Category Archives: Clinical Interviewing

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice, Writing

Neurogenesis and Ideas for Training Your Brain to Listen with Empathy

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To start, I should say that I generally dislike pop-psych articles and promotional efforts that include cute sayings like, you can “Train (or re-wire) your Brain.” Most of you know this about me, partly because I like to make pithy comments about how, in fact, our brains actually don’t have any wires.

Despite overuse of the “wiring” analogy, I’m all-in on the principle that our behavior influences our brain structure, function, including a vast array of neurochemicals, hormones, and yada, yada, yada. In the following excerpt from our forthcoming Clinical Interviewing text, we provide a brief scientific commentary and recommendations for what we might oversimplify as “empathy training.”

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Neurogenesis refers to the birth of neurons and is one of the biggest revelations in brain research. Although neurogenesis primarily occurs during prenatal brain development, humans and other mammals generate new neurons (brain cells) throughout the life span (Jenkins et al., 1990). When adult neurogenesis occurs, new neurons are integrated into existing neurocircuitry.

Over 30 years ago, researchers demonstrated that repeated tactile experiences produced functional reorganization in the primary somatosensory cortex of adult owl monkeys (Jenkins et al., 1990). This finding and subsequent research supporting neurogenesis underscore a commonsense principle: Whatever behavior you practice or repeat is likely to stimulate neural growth and strengthen skills in that area. This is our explanation and prescription for how you can become more like Carl Rogers.

Multiple brain regions are activated during an empathic experience. Kim and colleagues (2020) summarized the complexity of what’s happening in the brain during empathic or compassionate responding, “Our analysis of sixteen fMRI studies revealed activation across seven broad regions, with the largest peaks localized to the Periaqueductal Grey, Anterior Insula, Anterior Cingulate, and Inferior Frontal Gyrus” (p. 112). In a similar review, Sezer and colleagues (2022) wrote:

Mindfulness-mediated functional connectivity changes include (1) increased connectivity between posterior cingulate cortex (DMN) and dorsolateral prefrontal cortex (FPN), which may relate to attention control; (2) decreased connectivity between cuneus and SN, which may relate to self-awareness; (3) increased connectivity between rostral anterior cingulate cortex region and dorsomedial prefrontal cortex (DMN) and decreased connectivity between rostral anterior cingulate cortex region and amygdala region, both of which may relate to emotion regulation; and lastly, (4) increased connectivity between dorsal anterior cingulate cortex (SN) and anterior insula (SN) which may relate to pain relief. (https://doi.org/10.1016/j.neubiorev.2022.104583)

If we focus in (somewhat inappropriately) on a particular brain structure, the anterior insula or insular cortex, a small structure residing deep within the fissure that separates the temporal lobe from the frontal and parietal lobes, seems particularly linked to empathy experiences, self-regulation, and other compassionate counseling-type responses (Chen et al., 2022).

Compassion meditation (aka lovingkindness meditation) is also associated with neural activity and structural development (or thickening) of the insula. Individuals who engage in regular compassion meditation have thicker insula, and when they view or hear someone in distress, they show more insula-related neural activity than individuals without compassion meditation experience (Hölzel et al., 2011). Other researchers have conducted meta-analyses and written reviews indicating that several brain structures are activated during cognitive-emotional perception, regulation, and response, and the relationships among them are highly complex (Kim et al., 2020; Pernet et al., 2021).

To oversimplify a complex neurological process, it appears generally safe to conclude that compassion meditation and other human activities related to empathy may contribute in some way to the thickening of the insula and development of other brain processes that enhance empathic responsiveness.

Although our knowledge about what’s actually happening in the brain is limited, these findings imply that you should engage in rigorous training to strengthen and grow your insula—as well as some of its empathic and self-regulating buddies like the posterior cingulate cortex, dorsolateral prefrontal cortex, rostral anterior cingulate cortex region, and dorsomedial prefrontal cortex (Sezer et al., 2022). This “training regimen” might contribute to you becoming more empathic and therefore, more therapeutic. In addition to practicing mindfulness or lovingkindness meditation, such a regimen could include:

  1. Committing to the intention of becoming a person who listens to others in ways that are accepting, empathic, and respectful.
  2. Developing an empathic listening practice. This would involve regular interpersonal experiences where you devote time to using active listening skills described in this chapter. As you practice, it’s important to have listening with compassion as your primary goal.
  3. Engaging in the active listening, multicultural, and empathy development activities sprinkled throughout this text, offered in your classes, and obtained from additional outside readings.
  4. When watching videos/television/movies, reading literature, and obtaining information via technology, lingering on and experiencing emotions that these normal daily activities trigger.
  5. Reflecting on these experiences and then… repeating… repeating… and repeating them over time and across situations

Rogers wrote in personal ways about his core conditions for counseling and psychotherapy. Contemplating his perspective is part of our prescription for developing an empathic orientation toward the variety of individuals with whom you will work.

