The following content is adapted from: “Conversations about suicide: Strategies for detecting and assessing suicide risk.” It’s from an article I published in the Journal of Health Service Psychology earlier this year.

I’m posting it because I always think it helps to talk and write about suicide assessment and intervention issues, but also because this content addresses some unique nuances in approaching suicidal clients.

Here we go . . . please share your comments and questions . . . or just share this so others can have access.

Showing Empathy, Building Rapport, and Staying Balanced

Working with suicidal clients may involve unique empathic responses. For example, clients with depressive symptoms may have long response latencies and may focus exclusively on negative emotions. Showing patience while waiting for clients to respond is part of the empathic rapport-building process. You might say, “Take your time” or “I can see you’re thinking about how you want to answer my question” or “Right now everything is feeling sluggish.”

Speech content for suicidal clients can be or can become singularly and profoundly negative. This profound negativity can naturally affect you, causing you to react in ways that are positive and encouraging, but not empathic. Examples include:

•     This too shall pass.
•     Suicide is a permanent solution to a temporary problem.
•     Let’s focus on what’s been going well in your life.

The problem with these responses is that if they are used to counter client negativity, clients may conclude that you “don’t get them,” and then will cling even more strongly to their negative perceptions, while feeling greater isolation. Consequently, instead of shifting to positive content, you should use empathic reflections, at least briefly, to clearly connect with your clients’ unbearable distress and depressive symptoms (“I hear you saying that, right now, you feel completely miserable and hopeless”).

Empathic Reflections

Using a “completely miserable and hopeless” reflection can be useful in two ways. First, it demonstrates your willingness to be with your client right in the midst of despair. Second, as motivational interviewing practitioners have discussed, your “completely miserable and hopeless reflection” might function as an amplified reflection (Miller & Rollnick, 2013). If so, your client might respond with positive change talk (e.g., “I’m not completely miserable and hopeless”).

Along with expressing empathy directly in ways that connect with clients in their despair, it is also important to use emotional and behavioral reflections in ways that leave open the possibility of positive change. This could involve saying “Right now you’re feeling . . . “ instead of just saying “You’re feeling . . .” The difference is that saying “Right now” leaves open the possibility that the sad and bad feelings may change in the next moment, next hour, or next day.

Using the Client’s Language

When possible, using the client’s language is recommended. If, for example, a client says something like, “I feel like shit” or “I am completely stuck in this pit of despair,” you might want to use the words “shit” or “shitty” or “despair.” Additionally, offering an “invitation for collaboration” is important. This could involve statements like, “I’d like to know more about what it’s like in your pit of despair” or “Do you mind telling me more about what’s feeling shitty right now?” Expressing your interest in working with and hearing from clients and intermittently asking permission to explore different problems or emotions can contribute significantly to collaborative mental health professional-client work.

Using Validation

Validation or reassurance also can facilitate rapport. Validation includes statements like, “Given the very difficult things going on in your life right now, it’s natural that you would feel down and depressed.” As long as your response is authentic, using immediacy or brief self-disclosure is another validation strategy that deepens the working alliance: “As you talk about the great sadness you have around the loss of your daughter, I find myself feeling sadness along with you” (Sommers-Flanagan & Sommers-Flanagan, 2017).

Dealing with Irritability

Suicidal clients are sometimes extremely irritable. In such cases it may be difficult to develop rapport. Client irritability also can provoke negative emotional reactions in you. Consequently, when clients express irritability, using a three-part response is recommended: (a) reflective listening, (b) gentle interpretation, and (c) a statement of commitment to keep working with and through the irritability.

•     As you talk, I hear annoyance and irritability in your voice (reflective listening).
•     When I hear that, to me it seems like it’s partly just an expression of how tired you are of feeling bad and sad. Irritability is really just a part of being very depressed (gentle interpretation).
•     I want you to know, that my plan is to keep on working with you and to try not to let any of the annoyance or irritability you’re feeling get in the way of our work together (statement of commitment).

Dealing with Ruptures

Clients’ expressions of irritability can also signal a mental health professional-client relationship rupture. You may have said something that your client didn’t like and, in response, your client may show irritability and anger, or withdraw. If you think your client’s irritability is about a relational rupture (instead of irritability associated with depression), several options can be useful (Safran, Muran, & Eubanks-Carter, 2011; Sommers-Flanagan & Sommers-Flanagan, 2017).

•     Acknowledge you empathic or interpretive “miss” or error: “I missed the importance you’re feeling about your physical symptoms”
•     Apologize directly to the client: “I’m sorry for not getting how strongly you feel about your relationship break up.”
•     Concede to the client’s perspective: “I think I need to see this from your shoes.”
•     Change the task or goals: “What I’m sensing is that you’d rather not talk about your past. How about we shift to talking about right now or about the future?”

