and Jon’s wisdom transforms what might otherwise be viewed as a pathologizing personality disorder system into language that can be used collaboratively with clients to identify contextually maladaptive interpersonal patterns. This is a beautiful transformation because it spins psychopathology into something clients not only understand but will feel compelled to embrace. The process goes something like this:

  1. Therapist and client engage in an assessment process that touches on the client’s repeating maladaptive behavior patterns. These behavior patterns are palpably troubling and far less than optimal for the client.
  2. As all clinicians inherently know, touching upon clients’ repetitive maladaptive behavior patterns can activate client vulnerability. This is a primary challenge of all counseling and psychotherapy: How can we nudge clients toward awareness without simultaneously activating resistance? For decades, psychoanalysts managed this through cautious trial interpretations. Solution-focused therapists dealt with this by never speaking of problems. Gently coaxing ambivalent clients toward awareness and change is the whole point of motivational interviewing.
  3. When addressed in a sensitive and non-pathologizing way, deep maladaptive behavior patterns can be discussed without activating resistance or excessive emotionality. This is a critical and not often discussed part of case conceptualization. Len and Jon illuminate a path for gentle, sensitive, and collaborative case conceptualization.
  4. When clients can feel, recognize, and embrace their maladaptive behavioral patterns in the context of an accepting therapeutic relationship, insight is possible. In the tradition of Adlerian therapy, when insight happens, client interest is piqued and motivation to change spikes. Good case conceptualizations articulate problem patterns in ways that compel clients to invest in change.

I’m not surprised that Len and Jon Sperry have produced such a magnificently helpful book. If you dig into their backgrounds and conduct a case conceptualization of their personality patterns, you’ll discover they wholeheartedly embrace Alfred Adler’s work and consequently, much of what they do is all about social interest or Gemeinschaftsgefühl. Len and Jon Sperry are in the business of helping others. Reading their book has already helped me become better at teaching case conceptualization. I appreciate their work, and, no doubt, the next time I begin waving my hands in front of my Zoom camera, my students will appreciate their work too.

John Sommers-Flanagan – Missoula, MT

Vid-Podding with Francesca on “Normalize the Conversation”

Apparently, video podcasts are the thing. Or maybe they’ve been a thing for a while. . . or at least since early 2020 and the onset of the Zoom age. I think we should call them vid-pods.

Two weeks ago, I promoted a vid-pod with Paula Fontenelle, Stacey Freedenthal, and me. It was Paula’s vid-pod, titled “Understand Suicide.” Paula is very experienced, very knowledgeable and produces great vid-pods. You can check out all her work, including her podcast (aka vid-pod) at: https://www.understandsuicide.com/

Late last year, Victor Yalom of Psychotherapy.net asked if he could connect me for a possible appearance on a vid-pod called “Normalize the Conversation.” Normalize the Conversation is the brain-child of Francesca Reicherter. Francesca is also the Founder and President of “Inspiring My Generation.” I think Victor wanted me to promote our 7.5-hour marathon Suicide Assessment and Treatment video training series with Psychotherapy.net. . . so here’s the link to that: https://www.psychotherapy.net/videos/expert/john-sommers-flanagan

In contrast to Paula, Stacey, Victor, and me, Francesca is very young. . . and she’s a powerhouse. I’m not sure where she finds the time to do all that she’s doing. She’s 23, but started her mental health advocacy work at age 12. She has published a workbook, founded her own organization, and has over 60 vid-pod episodes online. She’s also a graduate student. You can read more about Francesca here: https://inspiringmygeneration.org/2021/05/28/francesca-reicherter-starting-the-conversation-on-mental-health-conditions/

You can also check out all her vid-pods at: https://podcasts.apple.com/us/podcast/normalize-the-conversation/id1587903841 – The vid-pod with me is from February 2, 2022 and here: https://podcasts.apple.com/us/podcast/what-you-should-know-about-the-clinical-interview/id1587903841?i=1000549745008

Francesca and I did a recording together and she did a bunch of editing and promoting and this past week she sent me some video clips of our time together. What you’ll immediately notice in the video clips is that Francesca is an artist at getting people to talk. Throughout the clips, I’m talking and she’s not. Somehow, she got me to talk for about 47 minutes (although she did some nice summaries and commentary here and there). If my experience is at all representative, I suspect Francesca will be a talented therapist and fabulous listener.

