Category Archives: Clinical Interviewing

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

What’s the Difference between the Clinical Interview and Full-On Counseling or Psychotherapy?

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I know my obsession with all things clinical interviewing is abnormal. This means I already know that most humans on the planet will have no interest in my hashing out the details and differences between clinical interviewing and psychotherapy. So, why then do I persist on blogging about such things? Well, the answer is simple: Obsessions are thoughts and compulsions are behaviors. Therefore, obsessions and compulsions go together like beans and rice. And so, as George Bush senior might have said, “It wouldn’t be prudent to not follow my clinical interviewing obsessions with a clinical interviewing behavior or two.” Now that I think of it, I’m certain that’s exactly what GWB I would have said, had he been asked about this very important situation.

There is, of course, the other reason. I’m revising (along with Rita) our Clinical Interviewing text to put it into the 6th edition. While doing so I have intermittent inspirations to post some of the new material we’re adding here and there. I think to myself . . . “this is the 6th edition of one of the most profound and exciting textbooks of all time and so I’m sure there might be 6 people out there who are interested in reading about what we’re writing.” Then again, as most of us know from either psychological research or common sense, it’s super-easy for me to fool myself into thinking other people are interested in whatever I’m interested in.

Now, having sufficiently fooled or rationalized or intellectualized or inspired myself . . . I present you with our latest thinking on clinical interviewing vs. counseling and psychotherapy.

Clinical interviewing vs. Counseling and Psychotherapy

Students often ask: “What’s the difference between a clinical interview and counseling or psychotherapy?” This is an excellent question and although it’s tempting to answer flatly, “There’s no difference whatsoever” the question deserves a more nuanced response.

The clinical interview is a remarkably flexible and ubiquitous interpersonal process. It’s designed to simultaneously initiate a therapeutic relationship, gather assessment information, and begin therapy. As such, it’s the entry point for clients (or patients) seeking mental health treatment, case management, or any form of counseling. Depending on setting, clinician discipline, theoretical orientation, and other factors, the clinical interview is also commonly known as the intake interview, the initial interview, the psychiatric interview, the diagnostic interview, the first contact or meeting, or any one of a number of other idiosyncratic and theoretically-driven names (Sommers-Flanagan, 2016, in press).

Although it includes therapeutic dimensions, the clinical interview is viewed primarily as an assessment procedure. This is one reason why clinical interviewing is typically included within the assessment portion of course curricula in counseling, psychology, psychiatry, psychiatric nursing, and social work. However, beginning with Constance Fischer’s work on Individualized Psychological Assessment and continuing with Stephen Finn’s articulation and development of therapeutic assessment, it’s also clear that, when done well, clinical assessment is or can be simultaneously therapeutic.

To make matters more complex, every attitude, technique, and strategy described in this text are also the attitudes, techniques, and strategies used in counseling and psychotherapy. Examples (along with their theoretical orientations) range from projective questions (psychoanalytic), therapeutic questions (solution-focused therapy), unconditional positive regard (person-centered), to psychoeducation (cognitive behavior therapy). Even further, some theoretical orientations ignore or de-emphasize assessment to such an extent that the traditional initial clinical assessment interview is transformed completely into an intervention (think solution-focused or narrative). In other cases, the clinical setting or client problem require that single therapy sessions involve an entire course of counseling or psychotherapy. For example,

“. . . in a crisis situation, a mental health professional might conduct a clinical interview designed to quickly establish . . . an alliance, gather assessment data, formulate and discuss an initial treatment plan, and implement an intervention or make a referral.” (Sommers-Flanagan et al., 2015, p. 2)

From this perspective, not only is the clinical interview always the starting point for counseling, psychotherapy, and case management, it also may be the end-point. This is partly because many clients stop treatment after only one therapy session.

There may be other situations where an ordinary therapy session (if there is such a thing) can suddenly transform into a clinical assessment interview. The most common example of this involves suicide assessment interviewing (see Chapter 10). If and when clients begin talking about suicide ideation or exhibiting other suicide risk factors, the usual and customary standard of practice for all mental health and healthcare professionals is to smoothly shift the clinical focus from whatever was happening to a state-of-the-art suicide assessment.

All this leads us to the stunning conclusion: Everything that happens in a full course of counseling or psychotherapy may also occur within the context of a single clinical interview—and vice versa. Although it’s usually the starting point of counseling and psychotherapy, parts of a traditional clinical interview also occur during counseling and psychotherapy, regardless of theoretical orientation. The entire range of attitudes, techniques, and strategies you learn from this text constitute the foundation of skills you’ll need for conducting more advanced and theoretically specific counseling or psychotherapy.

R and J in Field

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

Cleavage, Revisited

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It’s revision time for the Clinical Interviewing textbook (the 6th edition is coming). Revision time also means revisiting time. About three years ago I posted a new proposed section for the 5th edition cleverly titled, “Straight Talk about Cleavage.”

This time around I’m posting our slightly revised version of that section. What’s new is that I’m explicitly asking and hoping for your comments and feedback. Please note that this makes me nervous, but we (Rita and I) hope your comments and feedback will help us provide more perspective and depth to our discussion. We don’t want to come across as old fogeys or rabid feminists. Instead, we want to be reasonable, thoughtful, and balanced . . . and so we’re turning to YOU.

The section is below. You can post comments directly here at Word Press for all to see or email me privately at john.sf@mso.umt.edu.