Using Balanced Questioning

Before or after asking directly about suicide, you may find yourself using traditional diagnostic questions about depression and/or other suicide risk factors. In general, diagnostic and risk factor questions are good questions because they help deepen your understanding of the client’s unique psychological-emotional-behavioral state. However, using a balance of positive and negative questioning is recommended. Specifically, if you ask about sadness, it is also important to ask about happiness (e.g., “What are the things in your life right now that lift your mood just a bit?”). Although it is possible that clients who are depressed and suicidal will answer all your questions (even the positive ones) in the negative (e.g., “Nothing lifts my mood, ever.”), when that happens you gain valuable information about the depth of your clients’ depression and whether they have a reactive mood. As needed, you can use Linehan’s Reasons for Living Scale (Linehan, Goodstein, Nielsen, & Chiles, 1983) and solution-focused resources to identify questions with positive phrasing that balance traditional diagnostic assessment protocols (de Shazer, Dolan, Korman, McCollum, Trepper, & Berg, 2007).

Asking Directly about Suicide Ideation

The standard for all helping professionals is to ask clients directly about suicide ideation. Despite this universal guidance, asking directly can trigger clinician anxiety; it can also be difficult to find the right words to elicit an honest and open client response. Many questionnaires and suicide prevention protocols encourage asking directly with a question like, “Have you been having any thoughts about suicide?”

Using the “Have you been having . . .” question is a reasonable default, but it lacks clinical sophistication. Various writers in the suicide assessment and intervention area recommend using alternative wording and framing when asking clients directly about suicide (Jobes, 2016; Shea and Barney, 2015; Sommers-Flanagan & Shaw, 2017). Three distinct approaches are described here.

Using a Normative Frame

Wollersheim (1974) advocated for using a normalizing frame when interviewing suicidal clients. She wrote,

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)

Although Wollersheim is offering reassurance to her client after asking about suicide, her recommendation captures the essence of using a normative frame. The question flows from the client’s descriptions of depressive symptoms or personal distress and then frames suicide ideation as normative, given the client’s distressing condition. Depending on the specific client population and symptoms, normative framing could include:

•     You’re saying you’ve been very down and depressed. It’s normal for people who are feeling depressed to sometimes think about suicide. Has that been the case for you? Have you had thoughts about dying or ending your life?
•     It’s not unusual for teenagers to sometimes have thoughts about suicide. I’m wondering if you’ve had thoughts about suicide.

Some clinicians resist using the normative frame. They complain that a normative frame increases their worry about putting the idea in the client’s mind. Although there is research indicating that most clients appreciate being asked directly about suicide, it can still be difficult to embrace the normative frame. If so, there are several alternatives, including the “I ask all my clients about suicide” frame. Here’s an example:

I’m a mental health professional and so part of my job is to ask all of my clients about suicide.  And so I’m wondering, have you had any suicidal thoughts now, recently, or farther back in the past?

A normative frame lowers the bar and makes it easier for clients to admit to suicide ideation. Although suicide ideation is not a good predictor of suicide attempts, it is obvious that clients do not make attempts or die by suicide without first having thoughts about suicide. Additionally, it is important to note that whether you use a normative frame that focuses on reducing clients’ feelings of being deviant, or the frame where you emphasize that it is normal for you to ask all your clients about suicide, it is important that you practice, in advance and aloud, so that using normalizing statements becomes comfortable for you.

AS ALWAYS . . . FEEL FREE TO CONTINUE THE DISCUSSION BY SHARING YOUR THOUGHTS AND REACTIONS TO THIS POST.

Hi All.

Here are the slides for our workshop today.

More stuff coming soon.

JohnHow to Listen 2018 UMT REV4

This is an excerpt from “How to Listen so Parents will Talk and Talk so Parents will Listen.” But BEFORE moving to the excerpt . . . you should know that the latest Practically Perfect Parenting Podcast focuses on the foundations of parenting education. You can listen here: http://practicallyperfectparenting.libsyn.com/how-to-listen-so-parents-will-talk-and-talk-so-parents-will-listen?tdest_id=431110

Or on iTunes: https://itunes.apple.com/us/podcast/practically-perfect-parenting-podcast/id1170841304?mt=2

Theory into Practice: The Three Parenting Educator Attitudes in Action

In the following example, Cassandra is discussing her son’s “strong-willed” behaviors with a parenting professional.

Case: “Wanna Piece of Me?”

Cassandra: My son is so stubborn. Everything is fine one minute, but if I ask him to do something, he goes ballistic. And then I can’t get him to do anything.

Consultant: Some kids seem built to focus on getting what they want. It sounds like your boy is very strong-willed. [A simple initial reflection using common language is used to quickly formulate the problem in a way that empathically resonates with the parent’s experience.]

Cassandra: He’s way beyond strong-willed. The other day I asked him to go upstairs and clean his room and he said “No!” [The mom wants the consultant to know that her son is not your ordinary strong-willed boy.]