“I come now to a central learning which has had a great deal of significance for me. I can state this learning as follows: I have found it of enormous value when I can permit myself to understand another person. The way in which I have worded this statement may seem strange to you. Is it necessary to permit oneself to understand another? I think that it is. Our first reaction to most of the statements which we hear from other people is an immediate evaluation or judgment, rather than an understanding of it. When someone expresses some feeling or attitude or belief, our tendency is, almost immediately, to feel “That’s right”; or “That’s stupid”; “That’s abnormal”; “That’s unreasonable”; “That’s incorrect”; “That’s not nice.” Very rarely do we permit ourselves to understand precisely what the meaning of [the] statement is to him [or her or them]. I believe this is because understanding is risky. If I let myself really understand another person, I might be changed by that understanding.” (Rogers, 1961, p. 18; italics in original)

As always, send me your thoughts on this content, as well as any ideas for improvement. Thanks and happy Friday!

Clinical Interviewing, Personal Reflections, Research, Writing

The Delight of Scientific Discovery

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Art historians point to images like John Henry Fuseli’s 1754 painting “The Nightmare” as early depictions of sleep paralysis.

Consensus among my family and friends is that I’m weird. I’m good with that. Being weird may explain why, on the Saturday morning of Thanksgiving weekend, I was delighted to be searching PsycINFO for citations to fit into the revised Mental Status Examination chapter of our Clinical Interviewing textbook.

One thing: I found a fantastic article on Foreign Accent Syndrome (FAS). If you’ve never heard of FAS, you’re certainly not alone. Here’s the excerpt from our chapter:   

Many other distinctive deviations from normal speech are possible, including a rare condition referred to as “foreign accent syndrome.” Individuals with this syndrome speak with a nonnative accent. Both neurological and psychogenic factors have been implicated in the development of foreign accent syndrome (Romö et al., 2021).

Romö’s article, cited above, described research indicating that some forms of FAS have clear neurological or brain-based etiologies, while others appear psychological in origin. Turns out they may be able to discriminate between the two based on “Schwa insertion and /r/ production.” How cool is that? To answer my own question: Very cool!.

Not to be outdone, a research team from Oxford (Isham et al., 2021) reported on qualitative interviews with 15 patients who had grandiose delusions. They wrote: “All patients described the grandiose belief as highly meaningful: it provided a sense of purpose, belonging, or self-identity, or it made sense of unusual or difficult events.” Ever since I worked about 1.5 years in a psychiatric hospital back in 1980-81, I’ve had affection for people with psychotic disorders, and felt their grandiose delusions held meaning. Wow.  

One last delight, and then I’ll get back to my obsessive PsycINFO search-aholism.

Having experienced sleep paralysis when I was a frosh/soph attending Mount Hood Community College in 1975-1976, I’ve always been super-delighted to discover old and new information about multi-sensory (and bizarre) experiences linked to sleep paralysis episodes. Today I found two articles stunningly relevant to my 1970s SP experiences. One looked at over 300 people and their sleep paralysis/out-of-body experiences. They found that having out-of-body experiences during sleep paralysis reduced the usual distress linked to sleep paralysis. The other study surveyed 185 people with sleep paralysis and found that most of them, as I did in the 1970s, experienced hallucinations of people in the room and many believed the “others” in the room to be supernatural. I find these results oddly confirming of my long-passed sleep insomnia experiences.

All this delight at scientific discovery leads me to conclude that (a) knowledge exists, (b) we should seek out that knowledge, and (c) gaining knowledge can help us better understand our own experiences, as well as the experiences of others.

And another conclusion: We should all offer a BIG THANKS to all the scientists out there grinding out research and contributing to society . . . one study at a time.

