As we begin the revision process for Clinical Interviewing, I’m discovering content here and there that I want to share. Below is a short excerpt from the Intake Interviewing chapter where we’re discussing the process of evaluating clients’ interpersonal behavior patterns. Please email me your reactions and recommendations if you have some.
Evaluating Interpersonal Behavior
Interpersonal behavior is central in the development and maintenance of client problems. Some theorists claim that all client problems have their roots in relationship problems (Glasser, 1998). Evaluating client interpersonal behavior is an essential part of an intake interview.
Intake interviewers have five potential data sources pertaining to client interpersonal behavior.
Client self-report. This includes self-report of (a) past relationship interactions (e.g., childhood) and (b) contemporary relationship interactions.
Clinician observations of client interpersonal behavior during the interview.
Formal psychological assessment data.
Information from past psychological records/reports.
Information from collateral informants.
Although some behaviorists and in-home family therapists also observe clients outside the office (e.g., in school, home, and work environments), it’s unusual to have those data available prior to an intake.
Evaluating interpersonal behavior is difficult. Each of the preceding data sources can be suspect. For example, client self-report may be distorted or biased; often clients cast their interpersonal behaviors in a favorable light, or they may excessively blame themselves for negative interpersonal experiences. Clinician observations are also subjective. When you’re evaluating client interpersonal behavior, it’s wise to use several basic assessment principles to temper your conclusions:
Single observations are often unreliable. This is partly because interpersonal behavior can shift dramatically from situation to situation. Multiple observations of behavior patterns (e.g., interpersonal aggression or interpersonal isolation) are more reliable.
Just as construct validity is established through multimethod, multitrait assessments (Campbell & Fiske, 1959), interpersonal assessments are more valid when you have converging data from more than one source (e.g., self-report plus clinician observation).
The literature is replete with theory-based models for interpersonal assessment. When clinicians hold strong theoretical beliefs, confirmation bias is more likely (in other words, you will make observations that confirm your theoretical stance or hypothesis). Therefore, you should regularly question conclusions about client interpersonal behavior based on your preexisting ideas.
One of the most popular models for conceptualizing interpersonal behavior is attachment theory. Adherents to this perspective believe that early caregiver-child relationship interactions create internal working models about how relationships work. Essentially, this leaves clients with consistent (and sometimes rigid) interpersonal expectations and reactions. For example, clients with insecure attachment styles may expect or anticipate rejection or abandonment, while clients with ambivalent attachment styles alternate between pushing others away and clinging to them. Typically, maladaptive components of client internal working models are activated during the early stages of new relationships or during times of significant stress, when support and reassurance are needed (O’Shea, Spence, & Donovan, 2014).
Interpersonal assessment based on attachment theory is a psychodynamic approach and involves a depth-oriented assessment process. However, the idea that individuals have internal working models that guide their interpersonal behaviors is consistent across many different theoretical perspectives. Specifically,
Cognitive therapists emphasize client schema or schemata that shape what clients expect in interpersonal relationships (Young, Klosko, & Weishaar, 2003).
Adlerian therapists use the term lifestyle assessment to refer to the evaluation of client expectations about the self, the world, and others (Carlson, Watts, & Maniacci, 2006).
Psychoanalytic therapists refer to the client’s core conflictual relational theme (CCRT) as a target for treatment (Luborsky, 1984).
The whole emphasis of the empirically supported interpersonal psychotherapy for depression is based on addressing problematic interpersonal relationship dynamics (Markowitz & Weissman, 2012).
It’s always advisable to attend to feelings and reactions that clients elicit in you (Teyber & McClure, 2011). For example, some clients may trigger boredom, arousal, sadness, or annoyance. These personal and emotional reactions can be viewed as countertransference (Luborsky & Barrett, 2006). However, if there’s convergent evidence that reactions the client is evoking in you are also evoked in others, it’s likely that the client’s interpersonal behavior is the culprit. If your reactions are unique, then your countertransference reaction may be more about you and less about the client.
Evaluating a client’s personal history and interpersonal behaviors is a formidable task that could easily take several sessions. Expecting that you should have a precise sense of your client’s interpersonal style after a single interview is unrealistic. A better goal is to have a few working hypotheses about your client’s interpersonal behavior patterns (see Case Example 8.2).
