Category Archives: Counseling and Psychotherapy Theory and Practice

Goodnight, South Carolina

Some days . . . the news is discouraging. Some days . . . evidence piles up suggesting that nearly everyone on the planet is far too greedy and selfish. On those days, I can’t help but wonder how our local, national, and worldwide communities survive. It feels like we’re a hopeless species heading for a cataclysmic end.

Sunset on StillwaterBut then I have a day like yesterday. A day where I had the honor and privilege to spend time hanging out with people who are professional, smart, compassionate, and dedicated to helping children learn, thrive, and get closer to reaching their potentials. I’m sure you know what I mean. If you turn off the media and peek under the surface, you’ll find tons of people “out there” who wake up every day and work tremendously hard to make the world just a little bit better, for everyone.

For me, yesterday’s group was the South Carolina Association of School Psychologists. They were amazing. They were kind. About 110 of them listened to me drone on about doing counseling with students who, due, in part, to the quirky nature of universe, just happen to be living lives in challenging life and school situations. The school psychologists barely blinked. They rarely checked their social media. They asked great questions and made illuminating comments. They were committed to learning, to counseling, to helping the next generation become a better generation.

All day yesterday and into the night I had an interesting question periodically popping up in the back of my mind. Maybe it was because while on my flight to South Carolina, I sat next to a Dean of Students from a small public and rural high school in Wisconsin. Maybe it was because of the SCASP’s members unwavering focus and commitment to education. The question kept nipping at my psyche. It emerged at my lunch with the Chair of the Psychology Department at Winthrop University.  It came up again after my dinner with four exceptionally cool women.

The question: “How did we end up with so many people in government who are anti-education?”

Yesterday, I couldn’t focus in on the answer. I told someone that–even though I’m a psychologist–I don’t understand why people do the things they do. But that was silly. This morning the answer came flowing into my brain like fresh spring Mountain run-off. Of course, of course, of course . . . the answer is the same as it always has been.

The question is about motivation. Lots of people before me figured this out. I even had it figured out before, but, silly me, I forgot. Why do people oppose education when, as John Adams (our second President) said, “Laws for the liberal education of youth, especially for the lower classes of people, are so extremely wise and useful that to a humane and generous mind, no expense for this purpose would be thought extravagant.”

The answer is all about money and power and control and greed and revenge and ignorance. Without these motivations, nearly everyone has a “humane and generous mind” and believes deeply in funding public education.

Thanks to all the members of the South Carolina Association of School Psychologists, for giving me hope that more people can be like you, moving past greed and ignorance and toward a more educated and better world.

Good night, South Carolina. It’s been a good day.

 

Revisiting the 3-Step Emotional Change Trick — Including a Video Example

One of my current students asked where she might find a video example of the 3-Step Emotional Change Trick. Since I made up the Emotional Change Trick in 1997, the answer was easy: No such video exists.

Then I remembered that this past summer, while putting together video content with Wiley for our Clinical Interviewing text, I did a video demo of the 3-Step ETC with a 12-year-old girl. Due to space considerations, the footage didn’t make it into the text, but Wiley sent me a copy of the 6:44 minute clip.

Keep in mind that the girl in this video is exceptional. She’s the daughter of some friends and she agreed to be filmed for educational purposes. My sense is that she could have taught me the 3-Step ECT, but I tried to make it look like I was teaching her anyway.

Here’s the youtube link: https://www.youtube.com/watch?v=ITWhMYANC5c

And below you can read a version of the Emotional Change Technique adapted from Tough Kids, Cool Counseling:

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The Three-Step, Push-Button Emotional Change Technique

            An early and prominent Adlerian therapist, Harold Mosak, originally developed and tested the push-button technique as a method for demonstrating to clients that thinking different thoughts can effectively change mood states (Mosak, 1985). The purpose of Mosak’s technique was to help clients experience an increased sense of control over their emotions, thereby facilitating a sense of encouragement or empowerment (Mosak, 2000, personal communication).

            Mosak’s push-button technique can be easily adapted to work with young clients. When we implement this technique with younger clients, we are playful and call it an emotional change trick. When using this technique with teenagers, we describe it as a strategy for gaining more personal control over less desirable emotions. In essence, the three-step, push-button, emotional change technique is an emotional education technique; the primary goal is to teach clients that, rather than being at the mercy of their feelings, they may learn some strategies and techniques that provide them with increased personal control over their feelings.

The following example illustrates Adlerian emotional education principles and Mosak’s push-button technique expanded to three distinct steps.

Case example.  Sam, a 13-year-old European American boy, was referred because of his tendency to become suddenly stubborn, rigid, and disagreeable when interacting with authority figures. Sam arrived for his appointment accompanied by his mother. It quickly became obvious that Sam and his mother were in conflict. Sam was sullen, antagonistic, and difficult to talk with for several minutes at the outset of the session. Consequently, the Three-Step, Push-Button Emotional Change Technique (TSPB) was initiated:

Preparation/Explanation.