For more: Here’ a link to a cool NPR story on sleep paralysis: https://www.npr.org/2019/11/21/781724874/seeing-monsters-it-could-be-the-nightmare-of-sleep-paralysis

References

Isham, L., Griffith, L., Boylan, A., Hicks, A., Wilson, N., Byrne, R., . . . Freeman, D. (2021). Understanding, treating, and renaming grandiose delusions: A qualitative study. Psychology and Psychotherapy: Theory, Research and Practice, 94(1), 119-140. doi:https://doi.org/10.1111/papt.12260

Herrero, N. L., Gallo, F. T., Gasca‐Rolín, M., Gleiser, P. M., & Forcato, C. (2022). Spontaneous and induced out‐of‐body experiences during sleep paralysis: Emotions, “aura” recognition, and clinical implications. Journal of Sleep Research, 9. doi:https://doi.org/10.1111/jsr.13703

Romö, N., Miller, N., & Cardoso, A. (2021). Segmental diagnostics of neurogenic and functional foreign accent syndrome. Journal of Neurolinguistics, 58, 15. doi:https://doi.org/10.1016/j.jneuroling.2020.100983

Sharpless, B. A., & Kliková, M. (2019). Clinical features of isolated sleep paralysis. Sleep Medicine, 58, 102-106. doi:https://doi.org/10.1016/j.sleep.2019.03.007

Clinical Interviewing

Checklists from the Forthcoming 7th Edition of Clinical Interviewing

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Textbook writing is a particular kind of writing that requires a variety of ways to present relatively boring material to students and aspiring professionals. Although we pride ourselves on writing the most entertaining textbooks in the business, our efforts to entertain are all part of a reader-friendly delivery system.

Another (less humorous) reader-friendly delivery strategy is the checklist. We intermittently use checklists to summarize essential information in our Clinical Interviewing text. Below, I’m including links to three checklists. Please note, these checklists are in process, and so if you see any typos or missing information or have some excellent feedback to share with me . . . post your feedback here on this blog or email me: john.sf@mso.umt.edu. I will greatly appreciate your feedback!

From Chapter 10: A Checklist on Suicide Assessment Documentation:

suicide-documentation-checklistDownload

From Chapter 12: A Checklist on Strategies and Techniques for Working with Client Ambivalence or Natural Client Resistance.

checklist-for-challenging-client-behaviorsDownload

From Chapter 13: A Checklist on Getting Prepped for Your First Session with a Child or Adolescent Client

checklist-to-prep-for-young-clientsDownload

For those of you who are still reading (and I hope that’s everyone), I’m still looking for someone who can write me a short (400 word) case or two on working with LGBTQ+ youth. A transgender case would be especially nice. If you’re interested, send me an email: john.sf@mso.umt.edu

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

A Free Video on Collaborative Safety Planning for Suicide Prevention

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Engaging clients in a collaborative safety planning process is an evidence-based suicide intervention. The typical gold standard for safety planning is the Safety Planning Intervention (SPI) by Stanley and Brown (2012). You can access free material on the SPI and learn how to obtain professional training for using SPIs at this link: https://suicidesafetyplan.com/

As a part of the 7.5-hour Assessment and Intervention with Suicidal Clients video published by psychotherapy.net, I did a short (about 7 minute) demonstration of safety planning with a 15-year-old cisgender female client. The demo comes at the end of the session and naturally, I already know lots of information that can be integrated into the safety plan. Nevertheless, introducing and completing the safety plan is an excellent organizing experience.

In part, safety planning emerged as an alternative to what were called “No-suicide contracts.” No suicide contracts fell out of favor in the mid-to-late 1990s, because many clients/patients viewed them as coercive and liability-dodging behaviors by clinicians, and because they focused on what NOT TO DO, instead of what clients/patients should do, when feeling suicidal. Safety planning involves proactive planning for what clients can do to effectively cope during a suicidal crisis.

Victor Yalom of psychotherapy.net has given me permission to offer this video clip to everyone as a free resource to guide and inspire you as you work to develop your skills for collaborative safety planning. You can find a glittering array of videos, including the previously mentioned, three-part 7.5 hour classic at: https://www.psychotherapy.net/ and https://www.psychotherapy.net/video/suicidal-clients-series

Here’s the video link: https://youtu.be/jd7PM9HFDO4

Have a great holiday week.