CASE EXAMPLE 8.2: DESCRIBING INTERPERSONAL OBSERVATIONS
The following intake note focuses on interpersonal observations and, consistent with a collaborative/therapeutic assessment model, uses a descriptive rather than a labeling approach.
Miriam, a 36-year-old White, married female, described herself as suffering from tension and stress in her marital relationship. She reported, “My husband always calls me controlling, and I hate that, but sometimes he’s right.” During our session, Miriam repeatedly (about five times) asked for more information, complaining that she “really needed” to understand exactly what counseling was about before she could be sure she wanted to proceed. As we discussed her husband’s comments in greater detail, Miriam noted that she believed her “need for control” was related to anxiety. Together we identified several triggers that elicit anxiety and are then followed by self-identified controlling behaviors. These comprised (a) new situations (like counseling), (b) her husband leaving the house without telling her his plans, and (c) when she feels neglected by her husband. Overall, these triggers may be related to an internal working model where Miriam’s sense of relational security is threatened. Consequently, one of our first therapy tasks is for Miriam to engage in a self-monitoring homework assignment to help further refine our understanding of the interpersonal triggers that activate her “controlling” behaviors.
Rita and I are signing a contract with John Wiley & Sons to update our Clinical Interviewing text to the 7th edition. Clinical Interviewing was first published in 1993 under the title, Foundations of Therapeutic Interviewing with Allyn & Bacon publishers. As one of my academic friends once said, it was a good book, but it fell apart in the end. I was instantly worried that we hadn’t handled the final chapter very well. Turns out, he was referring to the binding.
After Allyn & Bacon let go of the copyright in 1996, we shopped the book and got great offers from Norton, Guilford, and Wiley. We went with Wiley, received excellent editorial guidance, and Clinical Interviewing was born; the text has been very popular in the graduate textbook market in psychology, counseling, and social work.
Along with the great news that we’re headed for another edition comes a rather large chunk of planning and work.
First, the planning . . .
Clinical Interviewing became popular and has remained popular because it’s a practical and accessible text that focuses on clinician competencies. We will continue that focus—we want students to not only read the text, but to return to it, keep it, and use it to remind themselves of the foundations that underlie the clinical encounter.
Another reason the book has been popular is because of the fabulous feedback and ideas we’ve gotten from people like you. We want to continue that emphasis too. If you’re familiar with Clinical Interviewing—as a professor or as a student—I’d love to hear your ideas about what we should change or add. Please, email me with any and all your ideas: email@example.com. We’ve already have some feedback, including:
Update the text to sync with DSM-5-TR
Add more content, and a video demonstration, of online (remote) interviewing (tele-mental health)
Add more specific content pertaining to interviewing special populations in general, and working across cultures and sexualities in particular
Add more (and updated) video demonstrations
Consider stronger and more traditional diagnostic assessment content (I’m mixed on this)
Second, the work . . .
During the past two revisions, I asked people to volunteer to read and review specific chapters. This is extra work for you, but it’s also a good academic process. Everyone who provides a chapter review will be listed in the acknowledgements. And so, if any of you would like to review a chapter (or more) and provide us with feedback and guidance for the 7th edition, please email me at firstname.lastname@example.org
As always, thanks for reading this and thanks for considering the opportunity to share your clinical interviewing expertise.
Last week I got a press query to answer a few questions for an upcoming article in Parents magazine. The questions were sent to a broad spectrum of media reps and professionals. There was understandably no guarantee I would be quoted in the magazine.
No surprise, I wasn’t quoted. But my media connection was thoughtful enough to send me the article (it came out a couple days ago). IMHO commentary in the article was really good, and so I’m including a link to the article below.
Although I like the article, I have one objection. The authors immediately pathologize children’s anxiety. In the second sentence of the article, they write, “Both conditions (separation anxiety and social anxiety) are treatable with the proper diagnosis.” Using words like “conditions” and “treatable” and “diagnosis” deeply medicalizes children’s anxiety and is a bad idea. Separation anxiety and social anxiety are NOT necessarily mental disorders. It would have been better to start the article by noting that given our current global situation of uncertainty–with COVID, and other sources of angst all around us–it’s normal and natural for children to feel anxiety.
