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:
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.
Linehan (1993) discussed several directive approaches for reducing suicide behaviors based on dialectical behavior therapy. She advocated:
These suggestions can give you a sense of how directive you may need to be when working with clients who are suicidal.
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:
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:
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.
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.
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
b. Gentle assumption (Shea, 2002, 2004, 2015)
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.
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.
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:
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:
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/
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.
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.
The American Psychological Association (APA) has an online guide to record keeping for psychologists. Of the different mental health disciplines, the APA’s guidelines are the most extensive. For the full guide (and tons of fun), go to: http://www.apa.org/practice/guidelines/record-keeping.aspx. A brief summary of the guide follows.
As an introduction, the APA emphasizes that clinical records are beneficial for clients and practitioners. When done well, clinical records can:
1. Document that planning has occurred
2. Guide treatment services.
3. Allow providers to review and monitor their work.
4. Enhance continuity when there are treatment breaks or referrals to other providers.
5. Protect clients and providers during legal or ethical proceedings.
6. Fulfill insurance or third-party reimbursement requirements.
The APA’s document is a guide and not a mandate. It’s designed as aspirational. APA also notes that there’s no significant empirical research foundation upon which their guidelines are based. Instead, the guidelines are broadly based on APA policy, professional consensus, and other sources of ethics and legal information.
The following list paraphrases and summarizes APA’s 13 guidelines. There’s always the possibility that our list and descriptions include minor mistranslations. Consequently, please see the full document for comprehensive coverage of this important content.
1. Responsibility: Practitioners are responsible for the development and maintenance of their clinical records. This includes training staff in the appropriate confidential handling of client records.
2. Record Content: Records include information about the nature, delivery, treatment progress and outcomes, and fees. Information included is directly relevant to the clinical purpose of client contacts. Although detail is important, the following factors guide the level of details included in individual client case files:
a. Clients’ wishes
b. Disaster or emergency settings
c. Ethical or legal limitations (e.g., HIV testing results)
d. Contracts with third party payers
e. The APA guide includes extensive information regarding what content may or may not be appropriate.
3. Confidentiality: Maintenance of confidentiality is essential. In situations where who has access to records may be unclear (e.g., child custody conflicts), the provider seeks pertinent legal information to guide decision-making.
4. Informed Consent: Practitioners provide clients with information regarding their record keeping procedures, including limits to confidentiality.
5. Records Maintenance: Records are organized to comply with federal law (HIPAA) and accuracy is maintained.
6. Records Security: Records are kept safe from physical damage. Access to records is controlled via a variety of methods, including locked cabinets, locked storage rooms, passwords, data encryption, etc.).
7. Records Retention: Records are retained for a time period consistent with legal requirements. The general guide is seven years after service ended for adults and three years after a minor reaches age 18 (whichever is later).
8. Records Context: Because client symptoms or condition can vary with situational contexts, providers frame the content of client records within the appropriate historical context.
9. Electronic Records: Electronic records use and storage presents ongoing challenges. The best guidance is for practitioners to follow the HIPAA Security Rule, conduct a security analysis, and consistently upgrade policies and practices to keep up with changes in technology.
10. Records within Agencies: Practitioners must balance their professional ethical requirements and agency policy. The APA identifies three main areas: (a) conflicts between the agency and other requirements, (b) records ownership, and (c) records access.
11. Multiple Client Records: When providing couple, family, or group services, records management may become complex. You can consider either creating separate records for all clients or to identify a primary client and keep records for that person.
12. Financial Records: The nature of the fee agreement (including bartering agreements) as well as adjustments to account balances should be specified. Financial records include essential information such as procedure codes, treatment duration, fees paid, fee agreements, dates of service, etc.
13. Records Disposition: In the case of unexpected events, there may be a need for records transfer or disposal. This implies a need for a records transfer and disposal policy, including information on how current and former clients will be informed if the policy needs to be enacted.
The APA guide is a comprehensive document that can help all practicing clinicians maintain high ethical standards with respect to documentation.
In 2013, for the first time in the history of counseling and psychotherapy textbook writing (at least our history), Rita and I included a section heading titled “Straight Talk about Cleavage” in the 5th edition of Clinical Interviewing. This section was inspired by comments posted on the Counselor Education and Supervision Listserv (aka CESNET). Now, we’re working on the revision for the 6th edition (affectionately referred to as CI6). For CI6 we solicited reactions from students, professional counselors, and professional psychologists. Not surprisingly, we received some fun, stimulating, and challenging responses.
For your reading pleasure, here’s the first draft of the revised section on cleavage. You’ll notice that it begins with a section on “Self-Presentation.” That’s because the cleavage and related content is a subsection of the self-presentation section.
This is a draft . . . and so please feel free to message me (or post) your comments and reactions. Thanks for reading.