Straight Talk about Cleavage

Although we don’t have any solid scientific data upon which to base this statement, our best guess is that most of the time 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) and saying something like, “Okay, we need to have a serious talk about cleavage” makes us feel terribly old. But we also 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 somewhat 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 back 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.
  • Commenting on how women dress and making specific recommendations may be viewed as sexist or inappropriately limiting.
  • It’s true that women should be able to dress any way they want.
  • It’s also true that 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 certain 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 appropriate venue for initiating a discourse on social and feminist change.
  • For better or worse, it’s a fact that both 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 phrase) 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 (and men) watch themselves on video from the viewpoint of a client (of either sex) that might feel attracted to them and then discuss how to manage sexual attraction that might occur during therapy.

Obviously, we don’t have perfect or absolute 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 take time to think about this dimension of professional attire and hope you’ll openly discuss cleavage and related issues with fellow students, colleagues, and supervisors.

Clinical Interviewing

Opportunities for Graduate Students and Professors as We Revise Our Clinical Interviewing Textbook

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Revising textbooks is a joy and a burden. When I’m first forced to face the revision process, I feel unfairly burdened. I think things like, “I thought we wrote a perfect book that would last forever. How could anyone think it needs revision?” To say that I lack the necessary enthusiasm is an understatement. I lack any enthusiasm.

However, once I dive back into the text, it’s like visiting an old friend. And in this case, the good news is that it’s like visiting an old friend whom I like very much.

Rita and I started working on the first edition of Clinical Interviewing way back in 1990. Yep. It’s a very old friend.

During the next 6-8 months, we’ll be working on the 6th edition revision. If you’re a graduate student or faculty in Counselor Education, Psychology, or Social Work, we’re looking for your help. But, as before, we really only want your help if it will be meaningful to you. If you think that might be the case, read on:

You’re invited to help in one of four ways:

1. You can choose one or more of the chapters from the fifth edition, read it (them), and offer feedback and advice on changes you think would improve the text. We can take up to three reviewers for each chapter, but more than that will overwhelm us.

2. You can provide us with feedback and recommendations for DVD content that will help in the teaching and learning of basic and advanced counseling and interviewing assessment skills. This is very important because having excellent video content facilitates learning and is one of our big goals.

3. You can provide expert analysis of specific literature related to basic counseling skills and/or advanced interviewing assessment strategies. For example, if you’re on the cutting edge of administering mental status exams (or want to be), we can work together to read and select new literature that will help us update that chapter.

4. You can develop and write up specific classroom activities that help students learn basic and more advanced interviewing skills. If your contribution in this area is original, we’ll work with you to organize your learning activity so that it can be included as a short publication in our electronic instructor’s manual.

5. If you’re an expert in a particular area and want to send us citations of your published work, we’ll review your work and consider including those citations in the 6th edition, as appropriate.

If any of these opportunities sound good to you, or, if you have other ideas, questions, or comments about our revision process, please email me directly at: john.sf@mso.umt.edu.

Thanks for considering these opportunities to contribute to the Clinical Interviewing 6th edition!

Sincerely yours,

John SF

P.S.: In case you don’t know much about this text and the accompanying DVD, here’s what a couple reviewers said:

“A superb synthesis and presentation of the key concepts any beginning student absolutely needs to know about clinical interviewing. John and Rita Sommers-Flanagan make an eloquent case that connecting with the client on a human level is the superordinate task, without which little else of value can be achieved. Replete with relevant clinical examples, helpful how-to hints, as well as pearls of clinical wisdom, this comprehensive yet accessible text is highly recommended.”—Victor Yalom, Ph.D., Founder and CEO, Psychotherapy.net

About the DVD:
“Indispensable interviewing skills imparted by two master teachers in an engaging, multimedia presentation. Following the maxim of ‘show and tell,’ the Sommers-Flanagans provide evidence-based, culture-sensitive relational skills tailored to individual clients. An instructional gem!”
— John C. Norcross, PhD, ABPP, Distinguished Professor of Psychology, University of Scranton; Editor, Psychotherapy Relationships That Work

Clinical Interviewing, Personal Reflections

The Art and Science of Clinical Interviewing (in Chicago)

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In about 10 days I’ll be on my way to Chicago to video-record five short lectures on Clinical Interviewing. Alexander Street Press is producing this video project and Dr. Sharon Dermer of Governor’s State University is hosting. The project is titled “Great Teachers, Great Courses.” [This is pretty cool and my thanks to JC for getting me included.]

I’ll be recording the morning of Tuesday, May 19, which happens to be just before Debbie Joffe Ellis, who just happens to be the wife of the late Albert Ellis. She asked to switch times with me and so I obliged, noting in an email to Dr. Dermer:

Sure. I can do morning. Besides, if I said no I would end up with the Ghost of Albert Ellis’s scratchy voice in the back of my head saying things like, “What the Holy Hell is wrong with you?”

I’d just as soon avoid that.

All this is my slightly braggy way of explaining why I’ll be writing about five upcoming blogs on Clinical Interviewing. Here we go.

What is a Clinical Interview?

Definitions can be slippery. This is especially true when our intention is to define something related to human interaction.

One of my favorite descriptions of clinical interviewing is scheduled for inclusion in the forthcoming “Handbook of Clinical Psychology.” Mostly I suppose I like this description because I wrote it (smiley face). Here it is:

In one form or another, the clinical interview is unarguably the headwaters from which all mental health interventions flow. This remarkable statement has two primary implications. First, although clinical psychologists often disagree about many important matters, the status of clinical interviewing as a fundamental procedure is more or less universal. Second, as a universal procedure, the clinical interview is naturally flexible. This is essential because otherwise achieving agreement regarding its significance amongst any group of psychologists would not be possible. (page numbers tbd)

When it comes to formal definitions, it’s clear that clinical interviewing has been defined in many ways by many authors. Some authors appear to prefer a narrow definition:

An interview is a controlled situation in which one person, the interviewer, asks a series of questions of another person, the respondent. (Keats, 2000, p. 1)