This blog post has three parts. First, I’m including a link to the article. Second, I’m including my responses to the media query. Third—and I think the best part—is a old handout I wrote for helping parents deal with children’s anxiety and fear.
Here are my responses to the magazine’s questions:
What is anxiety, in a nutshell?
Anxiety is a natural human emotional response to stress, danger, or threat. One thing that makes anxiety especially distinctive and problematic is that it comes with strong physiological components. Other words used to describe anxiety states include, nervous, worried, jittery, jumpy, scared, and afraid.
Anxiety usually has a trigger or is linked to an activating situation, thought, or physical sensation. Hearing about COVID in the news or seeing someone fall ill can activate anxiety in children (and adults too!).
Anxiety is often, but not always, about the future because people tend to worry about what will happen or what is unfolding in the present. Even when children feel anxious about the past, they tend to worry about how the past will play out in the future.
How has COVID-19 affected children mentally? Has there been an uptick in anxiety-related conditions?
COVID-19 is a stressor or threat because of its implications (it can kill you and your loved ones) and because of how it affects children situationally. During my 30+ years as a professional psychologist, anxiety in children, teens, and adults has done nothing but increase. COVID-19 is another factor in contemporary life that has increased anxiety.
In some ways, the fact that more children are feeling anxious can be a positive thing. I know that sounds weird, but anxiety is mostly normal. A professor of mine used to say that the old saying “Misery loves company” isn’t quite true. What is true (and supported by data) is that misery loves miserable company. In other word, people feel a little better when their problems are more universal. When it comes to COVID-related anxiety, we should all recognize we’re in good company.
What are the symptoms of social anxiety in kids?
Social anxiety is defined as fear of being scrutinized or negatively evaluated by others. Symptoms can be physical (headaches, stomach aches, shaking, etc.), emotional (feeling scared), mental (thinking something terrible will happen), and behavioral (running away). Social anxiety is usually most intense in anticipation and during exposure to potential social evaluation. Of course, almost always, anxiety will make us imagine that everyone is staring at us—even though many other kids are also feeling anxious and as if everyone is staring at them.
What are the symptoms of separation anxiety in kids?
Separation anxiety occurs when children leave or part from a safe person or a safe place. Leaving the home or leaving mom or dad or grandma or grandpa will often trigger anxiety. The symptoms—because it’s anxiety—are the same as above (physical, emotional, mental, behavioral); they’re just triggered by a different situation.
How can you help children cope with anxiety–both in general and specific to each condition?
Children should be assured that anxiety is a message from your brain and your body. When anxiety spikes, there may be a good reason for it, just like when a fire alarm goes off and there’s really a fire and there’s physical danger and getting to a safe place is important. Children should be encouraged to identify their safe places and their safe people.
However, sometimes anxiety spikes and instead of a real fire alarm, the body and the brain are experiencing a false alarm. When there’s no immediate danger and the anxiety builds up anyway, it’s crucial for children to have a plan for how they’ll handle the anxiety. Having a plan to approach and deal with anxiety is nearly always preferable to letting the anxiety be the boss. Leaning into, facing, and embracing anxiety as a normal part of life is very important. We should all avoid taking actions designed to run away from or avoid anxiety. Developing a personal plan (along with parents, teachers, and counselors) for dealing with anxiety is the best strategy.
And, finally, here’s my tip sheet for helping with children’s anxiety
How to Help Children Deal with Fears and Anxiety
Manage Your Own Anxiety and Negative Expectations: If you don’t have and display confidence in your own preparation and skills, YOUR WORRIES and negative expectations will leak into the child. Additionally, if you don’t show confidence in your child’s coping abilities, that lack of confidence will leak into them too!
Use Storytelling for Preparation and to Teach Coping Strategies: “Let’s read, Where the Wild Things Are.” Afterwards, launch into a discussion of how people deal with fears.
Focus on Problem-Solving and Coping (especially as preparation): “How do you suppose people manage or get over their fears?”
Instead of Dismissing Feelings, Use Soothing Empathy: “It’s no fun to be feeling so scared.”
