Tomorrow at noon Mountain Time, Western Montana Addiction Services is sponsoring a one-hour webinar on the diagnosis and assessment of oppositional defiant disorder and conduct disorder. I’ll be the presenter. If you’re interested in tuning in, you’ll need to email Erin Wenner at: ewenner@wmmhc.org to get instructions on how to gain access. This month I’ll be focusing on very basic diagnosis and assessment issues related to ODD and CD. Next month on June 10th at noon, I’ll be focusing counseling or treatment issues.
Category Archives: Clinical Interviewing
An Intake Interview Outline and Activity
Aloha from Honolulu. This week Rita and I have been working from Honolulu, Hawaii as we attend and present at the annual convention of the American Counseling Association. Yesterday we presented on how counselors can integrate evidence-based relationships into the first interview. This is mostly based on John Norcross’s excellent work on evidence-based relationships. After the presentation one attendee asked if I could send him a copy of an intake interview outline. . . and so I’m posting a brief intake interview outline and an associated classroom activity below.
More on Highlights from Honolulu soon. But here’s an intake outline for now. This is from the Clinical Interviewing text, but you should keep in mind that the Clinical Interviewing text also includes a more extensive outline. See: http://www.amazon.com/Clinical-Interviewing-John-Sommers-Flanagan/dp/1118270045/ref=la_B0030LK6NM_1_1?s=books&ie=UTF8&qid=1396163487&sr=1-1
A Brief Intake Checklist
When necessary, the following topics may be covered quickly and efficiently within a time-limited model.
______ 1. Obtain presession or registration information from the client in a sensitive manner. Specifically, explain: “This background information will help us provide you with services more efficiently.”
______ 2. Inform clients of session time limits at the beginning of their session. This information can also be provided on the registration materials. All policy information, as well as informed consent forms, should be provided to clients prior to meeting with their therapist.
______ 3. Allow clients a brief time period (not more than 10 minutes) to introduce themselves and their problems to you. Begin asking specific diagnostic questions toward the 10-minute mark, if not before.
______ 4. Summarize clients’ major problem (and sometimes a secondary problem) back to them. Obtain agreement from them that they would like to work on their primary problem area.
______ 5. Help clients reframe their primary problem into a realistic long-term goal.
______ 6. Briefly identify how long clients have had their particular problem. Also, ask for a review of how they have tried to remediate their problem (e.g., what approaches have been used previously).
______ 7. Identify problem antecedents and consequences, but also ask clients about problem exceptions. For example: “Tell me about times when your problem isn’t occurring. What happens that helps you eliminate the problem at those times?”
______ 8. Tell clients that their personal history is important to you, but that there is obviously not time available to explore their past. Instead, ask them to tell you two or three critical events that they believe you should know about them. Also, ask them about (a) sexual abuse, (b) physical abuse, (c) traumatic experiences, (d) suicide attempts, (e) episodes of violent behavior or loss of personal control, (f) brain injuries or pertinent medical problems, and (g) current suicidal or homicidal impulses.
______ 9. If you will be conducting ongoing counseling, you may ask clients to write a brief (two- to three-page) autobiography.
______ 10. Emphasize goals and solutions rather than problems and causes.
______ 11. Give clients a homework assignment to be completed before they return for another session. This may include behavioral or cognitive self-monitoring or a solution-oriented exception assignment.
______ 12. After the initial session, write up a treatment plan that clients can sign at the beginning of the second session.
Prompting Clients to Stick With Essential Information
Using the limited-session intake-interviewing checklist provided in Table 7.2, work with a partner from class to streamline your intake interviewing skills. Therapists working in a managed care environment must stay focused and goal-directed throughout the intake interview. To maintain this crucial focus, it may be helpful to:
1. Inform your client in advance that you have only a limited amount of time and therefore must stick to essential issues or key factors.
2. If your client drifts into some less-essential area, gently redirect him or her by saying something such as:
“You know, I’d like to hear more about what your mother thinks about global warming (or whatever issue is being discussed), but because our time is limited, I’m going to ask you a different set of questions. Between this meeting and our next meeting, I want you to write me an autobiography—maybe a couple of pages about your personal history and experiences that have shaped your life. If you want, you can include some information about your mom in your autobiography and get it to me before our next session.”
Often, clients are willing to talk about particular issues at great length, but when asked to write about those issues, they’re much more succinct.
