Category Archives: Clinical Interviewing

Free Video Links for Online Teaching

JSF Travel

This past week I’ve been grateful for the many professionals and organizations (including my publisher, John Wiley & Sons) who are providing free guidance and materials to help with the transition from face-to-face teaching to online instruction. In an effort to contribute back in a small way, I’m posting 10 counseling- and psychotherapy-related videos that can be integrated into online teaching. These videos are free and posted on my YouTube channel. The links are all below with a brief description of the video content.

Some of these videos are rough cuts and all of them are far from perfect demonstrations; that’s partly the point. Although many of the videos show reasonably good counseling skills and interesting assessment processes and therapeutic interventions, none of the videos are scripted, and so there’s plenty of room for review, analysis, critique, and discussion. You can show them as efforts to do CBT, SFBT, Motivational Interviewing, administration of a mental status examination, etc., and prompt students to describe how they would do these sessions even better.

These videos are meant to stimulate learning. In an ideal world, I would include a list of discussion questions, but I’ll leave that to you. If you like, please feel free to use these videos for educational purposes. Here’s the annotated list with video links:

  1. Counseling demonstrations with a 12-year-old.
    1. Opening a counseling session: https://www.youtube.com/watch?v=rHHrMC8t6vY
    2. The three-step emotional change trick: https://www.youtube.com/watch?v=ITWhMYANC5c
    3. John SF demonstrates the What’s Good About You? informal assessment technique: https://www.youtube.com/watch?v=MUhmLQUg_g8
    4. Closing a session: https://www.youtube.com/watch?v=GpuH80tf2jM
  2. Demo of assessment for anger management with a solution-focused spin with a 20-year-old client: https://www.youtube.com/watch?v=noE2wMMNLY4
  3. Demo of motivational interviewing with a 30-year-old client: https://www.youtube.com/watch?v=rtN7kEk0Sv4
  4. Demo of the affect bridge technique with an 18-year-old: https://www.youtube.com/watch?v=fEtiGuc914E
  5. Demo of CBT for social anxiety with a graduate student: https://www.youtube.com/watch?v=jfVeeGJHFjA
  6. Demo of an MSE with a 20-year-old: https://www.youtube.com/watch?v=adwOxj1o7po
  7. A lecture vignette of a demonstration of psychoanalytic ego defense mechanisms: https://studio.youtube.com/video/E818UlgHMXY/edit
  8. The University of Montana Department of Counseling does a spoof video of The Office: https://www.youtube.com/watch?v=eM8-I8_1CqQ

Good luck with the transition to online teaching and stay healthy!

John S-F

Apple Core, Baltimore, Who’s Your Friend? #NASP2020

 

Camden

I’m in Baltimore this week for the annual meeting of the National Association of School Psychologists. Although I’m not a school psychologist, I’ve been invited the past 5+ years to offer workshops on “Tough Kids, Cool Counseling.” I’ve also had the good fortune of being invited to present professional workshops for state school psychology associations in California, Montana, Ohio, South Carolina, and Washington.

I’ve worked many different professional groups (clinical psychologists, mental health counselors, school counselors, teachers, childcare workers, and more). All of these groups are amazing, but every time I work with a group of school psychologists, I walk away thinking that maybe school psychologist are my favorite professional group of all.

Notice I said “maybe.” I don’t want to start an inter-disciplinary competition for my official endorsement.

NASP in Baltimore was typical NASP. An intense group of very smart people who are dedicated to the psychological and intellectual well-being of K-12 students everywhere. They swarm the exhibition hall looking for resources and at my workshop they asked incredibly good questions and made insightful comments.

To be honest (not a bad policy), maybe the fact that I got a standing ovation from 300+ school psychology attendees in Columbus, Ohio (after 6.5 hours of presenting) is part of the reason I love school psychologists. For minor league professionals like me, that’s about as good as it gets . . . and that was pretty fantastic.

The links that follow include my presentation powerpoints and handouts for my workshop sessions in Baltimore. If you were there, thanks for your commitment to improving the lives of children and teenagers. If not, I hope to see you next time around.

NASP Workshop I 2020 for Handout

NASP Workshop II Advanced 2020 for Handout

NASP 2020 Extra Handout Introductory

NASP 2020 Extra Handout Advanced

By the way, the next big gig is March 1 in Richmond, Virginia with the Virginia School Counselor Association . . . which is just another chance to spend some time with another fabulous group of very cool people.