Show Gentle Curiosity: “You seem scared. Want to talk about it?”
Provide Comforting Reassurance or Universality (after using empathy and listening with interest): “Lots of people get afraid of things. I remember being really afraid of dogs.”
Offer Positive (Optimistic) Encouragement: “I know it’s hard to be brave, but I know you can do it.”
Have and Show Enormous Patience (connection—and holding hands—reduces anxiety): “Yes, I’ll help you walk by Mr. Johnson’s dog again. I think we’re both getting better at it, though.”
Set Reasonable Limits: “Even though you’re scared of monsters sometimes, you still have to be brave and go to bed.”
Model how to Sit with and through Fear (No negative reinforcement!): One thing that’s always true is when fear is big, it always gets smaller, eventually. “Hey. Let’s sit here together and watch our fear go away. Let’s pay attention to what makes it get smaller.” (This might include direct coping skill work . . . or simple distraction and funny stories).
Plan and Model Anxiety Management Skills: Specific skills, like deep breathing, aid with coping. Once you find some techniques or skills that are better than nothing, start to practice and rehearse using them. This can be for preparation, coping during the anxiety, or afterwards. “Let’s sit together and count our breaths. Just count one and then another. And we’ll try to find our sweet spot.”
As I type, Steven Hayes, the creator of acceptance and commitment therapy (ACT), is talking in a variety of voices about mindful acceptance. Earlier, he mentioned something about the whole human genome. In case you don’t already know, Steve is an older white guy. His writing about psychotherapy is fantastic. I really like his Ted talk. I’ve found his question, “What shall we do with our difficult thoughts?” an excellent prompt to reflect on.
Steve and I have a history. I’m glad to say that I’ve mindfully accepted that he missed his supervision appointment with me at AABT (now ABCT) back in 1987 in Los Angeles. Really. I’ve let go Steve standing me up, not because I’m all that good at forgiveness, but because him skipping out on our chance to meet makes for a better story. In fact, in this mindful moment, I’ve accepted him missing our meeting so completely that I have no urge to try to meet him today.
This is my first Networker “Symposium.” I hadn’t realized it was quite the distinctive thing. They’ve got numbers you can put on your badges to represent how many times you’ve attended the Symposium. Although it’s just a conference, it does have a particular flair and feel. From the beginning, there was movement, talk about love and sex-tech, dancing, singing, and learning. The breadth of content and diversity of attendees has been marvelous.
I started the first day with a workshop on Love and the Therapeutic relationship with Sabrina N’Diaye. Later, I took in a workshop on Tech-Sex with Tammy Nelson, author of Getting the Sex you Want. Nelson basically blew my mind. Did you know there are “devices” you can use to remotely vibrate your romantic partner’s genitalia? I didn’t . . . and maybe I didn’t want to. Did you know someone commented in the session that “Dominants” use that vibrating device to issue “commands?” I was sitting next to a professional cuddler and sexual surrogate. She was delightful. Steve Hayes (and Ram Dass) would be proud of the fact that I managed my difficult thoughts by staying in the here and now instead of trying to imagine her work or think about what the dominatrix had shared. Just saying. My mind remained as pure as the water of the Stillwater River.
There’s been lots of talk about racism at the Symposium. That’s a good thing. I’m better for it. The more we can all be less racist or anti-racist and aware of our biases, the better. Of course, while I’m typing this, my almost erstwhile buddy Steve continues to talk (and sometimes mumble). I’m aware (somewhat painfully) that I’m more “like” him in age and gender and ethnicity and can’t help but lament that (sorry Steve). Being an old white guy brings privilege (or advantage, as our first keynote speaker preferred). At the same time, looking in the mirror and seeing myself as just another old white guy also brings along gut-level unpleasantness.
Yesterday’s highlights were listening to Ester Perel (very smart, very articulate, very impressive) and learning more about Susan Johnson and her personal history of growing up in a Pub. We also listened to three young women talk about the couple therapy experiences that changed them. Fabulous.
One of my (many) take-aways from the past two days is for me to NOT be THAT old WHITE guy. I want to be a different white guy. How does that work? Among other things, I will try not to think too much of myself . . . or mumble.