JSF:     I see you’re in a bad mood today. I have this . . . well, it’s kind of a magic trick and I             thought maybe you’d be interested. Want to hear about it?

S:         (Shrugs).

JSF:     It’s a trick that helps people get themselves out of a bad mood if they want to. First, I need to tell you what I know about bad moods. Bad moods are weird because even             though they don’t really feel good, lots of times people don’t want to get out of their bad mood and into a better mood. Do you know what I mean? It’s like you kind of want to stay in a bad mood; you don’t want anybody forcing you to change out of a bad mood.

S:         (Nods in agreement.)

JSF:     And you know what, I’ve noticed when I’m in a bad mood, I really hate it when someone comes up to me and says: “Cheer up!” or “Smile!”

S:         Yeah, I hate that too.

JSF:     And so you can be sure I’m not going to say that to you. In fact, sometimes the best thing to do is just really be in that bad mood—be those bad feelings. Sometimes it feels great to get right into the middle of those feelings and be them.

S:       Uh, I’m not sure what you’re talking about.

JSF:     Well, to get in control of your own feelings, it’s important to admit they’re there, to get to   know them better. So, the first step of this emotional change trick is to express your bad feelings. See, by getting them out and expressing them, you’re in control. If you don’t  express your feelings, especially icky ones, you could get stuck in a bad mood even    longer than you want.

As you can see, preparation for the TSPB technique involves emotional validation of how it feels to be in a bad mood, information about bad moods and how people can resist changing their moods or even get stuck in them, hopeful information about how people can learn to change their moods, and more emotional validation about how it feels when people prematurely try to cheer someone up.

Step 1: Feel the feeling. Before moving clients away from their negative feelings, it’s appropriate—out of respect for the presence and meaning of emotions—to help them feel their feelings. This can be challenging because most young people have only very simplistic ideas about how to express negative feelings. Consequently, Step 1 of the TSPB technique involves helping youth identify various emotional expression techniques and then helping them to try these out. We recommend brainstorming with young clients about specific methods for expressing feelings. The client and counselor should work together (perhaps with a chalk/grease board or large drawing pad), generating a list of expressive strategies that might include:

  • scribbling on a note pad with a black marker
  • drawing an angry, ugly picture
  • punching or kicking a large pillow
  • jumping up and down really hard
  • writing a nasty note to someone (but not delivering it)
  • grimacing and making various angry faces into a mirror
  • using words, perhaps even yelling if appropriate, to express specific feelings.

The expressive procedures listed above are easier for young clients to learn and understand when counselors actively model affective expression or assist clients in their affective expression. It’s especially important to model emotional expression when clients are inhibited or unsure about how to express themselves. Again, we recommend engaging in affective expression jointly with clients. We’ve had particular success making facial grimaces into a mirror. (Young clients often become entertained when engaging in this task with their counselor.) The optimal time for shifting to Step 2 in the TSPB technique is when clients have just begun to show a slight change in affect. (Often this occurs as a result of the counselor joining the client in expressing anger or sadness or general nastiness.)

Note: If a young client is unresponsive to Step 1 of the TSPB technique, don’t move to Step 2. Instead, an alternative mood-changing strategy should be considered (e.g., perhaps food and mood or the personal note). Be careful to simply reflect what you see. “Seems like you aren’t feeling like expressing those yucky feelings right now. Hey, that’s okay. I can show you this trick some other day. Want some gum?”

Step 2: Think a new thought (or engage in a new behavior). This step focuses on Mosak’s push-button approach (Mosak, 1985). It’s designed to demonstrate to the client that emotions are linked to thoughts. Step 2 is illustrated in the following dialogue (an extension of the previous case example with John and Sam):

JSF:     Did you know you can change your mood just by thinking different thoughts? When you think certain things it’s like pushing a button in your brain and the     things you think start making you feel certain ways. Let’s try it. Tell me the funniest thing that happened to you this week.

S:         Yesterday in math, my friend Todd farted (client smiles and laughs).

JSF:     (Smiles and laughs back) Really! I bet people really laughed. In fact, I can see it makes you laugh just thinking about it. Way back when I was in school I had a friend who did that all the time.

The content of what young people consider funny may not seem particularly funny to adults. Nonetheless, it’s crucial to be interested and entertained—welcoming the challenge to empathically see the situation from the 13-year-old perspective. It’s also important to stay with and build on the mood shift, asking for additional humorous thoughts, favorite jokes, or recent events. With clients who respond well, counselors can pursue further experimentation with various affective states (e.g., “Tell me about a sad [or scary, or surprising] experience”).