Self-Presentation
You are your own primary instrument for a successful interview. Your appearance and the manner in which you present yourself to clients are important components of professional clinical interviewing.
Grooming and Attire
Choosing the right professional clothing can be difficult. Some students ignore the issue; others obsess about selecting just the right outfit. The question of how to dress may reflect a larger developmental issue: How seriously do you take yourself as a professional? Is it time to take off the ripped jeans, remove the nose ring, cover the tattoo, or lose the spike heels? Is it time to don the dreaded three-piece suit or carefully pressed skirt and come out to do battle with mature reality, as your parents may have suggested? Don’t worry. We recognize the preceding sentences are probably pushing your fashion-freedom buttons. We’re not really interested in telling you how you should dress or adorn your body. Our point is self-awareness. If you’re working in rural Texas your tattoo and nose ring will have a different effect than if you’re an intern in urban Chicago. Even if you ignore your physical self-presentation, your clients—and your supervisor—probably won’t.
We knew a student whose distinctive style included closely cropped, multicolored hair; large earrings; and an odd assortment of scarves, vests, sweaters, runner’s tights, and sandals. Imagine his effect on, say, a middle-aged dairy farmer referred to the clinic for depression, or a mother-son dyad having trouble with discipline, or the local mayor and his wife. No matter what effect you imagined, the point is that there’s likely to be an effect. Clothing, body art, and jewelry are not neutral; they’re intended to communicate, and they do (Human & Biesanz, 2012). An unusual fashion statement can be overcome, but it may use up time and energy better devoted to other issues (see Putting It in Practice 2.3). As a therapist your goals is to present yourself in a way that creates positive first impressions. This includes dress and grooming that foster rapport, trust, and credibility.
In one research study (albeit dated), Hubble and Gelso (1978) reported that clients experienced less anxiety and more positive feelings toward psychotherapists who were dressed in a manner that was slightly more formal than the client’s usual attire. The take home message from this research, along with common sense, is that it’s better to err slightly on the conservative side, at least until you’re certain that dressing more casually won’t have an adverse effect on your particular client population. As a professional colleague of ours tells her students, “A client should not walk away from your session thinking too much about what you wore” (S. Patrick, personal communication, June 27, 2015).
Straight Talk about Cleavage
Although we don’t have solid scientific data upon which to base this statement, our best guess is that most people on the planet don’t engage in open conversations about cleavage. Our goal in this section is to break that norm and to encourage you to break it along with us. To start, we should confess that the whole idea of us bringing up this topic (in writing or in person) makes us feel terribly old. But we hope this choice might reflect the wisdom and perspective that comes with aging.
In recent years we’ve noticed a greater tendency for female counseling and psychology students (especially younger females) to dress in ways that might be viewed as provocative. This includes, but is not limited to, low necklines that show considerable cleavage. Among other issues, cleavage and clothing were discussed in a series of postings on the Counselor Education and Supervision (CES) listserv in 2012. The CES discussion inspired many of the following statements that follow. Please read these bulleted statements and consider discussing them as an educational activity.
• Female (and male) students have the right to express themselves via how they dress and should be able to dress any way they want.
• Commenting on how women dress and making specific recommendations may be viewed as sexist.
• Agencies and institutions have some rights to establish dress codes regarding how their paid employees and volunteers dress.
• Despite egalitarian and feminist efforts to free women from the shackles of a patriarchal society, how women dress is still interpreted as having socially constructed messages that often, but not always, pertain to sex and sexuality.
• Although efforts to change socially constructed ideas about women dressing “sexy” can include activities like campus “slut-walks,” a counseling or psychotherapy session is probably not the venue for initiating a discourse on social and feminist change.
• For better or worse, most middle-school males and middle-aged men (and many “populations” in between) are likely to be distracted—and their ability to profit from a counseling experience may be compromised—if they have a close up view of their therapist’s breasts.
• At the very least, we think excessive cleavage (please don’t ask us to define this) is less likely to contribute to positive therapy outcomes and more likely to stimulate sexual fantasies—which we believe is probably contrary to the goals of most therapists.
• It may be useful to have young women watch themselves on video from the viewpoint of a client (of any sex or gender) and then discuss how to manage sexual attraction that might occur during therapy.
We don’t have perfect answers to the question of cleavage during a clinical interview. Guidelines depend, in part, on interview setting and specific client populations. At the very least, we recommend you think about this dimension of professional attire and hope you’ll openly discuss cleavage and related issues with fellow students, colleagues, and supervisors.