Steve is now trying to get us all to love ourselves. That’s a nice idea. Someday, Steve, I hope to get there. But, to channel our Saturday morning Symposium keynote speaker, Emily Nagoski, most of the time, things just don’t fucking work.
Wait. I know that sounds negative. Among many of her excellent points about coping with burnout, Emily played a cool song (of her twin sister’s), a song liberally infused with the F-word. If you’ve ever experienced technology frustration (which I suppose even happens with sex-tech), you should listen. Here’s the link: https://www.youtube.com/watch?v=eottd9Lw8l4 If you listen, don’t think about sex-tech at the same time. There’s no need to thank me for this great advice.
I’ve now abandoned Steve, in favor of one of the darling presenters of the Symposium and PESI. Sorry Steve . . . but I know you’ll mindfully accept your experience of me abandoning you. . . partly because you’ve never acknowledged my existence anyway (see, I’m totally over that 1987 incident).
There’s a woman talking . . . softly . . . without the changing voice routines of Steve Hayes. As she drones on, she mentions that therapy and therapists can be triggering. . . which is interesting given that I can’t find any affect in her voice. I’ve taken a seat on the floor in the back corner of the room and quickly recognized she’s right. She’s right because she instantly triggered me as I walked in the door with her monotone statement that talk therapy doesn’t work for trauma (what about CPT . . . or?). She continued to trigger me with her statement that PTSD was only identified in the 1970s (what about the diagnosis of war neurosis or battle fatigue or the many other earlier versions of PTSD?). And she finished triggering me with her laudatory comments on narrative therapy (does she NOT think of narrative therapy as “talk therapy?”).
I know my job here. Mindful acceptance. Learn what I can. Maybe the learning is about my own triggers or my own internal lament over being an increasingly irrelevant old white guy. Maybe the learning is about how to stay calm and embrace both ends of the constant dialectics and polarities of life.
On the whole, I’m so glad to be here at the Symposium, with Rita, and so grateful to continue learning. The fact that the conference has stimulated some of what Steve would call “difficult thoughts” is a blessing to be mindfully accepted. How else do we learn? How else do we grow? Should we expect to be constantly confronted with easy, comfortable, and affirming thoughts?
I think not. And I accept that . . . in my whole human genome.
Even a happy life cannot be without a measure of darkness, and the word happy would lose its meaning if it were not balanced by sadness. — Carl G. Jung
This opening quotation from Jung is a good start to a discussion of happiness. As many others have said, a “happy” life is a process and it includes the ability to embrace and experience darkness and sadness. I like the quote because it reminds us to not take happiness in the direction of toxic positivity. We don’t need that. At the same time, we need skills and attitudes to extend and prolong positive experiences and cope with our emotional challenges.
I’ve shared a bit about the Montana Happiness Project before, but it’s time for an update.
The Montana Happiness Project has four BIG initiatives.
We’ve gotten started on all these initiatives, but in particular, Dylan Wright and Lillian Martz have us rolling forward on the Happy Schools initiative. This past Friday, Dylan and Lillian presented their work in Frenchtown School at the “GradCon” event at the University of Montana. They didn’t win the grand prize, but they were in the running. Their work is amazing and I’m proud to have them as a part of the Montana Happiness Project. Given their hard and smart work, it’s only a matter of time until they win some sort of grand prize. To give you a taste of their work and all that’s going on with the project, here are a couple of video clips.
And here’s a link to the Dylan and Lillian’s presentation at GradCon. It’s under 15 minutes and will give you a great taste of the potential of integrating happiness into the lives of high school students: https://www.youtube.com/watch?v=cZvHqIMQNGg
Just in case you’re as inspired as I am, after you watch those videos, you’ll want to follow the new Montana Happiness Project YouTube site . . . and then you’ll probably want to go to Facebook where you can follow our new Facebook page: https://www.facebook.com/profile.php?id=100073966896370
Thanks, in advance, for your interest in and support of infusing happiness skills into Montana and beyond.
Today I’m spending all day with the Youth Homes staff in Missoula . . . talking about strengths-based approaches to suicide. Should be fun, or at least as fun as a day of talking about suicide can be . . . Happy Friday, and here are the ppts!