JSF

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

Using Reframing as a Counseling Intervention and What to do When They Fail

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Reframing, as a counseling and psychotherapy intervention, involves nudging clients toward viewing their thoughts, emotions, behaviors, and life situations from a different or new perspective. Reframing is an especially popular technique among cognitive, existential, and solution-focused therapists. In the following excerpt from our book on the strengths-based approach to suicide assessment and treatment, we discuss reframing . . . and what to do when it fails.

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Framing Pain and Suicidality as Evidence of a Normal Self-Care Impulse

Another reframe involves viewing suicidality as coming from a place of self-care or self-compassion. Using your own words, you might try a reframe like this:

As you talk about wanting to die, I’m struck that your wish for death also comes from your wish to feel better . . . and your wish to feel better is normal, natural, and healthy. What I’d like to do for now, is to partner with you on the healthy goal of feeling better. I need your help on this. For now, we can put your wish to die on the sidelines, and focus on feeling better. We can’t expect immediate positive results. Will you work with me to battle your pain, and little by little, to help you feel better? 

            This reframing message is intentionally repetitive, and almost hypnotic. The purpose is to engage with and activate the healthy part of the self that wants to feel better. When clients respond to this message, hope for positive outcomes may increase. If clients reject this reframing message, suicide risk may be high.  

Framing Pain as Meaningful

Victor Frankl (1967) used reframing to address depressive symptoms in the following case.

An old doctor consulted me in Vienna because he could not get rid of a severe depression caused by the death of his wife. I asked him, “What would have happened, Doctor, if you had died first, and your wife would have had to survive you?” Whereupon he said: “For her this would have been terrible; how she would have suffered!” I then added, “You see, Doctor, such a suffering has been spared her, and it is you who have spared her this suffering; but now you have to pay for it by surviving and mourning her.” The old man suddenly saw his plight in a new light, and reevaluated his suffering in the meaningful terms of a sacrifice for the sake of his wife. (1967, pp. 15–16)

Consistent with Frankl’s existential perspective, his reframe involves viewing suffering as meaningful. If clients view suffering as meaningful, life can feel more bearable.

When Reframes Fail

Reframing and redefining client emotional distress takes many forms. But, sometimes reframes don’t fit and don’t work. Reframes may be ineffective due to: (a) cultural insensitivity, (b) symptom severity, (c) inadequate rapport or alliance, and (d) countertransference (Lenes et al., 2020; Parrow et al., 2019). When your efforts to reframe fail, clients may withdraw or become agitated and you may risk a relationship rupture (Safran & Kraus, 2014). If the reframe doesn’t fit, process the issue (e.g., “Based on your reaction, it doesn’t seem like the idea I shared fits well for you”). After listening to your client’s response, you might need to proceed with strategies for rupture repair (see Sommers-Flanagan & Sommers-Flanagan, 2017). Relationship repair might include a direct apology and further processing. For example,

I’m sorry my idea for how to think about your pain wasn’t a good fit. But I’m glad you let me know it doesn’t fit. Lots of counseling is like an experiment. Sometimes we discover something doesn’t work. If you think something doesn’t fit or work for you, I will always want to know. Thank you for telling me.

When it comes to using reframing and redefinitions, your theoretical foundation is less important than the pragmatics of finding something that works for your client. The process involves: (a) identifying a potential reframe, (b) asking clients permission to try it out; (c) sharing the reframe; (d) observing client reactions, (e) verbally checking on client reactions and goodness of fit; (f) continuing to collaboratively experiment with the reframe or collaboratively discard it as a bad idea; and (g) addressing the relationship rupture—if one occurred.  

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If you’re interested in our suicide book, give it a Google. Given the our unique hyphenated last name, it’s not hard to find.

Clinical Interviewing, Happiness, Personal Reflections, Suicide Assessment and Intervention

Eye Contact, Influencers, and Self-Care CBT

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While searching for updated guidance on cross-cultural eye contact in counseling and psychotherapy (for the 7th edition revision of Clinical Interviewing), I came across a young therapist with over 1 million YouTube subscribers. She was perky, articulate, and very impressive in her delivery of almost-true information about the meaning of eye contact in counseling (from about 5 years ago). There were so many public comments on her video . . . I couldn’t possibly read or track them all. Sadly, although she waxed eloquent about trauma and eye contact, she never once mentioned culture, or how the meaning of eye contact varies based on cultural, familial, and individual factors. Part of my takeaway was her retelling a version of a John Wayne-esq sort of message wherein we should all strive to look the other person in the eye. Ugh. I’m sad we have so many perky, articulate influencers who share information that’s NOT inclusive or deep or particularly accurate. Oh well.

