Category Archives: Clinical Interviewing

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice

Five Recommendations for Developing a Positive Working Alliance

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The working alliance is one of the most robust predictors of positive counseling and psychotherapy outcomes. This excerpt, from the forthcoming 6th edition of Clinical Interviewing, describes five recommendations. You can always email me directly if you have questions about these resources I post. Have an excellent Wednesday evening.

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Therapists who want to develop a positive working alliance (and that should include everyone) will employ alliance-building strategies beginning with first contact. Using Bordin’s (1979) model, alliance-building strategies focus on (a) collaborative goal setting; (b) engaging clients in mutual therapy-related tasks; and (c) development of a positive emotional bond. Progress monitoring is also recommended. The following list includes alliance-building concepts and illustrations:

  1. Initial interviews and early sessions are especially important to alliance-building. Many clients will be naïve about psychotherapy. This makes role inductions essential. Here’s a cognitive-behavioral therapy (CBT) example:

For the rest of today’s session, we are going to be doing a structured clinical interview. This interview assesses a range of different psychological difficulties. It is a way to make sure that we “cover all of our bases.” We want to see if social anxiety is the best explanation for your problems and also whether you are having any other difficulties that we should be aware of. (Ledley, Marx, & Heimberg, 2010, p. 36)

  1. Asking clients direct questions about what they want from counseling and then integrating that information into your treatment plan helps build the alliance. In CBT this includes making a problem list (J. Beck, 2011).

Clinician:     What brings you to counseling and how can I be of help?

Client:         I’ve just been super down lately. You know. Tough to get up in the morning and face the world. Just feeling pretty crappy.

Clinician:     Then we definitely want to put that on our list of goals. Can I write that down? [Client nods assent] How about for now we say, “Find ways to help you start feeling more up?”

Client:         Sounds good to me.

  1. Engaging in collaborative goal-setting to achieve goal consensus is central to alliance-building. In CBT this involves transforming the “problem list” into a set of mutual treatment goals.

Clinician:     So far I’ve got three goals written down: (1) Find ways to help you start feeling more up, (2) Help you deal with the stress of having your sister living with you and your family, and (3) Improving your attitude about exercising. Does that sound about right?

Client:         Totally. It would be amazing to tackle those successfully.

Problem lists and goals are a good start, but clients engage with clinicians better when they know the treatment plan (TP) for moving from problems to goals. The TP includes specific tasks that will happen in therapy and may begin in the first clinical interview. Here’s an example of a “Devil’s Advocacy” technique where the clinician takes on the client’s negative thoughts and then has the client respond (Newman, 2013). You’ll notice that collaboratively engaging in mutual tasks offers spontaneous opportunities for deeper connection and clinician-client bonding:

Clinician:     You said you want a romantic relationship, but then you start thinking it’s too painful and pointless. Let’s try a technique where I take on your negative thinking and you respond with a reasonable counter argument. Would you try this with me?

Client:         Sure. I can try.

Clinician:     Excellent. Here we go: “It’s pointless to pursue a romantic relationship because they always come to a painful end.”

Client:         That’s possible, but it’s also possible to have some good times along the way toward the painful end.

Clinician:     [Smiles, breaks from role, and says] . . . That’s the best come-back ever.

  1. Soliciting feedback from clients from the first session on to monitor the quality and direction of the working alliance contributes to the alliance. Although you can use an instrument for this, you can also ask directly:

We’ve been talking for 20 minutes and so I want to check in with you on how you’re feeling about our time together so far. How are you doing with this process?

  1. Making sure you’re able to respond to client anger without becoming defensive or counterattacking is essential to positive working relationships. We usually apply radical acceptance (Linehan, 1993). Here’s an excerpt from an initial session with an 18-year-old male where the clinician accepted the client’s aggressive message and transformed it into a relational issue:

Clinician:     I want to welcome you to therapy with me and I hope we can work together in ways you find helpful.

Client:         You talk just like a shrink. I punched my last therapist in the nose (client glares at therapist and awaits a response) (J. Sommers-Flanagan & Bequette, 2013, p. 15).

Clinician:     Thanks for telling me that. I’d never want to have the kind of relationship with you where you felt like hitting me. And so if I ever say anything that offensive, I hope you’ll just tell me, and I’ll stop.

 

Clinical Interviewing, Cool Counseling, Counseling and Psychotherapy Theory and Practice, Tough Kids Cool Counseling

Using an Invitation for Collaboration in Counseling and Psychotherapy

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As I’m sure you know, I believe (rather strongly) that counselors and psychotherapists should work hard to collaborate with clients. Being an authoritarian therapist is passe.

Sometimes collaboration sounds easy in theory, but it can be difficult in practice. It’s especially difficult if clients come into your office not “believing in therapy” and not trusting you. In the following excerpt from the forthcoming 6th edition of Clinical Interviewing, you can see how a skilled therapist deals with some initial client hostility.

Case Example 3.1: An Early Invitation for Collaboration

Sophia, a 26-year-old mother of two was referred for counseling by her children’s pediatrician. When she sat down with her counselor, she stated:

I don’t believe in this counseling thing. I’m stressed, that’s true, but I’m a private person and I believe very strongly that I should take care of myself and not have anyone take care of my problems for me. Besides, you look like you might be 18 years old and I doubt that you’re married or have children. So I don’t see how this is supposed to help.