Back in the days when video recording involved film rather than digits, editors would talk about leaving excellent footage “on the floor.” How do I know this? I was alive back in the day.
Today I’ve been working on revising a continuing education “course” for ContinuingEdCourses.net. The course has been popular and so the ContinuingEdCourses.net owners asked for a revision. I stalled until they recognized my stalling for what it was essentially told me I was overdue and late, which made me decide it would feel better to finish the revision than it would to keep procrastinating. I’m guessing maybe others of you out there can relate to that particular moment in time.
While editing and revising I discovered (actually I rediscovered) my penchant for redundancy. Sometimes that penchant is intentional and other times the penchant is an annoying rediscovery. This paragraph that you’re reading in the here-and-now includes an intentional penchant. The CE course included an unintentional penchant. Are you familiar with the research on the overuse of words? If you repeat a word over and over, after only a few seconds you can become desensitized to the meaning of the word and the word will just sound like a sound. I’m feeling a penchant for that too.
Bottom line: I had to cut some nice content. It ended up on the metaphorical floor, until I picked it up, dusted it off, and put it in this blog. Here you go. . .
Editor’s note [BTW, I’m the editor here, because it’s my blog, so I own all the mistakes, misspellings, and misplaced commas]: Turns out I edited out the other redundant content, but I’m posting this anyway, because it’s still 2/22/22, which happens to be most redundant date of the year. Now, here you go. . .
Four Suicide Myths
The word “myth” has two primary meanings.:
A myth is a traditional or popular story or legend used to explain current cultural beliefs and practices. This definition emphasizes the positive guidance that myths sometimes provide. For example, the Greek myth of Narcissus warns that excessive preoccupation with one’s own beauty can become dangerous. Whether or not someone named Narcissus ever existed is irrelevant; the story tells us that too much self-love may lead to our own downfall.
The word myth is also used to describe an unfounded idea, or false notion. Typically, the false notion gets spread around and, over time, becomes a generally accepted, but inaccurate, popular belief. One contemporary example is the statement, “Lightning never strikes the same place twice.” In fact, lightning can and does strike the same place twice (or more). During an electrical storm, standing on a spot where lightning has already struck, doesn’t make for a good safety strategy.
The statement “We only use 10% of our brains” is another common myth. Although it’s likely that most of us can and should more fully engage our brains, scientific researchers (along with the Mythbusters television show) have shown that much more than 10% of our brains are active most of the time – and probably even when we’re sleeping.
False myths can stick around for much longer than they should; sometimes they stick around despite truckloads of contradictory evidence. As humans, we tend to like easy explanations, especially if we find them personally meaningful or affirming. Never mind if they’re accurate or true.
Historically, myths were passed from individuals to groups and other individuals via word of mouth. Later, print media was used to more efficiently communicate ideas, both factual and mythical. Today we have the internet and instant mythical messaging.
Suicide myths weren’t and aren’t designed to intentionally mislead; mostly (although there are some exceptions) they’re not about pushing a political agenda or selling specific products. Instead, suicide myths are the product of dedicated, well-intended people whose passion for suicide prevention sometimes outpaces their knowledge of suicide-related facts (Bryan, 2022).
Depending on your perspective, your experiences, and your knowledge base, it’s possible that my upcoming list of suicide myths will push your emotional buttons. Maybe you were taught that “suicide is 100% preventable.” Or, maybe you believe that suicidal thoughts or impulses are inherently signs of deviance or a mental disturbance. If so, as I argue against these myths, you might find yourself resisting my perspective. That’s perfectly fine. The ideas that I’m labeling as unhelpful myths have been floating around in the suicide prevention world for a long time; there’s likely emotional and motivational reasons for that. Also, I don’t expect you to immediately agree with everything in this document. However, I hope you’ll give me a chance to make the case against these myths, mostly because I believe that hanging onto them is unhelpful to suicide assessment and prevention efforts.
Myth #1: Suicidal thoughts are about death and dying.
Most people assume that suicidal thoughts are about death and dying. Someone has thoughts about death, therefore, the thoughts must literally be about death. But the truth isn’t always how it appears from the surface. The human brain is complex. Thoughts about death may not be about death itself.