Curious, and TBH, perhaps a bit jealous of this therapist’s YouTube fame, I clicked on her most recent video. I discovered her in tears, describing how she needs a break, and detailing a range of symptoms that fit pretty well with major depressive disorder. Oh my. This time I felt sad for her and her life because it must have turned into a runaway train of influencer-related opportunities and demands. My jealousy of her particular type of fame evaporated.

Many therapists—including me—aren’t as good at practicing as we are preaching. Every day I try to get better and fail a little and succeed a little. Life is a marathon. Small changes can make their way into our lives and become bigger changes.

Because of our Clinical Interviewing revision, I’m saying “No” to presentation opportunities more often than usual. That’s a good thing. Setting limits and taking care of business at home is essential. However, in about one month, I’ve set aside a week for a gamut of presentations and appearances. These presentations and appearances all include some content related to positive psychology, positive coping, and how we can all live better lives in the face of challenging work. Here they are:

  1. On Friday, November 4 at 8:30am, I’ll be doing an opening keynote address for the Montana CBT conference. The keynote is titled, “Exploring the Potential of Evidence-Based Happiness.” The whole conference looks great (12.75 CEs available). I’ve also got a break-out session from 1:15pm to 3:15pm, titled, “Using a Strengths-Based Approach to Suicide Assessment and Treatment in Your Counseling Practice.” You can register for the two-day Montana CBT conference here: https://www.eventbrite.com/e/montana-cbt-conference-registration-367811452957Helena
  2. On Monday, November 7 at 11am in Missoula I’ll be presenting for the University of Montana Molli Program. Although in-person seats are sold-out, people can still register to attend online. https://www.missoulaevents.net/11/07/2022/the-art-science-and-practice-of-meaningful-happiness/ The presentation title is: The Art, Science, and Practice of Meaningful Happiness. Molli is the Osher Lifelong Learning Institute at UM – which focuses on educational offerings for folks 50+ years-old.
  3. On Wednesday, November 9 from 12:30-4:30pm I’ll be doing a Strengths-Based suicide assessment and treatment workshop for Bitterroot Connect in Hamilton, MT. https://sites.google.com/starckcounseling.com/adrianna-starck-counseling/bitterroot-valley-connect

In closing, I’m posting something everyone needs, an 11-second video featuring one of our new piglets, Alfalfa, doing her “lay down” trick.

Be well . . .

John S-F

Clinical Interviewing, Cool Counseling, Suicide Assessment and Intervention

Building Hope from the Bottom Up

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One more freebie in honor of suicide prevention month.

Building hope from the bottom up is one of the strengths-based suicide assessment and treatment techniques clinicians like best. I may be forgetting that I’ve already posted this here, but the approach is so popular that I’ll take that risk. Here’s the section for our Strengths-Based Suicide book . . .

Working from the Bottom Up to Build a Continuum of Hope

When clients are depressed and suicidal, they often think and talk about depressing thoughts and feelings. We shouldn’t expect otherwise. Even so, when clients ruminate on the negative, it fogs the window through which positive feelings and experiences are viewed. Within counseling, a potential conflict emerges: although clinicians want clients to problem-solve, focus on their strengths, and have hope for the future, clients are unable to generate solutions, can’t focus on their strengths or positive attributes, and seem unable to shake their hopelessness.

As discussed earlier in the case of Sophia, after an initial discussion of suicidality, there may come a natural time to pivot to the positive. One common strength-based tool for exploring what helps clients overcome their suicidality is a solution-focused question (Sommers-Flanagan, 2018a). If you’re working with a client who has made a previous attempt, you might ask something like “You’ve tried suicide before, but you’re here with me now, so there’s still a chance for a better life. What helped in the past?”