In some cases, young clients may be unable to generate a funny story or a funny memory. This may be an indicator of depression, as depressed clients often report greater difficulty recalling positive or happy events (Weerasekera, Linder, Greenberg, & Watson, 2001). Consequently, it may be necessary for the counselor to generate a funny statement.

S:         I can’t think of anything funny.

JSF:     Really? Well, keep trying . . . I’ll try too (therapist and client sit together in silence for about 20 seconds, trying to come up with a positive thought or memory).

JSF:     Got anything yet?

S:         Nope.

JSF:     Okay, I think I’ve got one. Actually, this is a joke.  What do you call it when 100 rabbits standing in a row all take one step backwards?

S:         Huh?

JSF:     (repeats the question)

S:         I don’t know.  I hate rabbits.

JSF:     Yeah.  Well, you call it a receding hare line.  Get it?

S:         Like rabbits are called hares?

JSF:     Yup.  It’s mostly funny to old guys like me.  (JSF holds up his own “hare line”)

S:         That’s totally stupid, man (smiling despite himself). I’m gonna get a buzz cut pretty             soon.

When you tell a joke or a funny story, it can help clients reciprocate with their own stories.  You can also use teasing riddles, puns, and word games if you’re comfortable with them.

We have two additional comments for counselors who might choose to use a teasing riddle which the client may get wrong. First, you should use teasing riddles only when a strong therapeutic relationship is established; otherwise, your client may interpret teasing negatively. Second, because preteen and teen clients often love to tease, you must be prepared to be teased back (i.e., young clients may generate a teasing riddle in response to a your teasing riddle).

Finally, counselors need to be sensitive to young clients who are unable to generate a positive thought or story, even after having heard an example or two. If a young client is unable to generate a funny thought, it’s important for you to remain positive and encouraging. For example:

JSF:     You know what. There are some days when I can’t think of any funny stories either. I’m sure you’ll be able to tell me something funny next time. Today I was able to think of some funny stuff . . . next time we can both give it a try again if you want.

Occasionally, young clients won’t be able to generate alternative thoughts or they won’t understand how the pushbutton technique works. In such cases, the counselor can focus more explicitly on changing mood through changing behaviors. This involves getting out a sheet of paper and mutually generating a list of actions that the client can take—when he or she feels like it—to improve mood.

Sometimes depressed young clients will need to borrow from your positive thoughts, affect, and ideas because they aren’t able to generate their own positive thoughts and feelings. If so, the TSPB technique should be discontinued for that particular session. The process of TSPB requires completion of each step before continuing on to the next step.

Step 3: Spread the good mood. Step 3 of this procedure involves teaching about the contagion quality of mood states. Teaching clients about contagious moods accomplishes two goals. First, it provides them with further general education about their emotional life. Second, if they complete the assignment associated with this activity, they may be able to have a positive effect on another person’s mood:

JSF:     I want to tell you another interesting thing about moods. They’re contagious. Do you  know what contagious means? It means that you can catch them from being around other  people who are in bad moods or good moods. Like when you got here. I noticed your  mom was in a pretty bad mood too. It made me wonder, did you catch the bad mood from    her or did she catch it from you? Anyway, now you seem to be in a much better mood. And so I was wondering, do you think you can make your mom “catch” your good mood?

S:         Oh yeah. I know my mom pretty well. All I have to do is tell her I love her and she’ll get all mushy and stuff.

JSF:     So, do you love her?

S:         Yeah, I guess so. She really bugs me sometimes though, you know what I mean?

JSF:     I think so. Sometimes it’s especially easy for people who love each other to bug each other. And parents can be especially good at bugging their kids. Not on purpose, but they bug you anyway.

S:         You can say that again. She’s a total bugging expert.

JSF:     But you did say you love her, right?

S:         Yeah.

JSF:     So if you told her “I love you, Mom,” it would be the truth, right?

S:         Yeah.

JSF:     And you think that would put her in a better mood too, right?

S:         No duh, man. She’d love it.

JSF:     So, now that you’re in a better mood, maybe you should just tell her you love her and spread the good mood. You could even tell her something like: “Dude, Mom, you really   bug me sometimes, but I love you.”

S:         Okay. I could do that.

It’s obvious that Sam knows at least one way to have a positive influence on his mother’s mood, but he’s reluctant to use the “I love you” approach. In this situation it would be useful for Sam to explore alternative methods for having a positive effect on his mother’s mood.

Although some observers of this therapy interaction may think the counselor is just teaching Sam emotional manipulation techniques, we believe that viewpoint makes a strong negative assumption about Sam and his family. Our position is that successful families (and successful marriages) include liberal doses of positive interaction (Gottman et al., 1995). Consequently, unless we believe Sam is an exceptionally manipulative boy (i.e., he has a conduct disorder diagnosis), we feel fine about reminding him of ways to share positive (and truthful) feelings with his mother.