It’s easy to be shaken when clients like Sophia pour out their doubts about therapy and about you at the beginning of the first session. Our best advice: (a) be ready for it; (b) don’t take it personally, Sophia is speaking of her doubts, don’t let them become yours; (c) be ready to respond directly to the client’s core message; and (d) end your response with an invitation for collaboration. An invitation for collaboration is a clinician statement that explicitly offers your client an opportunity to work together. In some cases, an invitation for collaboration is a time-limited “let’s try this out” offer.

Here’s a sample counselor response to Sophia:

Counselor: I hear you loud and clear. You don’t believe in counseling, you’re a private person, and you’re concerned that I don’t have the experiences needed to understand or help you.

Sophia: That’s right. [Sometimes when the counselor explicitly reflects the client’s core message (i.e., “. . . you’re concerned I don’t have the experience needed to understand or help you”) the client will retreat from this concern and say something like, “Well, it’s not that big of a deal.” But that’s not what Sophia does.]

Counselor: Well then, I can see why you wouldn’t want to be here. And you’re right, I don’t have a lot of the life experiences you’ve had. . But I do have knowledge and experience working with people who are stressed and concerned about parenting and I’d very much like to have a chance to be of help to you. How about since you’re here, we try out working together today and then toward the end of our time together I’ll check back in with you and you can be the judge of whether this might be helpful or not?

Sophia: Okay. That sounds reasonable.

In this case the counselor responded directly and with empathy to Sophia and then offered an invitation for collaboration. As the session ends, Sophia may or may not accept the counselor’s invitation. But either way, the counselor’s skillful response provides an opportunity for a collaborative relationship to develop.

Round Bales

 

Clinical Interviewing, Suicide Assessment and Intervention

Suicide Assessment Powerpoints for MSU-Billings

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I had a nice time today with the Student Health and Student Support staff of Montana State University Billings. Not only were they awesome, they were also awesomely dedicated to suicide prevention on their campus. Given that Spring is coming, that’s an excellent thing.

A link to the powerpoint for today’s talk is below:

MSU Billings Suicide Talk

Clinical Interviewing, Suicide Assessment and Intervention

Suicide Interventions for Mental Health Professionals

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This is the second follow up post to the MUS Suicide Summit in Bozeman this past week. It focuses on specific suicide interventions. As I looked through this and the material in the previous post, it reminded me that Dr. Janet P. Wollersheim was a huge influential force in my understanding of suicide assessment. Thanks Dr. Wollersheim!

Suicide Interventions

The following sections consist of basic ideas about suicide intervention options during a suicide crisis. These guidelines are consistent with Shneidman’s (1996) excellent advice for therapists working with suicidal clients: “Reduce the pain; remove the blinders; lighten the pressure—all three, even just a little bit” (p. 139).

Listening and Being Empathic

The first rule of working therapeutically with suicidal clients is to listen empathically. Your clients may have never openly discussed their suicidal thoughts and feelings with another person. Use basic attending behaviors and listening responses (e.g., paraphrasing and reflection of feeling) to show your empathy for the depth of your clients’ emotional pain is a solid foundation.

Establishing a Therapeutic Relationship

A positive therapy relationship is important to successful suicide assessment and effective treatment. In crisis situations (e.g., suicide telephone hotline) there’s less time for establishing therapeutic relationships and more focus on applying interventions. However, whether you’re working in a crisis or therapy setting, you should still use relationship-building counseling responses as much as possible given the constraints of your setting.

Within the CAMS approach, assessment is used to help therapists understand “the idiosyncratic nature of the client’s suicidality, so that both parties can intimately appreciate the client’s suicidal pain and suffering” (Jobes et al., 2007, p. 287). At some point after you’ve “intimately appreciated” your client’s suicidality, you may then make an empathic statement to facilitate hope:

I hear you saying you’re terribly depressed. Despite those feelings, it’s important for you to know that most people who get depressed get over it and eventually feel better. The fact that we’re meeting today and developing a plan to help you deal with your emotional pain is a big step in the right direction.

Clients who are depressed or emotionally distressed may have difficulty remembering positive events or emotions (Lau et al., 2004). Therefore, although you can help clients focus on positive events and past positive emotional experiences, you also need empathy with the fact that it isn’t easy for most clients who are suicidal to recall anything positive.

Clinician: Can you think of a time when you were feeling better and tell me what was happening then?
Client: (in a barely audible voice) No. I don’t remember feeling better.
Clinician: That’s okay. It’s perfectly natural for people who are feeling depressed to not be able to remember positive times.

Suicidal clients also may have difficulty attending to what you’re saying. It’s important to speak slowly and clearly, occasionally repeating key messages.