Overall, the key point is to politely prompt clients to only discuss essential and highly relevant information about themselves. Either before or after practicing this activity with your partner, see how many gentle prompts you can develop to facilitate managed care intake interviewing procedures.
What You Missed in Cincinnati
For me, the hardest thing about presenting professional workshops is time management. I want participants to comment, but how can I plan in advance for exactly how long their comments will be? Even worse, how can I accurately estimate the length of my own impromptu moments? It seems obvious that there’s a need for spontaneity. I don’t want to cut off potentially valuable comments from participants . . . and I don’t want to cut off my own creative musings either. Clearly, the clock is my workshop enemy.
For example, how could I know in advance that I would suddenly feel compelled to share a personal dream of mine with 85 of my new Cincinnati counselor friends? Never before had I shared with a workshop audience that 45 years-ago I dreamt I was Felix-the-Cat and then while crossing the road (as Felix), I got hit by a car . . . and died.
But then I woke up and have kept on living.
I like to think that particular disclosure is a perfectly normal thing to do when you’ve got a group of professional counselors to listen to you.
The point was to bust the myth that some teenage client have (and will talk about in counseling) that if they dream they die, it is prophetic and means they’ll die soon in real life also.
And beyond my personal dream disclosure, how would I know that one of the participants would have such passion that he would accept an invitation to come up to the microphone and share a physical relaxation technique that he uses with elementary school students.
These are just two samples of the sort of thing you missed because you weren’t in Cincinnati at the Schiff Center on the Xavier University campus yesterday.
But you also missed the start of the workshop where I decided on the spot that it was just the right time and place for me to open the workshop with a story of the most embarrassing moment in my life. It struck me as an awesome idea at the time . . . and it really was the most embarrassing moment of my life . . . until a few hours later when I shared my Felix-the-Cat dream.
There are always bigger mountains to climb.
You also missed meeting my incredibly gracious hosts from the Greater Cincinnati Counseling Association including, Butch Losey (who’s the most humble and understated guy who should be famous I’ve ever met), Kay Russ (who’s right up there with the most responsible person I’ve ever met), and Brent Richardson (who is as irreverent and insightful as ever), and Robert Wubbolding (who may be on his way to Casablanca to do a week long choice theory/reality therapy workshop by the time I post this and yet took eight hours out of his life to attend the workshop anyway).
So that’s just a little taste of what you missed in Cincinnati.
I’ll bet you wish you were there. I know I’m glad I was.
A Brief History of the Clinical Interview
This is a short excerpt (pre-publication) from the forthcoming Encyclopedia of Clinical Psychology, edited by R. Cautin and S. Lilienfeld. My coauthors on this were Waganesh Zeleke and Meredith Hood. Waganesh is now at Duquesne University and Meredith is busy working on her dissertation.
This section is an interesting–albeit academically oriented–description of the history of the clinical interview.
A Brief History of the Clinical Interview
The term “interview” was first used in the 1500s to refer to a formal conference or face-to-face meeting. The term “clinical” has origins from around 1780 and is linked to an objective or coldly dispassionate approach to bedside observations and treatment of hospital patients. Although difficult to determine the precise origin of the joining of clinical and interview in modern use, it appears that Jean Piaget (1896 – 1980) was the first psychologist to use a variant of the term clinical interview.
In 1920, as Piaget was working to develop a standardized French version of an English reasoning test with Theodore Simon in the Binet laboratory in Paris, he became more interested in the fundamental nature of children’s thinking than in the ranking of children’s intellectual ability on a standardized test. Realizing that existing psychological research methods were inadequate for studying cognitive development, he began using an interviewing approach that had much in common with psychiatric diagnostic interviews. He referred to his process as the “semiclinical interview” (Elkind 1964). Piaget’s semiclinical interview combined standard and nonstandard questioning as a means for exploring the richness of children’s thought.
Similar to Piaget’s initial efforts to combine a rigorously standardized protocol with spontaneous or unplanned questioning, the definition and implementation of the clinical interview has historically and presently been characterized by tension between a highly structured or protocol-driven interaction versus an unstructured or free-response process. In a report on structured clinical interviews, Abt (1949) provided an early articulation of this dialectical tension inherent to the clinical interview, noting that researchers did not want to lose the rich, projective, and idiosyncratic material obtained in a clinical interview, but also needed reliable interviewing procedures that were quantifiable.