To spread a good mood requires a certain amount of empathic perspective taking. Often, youth are more able to generate empathic responses and to initiate positive interactions with their parents (or siblings, teachers, etc.) after they’ve achieved an improved mood state and a concomitant increased sense of self-control. This is consistent with social–psychological literature suggesting that positive moods increase the likelihood of prosocial or altruistic behavior (Isen, 1987). Because of developmental issues associated with being young, it’s sometimes helpful to introduce the idea of changing other people’s moods as a challenge (Church, 1994).  “I wonder if you have the idea down well enough to actually try and change your mom’s mood.”

Once in a while, when using this technique, we’ve had the pleasure of witnessing some very surprised parents. One 12-year-old girl asked to go out in the waiting room to tell her grandmother that she was going to rake the lawn when they got home (something Grandma very much wanted and needed). Grandma looked positively stunned for minute, but then a huge smile spread across her face. The girl skipped around the office saying, “See.  I can do it.  I can change her mood.”

One 14-year-old boy thought a few minutes, then brought his mom into the office and said “Now Mom, I want you to think of how you would feel if I agree to clear the table and wash the dishes without you reminding me for a week.” Mom looked a bit surprised, but admitted she felt good at the thought, whereupon I (John) gave the boy a thumbs up signal and said, “Well done.”

Step 4.

At this point, readers should beware that although we’re describing a Three-Step technique, we’ve now moved to Step 4. We do this intentionally with young clients to make the point that whenever we’re working with or talking about emotions, surprising things can happen.

In keeping with the learn-do-teach model, we ask our young clients to teach the TSPB procedure to another person after they learn it in therapy. One girl successfully taught her younger brother the method when he was in a negative mood during a family hike. By teaching the technique to her brother, she achieved an especially empowering experience; she began to view herself as having increased control over her and her family’s emotional states.

A Brief Description of Motivational Interviewing

In response to some questions on CESNET, I’m posting a brief description of Motivational Interviewing. Of course, Miller and Rollnick’s Motivational Interviewing text is a much more thorough source and is highly recommended if you want more complete information.

This description is an excerpt from the second edition of our Counseling and Psychotherapy Theories textbook. If you’re interested, you can check it out here: http://bcs.wiley.com/he-bcs/Books?action=index&itemId=0470617934&bcsId=7103

For the third edition (in preparation now), we’ll be substantially expanding this section and so if you have insights, publications, or other information that you think we should be aware of, please email me at john.sf@mso.umt.edu.

Here’s the excerpt:

Motivational Interviewing: A Contemporary PCT Approach

Person-Centered Therapy (PCT) principles have been integrated into most other approaches to counseling and psychotherapy. However, there are three specific approaches that are explicitly new generation person-centered therapies. These include:

  1. Motivational interviewing
  2. Emotion-focused therapy
  3. Nondirective play therapy

Next, we discuss motivational interviewing. Due to its strong integrational characteristics, emotion-focused therapy is covered in Chapter 14. Additional resources are available on nondirective play therapy (Landreth, 2002).

Moving Away From Confrontation and Education

In his research with problem drinkers, William R. Miller was studying the efficacy of behavioral self-control techniques. To his surprise, he found that structured behavioral treatments were no more effective than an encouragement-based control group. When he explored the data for an explanation, he found that regardless of treatment protocol, therapist empathy ratings were the strongest predictors of positive outcomes at 6 months (r = .82), 12 months (r = .71), and 2 years (r = .51; W. R. Miller, 1978; W. R. Miller & Taylor, 1980). Consequently, he concluded that positive treatment outcomes with problem drinkers were less related to behavioral treatment and more related to reflective listening and empathy. He also found that active confrontation and education generally led to client resistance. These discoveries led him to develop motivational interviewing (MI).

MI builds on person-centered principles by adding more focused therapeutic targets and specific client goals. Rollnick and Miller (1995) define MI as “a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence” (p. 326).

Focusing on Client Ambivalence

Client ambivalence is the primary target of MI. When it comes to substance abuse and other health related behaviors, Miller and Rollnick (2002) view ambivalence as natural. Most all problem drinkers recognize or wish they could quit, but continue drinking for various reasons. Miller and Rollnick described what happens when therapists try to push healthy behaviors on clients:

[The therapist] then proceeds to advise, teach, persuade, counsel or argue for this particular resolution to [the client’s] ambivalence. One does not need a doctorate in psychology to anticipate what [the client’s] response is likely to be in this situation. By virtue of ambivalence, [the client] is apt to argue the opposite, or at least point out problems and shortcomings of the proposed solution. It is natural for [the client] to do so, because [he or she] feels at least two ways about this or almost any prescribed solution. It is the very nature of ambivalence. (pp. 20–21)

In many situations, humans are naturally inclined to resist authority. Therefore, when resistance rises up in clients, MI advocates person-centered attitudes and interventions. This leads to Miller and Rollnick’s (2002) foundational person-centered principle of treatment:

It is the client who should be voicing the arguments for change (p. 22).