Safety Planning

Helping clients develop practical plans for coping with and reducing psychological pain is central to suicide intervention. This plan can include relaxation, mindfulness, traditional meditation practices, cognitive restructuring, social outreach, and other strategies that increase self-soothing, decrease social isolation, improve problem-solving, and decrease feelings of being a social burden.
Instead of traditional no-suicide contracts, contemporary approaches emphasize obtaining a commitment to treatment statement from clients (Rudd et al., 2006). These treatment statements or plans go by various names including, “Commitment to Intervention,” “Crisis Response Plan,” “Safety Plan,” and “Safety Planning Intervention” (Jobes et al., 2008; Stanley & Brown, 2012). These statements describe activities that clients will do to address depressive and suicidal symptoms, rather than focusing narrowly on what the client will not do (i.e., commit suicide). These plans also include ways for clients to access emergency support after hours (such as the national suicide prevention lifeline (800) 273-TALK or a similar emergency crisis number.

Stanley and Brown (2005) developed a brief treatment for suicidal clients, called the Safety Planning Intervention (SPI). This intervention was developed from cognitive-therapy principles and can be used in hospital emergency rooms as well as inpatient and outpatient settings (Brown et al., 2005). The SPI includes six treatment components:

1. Recognizing warning signs of an impending suicidal crisis.
2. Employing internal coping strategies.
3. Utilizing social contacts as a means of distraction from suicidal thoughts.
4. Contacting family members or friends who may help to resolve the crisis.
5. Contacting mental health professionals or agencies.
6. Reducing the potential use of lethal means. (Stanley & Brown, 2012, p. 257)

Stanley and Brown (2012) noted that the sixth treatment component, reducing lethal means, isn’t addressed until the other five safety-plan components have been completed. Component six also may require assistance from family members or a friend, depending on the situation. All six of these components should be included in your documentation, including firearms management.

Identifying Alternatives to Suicide

Engaging in a debate about the acceptability of suicide or whether with clients with suicidal impulses “should” attempt suicide can backfire. Sometimes suicidal individuals feel so disempowered that they perceive the possibility of killing themselves as one of their few sources of control. Rather than argue, your focus is on helping clients identify methods for coping with suicidal impulses and find more desirable life alternatives. .

Suicidal clients may be unable to identify options to suicide. As Shneidman (1980) suggested, clients need help to “widen” their view of life’s options.

Shneidman (1980) wrote of a situation in which a pregnant teenager came to see him in suicidal crisis. She had a gun in her purse. He agreed with her that suicide was an option, while pulling out paper and a pen to write down alternatives to suicide. Shneidman generated most of the options (e.g., “You could have the baby and give it up for adoption”), while she systematically rejected them (“I can’t do that”). He wrote them down anyway, noting they were only making a list of options. Eventually, he handed her a list of options and asked her to rank her preferences. To both of their surprise, she indicated death by suicide was her third preferred option. They worked together to implement options one and two. Happily, she never needed to choose option three.

This is a straightforward intervention. You can practice it with your peers and implement it with suicidal clients. There’s always the possibility that clients will decide suicide is their #1 choice (at which point you’ve obtained important assessment information). However, it’s surprising how often suicidal clients, once they’ve had help expanding their mental constriction symptoms, discover more preferable options; options that involve embracing life.

Separating the Psychic Pain From the Self

Rosenberg (1999; 2000) 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” (p. 86). This technique can help suicidal clients because it provides empathy for their pain, while helping them see that their wish is for the pain, rather than the self, to stop existing.

Rosenberg (1999) also recommended helping 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 as an “actual intent to take action” (p. 86). Again, this approach can decrease clients’ needs to act on suicidal impulses, partly because of the cognitive reframe and partly because of the therapist’s empathic connection.

Becoming Directive and Responsible

Both ethically and legally, when clients are a clear danger to themselves, it’s the therapist’s responsibility to intervene and provide protection. This mandate means taking a directive role. You may have to tell the client what to do, where to go, and whom to call. It also may involve prescriptive therapeutic interventions, such as urging clients to get involved in daily exercise, recreational activities, church activities, or whatever is preventative based on their unique individual needs.

Clients who are acutely suicidal may require hospitalization. Many professionals view hospitalization as less than optimal, but if you have a client with acute suicide ideation, hospitalization may be your best alternative. If so, be positive and direct. Clients may have negative views of life inside a psychiatric hospital. Statements similar to the following can aid in beginning the discussion.

  • I wonder how you feel (or what you think) about staying in a hospital until you feel safer and more in control?
  • I think being in the hospital may be just the right thing for you. It’s a safe place. You can work on coping skills and on any medication adjustments you may need or want.

Linehan (1993) discussed several directive approaches for reducing suicide behaviors based on dialectical behavior therapy. She advocated:

  • Emphatically instructing the client not to commit suicide.
  • Repeatedly informing the client that suicide isn’t a good solution and that a better one will be found.
  • Giving advice and telling the client what to do when/if he or she is frozen and unable to construct a positive action plan.

These suggestions can give you a sense of how directive you may need to be when working with clients who are suicidal.