Abt’s comments captured the qualitative vs. quantitative nature of most historical and contemporary controversies concerning the clinical interview. On the one side, adherents to the medical model view the clinical interview as a scientific assessment endeavor, emphasizing its quantitative nature and psychometrics (e.g., reliability and validity). On the other side, many practitioners view the clinical interview as a means for obtaining qualitative and idiosyncratic data about patients, using both the process and the data obtained to strengthen the therapeutic relationship and move toward a culturally and individually tailored intervention. Since the 1940s the clinical interview has been considered as either a method for gathering facts about symptoms that align with a scientifically valid diagnosis or a relational experience designed to understand the subjective world of another. There are some who contend that the clinical interview can and should be both a scientific and relational process (Sommers-Flanagan and Sommers-Flanagan 2012).
January is an Excellent Month to Attend Workshops in Cincinnati
Just in case you’re planning to be in or around the Cincinnati area this weekend, the Greater Cincinnati Counseling Association (GCCA) is offering a day and a half of workshops starting on Friday afternoon, January 10 and two workshops with one of my favorite workshop presenters on Saturday, January 11. Here’s the info:
On Friday, January 10, there are two Ethics workshops to choose from:
2:00-5:15
School Counselor Ethics: Case
Discussions and Current Trends
Tanya Ficklin
Or
2:00-5:15
Ethical and Professional Issues:
Therapeutic Alliance Building and
Ethical Considerations When
Working with Children and
Families
Barbara Mahaffey
On Saturday, January 11, I’m doing two separate ½ day workshops:
Tough Kids, Cool Counseling
John Sommers-Flanagan
Saturday 8:45-12:00
Therapy with adolescents can be immensely frustrating or splendidly gratifying. The truth of this statement is so obvious that the supportive reference, at least according to many adolescents is, “Duh!” In this workshop participants will sharpen their therapy skills by viewing and discussing video clips from actual sessions and participating in live demonstrations. Over 20 specific cognitive, emotional, and constructive therapy techniques will be illustrated and/or demonstrated. Examples include acknowledging reality, informal assessment, the affect bridge, therapist spontaneity, early interpretations, asset flooding, externalizing language, and more. Countertransference and multicultural issues will be highlighted.
Suicide Assessment Interviewing
Saturday 1:00-4:15
John Sommers-Flanagan
Freud once said, “By words one person can make another blissfully happy or drive him to despair.” Ironically, traditional adolescent suicide assessment and intervention procedures overemphasize a pathology-based biomedical model that orients adolescents toward despair. In this workshop suicidal crises are reformulated as normal expressions of human suffering and a specific, positive, and practical approach to adolescent suicide assessment interviewing is described. This contemporary adolescent suicide assessment model has a constructive focus, addresses diversity issues, and integrates differential activation theory and Jobes’s approach to Collaborative Assessment and Management of Suicidality. Specific suicide intervention procedures will be described and reformulated.
You can register for these workshops by phone by calling: 513-688-0092
The Therapist’s Opening Statement (or Question) with Adolescents
Working with adolescents or teenagers is different from working with adults. In this excerpt from a recently published article with Ty Bequette, we briefly focus on how the opening interaction with an adolescent client might look different than an opening interaction with an adult client. This is from: Sommers-Flanagan, J., & Bequette, T. (2013). The initial interview with adolescents. Journal of Contemporary Psychotherapy, 43(1), 13-22.
When working with adults, therapists often open with a variation of, “What brings you for counseling” or “How can I be of help” (J. Sommers-Flanagan & Sommers-Flanagan, 2012). These openings are ill-fitted for psychotherapy with adolescents because they assume the presence of insight, motivation, and a desire for help—which may or may not be correct.
Based on clinical experience, we recommend opening statements or questions that are invitations to work together. Adolescent clients may or may not reject the invitation, but because adolescent clients typically did not select their psychotherapist, offering an invitation is a reasonable opening. We recommend invitations that emphasize disclosure, collaboration, and interest and that initiates a process of exploring client goals. For example,
I’d like to start by telling you how I like to work with teenagers. I’m interested in helping you be successful. That’s my goal, to help you be successful in here or out in the world. My goal is to help you accomplish your goals. But there’s a limit on that. My goals are your goals just as long as your goals are legal and healthy.