Although Miller and Rollnick describe Rogers as collaborative, caring, and supportive—they emphasize that he was not nondirective (W. R. Miller & Rollnick, 1998). Instead, they note that Rogers gently guided clients to places where they were most confused, in pain, or agitated and then helped them stay in that place and work through it. The four central principles of MI flow from their conceptualization of Rogers’s approach (W. R. Miller & Rollnick, 2002). According to these principles, it’s the therapist’s job to:

  • Use reflective listening skills to express empathy for the client’s message and genuine caring for the client.
  • Notice and develop the theme of discrepancy between the client’s deep values and current behavior.
  • Meet client resistance with reflection rather than confrontation (Miller and Rollnick refer to this as “rolling with resistance”).
  • Enhance client self-efficacy by focusing on optimism, confidence that change is possible, and small interventions that are likely to be successful.

MI is both a set of techniques and a person-centered philosophy or style. The philosophical MI perspective emphasizes that motivation for change is not something therapists can effectively impose on clients. Change must be drawn out from clients, gently and with careful timing. Motivational interviewers do not use direct persuasion.

A Sampling of MI Techniques

Miller and Rollnick (2002) provide many excellent examples of how reflection responses reduce resistance. The following interactions capture how reflection of client efforts lessens the need for resistance:

Client: I’m trying! If my probation officer would just get off my back, I could focus on getting my life in order.

Interviewer: You’re working hard on the changes you need to make.

or

Interviewer: It’s frustrating to have a probation officer looking over your shoulder.

Client: Who are you to be giving me advice? What do you know about drugs? You’ve probably never even smoked a joint!

Interviewer: It’s hard to imagine how I could possibly understand.

Client: I couldn’t keep the weight off even if I lost it.

Interviewer: You can’t see any way that would work for you.

or

Interviewer: You’re rather discouraged about trying again. (pp. 100–101)

In the following excerpt from Clinical Interviewing (2009), we describe the MI technique of amplified reflection:

Recently, in hundreds of brief interviews conducted by graduate students in psychology and counseling with client—volunteers from introductory psychology courses, consistent with Miller and Rollnick’s (2002) motivational interviewing work, we found that clients have a strong need for their interviewers to accurately hear what they’re saying. When their interviewer made an inaccurate reflection, clients felt compelled to clarify their feelings and beliefs—often in ways that rebalanced their ambivalence.

For example, when an interviewer “went too far” with a reflection, the following exchange was typical:

Client: I am so pissed at my roommate. She won’t pick up her clothes or do the dishes or anything.

Interviewer: You’d sort of like to fire her as a roommate.

Client: No. Not exactly. There are lots of things I like about her, but her messiness really annoys me.

This phenomenon suggests that it might be possible for interviewers to intentionally overstate a client’s position in an effort to get clients to come back around to clarify or articulate the more positive side of an issue. In fact, this is a particular motivational interviewing technique referred to as amplified reflection.

When used intentionally, amplified reflection can seem manipulative, which is why amplified reflection is used along with genuine empathy. Instead of being a manipulative response it can also be viewed as an effort on the interviewer’s part to more deeply empathize with the client’s frustration, anger, discouragement, and so on. Examples of this technique include:

Client: My child has a serious disability and so I have to be home for him.

Interviewer: You really need to be home 24/7 and really need to turn off any needs you have to get out and take a break.

Client: Actually, that’s not totally true. Sometimes, I think I need to take some breaks so I can do a better job when I am home.

Client: When my grandmother died last semester I had to miss classes and it was a total hassle.

Interviewer: You don’t have much of an emotional response to your grandmother’s death—other than it really inconveniencing you.

Client: Well, it’s not like I don’t miss her, too.

Again, we should emphasize that amplified reflection is an empathic effort to get completely in touch with or resonate with one side of the client’s ambivalence (from J. Sommers-Flanagan & Sommers-Flanagan, 2009, pp. 316–317).

End of excerpt

Post-Partum (now Peripartum) Depression: What you should know . . . and some resources to help you know it

Note: This post is provided for individuals interested in learning more about post-partum or peripartum depression. It’s also a supplement for the recent Practically Perfect Parenting Podcast on “Post-Partum Depression.” You can listen to the podcast on iTunes: https://itunes.apple.com/us/podcast/practically-perfect-parenting/id1170841304?mt=2

stillwater-winter-view

For the first time ever on planet Earth, the latest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) includes the diagnosis of Peripartum Depression. Although I’m not usually a fan of labeling or big psychiatry, this is generally good news.