Others are more ambiguous:

An interview is an interaction between at least two persons. Each participant contributes to the process, and each influences the responses of the other. However, this characterization falls short of defining the process. Ordinary conversation is interactional, but surely interviewing goes beyond that. (Trull & Prinstein, 2013, p. 165)

Others emphasize the development of a positive and respectful relationship:

. . . we mean a conversation characterized by respect and mutuality, by immediacy and warm presence, and by emphasis on strengths and potential. Because clinical interviewing is essentially relational, it requires ongoing attention to how things are said and done, as well as to what is said and done. The emphasis on the relationship is at the heart of the “different kind of talking” that is the clinical interview. (Murphy & Dillon, 2011, p. 3)

From my perspective, the BIG goals of this “different kind of talking” can be broken into two main parts: (1) ASSESSMENT and (2) HELPING That said, I’m likely to further break these two main parts into four interrelated and overlapping parts that may or may not be formally including in a single clinical interview:

1. Establishing a therapeutic relationship
2. Collecting assessment information
3. Developing a case formulation or treatment plan
4. Providing a specific educational or psychotherapeutic intervention

What are the Goals of a Clinical Interview?

[In the following two paragraphs I’m including a more wordy and erudite way of saying the preceding . . . which is one of the things that we academics are wont to do. I should note these paragraphs are excerpted from my entry in the Encyclopedia of Clinical Psychology (2015). This piece, very recently published, is cleverly titled, “The Clinical Interview” and coauthored with Drs. Waganesh Abeje Zeleke, and Meredith H. E. Hood.]

Perhaps the clearest way to define a clinical interview is to describe its purpose or goals. Generally, there are four possible goals of a clinical interview. These include: (a) the goal of establishing (and maintaining) a working relationship or therapeutic alliance between clinical interviewer and patient; research has suggested the relationship between interviewer and patient is multidimensional, including agreement on mutual goals, engagement in mutual tasks, and development of a relational bond (Bordin, 1979; Norcross & Lambert, 2011); (b) the goal of obtaining assessment information or data about patients; in situations where the goal of the clinical interview is to formulate a psychiatric diagnosis, the process is typically referred to as a diagnostic interview; (c) the goal of developing a case formulation and treatment plan (although this goal includes gathering assessment information, it also moves beyond problem definition or diagnosis and involves the introduction of a treatment plan to a patient); (d) the goal of providing, as appropriate and as needed, a specific educational or therapeutic intervention, or referral for a specific intervention; this intervention is tailored to the patient’s particular problem or problem situation (as defined in items b and c).

All clinical interviews implicitly address the first two primary goals (i.e., relationship development and assessment or evaluation). Some clinical interviews also include, to some extent, case formulation or psychological intervention. A single clinical interview can simultaneously address all of the aforementioned goals. For example, in a crisis situation, a mental health professional might conduct a clinical interview designed to quickly establish rapport or an alliance, gather assessment data, formulate and discuss an initial treatment plan, and implement an intervention or make a referral.

What Happens During a Clinical Interview?

The range of interactions that can happen during a clinical interview is staggering. This could partly explain why we (foolishly) wrote a textbook on this topic that’s 598 pages long and includes an instructional DVD.

My son-in-law says one good way to get a flavor for any book is to put together the first and last words. In this case, our Clinical Interviewing text reads (not including the front or back matter), “This . . . culture.” To give you a further taste of “This . . . Clinical Interviewing . . . culture,” here’s a modified excerpt from the text:

Imagine sitting face-to-face with your first client. You carefully chose your clothing. You intentionally arranged the seating, set up the video camera, and completed the introductory paperwork. You’re doing your best to communicate warmth and helpfulness through your body posture and facial expressions. Now, imagine that your client:

  • Refuses to talk.
  • Talks so much you can’t get a word in.
  • Asks to leave early.
  • Starts crying.
  • Tells you that you’ll never understand because of your racial or ethnic differences.
  • Suddenly gets angry (or scared) and storms out.

Any and all of these responses are possible in an initial clinical interview. If one of these scenarios plays out, how will you respond? What will you say? What will you do?

From the first client forward, every client you meet will be different. Your challenge or mission (if you choose to accept it) is to make human contact with each client, to establish rapport, to build a working alliance, to gather information, to instill hope, and, if appropriate, to provide clear and helpful professional interventions. To top it off, you must gracefully end the interview on time and sometimes you’ll need to do all this with clients who don’t trust you or don’t want to work with you. (pp. 3-4)

In my opening Great Teachers, Great Courses lecture I’ll be focusing on the definition of the clinical interview and then limit myself to describing and demonstrating about 18 different interviewing “behaviors” or responses that clinicians who conduct clinical interviewing have at their disposal. These behaviors are named and organized into three categories. And so to help myself stop writing this blog and get back to work, I’ll wait and write about them later.