Consultant: He just refused? What happened then? [The consultant shows appropriate interest and curiosity, which honors the parent’s perspective and helps build the collaborative relationship.]

Cassandra: I asked him again and then, while standing at the bottom of the stairs, he put his hands on his hips and yelled, “I said no! You wanna piece of me??!”

Consultant: Wow. You’re right. He is in the advanced class on how to be strong-willed. What did you do next? [The consultant accepts and validates the parent’s perception of having an exceptionally strong-willed child and continues with collaborative curiosity.]

Cassandra: I carried him upstairs and spanked his butt because, at that point, I did want a piece of him! [Mom discloses becoming angry and acting on her anger.]

Consultant: It’s funny how often when our kids challenge our authority so directly, like your son did, it really does make us want a piece of them. [The consultant is universalizing, validating, and accepting the mom’s anger as normal, but does not use the word anger.]

Cassandra: It sure gets me! [Mom acknowledges that her son can really get to her, but there’s still no mention of anger.]

Consultant: I know my next question is a cliché counseling question, but I can’t help but wonder how you feel about what happened in that situation. [This is a gentle and self-effacing effort to have the parent focus on herself and perhaps reflect on her behavior.]

Cassandra: I believe he got what he deserved. [Mom does not explore her feelings or question her behavior, but instead, shows a defensive side; this suggests the consultant may have been premature in trying to get the mom to critique her own behavior.]

Consultant: It sounds like you were pretty mad. You were thinking something like, “He’s being defiant and so I’m giving him what he deserves.” [The consultant provides a corrective empathic response and uses radical acceptance; there is no effort to judge or question whether the son “deserved” physical punishment, which might be a good question, but would be premature and would likely close down exploration; the consultant also uses the personal pronoun I when reflecting the mom’s perspective, which is an example of the Rogerian technique of “walking within.”]

Cassandra: Yes, I did. But I’m also here because I need to find other ways of dealing with him. I can’t keep hauling him up the stairs and spanking him forever. It’s unacceptable for him to be disrespectful to me, but I need other options. [Mom responds to radical acceptance and empathy by opening up and expressing her interest in exploring alternatives; Miller and Rollnick (2002) might classify the therapist’s strategy as a “coming alongside” response.]

Consultant: That’s a great reason for you to be here. Of course, he shouldn’t be disrespectful to you. You don’t deserve that. But I hear you saying that you want options beyond spanking and that’s exactly one of the things we can talk about today. [The consultant accepts and validates the mom’s perspective—both her reason for seeking a consultation and the fact that she doesn’t deserve disrespect; resonating with parents about their hurt over being disrespected can be very powerful.]

Cassandra: Thank you. It feels good to talk about this, but I do need other ideas for how to handle my wonderful little monster. [Mom expresses appreciation for the validation and continues to show interest in change.]

As noted previously, parents who come for professional help are often very ambivalent about their parenting behaviors. Although they feel insecure and want to do a better job, if parenting consultants  are initially judgmental, parents can quickly become defensive and may sometimes make rather absurd declarations like, “This is a free country! I can parent any way I want!”

In Cassandra’s case, she needed to establish her right to be respected by her child (or at least not disrespected). Consequently, until the consultant demonstrated respect or unconditional positive regard or radical acceptance for Cassandra in the session, collaboration could not begin.

Another underlying principle in this example is that premature educational interventions can carry an inherently judgmental message. They convey, “I see you’re doing something wrong and, as an authority, I know what you should do instead.” Providing an educational intervention too early with parents violates the attitudes of empathy, radical acceptance, and collaboration. Even though parents usually say that educational information is exactly what they want, unless they first receive empathy and acceptance and perceive an attitude of collaboration, they will often resist the educational message.

To summarize, in Cassandra’s case, theory translates into practice in the following ways:

• Nonjudgmental listening and empathy increase parent openness and parent–clinician collaboration.
• Radical acceptance of undesirable parenting behaviors or attitudes strengthens the working relationship.
• Premature efforts to provide educational information violate the core attitudes of empathy, radical acceptance, and collaboration and therefore are likely to increase defensiveness.
• Without an adequate collaborative relationship built on empathy and acceptance, direct educational interventions with parents will be less effective.

This is just a link to the Missoulian newspaper OpEd page where they were nice enough to publish a piece I wrote. Click on the link to find out the stunning answer to the question of whether parents can do it all in 2017. And if you do, be sure to read the only comment that the article has generated. It’s taking all of the self-control I possess to not respond with an especially snarky retort. Must remember . . . When they go low, we go high or the story of Brer Rabbit and the Tar Baby or that saying about how you shouldn’t wrestle a pig or that Sweet Spot of Self-Control . . .

Here’s the link: http://missoulian.com/news/opinion/columnists/your-parenting-style-can-you-do-it-all-in/article_a2d9e96c-87e5-58ef-b454-f3ed6c5ba117.html

Feel free to post your sophisticated comments on the Missoulian website.