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Clinical Interviewing, Suicide Assessment and Intervention

R-I-P-SC-I-P: An Acronym for Remembering the Essential Components of a Suicide Assessment Interview

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This post is part 1 of a follow up to requests I’ve gotten following the MUS Suicide Prevention Summit in Bozeman. A number of people asked: What’s R-I-P-SC-I-P and how do I get more information about it? The answer is that it’s just an acronym to help practitioners recall key areas to cover in a comprehensive suicide assessment interview. But because I made it up in honor of Robert Wubbolding while doing a workshop in Cincinnati (he’s created several acronyms for Choice Theory and Reality Therapy), I’m pretty much the only source.

The following is a pre-published excerpt from the Suicide Assessment chapter in the forthcoming 6th edition of Clinical Interviewing. It includes some general information, a summary of R-I-P-SC-I-P, and some guidance on how to talk with clients about suicide ideation. Much more of this is in the whole chapter, but I can’t post it here.

Suicide Assessment Interviewing

A comprehensive and collaborative suicide assessment interview is the professional gold standard for assessing suicide risk. Suicide assessment scales and instruments can be a valuable supplement—but not a substitute—for suicide assessment interviewing (see Putting It in Practice 10.1).

A comprehensive suicide assessment interview includes the following components:

  • Gathering information about suicide risk and protective factors: This should be done in a manner that emphasizes your desire to understand the client and not as a checklist to estimate risk
  • Asking directly about possible suicidal thoughts
  • Asking directly about possible suicide plans
  • Gathering information about client self-control and agitation
  • Gathering information about client suicide intent and reasons to live
  • Consultation with one or more professionals
  • Implementation of one or more suicide interventions, including, at the very least, collaborative work on developing an individualized safety plan
  • Detailed documentation of your assessment and decision-making process (Table 10.3 includes an acronym to help you recall the components of a comprehensive suicide assessment interview)

Table 10.3: RIP SCIP – A Suicide Assessment Acronym

R = Risk and Protective Factors
I = Suicide Ideation
P = Suicide Plan
SC = Client Self-Control and Agitation
I = Suicide Intent and Reasons for Living
P = Safety Planning

These assessment domains or dimensions form the acronym R-I-P-SC-I-P (pronounced RIP SKIP).

Exploring Suicide Ideation

Unlike many other risk factors (e.g., demographic factors), suicide ideation is directly linked to potential suicide behavior. It’s difficult to imagine anyone ever dying by suicide without having first experienced suicide ideation.

Because of this, you may decide to systematically ask every client about suicide ideation during initial clinical interviews. This is a conservative approach and guarantees you won’t face a situation where you should have asked about suicide, but didn’t. Alternatively, you may decide to weave questions about suicide ideation into clinical interviews as appropriate. At least initially, for developing professionals, we recommend using the systematic approach. However, we recognize that this can seem rote. From our perspective, it is better to learn to ask artfully by doing it over and over than to fail to ask and regret it.

The nonverbal nature of communication has direct implications for how and when you ask about suicide ideation, depressive symptoms, previous attempts, and other emotionally laden issues. For example, it’s possible to ask: “Have you ever thought about suicide?” while nonverbally communicating to the client: “Please, please say no!” Therefore, before you decide how you’ll ask about suicide ideation, you need the right attitude about asking the question.

Individuals who have suicidal thoughts can be extremely sensitive to social judgment. They may have avoided sharing suicidal thoughts out of fear of being judged as “insane” or some other stigma. They’re likely monitoring you closely and gauging whether you’re someone to trust with this deeply intimate information. To pass this unspoken test of trust, it’s important to endorse, and directly or indirectly communicate the following beliefs:

  • Suicide ideation is normal and natural and counseling is a good place for clients to share those thoughts.
  • I can be of better help to clients if they tell me their emotional pain, distress, and suicidal thoughts.
  • I want my clients to share their suicidal thoughts.
  • If my clients share their suicidal thoughts and plans, I can handle it!

If you don’t embrace these beliefs, clients experiencing suicide ideation may choose to be less open.

Asking Directly about Suicide Ideation

Asking about suicide ideation may feel awkward. Learning to ask difficult questions in a deliberate, compassionate, professional, and calm manner requires practice. It also may help to know that, in a study by Hahn and Marks (1996), 97% of previously suicidal clients were either receptive or neutral about discussing suicide with their therapists during intake sessions. It also may help to know that you’re about to learn the three most effective approaches to asking about suicide that exist on this planet.

Use a normalizing frame. Most modern prevention and intervention programs recommend directly asking clients something like, “Have you been thinking about suicide recently?” This is an adequate approach if you’re in a situation with someone you know well and from whom you can expect an honest response.

A more nuanced approach is to ask about suicide along with a normalizing or universalizing statement about suicide ideation. Here’s the classic example:

Well, I asked this question since almost all people at one time or another during their lives have thought about suicide. There is nothing abnormal about the thought. In fact it is very normal when one feels so down in the dumps. The thought itself is not harmful. (Wollersheim, 1974, p. 223)

A common fear is that asking about suicide will put suicidal ideas in clients’ heads. There’s no evidence to support this (Jobes, 2006). More likely, your invitation to share suicidal thoughts will reassure clients that you’re comfortable with the subject, in control of the situation, and capable of dealing with the problem.