Let’s look at a parallel example. Couples who come to counseling often have conflicts about money. One partner likes to spend, while the other is serious about saving. From the surface, you might mistakenly assume that when couples have conflicts about money, the conflicts are about money – dollars, cents, spending, and saving. However, romantic relationships are complex, which is why money conflicts are usually about other issues, like love, power, and control. Nearly always there are underlying dynamics bubbling around that fuel couples’ conflicts over money.
Truth #1: Among suicidologists and psychotherapists, the consensus is clear: suicidal thoughts and impulses are less about death and more about a natural human response to intense emotional and psychological distress (aka psychache or excruciating distress). I use the term “excruciating distress” to describe the intense emotional misery that nearly always accompanies the suicidal state of mind. The take-home message from busting this myth should help you feel relief when clients mention suicide. You can feel relief because when clients trust you enough to share their suicidal thoughts and excruciating distress with you, it gives you a chance to help and support them. In contrast, when clients don’t tell you about their suicidal thoughts, then you’re not able to provide them with the services they deserve. Your holding an attitude that welcomes client openness and their sharing of distress and suicidal thoughts is foundational to effective treatment.
Myth #2: Suicide and suicidal thinking are signs of mental illness.
Philosophers and research scientists agree: nearly everyone on the planet thinks about suicide at one time or another – even if briefly. The philosopher Friedrich Nietzsche referred to suicidal thoughts as a coping strategy, writing, “The thought of suicide is a great consolation: by means of it one gets through many a dark night.” Additionally, the rates of suicidal thinking among high school and college students is so high (estimates of 20%-40% annual incidence) that it’s more appropriate to label suicidal thoughts as common, rather than a sign of deviance or illness.
Edwin Shneidman – the American “Father” of suicidology – denied a relationship between suicide and so-called mental illness in the 1973 Encyclopedia Britannica, stating succinctly:
Suicide is not a disease (although there are those who think so); it is not, in the view of the most detached observers, an immorality (although … it has often been so treated in Western and other cultures).
A recent report from the U.S. Centers for Disease Control (CDC) supports Shneidman’s perspective. The CDC noted that 54% of individuals who died by suicide did not have a documented mental disorder (Stone et al., 2018). Keep in mind that the CDC wasn’t focusing on people who only think about or attempt suicide; their study focused only on individuals who completed suicide. If most individuals who die by suicide don’t have a mental disorder, it’s even more unlikely that people who think about suicide (but don’t act on their thoughts), suffer from a mental disorder. As Wollersheim (1974) used to say, “Having the thought of suicide is not dangerous and is not the problem (p. 223).”
Truth #2: Suicidal thoughts are not – in and of themselves – a sign of illness. Instead, suicidal thoughts arise naturally, especially during times of excruciating distress. The take-home message here is that clinicians should avoid judgment. I know that’s a tough message, because most of us are trained in diagnosing mental disorders and as we begin hearing of signs of depression, emotional lability, or other symptoms, it’s difficult not to begin thinking in terms of psychopathology. However, especially during initial encounters with clients who have suicidal ideation, it’s deeply important for us to avoid labeling – because if clients sense clinicians judging them, it can increase client shame and decrease the chances of them sharing openly.
Myth #3: Scientific knowledge about suicide risk factors and warning signs support accurate allows for the prediction and prevention of suicide.
As discussed previously, mMost suicidologists agree: that Ssuicide is extremelyvery difficult to predict (Franklin et al., 2017).
To get perspective on the magnitude of the problem, imagine you’re at the Neyland football stadium at the University of Tennessee. The stadium is filled with 100,000 fans. Your job is to figure out which 13.54 of the 100,000 fans will die by suicide over the next 365 days.
A good first step would be to ask everyone in the stadium the question that many suicide prevention specialists ask, “Have you been thinking about suicide?” Assuming the usual base rates and assuming that every one of theall 100,000 fans answer you honestly, you might rule out 85,000 people (because they say they haven’t been thinking about suicide). Then you ask them to leave the stadium. Now you’re down to identifying which 13.54 of 15,000 will die by suicide.