The messages imbedded in that sample opening include: (a) this is what I am about; (b) I want to work with you; (c) I am interested in you and your success; (d) there are limits regarding what I will help you with. It is very possible for adolescent clients to oppose this opening in one way or another, but no matter how they respond, a message that includes disclosure, collaboration, interest, and limits is a good beginning.
Some adolescent clients will respond to an opening like the preceding with a clear goal statement. We’ve had clients state: “I want to be happier.” Although “I want to be happier” is somewhat general, it is a good beginning for parsing out more specific goals with clients. Other clients will be less clear or less cooperative in response to the invitation to collaborate. When asked to identify goals, some may say, “I don’t know” while others communicate “I don’t care.”
Concession and redirection are potentially helpful with clients who say they don’t care about therapy or about goal-setting. A concession and redirection response might look like this: “That’s okay. You don’t have to care. How about we just talk for a while about whatever you like to do. I’d be interested in hearing about the things you enjoy if you’re okay telling me.” Again, after conceding that the client does not have to care, the preceding response is an invitation to talk about something less threatening. If adolescent clients are willing to talk about something less threatening, psychotherapists then have a chance to listen well, express empathy, and build the positive emotional bond that A. Freud (1946, p. 31) considered a “prerequisite” to effective therapy with young clients.
Some adolescents may be unclear about limits to which psychotherapists influence and control others outside therapy. They may imbue therapists with greater power and authority than reality confers. Some adolescents may envision their therapist as a savior ready to provide rescue from antagonistic peers or oppressive administrators. Clarification is important:
Before starting, I want to make sure you understand my role. In therapy you and I work together to understand some of the things that might be bugging you and come up with solutions or ideas to try. But, even though I like to think I know everything and can solve any problem, there are limits to my power. For example, let’s say you’re having a conflict with peers. I would work with you to resolve these conflicts, but I’m not the police, and I can’t get them sent to jail or shipped to military school. I can’t get anyone fired, and I can’t help you break any laws. Does that make sense? Do you have any questions for me?
A clear explanation of the therapist’s role and an explanation about counseling process can allay uncertainties and fears about therapy. Inviting questions and allowing time for discussion helps empower adolescent clients, build rapport, and lower resistance.
Powerpoint Slides from the ACES Clinical Interviewing Presentation in Denver
This post includes a link to the powerpoiint slides for our presentation at the Association for Counselor Education and Supervision in Denver, CO. For this we offer a BIG THANKS to Sidney Shaw, Ed.D. who presented on our behalf so we could be in Erie, PA for the birth of our new granddaughter, Nora Flanagan Bodnar. Thanks Sidney!!
Strategies for Working Effectively with Challenging Clients
Working with clients who are reluctant or resistant to counseling can be very challenging . . . unless you use skills to help minimize resistance and maximize cooperation. The following is adapted from Chapter 12: Challenging Clients and Demanding Situations of the forthcoming 5th edition of Clinical Interviewing. Remember, these skills have to come from a foundation of therapist genuineness.
Using Emotional Validation, Radical Acceptance, Reframing, and Genuine Feedback
Clients sometimes begin interviews with expressions of hostility, anger, or resentment. If this is handled well, these clients may eventually open up and cooperate. The key is to refrain from lecturing, scolding, or retaliating when clients express hostility. Speaking from the consultation-liaison psychiatry perspective, Knesper (2007) noted: “Chastising and blaming the difficult patient for misbehavior seems only to make matters worse” (p. 246).
Instead, empathy, emotional validation, and concession are more effective responses. We often coach graduate students on how to use concession when power struggles emerge, especially when they’re working with adolescent clients (J. Sommers-Flanagan & Sommers-Flanagan, 2007b). For example, if a young client opens a session with, “I’m not talking and you can’t make me,” we recommend responding with complete concession of power and control: “You’re absolutely right. I can’t make you talk, and I definitely can’t make you talk about anything you don’t want to talk about.” This statement validates the client’s need for power and control and concedes an initial victory in what the client might be viewing as a struggle for power.
Empathy and Emotional Validation
Empathic, emotionally validating statements are also important. If clients express anger at meeting with you, a reflection of feeling and/or feeling validation response can let them know you hear their emotional message loud and clear. In some cases, as in the following example, therapists might go beyond empathy and emotional validation and actually join clients with a parallel emotional response:
- “Of course you feel angry about being here.”
- “I don’t blame you for feeling pissed about having to see me.”
- “I hear you saying you don’t trust me, which is totally normal. After all, I’m a stranger, and you shouldn’t trust me until you get to know me.”