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Clinical Interviewing

Nice Review

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Victor Yalom of Psychotherapy.net recently emailed us a copy of a review of our Clinical Interviewing DVD. This is a wonderful review from someone we’ve never met . . . but we think we’d like him. He’s a professor at Western Illinois University.
Here’s an abstract of the review.
Interviewing with humanity intact.
By Knight, Tracy A.
PsycCRITIQUES, Vol 60(9), 2015, No Pagination Specified.
Abstract
Reviews the video, Clinical Interviewing: Intake, Assessment & Therapeutic Alliance by John Sommers-Flanagan and Rita Sommers-Flanagan (2014). This video blends the procedural with the human in a way that will enhance and deepen the training of mental health professionals. Beyond describing the most valuable guidelines of clinical interviewing, John and Rita Sommers-Flanagan provide multiple illustrative interviews with clearly nonscripted participants. Most importantly, the Sommers-Flanagans discuss both the information as well as the interviews, displaying both their depth of knowledge and perhaps the most important attributes of gifted clinicians: humility and curiosity. They not only provide a map, therefore, but also fully display and describe the landscape that interviewers and their clients traverse. The DVD includes seven distinct areas of focus, each one building on the previous. Initially, the authors succinctly describe basic listening skills, including both nondirective and directive approaches. Their definitions are clear and evocative, and during the sample interviews, the distinct attributes of the therapist’s actions are listed for viewers. This sets the stage for the authors’ subsequent discussion, during which they explore the dynamics of the sample interview and lucidly discuss important human factors. The reviewer concludes this video offers both knowledge and wisdom, providing students and trainees with an approach to clinical interviewing that makes the process more efficient, while always respecting the beating heart of humanity that rests within it. (PsycINFO Database Record (c) 2015 APA, all rights reserved)
Clinical Interviewing, Suicide Assessment and Intervention

Suicide Risk Factors, Part III

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It’s been awhile since I started my holiday and post-holiday look at suicide risk factors. In previous posts I focused on Demographic and Ethnic Factors related to death by suicide and then on the broad category of Mental Disorders and Psychiatric Treatment. This post focuses on Personal and Social Factors that are linked to suicide.

Not to worry, soon I’ll be moving beyond this tragic but important topic.

The following is mostly an excerpt from our Clinical Interviewing text.

Social and Personal Factors

There are a number of social and personal factors linked to increased suicide risk. Many of these factors have been reviewed and integrated into Thomas Joiner’s interpersonal theory of suicide (Joiner & Silva, 2012; Van Orden et al., 2010).

Social Isolation/Loneliness
In a review of the literature, 34 research studies were identified that include support for social isolation as a suicide risk factor (Van Orden et al., 2010). These findings provide support for Joiner’s (Joiner & Silva, 2012) attachment-informed interpersonal theory of suicide. Van Orden et al (2008) described the two primary dimensions of Joiner’s interpersonal theory:

The theory proposes that the needs to belong and to contribute to the welfare of close others are so fundamental that the thwarting of these needs (i.e., thwarted belongingness and perceived burdensomeness) is a proximal cause of suicidal desire. (Van Orden et al., 2008, p. 72)

Interpersonal theory explains why a number of social factors, such as unemployment, social isolation, reduced productivity, and physical incapacitation are associated with increased suicide risk. Specifically, research indicates that divorced, widowed, and separated people are in a higher suicide-risk category and that single, never-married individuals have a suicide rate nearly double the rate of married individuals (Van Orden et al., 2010). Based on interpersonal theory, an underlying reason that these factors are linked to suicidality is because they involve thwarted belongingness and a self-perception of being a burden to family and friends, rather than contributing in a positive way to the lives of others.

In a fairly recent study, the suicide notes of 98 active duty U.S. Air Force (USAF) members were analyzed. Using Joiner’s interpersonal theory, results indicated strong themes of hopelessness, perceived burdensomeness, and thwarted belongingness. Overall, interpersonal risk factors were communicated more often than intrapsychic risk factors. (Cox et al., 2011).

Physical Illness

Many decades of research have established the link between physical illness and suicide. Specific illnesses that confer suicide risk include brain cancer, chronic pain, stroke, rheumatoid arthritis, hemodialysis, and HIV-AIDS (e.g., (Lin, Wu, & Lee, 2009; Martiny, de Oliveira e Silva, Neto, & Nardi, 2011). Overall, although physical illness is a major predictor, several social factors appear to mediate the relationship between illness and death by suicide. In particular, Joiner’s concept of becoming a social burden seems a likely contributor to suicidal behavior, regardless of specific diagnosis (Van Orden et al., 2010). Similar to previously hospitalized psychiatric patients, medical patients also exhibit higher suicidal behavior shortly after hospital discharge (McKenzie & Wurr, 2001).

Previous Attempts

Over 27 separate studies have indicated that suicide risk is higher for people who have previously attempted (Beghi & Rosenbaum, 2010). Van Orden et al. (2010) refer to previous attempts as “. . . one of the most reliable and potent predictors of future suicidal ideation, attempts, and death by suicide across the lifespan” (p. 577).

As one example, in a 15-year prospective British study of deliberate self-harm, repeated self-harm was a strong predictor of eventual suicide, especially in young women (Zahl & Hawton, 2004). By the study’s end, 4.7% of women who had repeatedly engaged in deliberate self-harm committed suicide as compared to 1.9% in the single episode group. In this study, deliberate self-harm was defined as intentionally poisoning or self-injuring that resulted in a hospital visit. The study concluded that repeated deliberate self-harm increases suicide risk in males and females, but is a particularly salient predictor in young females. This is the case despite the fact that some clients use cutting, burning, or other forms of self-harm to aid in emotional regulation. Overall the research suggests that self-harm that rises to the level of hospitalization is likely beyond that which enhances self-regulation and instead constitutes practicing or successive approximation toward suicide.

Unemployment

Individuals who have suffered any form of recent, significant personal loss should be considered higher suicide risk (Hall, Platt, & Hall, 1999). However, in particular, unemployment is a life situation that repeatedly has been linked to suicide attempts and death by suicide. Joiner’s (2005) interpersonal theory of suicide posits that unemployment confers suicide risk at least partly because of individuals experiencing an increased sense of themselves as a burden on others. Other losses that can increase risk include (a) status loss, (b) loss of a loved one, (c) loss of physical health or mobility, (d) loss of a pet loss, and (e) loss of face through recent shameful events (Beghi & Rosenbaum, 2010; Packman, Marlitt, Bongar, & Pennuto, 2004).