 

A Sneak Peek at the Suicide Assessment and Treatment Planning Workshop Coming to Billings on November 8

IMG-1852

Anybody wondering what’s new in suicide assessment and treatment?

If so, come listen to any or all of a very nice suicide prevention/intervention line-up on November 7 and 8 on the campus of Montana State University in Billings. Here’s a news link with detailed info: https://billingsgazette.com/news/local/let-s-talk-montana-suicide-prevention-workshops-coming-to-msub/article_9a6f04ff-376f-56b8-a6a8-9a0160ba1cbb.html

For my part, I’m presenting the latest iteration of the suicide assessment and treatment model Rita and I have been working on for the past couple years. To help make suicide assessment and treatment planning easier, we’ve started using six common sense life domains to organize, understand, and apply specific assessment and intervention tools.

Another unique component of our model is an emphasis on client strengths and wellness. Obviously, in the context of suicide, it’s impossible (and wrong) to ignore clients’ emotional pain and suffering. However, we also think it’s possible (and right) to intermittently recognize, nurture, and focus on clients’ strengths, well-being, and goals.

What follows is a sneak peek at what I’ll be covering on Friday, November 8.

Suicide Interventions and Treatment Planning: Foundational Principles

Two essential principles that cut across all modern evidence-based protocols and evidence-based interventions form the foundation of all contemporary suicide assessment and treatment models:

  • Collaboration – Working in partnership with clients
  • Compassion – Emotional attunement without judgment

Collaborative practitioners work with clients, not on clients. Clients experiencing suicidal thoughts and impulses typically know their struggles from the inside out. Their self-knowledge makes them an invaluable resource. Carl Rogers (1961) put it this way,

It is the client who knows what hurts, what directions to go, what problems are crucial, what experiences have been deeply buried. It began to occur to me that unless I had a need to demonstrate my own cleverness and learning, I would do better to rely upon the client for the direction of movement in the process. (p. 11)

Compassionate practitioners resonate with client emotions and engage in respectful and gentle emotional exploration. Although compassion involves an empathic emotional response, it also includes tuning into and respecting client cognitions, beliefs, and experiences. For example, some clients who are suicidal feel spiritually or culturally bereft or disconnected. Regardless of their own beliefs and cultural values, compassionate counselors show empathy for their clients’ particular spiritual or cultural distress.

Clients who are or who become suicidal are often observant, sensitive, and intelligent. If they feel you’re judging them, they’re likely to experience a relationship rupture (Safran, Muran, & Eubanks-Carter, 2011). When ruptures occur, clients typically become less open, less engaged, and less honest about their suicidal thoughts and impulses. They also may become angry, aggressive, and critical of your efforts to be of help. In both cases, relational ruptures signal a need to work on mending the therapeutic relationship.

[For a helpful meta-analysis with recommendations on repairing ruptures, check out this article from the Safran lab: http://www.safranlab.net/uploads/7/6/4/6/7646935/repairing_alliance_ruptures._psychotherapy_2011.pdf%5D

The Six Life Domains

Working with clients who are suicidal can be overwhelming. To help organize and streamline the assessment and treatment planning process, it’s helpful to consider six distinct, but overlapping life domains. These domains provide a holistic description of human functioning. When clients experience suicidal thoughts and impulses, you can be sure the suicidal state will manifest through one or more of these six domains (i.e., emotions, cognitions, interpersonal, physical, spiritual/cultural, and behavioral; see below for a brief description of the six domains). All case examples and content in the workshop use these six domains to focus and organize client problems, goals/strengths, and interventions.