Minding the Body for Males
It’s inappropriate to stop our discussion about sexuality and sexual perceptions without addressing the other end of the sexuality and gender continuum. To start, we should emphasize that, to a large extent, our cautions about cleavage aren’t really about breasts; instead, these are comments about cultural messages pertaining to sex and sexuality and how clients are likely to perceive and react to seeing too much of certain portions of their therapist’s skin. Back in Freud’s day and setting, viewing women’s ankles was reportedly rather titillating. This observation begs the question: “Is it possible for individuals who identify as being on the male end of the sexual identity continuum to dress in ways that might be described as titillating?” When we tried to experiment with this in a group counseling class, mostly the feedback was that the males were being “gross” and “disgusting.”
Despite the fact that our students reacted negatively to the idea of males exposing their skin, we should note that throughout the history of time, therapists who engaged in inappropriate, unethical, and illegal sexual behavior with clients have been disproportionately male. This leads us to conclude that our cautions about females showing cleavage is at the least ironic and at most sexist. Consistent with feminist theory, when men sexualize a woman’s body, it shouldn’t be viewed as the woman’s fault.
These issues are obviously laden with cultural stereotypes, norms, and expectations. In an effort to balance our coverage (no pun intended) of this topic, we went online and asked professionals and colleagues to give us feedback about the “Straight Talk about Cleavage” section. A summary of this feedback is included below.
Feedback on Cleavage
A warning to male therapists: Male therapists need to watch their own flirtatious behavior. They might consult with a female therapist friend to check out anything that might be questionable. I know, most males don’t have cleavage issues, but they sometimes do make provocative comments, such as, “You know, you should take that lovely sexuality of yours and use it to your advantage.” I’m not making this up. Also, they might want to rein in, “You are so pretty. I’ll bet this gets the guys going.” I’m not making this up either. (J. Hocker, personal communication, June 27, 2015).
Extending the conversation to male therapists: I do think part of the unfairness in professional attire for women vs. men is that men’s work wear is simply “easier.” But a woman doesn’t have to dress like a man in order to be taken seriously as a professional. Curiously, I do find that the conversation regarding appearance needs to take place with men; for example, male students who want to wear flip flops, large jewelry, or “muscle” shirts. We also talk about whether or not to wear things that reveal tattoos, hair styles, and so on – so I think men are now as much a part of the conversation as women (S. Patrick, personal communication, June 27, 2015)
A Message from a Licensed School Counselor: I know professionals in counseling and teaching who exhibit poor hygiene, dress, and might toss some cleavage out from time to time. Students do notice, and it’s not cool. In my profession I want students to see me as casual, clean, and someone they’re drawn to for a good ear and safe space. I don’t want them to see cleavage ever. It’s a distraction. Cleavage is sexy and draws attention no matter what. I’m not drawn to women sexually but I’m super distracted by cleav! I can’t imagine how a person attracted to females would react! I find that when I’m not at work there are dates and social functions available that allow me to find my sexy self, but that self doesn’t fit into the school counseling profession. Yes, women should be able to wear what they want, but the reality is if you sport cleav you’ll receive notice by everyone and there’s a time and place to celebrate our cleav; work may not be the place. (M. Robbins, personal communication, June 30, 2015)
The Man’s “Package”: I noticed there’s no mention of a man’s “package” or the open seating posture many men use that gives quite a clear view of any crotch bulging that may be had. I think this deserves to be discussed as well, and not just as an afterthought – it is at least as important as cleavage to the imagination and distraction.
One thing that seems to go on in common discourse is an acceptance of the idea that men are more sexually focused than women. This is problematic on a couple fronts, I think. Although research shows some increased arousal for men from visual stimuli compared to visual stimuli for women BOTH men and women have been shown to be aroused by visual stimuli. BOTH women and men want sex for physical pleasure, not just as a relational tool. The difference is in degree to which these things are acknowledged by each sex, perhaps, but I haven’t seen compelling evidence that there’s actually a difference in the degree to which men and women can be sexually distracted by physical bodies. It’s neither then men’s nor women’s job, then, to “protect” clients from that distraction more than another (C. Yoshimura, personal communication).
Monitoring Flirtatious Behavior
Behavior standards for mental health professionals are high. This is partly true for being a professional of any type. However, mental health professional standards for dress and flirtation are higher than most other professions. If you think about the setting and process, the high standards make sense. Personal disclosures and conversations that happen during clinical interviews and other mental health-related encounters naturally involve non-sexual intimacy. It follows that deep emotional disclosures and exchanges between client and therapist might arouse feelings related to sexual intimacy in clients and/or therapists. It’s perfectly natural for non-sexual intimacy to sometimes trigger feelings of sexual intimacy . . . and so maintaining professional boundaries in this area is essential. All ethical codes that pertain to professional counselors, psychologists, and social workers prohibit sexual contact between therapist and client. The bottom line is that it’s your responsibility, as a mental health professional or student therapist, to closely monitor your attire and behavior to make certain you’re not directly or indirectly communicating flirtatiously with your clients.
John Sommers-Flanagan 