Sexual Orientation

Over the years the data have been mixed regarding whether gay, lesbian, bisexual, or transgender individuals constitute a high suicide risk group. More recently, a 2011 publication in the Journal of Homosexuality reported there is no clear and convincing evidence that GLBT individuals die by suicide at a rate greater than the general population (Haas et al., 2011).
Although this is good news, the data also show that GLB populations have significantly higher suicide attempt rates. Haas et al (2011) wrote:

Since the early 1990s, population-based surveys of U.S. adolescents that have included questions about sexual orientation have consistently found rates of reported suicide attempts to be two to seven times higher in high school students who identify as LGB, compared to those who describe themselves as heterosexual. (p. 17)

Overall, it’s likely that transgender people and youth questioning their sexuality may be at increased risk for suicide attempts or death by suicide. Additionally, GLBT youth who have experienced homosexual-related verbal abuse and parental rejection for their behaviors related to gender and sexuality are more likely to engage in suicidal behaviors (D’augelli et al., 2005).

In conclusion, as you can probably see from this and the two previous posts, there are many complex and potentially interacting factors associated with increased suicide risk, but no great predictors. This is unfortunate for those of us who would like to use prediction methods to prevent and reduce suicide rates. But, at the same time, the fact that many people who experience great suffering in their lives still choose life, is a testament to human strength and resiliency.

And, speaking of resiliency, maybe I’ll be focusing on an exciting and upbeat topic like that next time. Until then, I wish you all the best in your efforts to help your clients through difficult times in their lives. Your work may be more important than you think.

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice, Suicide Assessment and Intervention

Suicide Risk Factors: Part II

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There are many ways to think about suicide risk factors. In my last post, I focused on demographic and ethnic factors related to death by suicide. In this post, the focus is on the broad category of Mental Disorders and Psychiatric Treatment. The next post will focus on Personal and Social Factors that are linked to suicide.

As you’ll see below, the relationship between mental disorders, psychiatric treatment, and suicide is complex. The following material is adapted from our textbook, Clinical Interviewing and so you can find more information there: http://www.amazon.com/Clinical-Interviewing-John-Sommers-Flanagan/dp/1118270045/ref=asap_B0030LK6NM?ie=UTF8

Mental Disorders and Psychiatric Treatment

In general, psychiatric diagnosis is considered a risk factor for suicide. However, some diagnostic conditions (e.g., bipolar disorder and schizophrenia) have higher suicide rates than others (e.g., specific phobias and oppositional-defiant disorder). Several diagnostic conditions associated with heightened suicide risk are discussed in this section.

Schizophrenia

Schizophrenia is a good example of a mental disorder that has a complex association with increased suicide risk. As you may realize, many individuals diagnosed with schizophrenia are unlikely to attempt suicide or die by suicide. Some individuals with a schizophrenia diagnosis are at higher suicide risk than others.

In 2010, Hor and Taylor conducted a research review of risk factors associated with suicide among individuals with a diagnosis of schizophrenia. They initially identified 1,281 studies, eventually narrowing their focus to 51 with relevant schizophrenia-suicide data. Overall, they reported a lifetime suicide risk of about 5% (Hor & Taylor, 2010). Given that the annual risk in the general population is about 12 in 100,000 and assuming a life expectancy of 70 years the general lifetime risk is likely about 840 in 100,000 or 0.84%. This suggests that suicide risk among individuals diagnosed with schizophrenia is about 6 times greater than suicide risk within the general population.

However, there are unique predictive factors within the general population of individuals diagnosed with schizophrenia that further refine and increase suicide prediction. Hor and Taylor (2010) reported the following more specific suicide risk factors within the general population of individuals with a schizophrenia diagnosis:

  • Age (being younger)
  • Sex (being male)
  • Higher education level
  • Number of prior suicide attempts
  • Depressive symptoms
  • Active hallucinations and delusions
  • Presence of insight into one’s problems
  • Family history of suicide
  • Comorbid substance misuse (p. 81)

If you’re working with a client diagnosed with schizophrenia, the lifetime suicide prevalence for that client is predicted to be higher than in the general population. Presence of any of the preceding factors further increases that risk. This leaves a “highest risk prototype” among clients with schizophrenia as:

A young, male, with higher educational achievement, insight into his problems/diagnosis, a family history of suicide, previous attempts, active hallucinations and delusions, along with depressive symptoms and substance misuse.

Given what’s known about suicide unpredictability, it’s also important to remember that someone who fits the highest risk prototype may not be suicidal, whereas a client with no additional risk factors may be actively suicidal.

Depression

The relationship between depression and suicidal behavior is very well established (Bolton, Pagura, Enns, Grant, & Sareen, 2010; Holikatti & Grover, 2010; Schneider, 2012). Some experts believe depression is always associated with suicide (Westefeld and Furr, 1987). This close association has led to the labeling of depression as a lethal disease (Coppen, 1994).

It’s also clear that not all people with depressive symptoms are suicidal. In fact, it appears that depression by itself is much less of a suicide predictor than depression combined with another disturbing condition or conditions. For example, when depression is comorbid (occurring simultaneously) with anxiety, substance use, post-traumatic stress disorder, and borderline or dependent personality disorder, risk substantially increases. (Bolton et al., 2010). Earlier research also supports this pattern, with suicidality increasing along with additional distressing symptoms or experiences, including:

  • Severe anxiety
  • Panic attacks
  • Severe anhedonia
  • Alcohol abuse
  • Substantially decreased ability to concentrate
  • Global insomnia
  • Repeated deliberate self-harm
  • History of physical/sexual abuse
  • Employment problems
  • Relationship loss
  • Hopelessness (Fawcett, Clark, & Busch, 1993; Marangell et al., 2006; Oquendo et al., 2007)

Given this pattern it seems reasonable to conclude that when clients are experiencing greater depression severity and/or additional distressing symptoms, suicide risk increases. Van Orden and colleagues offered a similar conclusion:

. . . data indicate that depression is likely associated with the development of desire for suicide, whereas other disorders, marked by agitation or impulse control deficits, are associated with increased likelihood of acting on suicidal thoughts. (Van Orden et al., 2010, p. 577)

Bipolar Disorder

Research has repeatedly shown that individuals diagnosed with bipolar disorder at increased risk of suicide. Similar to schizophrenia and depression, there are many specific risk factors that predict increased suicidality among clients with bipolar disorder.