Use gentle assumption. Based on over two decades of clinical experience with suicide assessment Shawn Shea (2002/ 2004/2015) recommends using a framing strategy referred to as gentle assumption. To use gentle assumption, the interviewer presumes that certain illegal or embarrassing behaviors are already occurring in the client’s life, and gently structures questions accordingly. For example, instead of asking “Have you been thinking about suicide?” you would ask: “When was the last time when you had thoughts about suicide?” Gentle assumption can make it easier for clients to disclose suicide ideation.

Use mood ratings with a suicidal floor. It can be helpful to ask about suicide in the context of a mood assessment (as in a mental status examination). Scaling questions such as those that follow can be used to empathically assess mood levels.

1. Is it okay if I ask some questions about your mood? (This is an invitation for collaboration; clients can say “no,” but rarely do.)

2. Please rate your mood right now, using a zero to 10 scale. Zero is the worst mood possible. In fact, zero would mean you’re totally depressed and so you’re just going to kill yourself. At the top, 10 is your best possible mood. A 10 would mean you’re as happy as you could possibly be. Maybe you would be dancing or singing or doing whatever you do when you’re extremely happy. Using that zero to 10 scale, what rating would you give your mood right now? (Each end of the scale must be anchored for mutual understanding.)

3. What’s happening now that makes you give your mood that rating? (This links the mood rating to the external situation.)

4. What’s the worst or lowest mood rating you’ve ever had? (This informs the interviewer about the lowest lows.)

5. What was happening back then to make you feel so down? (This links the lowest rating to the external situation and may lead to discussing previous attempts.)

6. For you, what would be a normal mood rating on a normal day? (Clients define their normal.)

7. Now tell me, what’s the best mood rating you think you’ve ever had? (The process ends with a positive mood rating.)

8. What was happening that helped you have such a high mood rating? (The positive rating is linked to an external situation.)

The preceding protocol assumes clients are minimally cooperative. More advanced interviewing procedures can be added when clients are resistant (see Chapter 12). The process facilitates a deeper understanding of life events linked to negative moods and suicide ideation. This can lead to formal counseling or psychotherapy, as well as safety planning.

Responding to Suicide Ideation

Let’s say you broach the question and your client openly discloses the presence of suicide ideation. What next?

First, remember that hearing about your client’s suicide ideation is good news. It reflects trust. Also remember that depressive and suicidal symptoms are part of a normal response to distress. Validate and normalize:

Given the stress you’re experiencing, it’s not unusual that you think about suicide sometimes. It sounds like things have been really hard lately.

This validation is important because many suicidal individuals feel socially disconnected, emotionally invalidated, and as if they’re a social burden (Joiner, 2005). Your empathic reflection may be more or less specific, depending on how much detailed information your client has given you.

As you continue the assessment, collaboratively explore the frequency, triggers, duration, and intensity of your client’s suicidal thoughts.

  • Frequency: How often do you find yourself thinking about suicide?
  • Triggers: What seems to trigger your suicidal thoughts? What gets them started?
  • Duration: How long do these thoughts stay with you once they start?
  • Intensity: How intense are your thoughts about suicide? Do they gently pop into your head or do they have lots of power and sort of smack you down?

As you explore the suicide ideation, strive to emanate calmness, and curiosity, rather than judgment. Instead of thinking, “We need to get rid of these thoughts,” engage in collaborative and empathic exploration.

Some clients will deny suicidal thoughts. If this happens, and it feels genuine, acknowledge and accept the denial, while noting that you were just using your standard practice.

Okay. Thanks. Asking about suicidal thoughts is just something I think is important to do with everyone.

On the other hand, if the denial seems forced, or is combined with depressive symptoms or other risk factors, you’ll still want to use acknowledgement and acceptance, but then find a way to return to the topic later in the session.

Clinical Interviewing, Suicide Assessment and Intervention

Three Strategies for Conducting State-of-the-Art Suicide Assessment Interviews

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Tomorrow is the first day of the MUS Statewide Summit on Suicide Prevention in Bozeman, Montana. From 2:30-3:45pm I’ll be participating on a panel: “Screening and Intervention Options with the Imminently Suicidal.” During my 10-12 minutes, I’ll be offering my version of what I view as essential strategies and skills for face-to-face suicide assessment interviewing. Below is the handout for the Summit. I think it’s a great thing that we’re meeting in an effort to address this important problem in Montana. Thanks to Lynne Weltzien of UM-Western in Dillon and Mike Frost of UM-Missoula for the invitation. Here’s the handout . . .

Three Strategies for Conducting
State-of-the-Art Suicide Assessment Interviews
John Sommers-Flanagan, Ph.D.
University of Montana

I. To conduct efficient and valid suicide assessment interviews, clinicians need to hold an attitude of acceptance (not judgment) and use several state-of-the-art assessment strategies.

II. If clinicians believe suicide ideation is a sign of psychopathology or deviance, students or clients will sense this and be less open.