- “It pretty much sucks to have a judge require you to meet with me.”
- “I know we’re being forced to meet, but we’re not being forced to have a bad time together.”
Radical Acceptance
Radical acceptance is a dialectical behavior therapy principle and technique based on person-centered theory (Linehan, 1993). It involves consciously accepting and actively welcoming any and all client comments—even odd, disturbing, or blatantly provocative comments (J. Sommers-Flanagan & Sommers-Flanagan, 2007a). For example, we’ve had experiences where clients begin their sessions with angry statements about the evils of psychology or counseling:
Opening Client Volley: I don’t need no stupid-ass counseling. I’m only here because my wife is forcing me. This counseling shit is worthless. It’s for pansy-ass wimps like you who need to sit around and talk rather than doing any real work.
Radical Acceptance Return: Wow. Thanks for being so honest about what you’re thinking. Lots of people really hate psychologists but they just sit here and pretend to cooperate. So I really appreciate you telling me exactly what you’re thinking.
Radical acceptance can be combined with reframing to communicate a deeper understanding about why clients have come for therapy. Our favorite version of this is the “Love reframe” (J. Sommers-Flanagan & Barr, 2005).
Client: This is total bullshit. I don’t need counseling. The judge required this. Otherwise, I can’t see my daughter for unsupervised visitation. So let’s just get this over with.
Therapist: I hear you saying this is bullshit. You must really love your daughter . . . to come here even when you think it’s a worthless waste of your time.
Client: (Softening) Yeah. I do love my daughter.
The magic of the love reframe is that clients nearly always agree with the positive observation about loving someone, which turns the interview toward a more pleasant focus.
Genuine Feedback
Often, when working with angry or hostile clients, there’s no better approach than reflecting and validating feelings . . . pausing . . . and then following with honest feedback and a solution-focused question.
“I hear you saying you hate the idea of talking with me, and I don’t blame you for that. I’d hate to be forced to talk to a stranger about my personal life too. But can I be honest with you for a minute? [Client nods in assent]. You know, you’re in legal trouble. I’d like to try to be helpful—even just a little. We’re stuck meeting together. We can either sit and stare at each other and have a miserable hour or we can talk about how you might dig yourself out of this legal hole you’re in. I can go either way. What do you think . . . if we had a good meeting today, what would we accomplish?”
Think about how you can incorporate, empathy, emotional validation, concession, radical acceptance, and genuine feedback into your clinical practice. For more on this, check out the 5th edition of Clinical Interviewing.
A General Guide to Using Stages of Change Principles in Clinical Interviewing
This week I’ve been working on reading and editing the page proofs for the forthcoming 5th edition of Clinical Interviewing (John Wiley & Sons). The information below is from a “Putting It Into Practice” box from the 4th chapter. It focuses on a brief Q&A regarding the application of Prochaska and DiClemente’s “Stages of Change” concept in clinical interviewing and presupposes that you have basic knowledge of that particular piece of their Transtheoretical Model.
A General Guide to Using Stages of Change Principles in Clinical Interviewing
Below we pose and answer four basic questions about how to apply stages of change principles (Prochaska & DiClemente, 2005) to guide the techniques and responses you choose to use within a clinical interviewing context.
Q1: When should I use directive techniques like psychoeducation or advice?
A1: When clients are in the action or maintenance stages of change you’re free to be more directive (provided you have useful information to share that fits with what the client recognizes as his or her problem).
Q2: When should I use less directive listening responses like paraphrasing, reflection of feeling, and summarization?
A2: As a general rule, if your client is in the precontemplative or contemplative stages of change, you should primarily use nondirective listening skills to help the client look at his or her own motivations for change. This would include: (a) attending behaviors, (b) paraphrasing, (c) clarification, (d) reflection of feeling, and (e) summarizing. Many questions, especially open questions and solution-focused or therapeutic questions, may be appropriate for clients who are precontemplative or contemplative. When you’re with clients who present as precontemplative or contemplative, your best theoretical orientation choices will likely be person-centered, motivational interviewing, and/or solution-focused. Using more directive approaches can produce defensiveness or resistance with clients in precontemplative or contemplative stages.
Q3: How do I know what stage of change my client is in?