You can check out the vid-pod clips below, but more importantly, check out all the amazing work of Paula, Stacey, Victor, and Francesca . . . all of whom are making the world a place where supportive and quality mental health services are more accessible.

How on Earth Could Suicide Rates Go Down Along with the Onset of the Pandemic in 2020?

Last week I got to be part of an amazing conversation with Paula Fontenelle and Stacey Freedenthal. Paula and Stacey are experts in suicide prevention, postvention, and treatment. You can easily find them and some of their great work online using your favorite search engine. They both have books out. Paula’s is: Understanding Suicide and Stacey’s is: Helping the Suicidal Person.

Paula invited Stacey and I onto her podcast (which is also a video production). We all sat in separate rooms in three different states (Oregon, Colorado, and Montana) and talked about, “How on earth” it could be that pandemic-related mental health stress and distress is up (the research says so), and yet suicide rates in 2020 dipped, for the first time in two decades? What a great question!

Between the three of us, we had many answers. That’s good, because death by suicide is always influenced by many factors (in the scientific world, we like to say that suicide is multi-determined). Our answers are speculative, but I think it’s good to be speculative, as long as you admit to the fact that you’re being speculative.

The most fascinating of many fascinating explanations for the recent reduction in suicide rates was our “in real time” discovery that the pandemic relief checks went out in April of 2020. That was important because, year-after-year, the CDC reports that April is nearly ALWAYS the month with the highest suicide rates and in 2020, it was the LOWEST. Why is April always linked to high suicide rates? No one knows for sure, but Paula, Stacey, and I talk about potential explanations for that too. As T. S. Eliot wrote:

“April is the cruelest month, breeding lilacs out of the dead land, mixing memory and desire, stirring dull roots with spring rain.”

If you’re interested in suicide-related phenomena—not everyone is—you should listen or watch Paula’s “Understand Suicide” podcast. You can watch any of the episodes for great info, but for our episode, here are the links.

To watch: https://youtu.be/fPrDdQg7G_E

To listen: https://bit.ly/3KrJILO

Have a great weekend.

Paradoxical Intention: Don’t Try This at Home (or maybe don’t try it anywhere)

People want change.

People don’t want change.

As W. R. Miller noted in his treatise on motivational interviewing (MI), ambivalence is nearly always the order of the day. Most people, most of the time, would like to be better and healthier versions of themselves. And, most people, most of the time, resist becoming better and healthier versions of themselves.  Who knew?

Alfred Adler may have been the first modern psychotherapist to write from a non-psychoanalytic perspective about how to work with individuals not interested in changing. What follows is a complex quote from Adler. He’s writing about how to work with a patient who is depressed, but not motivated or willing to change. You may need to read this excerpt several times to track it and appreciate Adler’s method. You may see all those words below and not want to put in the effort. That’s okay. You can stop reading now if you don’t want to gather in the nuance sprinkled into Adler’s indirect suggestion.

After establishing a sympathetic relation, I give suggestions for a change of conduct in two stages. In the first stage my suggestion is “Only do what is agreeable to you.” The patient usually answers, “Nothing is agreeable.” “Then at least,” I respond, “do not exert yourself to do what is disagreeable.” The patient, who has usually been exhorted to do various uncongenial things to remedy this condition, finds a rather flattering novelty in my advice, and may improve in behavior. Later I insinuate the second rule of conduct, saying that “It is much more difficult and I do not know if you can follow it.” After saying this I am silent, and look doubtfully at the patient. In this way I excite his [her/their] curiosity and ensure his attention, and then proceed, “If you could follow this second rule you would be cured in fourteen days. It is—to consider from time to time how you can give another person pleasure. It would very soon enable you to sleep and would chase away all your sad thoughts. You would feel yourself to be useful and worthwhile.”

I receive various replies to my suggestion, but every patient thinks it is too difficult to act upon. If the answer is, “How can I give pleasure to others when I have none myself?” I relieve the prospect by saying, “Then you will need four weeks.” The more transparent response, “Who gives me pleasure?” I counter with what is probably the strongest move in the game, by saying, “Perhaps you had better train yourself a little thus: do not actually do anything to please anyone else, but just think about how you could do it!” (Adler, 1964a, pp. 25–26)

Similar to Adler, Viktor Frankl also wrote about using “anti-suggestion” or paradox. Frankl was keen on this method as a means for treating anxiety, compulsions, and physical symptoms. An excerpt from our theories textbook describing Frankl’s paradoxical intention follows.

