Category Archives: Clinical Interviewing

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

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

Webinar Tomorrow: Diagnosis and Assessment of Oppositional Defiant Disorder and Conduct Disorder

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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.

Clinical Interviewing

An Intake Interview Outline and Activity

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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.

 

 

 

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

What You Missed in Cincinnati

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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.

Clinical Interviewing

A Brief History of the Clinical Interview

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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).

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

January is an Excellent Month to Attend Workshops in Cincinnati

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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

 

Clinical Interviewing, Therapy with Adolescents, Tough Kids Cool Counseling

The Therapist’s Opening Statement (or Question) with Adolescents

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           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.