In a large-scale French study, eight risk factors were linked to lifetime suicide attempts (Azorin et al., 2009). These included:

1. Multiple hospitalizations
2. Depressive or mixed polarity of first episode
3. Presence of stressful life events before illness onset
4. Younger age at onset
5. No symptom-free intervals between episodes
6. Female sex
7. Greater number of previous episodes
8. Cyclothymic temperament (p. 115)

These findings are consistent with the research on unipolar depression; it appears that severity of bipolar disorder and accumulation of additional distressing experiences increase suicide risk. Another study identified (a) White race, (b) family suicide history, (c) history of cocaine abuse, and (d) history of benzodiazepine abuse were associated with increased suicide attempts (Cassidy, 2011)

Post-Traumatic Stress

In 2006, renowned psychologist Donald Meichenbaum reflected on his 35-plus years of working with suicidal clients. He wrote:

In reviewing my clinical notes from these several suicidal patients and the consultations that I have conducted over the course of my years of clinical work, the one thing that they all had in common was a history of victimization, including combat exposure (my first clinical case), sexual abuse, and surviving the Holocaust. (Meichenbaum, 2006, p. 334)

Clinical research supports Meichenbaum’s reflections. For example, in a file review of 200 outpatients, child sexual abuse was a better predictor of suicidality than depression (Read, Agar, Barker-Collo, Davies, & Moskowitz, 2001). Similarly, data from the National Comorbidity Survey (N = 5,877) showed that women who were sexually abused as children were 2 to 4 times more likely to attempt suicide, and men sexually abused as children were 4 to 11 times more likely to attempt suicide (Molnar, Berkman, & Buka, 2001). Overall, research over the past two decades points to several stress-related experiences as linked to suicide attempts and death by suicide (Wilcox & Fawcett, 2012). These include general trauma, stressful life events, and childhood abuse and neglect. Characteristics of these experiences that are most predictive of suicide are:

  • Assaultive abuse or trauma.
  • Chronicity of stress or trauma.
  • Severity of stress or trauma.
  • Earlier developmental stress or trauma. (Wilcox & Fawcett, 2012)

These particular life experiences appear related to suicidal behavior across a variety of populations—including military personnel, street youth, and female victims of sexual assault (Black, Gallaway, Bell, & Ritchie, 2011; Cox et al., 2011; Hadland et al., 2012; Snarr et al., 2010; Spokas, Wenzel, Stirman, Brown, & Beck, 2009).

Substance Abuse

Research is unequivocal in linking alcohol and drug use to increased suicide risk (Sher, 2006). Suicide risk increases even more substantially when substance abuse is associated with depression, social isolation, and other suicide risk factors.

One way that alcohol and drug use increases suicide risk is by decreasing inhibition. People act more impulsively when in chemically altered states and suicide is usually considered an impulsive act. No matter how much planning has preceded a suicide act, at the moment the pills are taken, the trigger is pulled, or the wrist is slit, some theorists believe that some form of disinhibition or dissociation has probably occurred (Shneidman, 1996). Mixing alcohol and prescription medications can further elevate suicide risk.

Several other specific mental disorders have clear links to death by suicide. These include:

  • Anorexia nervosa
  • Borderline personality disorder
  • Conduct disorder (see Van Orden et al., 2010)

Post-Hospital Discharge

For individuals admitted to hospitals because of a mental disorder, the period immediately following discharge carries increased suicide risk. This is particularly true of individuals who have additional risk factors such as previous suicide attempts, lack of social support, and chronic psychiatric disorders. Overall, suicide ideation and attempts are predictably high. In one study 3.3% completed suicide within 6 months of discharge, whereas 39.4% had self-harm behaviors or suicide attempts (Links et al., 2012). Another study reported “3% of patients categorized as being at high risk can be expected to commit suicide in the year after discharge” (Large, Sharma, Cannon, Ryan, & Nielssen, 2011, p. 619).

Selective Serotonin Reuptake Inhibitors (SSRIs)

Over the past two decades, empirical data linking SSRI medications to suicidal impulses has accumulated to the point that recent administration of SSRI medications should be considered a possible suicide risk factor (Breggin, 2010; Valenstein et al., 2012). This is true despite the fact that some research also shows that SSRI antidepressants reduce suicide rates (Kuba et al., 2011; Leon et al., 2011). Overall, it appears that in a minority of clients (2–5%) SSRI antidepressants may increase agitation in a way that contributes to increased risk for suicidal behaviors (J. Sommers-Flanagan & Campbell, 2009).

In September 2004, an expert panel of the U.S. Food and Drug Administration (FDA) voted 25–0 in support of an SSRI-suicide link. Later, the panel voted 15–8 in favor of a “black box warning” on SSRI medication labels. The warning states:

Antidepressants increased the risk compared to placebo of suicidal thinking and behavior (suicidality) in children, adolescents, and young adults in short-term studies of Major Depressive Disorder (MDD) and other psychiatric disorders. Patients of all ages who are started on antidepressant therapy should be monitored appropriately and observed closely for clinical worsening, suicidality, or unusual changes in behavior. Families and caregivers should be advised of the need for close observation and communication with the prescriber.