So, why is Peripartum Depression good news?

The truth is that many pregnant women and new moms experience depressive symptoms related to pregnancy and childbirth. These symptoms are beyond the normal and transient “baby blues.” Depressive symptoms can be anywhere from mild to severe and, combined with the rigors of pregnancy, childbirth, and parenting a newborn, these symptoms become very difficult to shake.

But the most important point is that Peripartum Depression is a problem that has been flying under the RADAR for a very long time.

Approximately 20% of pregnant women struggle with depressive symptoms. The official 12-15% estimates of post-partum (after birth) depression in women are thought to be an underestimate. What makes these numbers even worse is the fact that society views childbirth as a dramatically positive life event. This makes it all-the-more difficult for most pregnant women and new moms to speak openly about their emotional pain and misery. And, as you probably know, when people feel they shouldn’t talk about their emotional pain, it makes getting the help they deserve and recovering from depression even more difficult.

Jane Honikman, a post-partum depression survivor and founder of Postpartum Support International has three universal messages for all couples and families. She says:

  • You’re not alone
  • It’s not your fault
  • You will be well

Keep in mind that although peripartum depression is thought to have strong biological roots, the first-line treatment of choice is psychotherapy. This is because many new moms are reluctant to take antidepressant medications, but also because psychotherapy is effective in directly addressing the social and contextual factors, as well as the physiological symptoms. Additionally, as Ms. Honikman emphasizes, support groups for post-partum depression can be transformative.

Below, I’m including links and resources related to peripartum or post-partum depression.

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A very helpful informational post by Dr. Nicola Gray: http://cognitive-psychiatry.com/peripartum-depression/

Books by Jane Honikman can be found at this Amazon link. Her books include: I’m Listening: A Guide to Supporting Postpartum Families.  https://www.amazon.com/s/ref=dp_byline_sr_book_1?ie=UTF8&text=Jane+I.+Honikman&search-alias=books&field-author=Jane+I.+Honikman&sort=relevancerank

Although it’s true that peripartum depression can be debilitating, it’s also true that it can be a source of personal growth. Dr. Walker Karraa shares optimistic stories of post-partum related trauma and growth in her book:

https://www.amazon.com/Walker-Karraa/e/B00QTWH9PW/ref=dp_byline_cont_book_1

 

More Methods for Discussing Suicide with Mental Health Clients

nick-nacksNearly everyone agrees that asking clients directly about suicide is the right thing. However, because every client situation is unique, there are also many different strategies for asking about suicide. In this short excerpt from Clinical Interviewing, we discuss how to bring up suicide using information from outside of the counseling or assessment session.

Using Outside Information to initiate Risk and Protective Factor Assessment

Outside of the formal suicide assessment interview, three main sources of information can be used to initiate a discussion with clients about suicide risk and protective factors:

  1. Client Records
  2. Assessment Instruments
  3. Collateral Informants

Client Records

If available, your client’s previous medical or mental health (med-psych) records are a quick and efficient source for client risk and protective factor information. Many risk factors listed in this chapter won’t be in your client’s records, but you should look closely for factors, such as: (a) previous suicide ideation and attempts; (b) a history of a depression diagnosis; and (c) familial suicide. After your standard intake interviewing opening and rapport building, you can use the records to broach these issues.

I saw in your records that you attempted suicide back in 2012. Could you tell me what was going on in your life back then to trigger that attempt? 

When exploring previous suicide attempts, it’s important to do so in a constructive manner that can contribute to treatment (see Case Example 10.2). Using psychoeducation to explain to clients why you’re asking about the past helps frame and facilitate the process.

The reason I’m asking about your previous suicide attempt is because the latest research indicates that the more we know about the specific stresses that triggered a past attempt, the better we can work together to help you cope with that stress now and in the future. 

Don’t forget to balance your questioning about previous suicide attempts with a focus on the positive.

Often, after a suicide attempt, people say they discovered some new strengths or resources or specific people who were especially helpful. How about for you? Did you have anything positive you discovered in the time after your suicide attempt.

It may be difficult to identify protective factors in your client’s med-psych records. However, if you find evidence of protective factors or personal strengths, you should bring them up in the appropriate context during a suicide assessment interview. For example, when interviewing a client who’s talking about despair associated with a current depressive episode, you might say something like:

I noticed in your records that you had a similar time a couple years ago when you were feeling very down and discouraged. And, according to your therapist back then, you worked very hard and managed to climb back up out of that depressing place. What worked for you back then?

Strive to use information from your clients’ records collaboratively. As illustrated, you can use the information to broach delicate issues (both positive and negative).