A3: We’re tempted to suggest you’ll know it when you see it . . . and there’s some truth to that. If you try directly recommending a strategy for change and the client responds defensively, you may be moving forward too fast and it’s advisable to retreat to using reflective listening skills. Conversely, if your client seems frustrated with your nondirective listening and expresses interest in changing now, then you’ve got the green light to be more directive. Also, we recommend using George Kelly’s (1955) credulous approach to assessment, meaning you can always just directly ask clients what they prefer. In our work with parents we do this explicitly by stating something like:
“I want to emphasize that this is your consultation. And so if I’m talking too much, just tell me to be quiet and listen and I will. Or, if you start feeling like you want more advice and suggestions, let me know that as well.” (J. Sommers-Flanagan & Sommers-Flanagan, 2011, p. 60)
There are also standardized methods for assessing clients’ readiness for change. Interestingly, most of these involve asking clients very direct questions about their motivation to change, how difficult they expect change to be, and how ready they are to change (all of which seem in the spirit of George Kelly’s credulous approach; for example, see (Chung et al., 2011) for a study on the predictive validity of four different measures assessing client readiness to stop smoking cigarettes).
Q4: Is the stages of change concept supported by empirical evidence?
A4: The data are mixed on whether and how much attending to and using interventions that fit your clients’ stages of change makes a difference. Of course, this is true for nearly every phenomenon in counseling and psychotherapy. Overall, some studies show strong support for gearing your interviewing techniques to your clients’ stage of change (Johnson et al., 2008). Other studies show that stages of change focused interventions do no better than interventions that don’t tune into clients’ particular motivational stage (Salmela, Poskiparta, Kasila, Vähäsarja, & Vanhala, 2009). We recognize this isn’t the clear and decisive research outcome you might hope for, but such is the nature of our profession.
For more information on Clinical Interviewing, 5th edition, go to: http://www.wiley.com/WileyCDA/WileyTitle/productCd-1118270045.html
IS PATH WARM – An Acronym to Guide Suicide Risk Assessment
Suicide Risk Factors, Acronyms, and the Evidence Base
[This is adapted from our forthcoming 5th edition of Clinical Interviewing]
In 2003, the American Association of Suicidology brought together a group of suicidologists to examine existing research and develop an evidence-based set of near-term signs or signals of immediate suicide intent and risk. These suicidologists came up with an acronym to help professionals and the public better anticipate and address heightened suicide risk. The acronym is: IS PATH WARM and it’s outlined below:
I = Ideation
S = Substance Use
P = Purposelessness
A = Anxiety
T = Trapped
H = Hopelessness
W = Withdrawal
A = Anger
R = Recklessness
M = Mood Change
IS PATH WARM is typically referred to as evidence-based and, in fact, it was developed based on known risk factors and warning signs. Unfortunately, reminiscent of other acronyms used to help providers identify clients at high risk for suicide, in the only published study we could find that tested this acronym, IS PATH WARM failed to differentiate between genuine and simulated suicide notes (Lester, McSwain, & Gunn, 2011). Although this is hardly convincing evidence against the use of this acronym, it illustrates the inevitably humbling process of trying to predict or anticipate suicidal behavior. In conclusion, we encourage you to use the acronym in conjunction with the comprehensive and collaborative suicide assessment interviewing process described in our chapter in the Clinical Interviewing textbook. See: http://www.amazon.com/Clinical-Interviewing-2012-2013-John-Sommers-Flanagan/dp/1118390113/ref=sr_1_1?s=books&ie=UTF8&qid=1373655813&sr=1-1
After talking about IS PATH WARM in workshops over the past year or so, it seems important to emphasize that these “risk” factors are near-term risk factors. Other, very important longer-term risk factors, are not included. For example, previous attempts and clinical depression aren’t even on the list. And, although they include withdrawal, it seems that words like isolation or loneliness capture this dimension of risk at least as well.
The point of my criticism is to emphasize that even the best suicidologists on the planet struggle in their efforts to identify the most important immediate and longer-term suicide risk factors. This is primarily because suicide is nearly always unpredictable and one of the reasons that it’s unpredictable is because it occurs, on average in the U.S. in 13 people per 100,000. The other side of this dialectical coin is that, of course, we need to try to predict it and prevent it anyway.
You can check out more details about IS PATH WARM on many different internet sites, including a description of its origin provided by the American Association of Suicidology: http://www.suicidology.org/c/document_library/get_file?folderId=231&name=DLFE-598.pdf
John Sommers-Flanagan 