In 2006, the FDA extended its SSRI suicidality warning to adult patients aged 18–24 years (United States Food and Drug Administration, 2007).

There’s no doubt that debate about whether SSRI medications increase suicide risk will continue. In the meantime, prudent practice dictates that mental health providers be alert to the possibility of increased suicide risk among clients who have recently been prescribed antidepressant medications (Sommers-Flanagan & Campbell, 2009).

In the next post in this series I’ll be focusing on Personal and Social factors associated with suicide.

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice

Reviews of our Counseling and Psychotherapy Theories and Clinical Interviewing DVDs

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For those interested, I’ve put together some information on our Theories and Clinical Interviewing DVDs. Obviously these are positive reviews and I feel shy about posting them, but I also am very happy that these tools for helping people become better counselors and psychotherapists have been so well-received. Thanks to everyone who made these productions possible.

The Theories DVD

From Psychotherapy.net:

Finding a single video demonstrating psychotherapy’s major theoretical orientations has long been next to impossible. Now, Psychotherapy.net is thrilled to offer a masterful survey of the field’s most studied theories to students and instructors alike. You won’t want to miss this video, in which seasoned clinical educators John and Rita Sommers-Flanagan present a practical, in-depth guide through the origins, recent developments, and applications related to eleven major counseling theories, complete with valuable learning aids and extended case studies.

Over the course of eleven compelling segments, the Sommers-Flanagans outline a range of therapeutic orientations, from psychoanalysis to solution-focused therapy and more; each has its own strategies, interventions, and beliefs about the nature of change. Watch John Sommers-Flanagan help 10-year-old Clayton feel better about his “tattletale” brother using an Adlerian family constellation interview. Understand what’s preventing Brittany from attending college classes—and how she can correct this to avoid expulsion—during a behavioral therapy session with Selena Beaumont Hill. See how a feminist approach informs Rita Sommers-Flanagan’s moving work with Amanda, a young woman finding her identity amid a culturally complex web of relationships. And see how family systems therapist Kirsten Murray reengages a stressed family of four in a powerful family sculpt.

Designed for beginners and seasoned therapists alike, this video distills the essence of the major theories of psychotherapy, offering theoretically-grounded interventions and techniques that will be of use to any therapists looking to broaden their toolbox.

Whether you’re a student wanting to understand the basics of different theoretical orientations, a practitioner seeking review materials, or an instructor looking for a single video comparing and contrasting a range of approaches, you’ll find what you need in this comprehensive, one-of-a-kind video.

Theories covered in this video include:
• Psychoanalytic/psychodynamic
• Existential
• Rogerian/Person-Centered
• Gestalt
• Behavior
• Cognitive-Behavioral (CBT)
• Solution-Focused
• Feminist
• Adlerian
• Reality
• Family Systems

Reviews of the Theories DVD from Amazon

1. I just completed my Marriage and Family Psychotherapist graduate program. This book and the DVD helped me to study for my comps.

I recommend that you buy it. I love the way that it is written. Very easy to follow. I really like these two authors. I have other books written by them.

2. There are some horrible counseling instructional videos out there on the market from the 70’s and 80’s and it is hard to find such a rare gem here.

This video can be watched in full screen on a HD television with excellent audio and instructional effects (being able to see counselor’s drawings, written goals, highlights of therapy, etc.). The two authors/producers of this video are also in roughly half of the respective therapies that are gone over. As for behavioral therapy, solutions focused therapy, and family systems they use outside “expert” counselors that do a fantastic job.

I am almost exclusively a visual learner, and this video not only made it simple to understand and grasp all common therapies out there in the professional counseling realm, but also was instrumental in measuring and understanding the intangible traits all good counselors should have (using pause appropriately, asking questions, demeanor, body language, etc.).

3. For the aspiring counselor, this video is worth its weight in gold. Thank you! This DvD is excellent for the classes I teach. It reinforces the students learning. I highly recommend it. Buy it.

4. Thank you Sommers-Flanagans for this great additional resource! Insightful look into the work of masters of the art of therapy.

You can access these DVDs through Wiley: http://lp.wileypub.com/SommersFlanagan/

psychotherapy.net: http://www.psychotherapy.net/

and other online booksellers like Amazon.

The Clinical Interviewing DVD

Professional Reviews:

“Indispensable interviewing skills imparted by two master teachers in an engaging, multimedia presentation. Following the maxim of ‘show and tell,’ the Sommers-Flanagans provide evidence-based, culture-sensitive relational skills tailored to individual clients. An instructional gem!”
— John C. Norcross, PhD, ABPP, Distinguished Professor of Psychology, University of Scranton; Editor, Psychotherapy Relationships That Work

“Before watching this video, I’d considered the text Clinical Interviewing a ‘must-read,’ and now after watching the accompanying video, I consider the book in combination with the video video to be a ‘must-have!’ This video clearly demonstrates essential skills for beginning therapists with a culturally diverse group of clients, and is a valuable resource for training programs and any beginning clinician who wants to be the best they can be!”
— Pamela A. Hays, PhD, Author of Addressing Cultural Complexities in Practice; Supervisor for The Kenaitze Tribe’s Nakenu Family Center, Soldotna, Alaska

From Psychotherapy.net

Simply put, we believe this to be the best video on this topic ever produced, and in fact one of the top training videos in the entire field of psychotherapy and counseling! We’ve been in the business of producing and distributing videos in the field since 1995, so we don’t make this statement lightly. (And we aren’t patting ourselves on the back; we wish we could take credit for this one, but we didn’t actually produce it ourselves.)