Although this is a perfectly reasonable question, the question may fall flat, and your client might respond with a hopelessness statement, “Nothing really ever helps.” This puts you in a predicament. Should you use Socratic questioning to identify a cognitive distortion? Should you interpret the distorted thinking in the here-and-now? Or should you retreat to empathy?

No matter what theoretical model you’re using, the predicament of how to deal with client non-responsiveness, negativity, or cognitive distortions remains. Let’s say you’re operating from a solution-focused or strength-based model and you ask the miracle question:

I’m going to ask you a strange question. What if, after we get done talking, you go back to doing your usual things at home, go to bed, and get some sleep. But in the middle of the night, a miracle happens, and your feelings of depression and suicide go away. You were asleep, and so you don’t know about the miracle. When you wake up, what will be the first thing you notice that will make you say to yourself, “Wow. Something amazing happened. I’m no longer depressed and suicidal.” (adapted from Berg & Dolan, 2001, p. 7).

Although the miracle question might do its magic and your client will respond with something positive, it’s equally possible that your client will say something like, “Not possible” or “The only way that would happen would be if I died in the night.” When clients are pervasively negative and hopeless, one error clinicians often make is to get into a yes-no questioning process that looks something like this:

Counselor: I’m sure there must be something that helps you feel more positive.

Client: I can’t think of anything.

Counselor: How about time with friends, does that help?

Client: No. I don’t have any real friends left.

Counselor: How about exercise?

Client: I can’t even get myself to exercise.

Counselor: Being in the outdoors helps with depression. Does that help?

Client: Nope.

Counselor: Have you tried medications?

Client: I hate medications. They made me feel like a zombie.

Entering into this exchange is unhelpful. In the end, both you and your client will be more depressed. Rather than continuing to ask what helps, try changing the focus to what doesn’t help. This shift is useful because when clients are experiencing suicidal depression, they’re more likely to resonate with negativity, and connecting with your client at the negative bottom is better than not connecting at all. The goal is to collaboratively build a continuum from the bottom up. By starting at the bottom, you’re simultaneously assessing hopelessness and intervening on the “Black-black” (as opposed to black-white) distorted thinking that you’re witnessing in session. Here’s an example:

Counselor: You’ve tried lots of different strategies to deal with your suicidal thoughts, without success. You’ve tried medications, exercise, and you’ve talked to your rabbi. Let’s list these and other things you’ve tried, and see which strategies were the worst. Of all the things you’ve tried, what was worst?

Client: I really hated exercising. It felt like I was being coerced to do something I’ve always hated. And it made me sore.

Counselor: Okay then. Exercise was the worst. You hated that. Of the other things you’ve tried, what was a little less bad than exercising?

Client: The medications. I just didn’t feel like myself.

Counselor: So that didn’t work either. So, of those three things, talking with your rabbi was the least bad?

Client: Yeah. It didn’t help much. But she was nice and supportive. I felt a little better, but I didn’t want to keep talking because she’s busy and I was a burden.

Focusing on the worst option resonates with a negative emotional state. For clients who are unhappy with the results of previous therapeutic efforts, beginning with the most worthless strategy of all is an easier therapeutic and assessment task, provides useful information, and is usually answered quickly. Subsequently, clinicians can move upward toward strategies that are “just a little less bad.” Building a unique continuum of what’s more and less helpful is the goal. Later, you can add new ideas that you or your client identify, and put them in their place on the continuum. If this approach works well, together with your client you will have generated several ideas (some new and some old) that are worth experimenting with in the future.

Beginning from the bottom puts a different spin on the problem-solving process. Even extremely depressed clients can acknowledge that every attempt to address their symptoms isn’t equally bad. Using a continuum is a useful tool for working with hopelessness and is consistent with the CBT technique, “Thinking in shades of grey.”

Clinical Interviewing, Personal Reflections, Suicide Assessment and Intervention

Welcome to Enterprise, Oregon

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I’m in Enterprise, Oregon today and tomorrow morning. I got here Sunday evening after a winding ride through forests and mountains. Yes, I’m in Eastern Oregon. Even I, having attended Mount Hood Community College and Oregon State University, had no idea there were forests and mountains in Enterprise.

The scenes are seriously amazing, but the people at the Wallowa Valley Center for Wellness-where I’m doing a series of presentations on suicide assessment and prevention-are no less amazing. I’ve been VERY pleasantly surprised at the quality, competence, and kindness of the staff and community.