Suicidality as Manifest through Six Life Domains             

The Emotional Domain. A driving force in the suicidal state is excruciating emotional distress. Shneidman called this “psychache” and toward the end of his career concluded: “Suicide is caused by psychache” (1993, p. 53). Extreme distress is experienced subjectively. This is one reason there are so many different suicide risk factors. When a specific experience triggers excruciating distress for a given individual (e.g., unemployment, insomnia, etc.), it may increase suicide risk. Reducing emotional distress and facilitating positive emotional experiences is usually goal #1 in your treatment plan. Treatment plans often target general distress as well as specific and problematic emotions like (a) sadness, (b) shame, (c) fear/anxiety, and (d) guilt/regret.
The Cognitive Domain. Suicidal distress interferes with cognitive functioning. The resulting constricted thinking impairs problem-solving and creativity. The emotional distress and depressed mood associated with suicidality decreases the ability to think of or value alternatives to suicide. Several other cognitive variables are also linked to suicidality, including hopelessness and self-hatred. Most treatment plans will include collaborative problem-solving, and gentle challenging of maladaptive thoughts. Specific interventions may be employed to support client problem-solving, increase client hopefulness, and decrease client self-hatred.
The Interpersonal Domain. Hundreds of studies link social problems to suicidality, suicide attempts, and suicide deaths. Joiner (2005) identified two interpersonal problems that are deeply linked to suicide: thwarted belongingness and perceived burdensomeness. Many risk factors (e.g., recent romantic break-up, family rejection of sexuality, health conditions that cause people to feel like a burden) can exacerbate thwarted belongingness and cause people to perceive themselves as a social burden. Improving interpersonal relationships is often a key part of treatment planning.
The Physical/Biogenetic Domain. Physiological factors can contribute to suicide risk. In particular, researchers have recently focused on agitation or physiological arousal; these physical states tend to push individuals toward suicidal action. Additionally, chronic illness or pain, insomnia, and other disturbing health situations (including addictions) contribute to suicide, especially when accompanied by hopelessness. When present, physical conditions and biogenetic predispositions should be integrated into suicide prevention, treatment planning, and risk management.
The Spiritual/Cultural Domain. Meaningful life experiences can be a protective influence against suicide. No doubt, a wide range of cultural or religious pressures, spiritual/religious exile, or other factors can decrease an individual’s sense of meaning and can contribute to suicidal thoughts and behaviors. Including spiritual or meaning-focused components in a treatment plan can improve outcomes, especially among clients who hold deep spiritual and cultural values.
The Behavioral Domain. All of the preceding life domains can contribute to suicide, but suicide doesn’t occur unless individuals act on suicidal thoughts and impulses. The behavioral domain focuses on suicide intentions and active suicide planning. When clients actively plan or rehearse suicide, they may be doing so to overcome natural fears and aversions to physical pain and death; natural fears and aversions stop many people from suicide. Joiner (2005) and Klonsky and May (2015) have written about how desensitization to physical pain and to ideas of death move people toward suicidal action. Several factors increase risk in this domain and may be relevant to treatment planning, (a) availability of lethal means (especially firearms), (b) using substances for emotional/physical numbing, and (c) repeated suicide rehearsal (e.g., increased cutting behaviors).

*Note: These domains will always overlap, but they can prove helpful as you collaboratively identify problem areas and goals with your client.

If you’re interested in learning more about this suicide assessment and treatment planning model, I hope to see you in Billings on November 8!

 

 

 

The Dialectics of Diagnosis at MFPE in Belgrade

Waving

Today I’m in Bozeman on my way to present to the Montana School Counselors in Belgrade, MT. As my friends at the Big Sky Youth Empowerment Program like to say, “I’m stoked!” I’m stoked because there’s hardly anything much better than spending a day with Montana School Counselors. Woohoo!

My topic tomorrow is “Strategies for Supporting Students with Common Mental Health Conditions.” That means I’ll be reviewing some DSM/ICD diagnostic criteria and that brings me to reflect on the following. . . .

Not long ago (July, 2019), Allsopp, Read, Corcoran, & Kinderman published an article in Psychiatry Research, not so boldly titled, “Heterogeneity in psychiatric diagnostic classification.” Hmm, sounds fascinating (not!).

A few days later, a summary of the article appeared in the less academically and more media oriented, ScienceDaily. The ScienceDaily’s contrasting and much bolder title was, “Psychiatric diagnosis ‘scientifically meaningless.” Wow!

The ScienceDaily summary took the issue even further. They wrote: “A new study, published in Psychiatry Research, has concluded that psychiatric diagnoses are scientifically worthless as tools to identify discrete mental health disorders.”

Did you catch that? Scientifically worthless!

In an interview with ScienceDaily, Allsopp, Read, and Kinderman stoked the passion, and avoided any word-mincing.

Dr. Kate Allsopp said, “Although diagnostic labels create the illusion of an explanation they are scientifically meaningless and can create stigma and prejudice. I hope these findings will encourage mental health professionals to think beyond diagnoses and consider other explanations of mental distress, such as trauma and other adverse life experiences.”