Traditionally, previous suicide attempts are considered one of the strongest predictors of future suicidal behaviors. However, as with all risk factors, previous attempts should be considered within the idiosyncratic context of each individual client. Case example 10.2 provides a glimpse of a case where a previous attempt ends up serving as a protective factor, rather than a risk factor.

Case Example 10.2

Exploring Previous Attempts as a Method for Understanding Client Stressors and Coping Strategies

Exploring previous suicide attempts is an assessment process. It can illuminate past stressors, but it’s equally useful for helping clients articulate past, present, and future coping responses.

Therapist: You wrote on your intake form that you attempted suicide about a year and a half ago. Can you tell me a bit about that?

Client: Right. I shot myself in the head. It’s obvious. You can see the scar right here.

Therapist: What was happening in your life that brought you to that point?

Client: I was getting bullied in school. I hated my step-father. Life was shit, so one day after school I took the pistol out of my mom’s room, aimed at my head and shot.

Therapist: What happened then?

Client: I woke up in the hospital with a bad fucking headache. And then there was rehab. It was a long road, but here I am.

Therapist: Right. Here you are. What do you make of that?

Client: I’m lucky. I’m bad at suicide. I don’t know. I suppose I took it to mean that I’m supposed to be alive.

Therapist: Have you had any thoughts about suicide recently?

Client: Nope. Nada. Not one.

Therapist: I guess from what you said that getting bullied or having family issues could still be hard for you. How do you cope with that now?

Client: I’ve got some friends. I’ve got my sister. I talk to them. You know, after you do what I did, you find out who really cares about you. Now I know.

 

Talking with Clients about Suicidal Thoughts and Feelings

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Spring is coming to the Northern Hemisphere. Along with spring, there will also be a bump in death by suicide. To help prepare counselors and clinicians to talk directly with clients about suicide, I’m posting an excerpt from the Clinical Interviewing text. The purpose is to help everyone be more comfortable talking about suicidal thoughts and feelings because the more comfortable we are, the more likely clients are to openly share their suicidal thoughts and feelings and that gives us a chance to engage them as a collaborative helper.

Here’s a link to the text https://www.amazon.com/Clinical-Interviewing-Video-Resource-Center/dp/1119084237/ref=asap_bc?ie=UTF8

And here’s the excerpt:

Exploring Suicide Ideation

Unlike many other risk factors (e.g., demographic factors), suicide ideation is directly linked to potential suicide behavior. It’s difficult to imagine anyone ever dying by suicide without having first experienced suicide ideation.

Because of this, you may decide to systematically ask every client about suicide ideation during initial clinical interviews. This is a conservative approach and guarantees you won’t face a situation where you should have asked about suicide, but didn’t. Alternatively, you may decide to weave questions about suicide ideation into clinical interviews as appropriate. At least initially, for developing professionals, we recommend using the systematic approach. However, we recognize that this can se0em rote. From our perspective, it is better to learn to ask artfully by doing it over and over than to fail to ask and regret it.

The nonverbal nature of communication has direct implications for how and when you ask about suicide ideation, depressive symptoms, previous attempts, and other emotionally laden issues. For example, it’s possible to ask: “Have you ever thought about suicide?” while nonverbally communicating to the client: “Please, please say no!” Therefore, before you decide how you’ll ask about suicide ideation, you need the right attitude about asking the question.

Individuals who have suicidal thoughts can be extremely sensitive to social judgment. They may have avoided sharing suicidal thoughts out of fear of being judged as “insane” or some other stigma. They’re likely monitoring you closely and gauging whether you’re someone to trust with this deeply intimate information. To pass this unspoken test of trust, it’s important to endorse, and directly or indirectly communicate the following beliefs:

  • Suicide ideation is normal and natural and counseling is a good place for clients to share those thoughts.
  • I can be of better help to clients if they tell me their emotional pain, distress, and suicidal thoughts.
  • I want my clients to share their suicidal thoughts.
  • If my clients share their suicidal thoughts and plans, I can handle it!

If you don’t embrace these beliefs, clients experiencing suicide ideation may choose to be less open.

Asking Directly about Suicide Ideation

Asking about suicide ideation may feel awkward. Learning to ask difficult questions in a deliberate, compassionate, professional, and calm manner requires practice. It also may help to know that, in a study by Hahn and Marks (1996), 97% of previously suicidal clients were either receptive or neutral about discussing suicide with their therapists during intake sessions. It also may help to know that you’re about to learn the three most effective approaches to asking about suicide that exist on this planet.

Use a normalizing frame. Most modern prevention and intervention programs recommend directly asking clients something like, “Have you been thinking about suicide recently?” This is an adequate approach if you’re in a situation with someone you know well and from whom you can expect an honest response.