Just in case you’re interested, below I’m posting ppts for my three different presentations. They overlap, but are somewhat distinct.

Here’s the one-hour intro:

final-enterprise-suicide-one-hourDownload

Here’s the two-hour session for clinicians and staff:

final-enterprise-two-hours-9-20-22Download

Here’s the upcoming 90 minute session for the community:

final-community-happiness-for-enterprise-2022Download

And here’s a view!

Clinical Interviewing, Suicide Assessment and Intervention

A Free, One-Hour Video on the Strengths-Based Approach to Suicide Assessment and Treatment

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Earlier this year I was asked by a school district to create and record a one-hour training on strengths-based suicide assessment. I made the recording, shipped it off, got paid, and mostly forgot about it. However, because I have the recording and sometimes I think it’s good to give things away, I’m sharing the link here: https://youtu.be/kLlkh8nJ2pI

The video is about 62 minutes, recorded on Zoom, and slightly oriented toward school counselors and school psychologists. I’m sharing this video just in case it might be useful to you in your teaching or for your clinical group or personal knowledge, etc. Feel free to share the link.

If you feel you benefit from this video, I hope you’ll consider the “pay it forward” concept. No need to pay me . . . just notice opportunities where you can share your gifts and talents and resources with others and pay it forward.

Clinical Interviewing, Suicide Assessment and Intervention

Working in the Emotional Dimension with Clients who are Suicidal

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In honor of National Suicide Prevention Month, I’m offering another chunk of information about suicide assessment and treatment. This information is an excerpt from our book, Suicide Assessment and Treatment Planning: A Strengths-Based Approach. In the book, we discuss assessment and treatment planning using a dimensional approach. The first (and central) dimension for suicide assessment and treatment is the emotional dimension.

To get a bigger sense of the topic, you can read 33 pages of the book for free on Google Books: https://www.google.com/books/edition/Suicide_Assessment_and_Treatment_Plannin/bOQUEAAAQBAJ?hl=en

Here’s the excerpt:

Working in the Emotional Dimension

When clients are depressed and suicidal, everyone—including family, friends, co-workers, counselors, and clients—wish for an improved emotional state. But often the process is slow, and as a result, the very people upon whom the client relies for support may lose patience. Supportive people, even counselors, may feel urges to say things that are emotionally dismissive, like, “Cheer up” or “Come on, you need to exercise!” or “Why can’t you do something to make your life better?”

Moving clients out of despair and into the light is difficult; if it were otherwise, clients would resolve suicidality on their own. Directly or indirectly suggesting to clients in suicidal pain to “cheer up” often backfires, creating anger, hostility, and resistance to treatment; this resistance is a powerful phenomenon called, psychological reactance(Brehm & Brehm, 1981).

Psychological reactance occurs when clients perceive their ultimate freedoms as threatened. If clients sense that clinicians want to coerce them to stay alive, in response, they may dig in their heels and engage in behaviors designed to restore feelings of autonomy. Psychological reactance is one explanation for why clients who are suicidal sometimes vehemently resist help, insisting on their right to think about and act on suicidal impulses. Repeated empathic acceptance of the client’s emotional pain is one way to avoid activating reactance; empathic acceptance also allows clients to begin exploring and addressing key emotional issues in counseling.

Key Emotional Issues to Address

Many emotional issues are relevant to suicide treatment planning. These include: (a) excruciating distress, (b) specific disturbing emotions, such as, acute or chronic shame and guilt, anger, or sadness, and (c) emotional dysregulation. In this next section, we briefly review core emotional issues that you may guide your treatment planning. Later in the chapter we provide case examples and vignettes illustrating methods for working in the emotional dimension.

Excruciating Distress

Shneidman referred to the emotional state surrounding suicide as “psychache” or unbearable distress. He wrote: “The suicidal drama is almost always driven by psychological pain, the pain of negative emotions—what I call psychache. Psychache is at the dark heart of suicide; no psychache, no suicide.” (2001, p. 200, italics added).