Professor Peter Kinderman, University of Liverpool, said: “This study provides yet more evidence that the biomedical diagnostic approach in psychiatry is not fit for purpose. Diagnoses frequently and uncritically reported as ‘real illnesses’ are in fact made on the basis of internally inconsistent, confused and contradictory patterns of largely arbitrary criteria. The diagnostic system wrongly assumes that all distress results from disorder, and relies heavily on subjective judgments about what is normal.”

Professor John Read, University of East London, said: “Perhaps it is time we stopped pretending that medical-sounding labels contribute anything to our understanding of the complex causes of human distress or of what kind of help we need when distressed.”

In contrast to the authors’ conclusions, nearly every conventional psychiatrist believes the opposite–and emphasizes that psychiatric diagnosis is of great scientific and medical importance. For example, the Midtown Psychiatry and TMS Center website says, “A correct diagnosis helps the psychiatrist formulate the most effective treatment that will result in remission.”

No doubt there.

In addition, although I literally love that Allsopp, Read, and Kinderman are so outspoken about the potential deleterious effects of diagnosis, I think maybe they take it too far. For example, “Shall we pretend that we should provide the same intervention for panic attacks as we provide for conduct disorder, autism spectrum disorder, and gender dysphoria?”

That’s me talking now . . . and as I discussed this with Rita, she amplified that, of course, if you have a student who’s intentionally engaging in violent acts that harm others, we’re not treating them the same as a student who’s suffering panic attacks. Obviously.

Psychiatric diagnosis is a great example of a dialectic. Yes, in some ways it’s meaningless and overblown. And yes, in some ways it provides crucial information that informs our treatment approaches.

This leads me to my final point, and to my handouts.

What’s our School Counseling take-away message?

Let’s keep the baby and throw out with the bathwater.

Let’s de-emphasize labels – because labelling, whether accurate or inaccurate and whether self-inflicted or other inflicted, are possibly pathology-inducing.

Instead, let’s focus on specific behavior patterns, as well as abilities, impairments, stressors, and trauma experiences that interfere with academic achievement, personal and social functioning, and career potential.

In case you’re interested in more on this. My handouts for the workshop are below.

The Powerpoints: MFPE 2019 Belgrade Final

Managing fear and anxiety:Childhood Fears Rev

Student de-escalation tips: De-escalation Handout REV

Why Kids Lie and What to Do About It

 

 

Hacking Affect and Mood in 325 Words

Rita Wood Surfing

Affect is how you look to me.

Affect involves me (an outsider) judging your internal emotional state (as it looks from the outside). Whew.

Mood is how you feel to you.

Mood is inherently subjective and limited by your vocabulary, previous experiences, and inclination or disinclination toward feeling your feelings.

Independently, neither affect nor mood makes for a perfect assessment. But let’s be honest, there’s no such thing as a free lunch, and there’s no such thing as a perfect assessment. Even in elegant combination, affect and mood only provide us with limited information about a client’s emotional life.

Our information is limited and always falls short of truth because, not only is there always that pesky standard error of measurement, also, emotion is, by definition, phenomenologically subjective and elusive. Emotion, especially in the form of affect or mood, is a particularly fragile and quirky entrepreneur of physiology and cascading neurochemical caveats. Nothing and everything is or isn’t as it seems.

As an interviewer, even a simple emotional observation may be perceived as critical or inaccurate or offensive in ways we can only imagine. Saying, “You seem angry” might be experienced as critical or inaccurate and inspire the affect you’re watching and the mood your client is experiencing to hide, like Jonah, inside the belly of a whale.

Oddly, on another day with the same client, your emotional reflection—whether accurate or inaccurate—might facilitate emotional clarity; affect and mood may re-unite, and your client will experience insight and deepening emotional awareness.

As a clinician, despite your efforts to be a detached, objective observer, you might experience a parallel emotional process. Not only could your understanding of your client deepen, but ironically, because emotional lives resist isolation, you might experience your own emotional epiphany.

Rest assured, as with all emotional epiphanies—including our constitutionally guaranteed inevitable and unenviable pursuit of happiness—you’ll soon find yourself staring at your emotional epiphany through your rear view mirror.