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Paradoxical Intention

. . . In a case example, Frankl discussed using paradox with a bookkeeper who was suffering from chronic writer’s cramp. The man had seen many physicians without improvement; he was in danger of losing his job. Frankl’s approach was to instruct the man to:

Do just the opposite from what he usually had done; namely, instead of trying to write as neatly and legibly as possible, to write with the worst possible scrawl. He was advised to say to himself, “now I will show people what a good scribbler I am!” And at that moment in which he deliberately tried to scribble, he was unable to do so. “I tried to scrawl but simply could not do it,” he said the next day. Within forty-eight hours the patient was in this way freed from his writer’s cramp, and remained free for the observation period after he had been treated. He is a happy man again and fully able to work. (Frankl, 1967, p. 4)

Frankl attributed the success of paradox, in part, to humor. He claimed that paradox allows individuals to place distance between themselves and their situation. New (humorous) perspectives allow clients to let go of symptoms. Frankl considered paradoxically facilitated attitude changes to represent deep and not superficial change.

Given that Frankl emphasized humor as the therapeutic mechanism underlying paradoxical intention, it fits that he would use a joke to explain how paradoxical intention works,

The basic mechanism underlying the technique…perhaps can best be illustrated by a joke which was told to me some years ago: A boy who came to school late excused himself to the teacher on the grounds that the icy streets were so slippery that whenever he moved one step forward he slipped two steps back again. Thereupon the teacher retorted, “Now I have caught you in a lie—if this were true, how did you ever get to school?” Whereupon the boy calmly replied, “I finally turned around and went home!” (Frankl, 1967, pp. 4–5)

Frankl believed paradoxical intention was especially effective for anxiety, compulsions, and physical symptoms. He reported on numerous cases, similar to the man with writer’s cramp, in which a nearly instantaneous cure resulted from the intervention. In addition to ascribing the cure to humor and distancing from the symptom, Frankl emphasized that paradox teaches clients to intentionally exaggerate, rather than avoid, their existential realities.

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I’m writing about paradoxical intention today because of an inspiration from Rita’s blog yesterday. There’s so much ostensible hate, judgment, and certainty in contemporary discourse. That got me thinking about whether a paradoxical approach might be timely and effective. Yesterday, I tried it on myself. Stay tuned, in my next post, I’ll write about how a little paradox worked out for me, and how it might help shift some of the lamentable, polarized arguments happening all around us.  

Who Wants a Two-Day Professional Workshop on Strengths-Based Suicide Assessment and Treatment?

I’ve got a friend who writes to me in acronyms. TBH is “To be honest.” LMK is “Let me know.” IMHO is “In my humble opinion.” FYI is “For your information.” YSKAT is “You should know about this.”

When I read my friend’s emails, there are always more letters than words, if YKWIM (you know what I mean).

This leads me to my PP (promotional point).

TBH signing up for a two-day SBSASTW (strengths-based suicide assessment and treatment workshop) isn’t everyone’s COT (cup of tea). TAI (think about it). That’s like 13 hours of suicide-related content. If you TAI, it CBYD (could bring you down).

That’s why, we will weave some PDC (pretty damn cool) EBHIs (evidence-based happiness interventions) into our 13 hours. This will be the MFE (most fun ever) two days of suicide training on November 19 and 20. YCBOI (you can bet on it).

But IMHO, woohoo. Really YSKAT. IMHO signing up for a two-day strengths-based suicide assessment and treatment workshop is TRTTD (the right thing to do).

YAMBWing (You also may be wondering), when John writes “we” is he going with the singular “we” or is he indicating there will be other presenters. TBH, John doesn’t know, but he’s hoping to recruit some of the amazing participants from this summer MHP (Montana Happiness Project) retreat to join in on the FUN (fricken unbelievably nice).

OK. I’ve had it with all these letters. And so, if you want to sign up, check out “Session three” on this link: https://www.familiesfirstmt.org/umworkshops.html

If that doesn’t help, send me an email (john.sf@mso.umt.edu) and I’ll see if I can help you figure out how to sign up. Just LMK. The session is also Zoomable.