Even when using a strength-based or wellness model, exploring the “pain of negative emotions” or excruciating distress is usually your first focus. Sometimes, to avoid activating reactance or resistance, you’ll need to stay with your client’s emotional pain longer than you’d prefer. Staying with your clients’ pain not only helps bypass resistance, it also models that facing negative affective states without fear, avoidance, or dissociation requires personal strength. Even so, as you focus on suicidal pain, you might wish the client would immediately adopt a more positive mindset, or find the process difficult to bear. You also might need to turn to colleagues or your self-care plan for support. Nevertheless, job one in the emotional dimension is to recognize and resonate with your client’s emotional pain.

Acute or Chronic Shame and Guilt

Shame and guilt are non-primary emotions because they involve significant self-reflection. Shame connotes beliefs of being unworthy, defective, or bad. Shame is often directly linked to core beliefs about the self, and activated by particular life situations. In contrast, guilt is more specific, often associated with certain actions or lack of actions (e.g., “I should be doing more to fight racism” or “I shouldn’t have been so critical of my professor”). Generally, guilt can lead to shame, and shame is more likely to ignite suicidality. Reducing or resolving shame or guilt may be a crucial therapeutic goal.

Suicidal thoughts are often accompanied by shame. Cultures around the world have historically judged death by suicide as a shameful or sinful event, and many still do. Your client’s experience may be something like, “Not only do I have suicidal thoughts—which are terrible in their own right—but the fact that these thoughts exist in my mind also make me a bad person.” This double dose of negative judgment, emotional pain plus self-condemnation, often needs to be addressed in counseling. One strategy that may fit into your treatment plan is to help clients develop greater self-compassion as a method for countering their self-condemnation.

Anger

            In graduate school, we had a professor who suggested we consider this question: “Who is this client planning to commit suicide at?” Often, people who are suicidal carry great anger toward one or more friends, lovers, or family members and thus think of suicide as an act of revenge. Counselors should listen for underlying themes that involve using suicide as a behavioral goal for getting even or intentionally hurting others (Marvasti & Wank, 2013).

            Thoughts of dying by suicide sometimes emerge as a revenge fantasy. Thoughts like, “I’ll show them” or “they’ll suffer forever” represent anger, along with the desire to punish others. It can be tempting to point out to clients that death is an irrationally high price for fulfilling revenge fantasies. However, helping clients express, accept, and understand the depth of their anger will usually reduce suicidality more efficiently than pointing out that death is a maladaptive revenge strategy. If revenge is central and forgiveness isn’t a viable option, then an apt philosophy to gently infuse into your clients is that the best revenge is a well-lived life.

Sadness

            Major depression is the psychiatric diagnosis most commonly linked with suicide attempts, especially among older adults (Melhem et al., 2019). Clients who present with sadness as a dominant emotion may or may not meet diagnostic criteria for major depression. However, when sadness and the associated emotions and cognitions of irritability, regret, discouragement, and disappointment are central sources of distress, we recommend targeting those symptoms with evidence-based counseling interventions. Weaving positive psychology or happiness interventions into treatment planning is especially appropriate for clients struggling with sadness and depression (Seligman, 2018; Rashid & Seligman, 2018). More information about evidence-based approaches and positive psychology interventions is provided later in this chapter and in upcoming chapters.

Emotional Dysregulation

Clients who are suicidal may exhibit emotional dysregulation during counseling sessions and in their everyday lives. Clients may be emotionally labile, shifting from expressing anger to feelings of affection, appreciation, and deep connection. Clients may share stories of repeated maladaptive emotional overreactions to life’s challenges. Although unstable relationships, emotional swings, and explosive anger fit with the diagnostic criteria for borderline personality disorder, when clients are experiencing excruciating distress, they may behave in ways that resemble borderline personality disorder. However, instead of pathologizing clients with a personality disorder diagnosis, we recommend framing client behaviors using a social constructionist strength-based orientation, such as: Given enough situationally-based stress, including, as Linehan (1993) noted—emotionally invalidating environments—nearly everyone becomes dysregulated and appears unstable. Normalizing dysregulation as a natural response to intense distress helps maintain a strength-based perspective.

Treatment plans for clients who are suicidal often include teaching emotional regulation skills; this translates to helping clients become more capable of regulating themselves in the face of emotionally activating circumstances. Linehan’s (1993, 2015) protocols for working with clients with borderline personality characteristics are recommended for emotional regulation skill development. However, alternative approaches exist, some of which come from positive psychology, happiness, and well-being literature (Hays, 2014; Lyubomirsky, 2007, 2013; see Wellness Practice 4.1).