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

Just for fun, below I’ve included a link to a brief clip of me doing a mental status examination with a young man named Carl. A longer version of my interview with Carl is available with the 6th edition of Clinical Interviewing. https://www.youtube.com/watch?v=1lu50uciF5Y

 

 

 

Separating the Psychological (Emotional) Pain from the Self: A Technique for Working with Suicidal Clients

Blogs I follow

I’m working on a Suicide Assessment and Treatment Planning manuscript and here’s a small piece of what I just wrote:

Rosenberg (1999; 2000) and others have described a helpful cognitive reframe intervention for use with clients who are suicidal. She wrote,

The therapist can help the client understand that what she or he really desires is to eradicate the feelings of intolerable pain rather than to eradicate the self (1999, p. 86).

Shneidman’s (1996) guidance on this was similar, but perhaps even more emphatic. He recommended that therapists partner with clients and with members of the client’s support system (e.g., family) to do whatever possible to reduce the psychological pain.

Reduce the pain; remove the blinders; lighten the pressure—all three, even just a little bit (p. 139).

Suicidal clients need empathy for their emotional pain, but they also need to partner with therapists to fight against their pain. Framing the pain as separate from the self can help because therapists can be empathic, but simultaneously illuminate the possibility that the wish isn’t to eliminate the self, but instead, to eliminate the pain.

Rosenberg (1999) also recommended that therapists help clients reframe what’s usually meant by the phrase feeling suicidal. She noted that clients benefit from seeing their suicidal thoughts and impulses as a communication about their depth of feeling, rather than an “actual intent to take action” (p. 86). Once again, this approach to intervening with suicidal clients can decrease clients’ needs to act, partly because of the elegant cognitive reframe and partly because of the therapist’s empathic message.

Here’s a case vignette to illustrate how therapists can work with clients to separate the emotional pain from the self and then partner with clients to reduce the pain. As always, this case vignette is a composite compiled from clinical work and simulations with various individuals.

Case Vignette. Kate is a 44-year-old cisgender married female with two children. She arrived for counseling in extreme emotional distress. She was also agitated, stating, “It just hurts so badly to be alive. It hurts so badly.”

Much of Kate’s emotional pain was centered around the recent death of her mother, whom Kate had cared for over the past seven years. Kate had an ambivalent relationship with her; her mother had been diagnosed as having schizophrenia and caring for her was extremely challenging. Kate’s acute emotional distress was accompanied by fears of turning out like her mother and thoughts of reunifying with her mother. She said, “I just need to be with her.”

To help Kate separate her intense emotional pain from the self, I began by noticing that there were two different parts of Kate, and that these two different parts had different ideas about how to move forward. Noticing and articulating different perspectives of the self is a common approach from a person-centered theoretical perspective. Because of Kate’s family history of schizophrenia, I wouldn’t use an expressive Gestalt technique to separate her different ego states, but it felt like reflecting her obvious ambivalence was a safe approach. Specifically, I said, “Sounds like a part of yourself thinks the solution is to die, and that your kids will be better off. But there’s another part of you that says, maybe the solution isn’t to die. Maybe I can come in here and talk. Maybe my kids actually would suffer if I died.”

Kate accepted that she was “of two minds” about how to go forward. Next, I tried to further clarify these parts of herself, emphasizing that I wanted to align with the “second” part of herself, so that we could work together on her emotional pain.

The one part of yourself thinks your only hope of dealing with the pain is to kill yourself. The other part thinks, maybe I can stay alive, work in counseling to get rid of the pain, and then my children wouldn’t suffer from my death. How about, for now, we work from that second perspective. We can be a team that works hard to decrease the emotional pain you’re feeling. It might not go away immediately, but if you stay alive and we work together, we can chip away at the pain and make it shrink.

You may notice the words I used were somewhat redundant. Using redundancy with clients who are feeling suicidal may be needed because the agitated, depressed state of mind makes cognitive focusing difficult. Sometimes, if you don’t repeat the therapeutic perspective and keep focused on it, the therapeutic perspective can slip away from your clients’ cognitive grasp.

Linehan often uses a more provocative way of talking about partnering with clients to diminish their pain. For example, she might say, “Getting through this is like going through Hell. But I know therapy can help and I want to work with you on this. But I have to tell you this, therapy will only work if you stay alive. Therapy doesn’t work on dead people. So I want you to stay alive and work with me at attacking your pain. Will you give me six months for us to go through hell together so we can get control of your pain?

Either way, the goal is to partner with clients to work on decreasing emotional or psychological pain. This approach combines empathic listening, with an emphasis on the therapeutic alliance. As therapist and client partner together, then cognitive-behavioral problem-solving can commence.