III. Asking directly about suicide is essential, but experienced clinicians use more nuanced assessment strategies.

a. Normalizing statements

  • I’ve read that up to 50% of teenagers have thought about suicide. Is that true for you?
  • When people are depressed or feeling miserable, it’s not unusual to have thoughts of suicide pass through their mind. Have you had any thoughts of suicide?

b. Gentle assumption (Shea, 2002, 2004, 2015)

  • When was the last time you had thoughts about suicide?

c. A solution-focused mood evaluation with a suicide floor

1. “Is it okay if I ask some questions about your mood?” (This is an invitation for collaboration; clients can say “no,” but rarely do.)

2. “Please rate your mood right now, using a zero to 10 scale. Zero is the worst mood possible. In fact, zero would mean you’re totally depressed and so you’re just going to kill yourself. At the top, 10 is your best possible mood. A 10 would mean you’re as happy as you could possibly be. Maybe you would be dancing or singing or doing whatever you do when you’re extremely happy. Using that zero to 10 scale, what rating would you give your mood right now?” (Each end of the scale must be anchored for mutual understanding.)

3. “What’s happening now that makes you give your mood that rating?” (This links the mood rating to the external situation.)

4. “What’s the worst or lowest mood rating you’ve ever had?” (This informs the interviewer about the lowest lows.)

5. “What was happening back then to make you feel so down?” (This links the lowest rating to the external situation and may lead to discussing previous attempts.)

6. “For you, what would be a normal mood rating on a normal day?” (Clients define their normal.)

7. “Now tell me, what’s the best mood rating you think you’ve ever had?” (The process ends with a positive mood rating.)

8. “What was happening that helped you have such a high mood rating?” (The positive rating is linked to an external situation.)

This protocol assumes cooperation. More advanced interviewing procedures can be added if clients are resistant. The goal is a deeper understanding of life events linked to negative moods and suicide ideation and a possible direct transition to counseling or safety planning.

 

IV. When students or clients disclose suicide ideation clinicians should:

a. Stay calm

b. Express empathy

c. Normalize ideation

d. Move to conducting a full suicide assessment interview (i.e., R-I-P-SC-I-P*) or refer the student/client to someone who will do a full assessment along with safety planning

e. Use suicide interventions as appropriate

 

V. Using Shneidman’s “Alternatives to Suicide” approach is a parsimonious way to simultaneously assess and intervene to reduce danger to self

 

VI. IMHO: All health and mental health providers should be trained to use these clinical skills and strategies when working with potentially suicidal students/clients.

 

Adapted from: Clinical Interviewing (6th ed., 2016), Wiley. Feel free to share this handout as long as authorship is included. For more information or to ask about professional workshops for your organization, contact John Sommers-Flanagan: john.sf@mso.umt.edu or 406-721-6367.

 

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Clinical Interviewing, Counseling and Psychotherapy Theory and Practice, Personal Reflections

Parallel Process in Clinical Supervision

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This short case example from the forthcoming 6th edition of Clinical Interviewing is a small tribute to all the great supervisors I had over the years.

Case Example 7.2:

Intermittent Unconditional Positive Regard and Parallel Process

Abby is a 26-year-old graduate student. She identifies as a White Heterosexual female. After an initial clinical interview with Jorge, a 35-year-old who identifies as a male heterosexual Latino, she meets with her supervisor. During the meeting she expresses frustration about her judgmental feelings toward Jorge. She tells her supervisor that Jorge sees everyone as against him. He’s extremely angry at his ex-wife and he’s returning to college following his divorce and believes his poor grades are due to racial discrimination. Abby tells her supervisor that she just doesn’t get Jorge. She thinks she should refer him instead of having a second session.

Abby’s supervisor listens empathically and is accepting of Abby’s concerns and frustrations. The supervisor shares a brief story of a case where she had difficulty experiencing positive regard toward a client who had a disability. Then, she asks Abby to put herself in Jorge’s shoes and imagine what it would be like to return to college as a 35-year-old Latino man. She has Abby imagine what might be “under” Jorge’s palpable anger toward his ex-wife. The supervisor also tells Abby, “When you have a client who views everyone as against him, it’s all the more important for you to make an authentic effort to be with him.” At the end of supervision Abby agrees to meet with Jorge for a second session and to try to explore and understand his perspectives on a deeper level. During their next supervision session, Abby reports great progress at experiencing intermittent unconditional positive regard for Jorge and is enthused about working with him in the future.

One way to enhance your ability to experience unconditional positive regard is to have a supervisor who accepts your frustrations and intermittent judgmental-ness. If the issues that arise in therapy are similar (or parallel) to the issues that arise in supervision, it’s referred to as parallel process (Searles, 1955). This is one reason why when you get a dose of unconditional positive regard in supervision, it may help you pass it on to your client.

 

John Rap

Clinical Interviewing

Can Mental Health Professionals Predict Violent Behavior in Schools and Agencies?

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Not surprisingly, violence has been on my mind lately. And so when I reached the Violence Risk Assessment section of the Clinical Interviewing text revision, I decided to cut and paste it here. It doesn’t immediately answer the question of whether mental health professionals can predict violence and so if you’re impatient and prefer to stop reading now, the answer to that question is, more or less, “No.”

Assessment and Prediction of Violence and Dangerousness

During an assessment interview, John had the following exchange with a 16-year-old client.

John: I hear you’ve been pretty mad at your shop teacher.