A more nuanced approach is to ask about suicide along with a normalizing or universalizing statement about suicide ideation. Here’s the classic example:

Well, I asked this question since almost all people at one time or another during their lives have thought about suicide. There is nothing abnormal about the thought. In fact it is very normal when one feels so down in the dumps. The thought itself is not harmful. (Wollersheim, 1974, p. 223)

Three more examples of using a normalizing frame follow:

  • I’ve read that up to 50% of teenagers have thought about suicide. Is that true for you?
  • Sometimes when people are down or feeling miserable, they think about suicide and reject the idea or they think about suicide as a solution. Have you had either of these thoughts about suicide?
  • I have a practice of asking everyone I meet with about suicide and so I’m going to ask you: Have you had thoughts about death or suicide?

A common fear is that asking about suicide will put suicidal ideas in clients’ heads. There’s no evidence to support this  (Jobes, 2006). More likely, your invitation to share suicidal thoughts will reassure clients that you’re comfortable with the subject, in control of the situation, and capable of dealing with the problem.

Use gentle assumption. Based on over two decades of clinical experience with suicide assessment Shawn Shea (2002/ 2004/2015) recommends using a framing strategy referred to as gentle assumption. To use gentle assumption, the interviewer presumes that certain illegal or embarrassing behaviors are already occurring in the client’s life, and gently structures questions accordingly. For example, instead of asking “Have you been thinking about suicide?” you would ask:

When was the last time when you had thoughts about suicide?

Gentle assumption can make it easier for clients to disclose suicide ideation.

Use mood ratings with a suicidal floor. It can be helpful to ask about suicide in the context of a mood assessment (as in a mental status examination). Scaling questions such as those that follow can be used to empathically assess mood levels.

  1. Is it okay if I ask some questions about your mood? (This is an invitation for collaboration; clients can say “no,” but rarely do.)
  2. Please rate your mood right now, using a zero to 10 scale. Zero is the worst mood possible. In fact, zero would mean you’re totally depressed and so you’re just going to kill yourself. At the top, 10 is your best possible mood. A 10 would mean you’re as happy as you could possibly be. Maybe you would be dancing or singing or doing whatever you do when you’re extremely happy. Using that zero to 10 scale, what rating would you give your mood right now? (Each end of the scale must be anchored for mutual understanding.)
  3. What’s happening now that makes you give your mood that rating? (This links the mood rating to the external situation.)
  4. What’s the worst or lowest mood rating you’ve ever had? (This informs the interviewer about the lowest lows.)
  5. What was happening back then to make you feel so down? (This links the lowest rating to the external situation and may lead to discussing previous attempts.)
  6. For you, what would be a normal mood rating on a normal day? (Clients define their normal.)
  7. Now tell me, what’s the best mood rating you think you’ve ever had? (The process ends with a positive mood rating.)
  8. What was happening that helped you have such a high mood rating? (The positive rating is linked to an external situation.)

The preceding protocol assumes clients are minimally cooperative. More advanced interviewing procedures can be added when clients are resistant (see Chapter 12). The process facilitates a deeper understanding of life events linked to negative moods and suicide ideation. This can lead to formal counseling or psychotherapy, as well as safety planning.

Responding to Suicide Ideation

Let’s say you broach the question and your client openly discloses the presence of suicide ideation. What next?

First, remember that hearing about your client’s suicide ideation is good news. It reflects trust. Also remember that depressive and suicidal symptoms are part of a normal response to distress. Validate and normalize:

Given the stress you’re experiencing, it’s not unusual for you to sometimes think about suicide. It sounds like things have been really hard lately.

This validation is important because many suicidal individuals feel socially disconnected, emotionally invalidated, and as if they’re a social burden (Joiner, 2005). Your empathic reflection may be more or less specific, depending on how much detailed information your client has given you.

As you continue the assessment, collaboratively explore the frequency, triggers, duration, and intensity of your client’s suicidal thoughts.

  • Frequency: How often do you find yourself thinking about suicide?
  • Triggers: What seems to trigger your suicidal thoughts? What gets them started?
  • Duration: How long do these thoughts stay with you once they start?
  • Intensity: How intense are your thoughts about suicide? Do they gently pop into your head or do they have lots of power and sort of smack you down?

As you explore the suicide ideation, strive to emanate calmness, and curiosity, rather than judgment. Instead of thinking, “We need to get rid of these thoughts,” engage in collaborative and empathic exploration.

Some clients will deny suicidal thoughts. If this happens, and it feels genuine, acknowledge and accept the denial, while noting that you were just using your standard practice.

Okay. Thanks. Asking about suicidal thoughts is just something I think is important to do with everyone.

On the other hand, if the denial seems forced, or is combined with depressive symptoms or other risk factors, you’ll still want to use acknowledgement and acceptance, but then find a way to return to the topic later in the session.