Whether you’re just starting out with clients or looking to expand your intake and assessment skills, this comprehensive video with John and Rita Sommers-Flanagan will guide you through the full assortment of clinical interviewing techniques.

This video will help you gain confidence in both the science and the art of the clinical interview, and offer you the “foundation for intuition” that informs therapeutic assessment, intervention, and relationship-building skills.

Skills, steps, and protocols are all covered here, with discussions of multicultural counseling, mental status examinations, and collaborative processes. You’ll also see what not to do with a client, as part of a comical but cautionary demonstration on the pitfalls of directive interventions. For new and experienced clinicians alike, this comprehensive yet accessible video is a must-have in your toolkit.

By watching this video, you will:
• Identify interventions along a continuum of clinical listening responses, from basic to complex.
• Understand the goals and steps of different clinical assessments and examinations.
• Learn tools for establishing and deepening the therapeutic alliance during various types of clinical interventions.

Clinical Interviewing, Multicultural, Personal Reflections

Cultural Adaptations in the DSM-5: Insert Foot in Mouth Here

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Sometimes it just seems easier to be snarky than balanced. This basic truth comes to mind because of a recent analysis I did of the Cultural Formulation Interview (CFI) from the DSM-5. As I read about the CFI and looked through its Introduction and 16 questions for “patients,” I kept thinking to myself things like,

“Seriously . . . could this really be the best cultural sensitivity that the American Psychiatric Association can manage when it comes to guidelines for interviewing minority cultures?”

And,

“Who wrote this and why didn’t they ask me for some help?” (insert smiley face here; please note that some of my colleagues at the University of Montana have noticed—and commented—on the fact that I tend to insert a smiley face icon right after texting or emailing my personal version of punchy, snarky, sarcasm).

Ha! is all I have to say to them (FYI: Ha! is my programmed default back up to my default smiley face snark signal).

Anyway . . . the point! It’s way easier for me to be critical of the American Psychiatric Association than balanced. In truth, the CFI is a reasonable effort. And, if you think about where the APA is coming from (and likely going to) then the CFI is a massive effort. I should be saying, “Cool! I’m so excited to see the CFI as part of the DSM-5.

All this is prologue for the excerpt I include below. This is an excerpt from a draft chapter I’m writing for the Handbook of Clinical Psychology . . . to be published at some point in the not too distant future. Here’s the excerpt; it focuses on cultural adaptations we can make when conducting initial clinical interviews with minority clients; forgive the roughness of the draft.

Cultural Adaptations

A clinical interview is a first impression, and first impressions are powerful influences on later relational interactions, which is why we need to make cultural adaptations when conducting clinical interviews. One of the best sources for cultural adaptations is the already-existing guidance from psychotherapy research on working multiculturally. These guidelines include: (a) using small talk and self-disclosure with some cultural groups, (b) when feasible, conducting initial interviews in the patient’s native language, (c) seeking professional consultations with professionals familiar with the patient’s culture; (d) avoiding the use of interpreters except in emergency situations; (e) providing services (e.g., childcare) that help increase patient retention, (f) oral administration of written materials to patients with limited literacy, (g) having awareness and sensitivity to client age and acculturation, (h) aligning assessment and treatment goals with client culturally-informed expectations and values, (i) regularly soliciting feedback regarding progress and client expectations and responding immediately to client feedback, and (j) explicitly incorporating cultural content and cultural values into the interview, especially with patients not acculturated to the dominant culture (see Griner & Smith, 2006; Hays, 2008; Smith, Rodriguez, & Bernal, 2011).

Cultural awareness, cross cultural sensitivity, and making cultural adaptations are especially important to assessment and diagnosis. This is partly because mental health professionals have a long history of inappropriately or inaccurately assigning psychiatric diagnoses to cultural minority groups (Paniagua, 2014). To address this challenge, in the latest edition of the Diagnostic and Statistical Manual (DSM-5; American Psychiatric Association, 2014), a Cultural Formulation Interview (CFI) protocol is included to aid the diagnostic interview process.

The CFI is a highly structured brief interview. It is not a method for assigning clinical diagnoses; instead, its purpose is to function as a supplementary interview that enhances the clinician’s understanding of potential cultural factors. It also may aid in the diagnostic decision-making process. The CFI includes an introduction and four sections (composed of 16 specific questions). The four sections include:

1. Cultural definition of the problem
2. Cultural perceptions of cause, context, and support
3. Cultural factors affecting self-coping and past help seeking
4. Cultural factors affecting current help seeking

Questions from each section are worded in ways to help clinicians gently explore cultural dimensions of their clients’ problems. Question 2 is a good representation: “Sometimes people have different ways of describing their problem to their family, friends, or others in their community. How would you describe your problem to them?” (American Psychiatric Association, 2014).

Clinicians are encouraged to use the CFI in research and clinical settings. There is also a mechanism for users to provide the American Psychiatric Association with feedback on the CFI’s utility. It may be reproduced for research and clinical work without permission, which is a cool thing.

If you Google: “Cultural Formulation Interview” the first non-advertised hit should be a .pdf of the CFI.

If you Google: “Clinical Interviewing” the first several hits will take you to some form or another of our text on the topic.

Here’s a photo of me “working” inter-culturally with my brother-in-law (insert smiley face here):

Rebekah.Johnson.photo_0451

 

 

Clinical Interviewing, Therapy with Adolescents, Tough Kids, Tough Kids Cool Counseling

Two Conduct Disorder Articles and Powerpoints

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In concert with my Webinar today with Western Montana Addiction Services, below are links to two Conduct Disorder assessment articles. One is by Rita and me from 1998; the other is a 2013 article in Professional Psychology.

Evidence-Based CD Assessment 2013

SF and SF Conduct Disorder Article

WMAS ODD REV