Client: I totally hate Mr. Smith. He’s a jerk. He puts us down just to make us feel bad. He deserves to be punished.

John: You sound a little pissed off at him.

Client: We get along fine some days.

John: What do you mean when you say he “deserves to be punished”?

Client: I believe in revenge. Really, I feel sorry for him. But if I kill him, I’ll be doing him a favor. It would end his miserable life and stop him from making other people feel like shit.

John: So you’ve thought about killing him?

Client: I’ve thought about walking up behind him and slitting his throat.

John: How often have you thought about that?

Client: Just about every day. Whenever he talks shit in class.

John: And exactly what images go through your mind?

Client: I just slip up behind him while he’s talking with Cassie [fellow student] and then slit his throat with a welding rod. Then I see blood gushing out of his neck and Cassie starts screaming. But the world will be a better place without his sorry ass tormenting everybody.

John: Then what happens?

Client: Then I guess they’ll just take me away, but things will be better.

John: Where will they take you?

Client: To jail. But I’ll get sympathy because everyone knows what a dick he is.

During an initial interview or ongoing therapy, clients may describe aggressive thoughts and images. Some clients, as in the preceding example, will be concise about their thoughts, feelings, and images. Others will be less clear. Still others will be evasive and will avoid telling you anything about violent thoughts or intentions.

Assessing for violence potential is similar to assessing for suicide potential; it’s a stressful responsibility and predicting violence is extremely difficult. However, similar to suicide assessment, we still have a legal and ethical responsibility to conduct violence or dangerousness assessments that meet professional standards.

Over the years, there have been arguments about how to most accurately predict violence (Hilton, Harris, & Rice, 2006). Essentially, there are three perspectives.

1. Some researchers contend that actuarial prediction based on specific, predetermined statistical risk factors is consistently the most accurate procedure (Quinsey, Harris, Rice, & Cormier, 2006).

2. Some clinicians believe that because actuarial variables are dimensional and interactive with individual and situational characteristics, prediction based on the clinician’s experience and intuition is most accurate (Cooke, 2012).

3. Others take a moderate position, believing that combining actuarial and clinical approaches is best (Campbell, French, & Gendreau, 2009).

Researchers have consistently reported that actuarial approaches to violence prediction are more accurate than clinical judgment (Monahan, 2013). However, actuarial violence prediction is not without its flaws (Szmukler, 2012; Tardiff & Hughes, 2011).

Narrowing in on Particular Violent Behaviors

Researchers who investigate actuarial assessment protocols have reported that different violent behaviors are associated with unique predictor variables. Below, we provide three examples of violence predictors for three different specific violent behaviors or populations. The goal is to sensitize you to different violent behavior patterns.

Fire-setting. Fire-setting is a particular dangerous behavior that may or may not be associated with interpersonal violence. Nonetheless, depending on your work setting and the clinical population you serve, you may find yourself in a situation in which you need to decide whether to warn a family or potential victim about possible fire-setting behavior.

Mackay and colleagues (2006) reported on specific behaviors included on a fire-setting prediction assessment. They identified the following variables—in decreasing order—as predictive of fire setting:

  •  Younger age at the time of the first fire-setting behavior.
  • A higher total number of fire-setting offenses.
  • Lower IQ.
  • Additional criminal activities associated with the index (initial) fire.
  • An offender acting alone in setting the initial fire.
  • A lower offender’s aggression score. (Interestingly, offenders with higher aggression scores were more likely to be violent, but less likely to set fires.)

We focus first on fire setting here because fire-setting predictors illustrate a general violence-prediction principle. Past violence is a reasonably good predictor of future violence only with regard to specific past and future violence. For example, future fire-setting potential is best predicted by past fire-setting behavior. Similarly, future physical aggression is best predicted by past physical aggression. But a history of physical aggression is not a good predictor of fire setting.

Homicide Among Young Men. Loeber and associates (2005) conducted a large-scale landmark study of homicide among young men living in Pittsburgh. This study is notable because it was both prospective and comprehensive; the authors tracked 63 risk factor (predictor) variables in 1,517 inner-city youth. Obviously, even this large-scale study is limited in scope, and technically the results cannot be generalized beyond inner-city Pittsburgh youth. Nevertheless, the outcome data are interesting and lend insight into risk factors that might contribute to homicidal violence in other populations.
Results from the study indicated that violent offenders scored significantly higher than nonviolent offenders on 49 of 63 risk factors across domains associated with child, family, school, and demographic risk factors. The range and nature of these predictors were daunting. The authors reported:

. . . predictors included factors evident early in life, such as the mother’s cigarette or alcohol use during pregnancy, onset of delinquency prior to 10 years of age, physical aggression, cruelty, and callous/unemotional behavior. In addition, cognitive factors, such as having low expectations of being caught, predicted violence. Poor and unstable child-rearing factors contributed to the prediction of violence, including two or more caretaker changes prior to 10 years of age, physical punishment, poor supervision, and poor communication. Undesirable or delinquent peer behavior, based either on parent report or self-report, predicted violence. Poor school performance and truancy were also among the predictors of violence. Finally, demographic factors indicative of family disadvantage (low family SES, welfare, teenage motherhood) and residence in a disadvantaged neighborhood also predicted violence. Among the proximal correlates associated with violence were weapon carrying, weapon use, gang membership, drug selling, and persistent drug use. (p. 1084)

Homicidal violence was best predicted by a subset of general violence predictor variables. Specifically, homicide was predicted by “the presence or absence of nine significant risk factors:

• Screening risk score
• Positive attitude to substance use
• Conduct disorder
• Carrying a weapon
• Gang fight
• Selling hard drugs
• Peer delinquency
• Being held back in school
• Family on welfare (p. 1086).

In particular, boys who had at least four of these nine risk factors were 14 times more likely to have a future homicide conviction than violent offenders with a risk score less than four.

Violence and schizophrenia. In and of itself, a diagnosis of schizophrenia doesn’t confer increased violence risk. Instead, research indicates there are specific symptoms—when seen among individuals diagnosed with schizophrenia—associated with increased risk. These symptoms include severe manifestations of:

  • Hallucinations
  • Delusions
  • Excitement
  • Thinking disturbances. (Fresán, Apiquian, & Nicolini, 2006)

This research suggests that clinicians should be especially concerned about violence when clients diagnosed with schizophrenia have acute increases in the intensity and frequency of their psychotic symptoms.

Research versus Practice

For a short guide to predicting violence, see a previous post: https://johnsommersflanagan.com/2013/02/25/guidelines-for-violence-risk-assessment/

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Clinical Interviewing, Counseling and Psychotherapy Theory and Practice, Parenting

Doing an Internet Interview on IHeart Radio

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Today I did an internet interview with Dr. Carlos Vazquez on his “Circle of Insight” show on IHeart Radio. A few minutes after we finished, I got an email from Dr. Carlos indicating it was posted and ready to hear. Wow. Technology is amazing and it’s especially amazing when it works.

Here’s the link to the interview. Check it out if you like. Or ignore it if you prefer.

https://www.spreaker.com/episode/7224462

The show is titled: A discussion about Psychological Theories and how to talk to parents so they Listen with Dr. Sommers-Flanagan

This is what I look like when I do radio interviews.

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Clinical Interviewing, Cool Counseling, Counseling and Psychotherapy Theory and Practice, Multicultural, Therapy with Adolescents

Counseling Culturally Diverse Youth: Research-Based and Common Sense Tips

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This is a rough preview of a section from the 6th edition Clinical Interviewing. As always, your thoughts and feedback are welcome.

Counseling Culturally Diverse Youth: Research-Based and Common Sense Tips

Research on how to practice with culturally diverse youth is especially sparse. To make matters more complex, youth culture is already substantially different from adult culture. This means that if you’re different from young clients on traditional minority variables, you’ll be experiencing a double dose of the cultural divide. These complications led one writer to title an article “A knot in the gut” to describe the palpable transference and countertransference that can arise when working with race, ethnicity, and social class in adolescents (Levy-Warren, 2014).

To help reduce the size of the knot in your gut, we’ve developed a simple research- and common-sense list to guide your work with culturally diverse youth (Bhola & Kapur, 2013; Norton, 2011; Shirk, Karver, & Brown, 2011; Villalba, 2007):

1. Use the interpersonal skills (e.g., empathy, genuineness, respect) that are known to work well with adult minority group members. Keep in mind that interpersonal respect is an especially salient driver in smoothing out intercultural relationships.

2. Find ways to show genuine interest in your young clients, while also focusing on their assets or strengths.

3. Treat the meeting, greeting, and first session with freshness and eagerness. There’s evidence that young clients find less experienced therapists easier to form an alliance with.

4. Use a genuine and clear purpose statement. It should capture your “raison d’etre” (your reason for being in the room). We like a purpose statement that’s direct and has intrinsic limits built in. For example: “My goal is to help you achieve your goals . . . just as long as your goals are legal and healthy.” One nice thing about this purpose statement is that sometimes young clients think the “legal and healthy” limitations are funny.

5. Don’t use a standardized approach to always talking with youth about your cultural differences. Instead, wait for an opening that naturally springs up from your interactions. For example, when a teen says something like, “I don’t think you get what I’m saying” it’s a natural opening to talk about how you probably don’t get what the youth is saying. Then you can discuss some of your differences as well as you’re desire to understand as much as you can. For example: “You’re right. I probably don’t get you very well. It’s obvious that I’m way older than you and I’m not a Native American. But I’d like to understand you better and I hope you’ll be willing to help me understand you better. Then, in the end, you can tell me how much I get you and how much I don’t get you.”

6. Provide clear explanations of your procedure and rationale and then linger on those explanations as needed. If young clients don’t understand the point of what you’re doing, they’re less likely to engage.

7. Be patient with your clients; research with young clients and diverse clients indicate that alliance-building (and trust) takes extra time and won’t necessarily happen during an initial session

8. Be patient with yourself; it may take time for you to feel empathy for young clients who engage in behaviors outside your comfort zone (e.g., cutting)

I hope these ideas can help you make connections with youth from other cultures. The BIG summary is to BE GENUINE and BE RESPECTFUL. Nearly everything else flows from there.