For your next step you decide to do a quick screen for the diagnosis of clinical depression. Let’s say you’re highly efficient, taking only 20 minutes to screen and diagnose each of the 15,000 remaining fans. Never mind that it would take 5,000 hours. The result: Only 50% of the 15,000 fans meet the diagnostic criteria for clinical depression.
At this point, you’ve reduced your population to 7,500 University of Tennessee fans, all of whom are depressed and thinking about suicide. How will you accurately identify the 13 or 14 fans who will die by suicide? Mostly, based on mathematics and statistics, you won’t. Every effort to do this in the past has failed. Your best bet might be to provide aggressive pharmacological or psychological treatment for the remaining 7,500 people. If you choose antidepressant medications, you might inadvertently make about 200-250 of your “patients” even more suicidal. If you use psychotherapy, the time you need for effective treatment will be substantial. Either way, many of the fans will refuse treatment, including some of those who will later die by suicide. Further, as the year goes by, you’ll discover that several of the 85,000 fans who denied having suicidal thoughts, and whom you immediately ruled out as low risk, will confound your efforts at prediction and die by suicide.
To gain a broader perspective, imagine there are 3,270 stadiums across the U.S., each with 100,000 people, and each with 13 or 14 individuals who will die by suicide over the next year. All this points to the enormity of the problem. Most professionals who try to predict and prevent suicide realize that, at best, they will help some of the people some of the time.
Truth #3: Although there’s always the chance that future research will enable us to predict suicide, decades of scientific research don’t support suicide as a predictable event. Even if you know all the salient suicide predictors and warning signs, in the vast majority of cases you won’t be able to efficiently predict or prevent suicide attempts or suicide deaths. The take-home message from busting this myth is this: Lower your expectations about accurately categorizing client risk. Most of the research suggests you’ll be wrong (Bryan, 2022; Large & Ryan, 2014). Instead, as you explore risk factors with clients, use your understanding of risk factors as a method for deepening your understanding of the individual client with whom you’re working.
Myth #4: Suicide prevention and intervention should focus on eliminating suicidal thoughts.
Logical analysis implies that if psychotherapists or prevention specialists can get people to stop thinking about suicide, then suicide should be prevented. Why then, do the most knowledgeable psychotherapists in the U.S. advise against directly targeting suicidal thoughts in psychotherapy (Linehan, 1993; Sommers-Flanagan & Shaw, 2017)? The first reason is because most people who think about suicide never make a suicide attempt; that means you’re treating a symptom that isn’t necessarily predictive of the problem. But that’s only the tip of the iceberg.
After his son died by suicide, Rick Warren, a famous pastor and author, created a YouTube video titled, “Rick Warren’s Message for Those Considering Suicide.” The video summary reads,
If you have ever struggled with depression or suicide, Pastor Rick has a message for you. The pain you are experiencing will not last forever. There is hope!
Although over 1,000 viewers clicked on the “thumbs up” sign for the video, there were 535 comments; nearly all of these comments pushed back on Pastor Warren’s well-intended video message. Examples included:
Are you kidding me??? You’ve clearly never been suicidal or really depressed.
To say “Suicide is a permanent solution to a temporary problem” is like saying: “You couldn’t possibly have suffered long enough, even if you’ve suffered your entire life from many, many issues.”
This is extremely disheartening. With all due respect. Pastor, you just don’t get it.
Pastor Rick isn’t alone in not getting it. Most of us don’t really get the excruciating distress, deep self-hatred, and chronic shame linked to suicidal thoughts and impulses. And because we don’t get it, sometimes we slip into try toing rationally persuadesion to encourage individuals with suicidal thoughts to regain hope and embrace life. Unfortunately, a nearly universal phenomenon called “psychological reactance” helps explain why rational persuasion – even when well-intended – rarely makes for an effective intervention (Brehm & Brehm, 1981).
While working with chronically suicidal patients for over two decades, Marsha Linehan of the University of Washington made an important discovery: when psychotherapists try to get their patients to stop thinking about suicide, the opposite usually happens – the patients become more suicidal.
Linehan’s discovery has played out in my clinical practice. Nearly every time I’ve actively pushed clients to stop thinking about suicide – using various psychological ploys and techniques – my efforts have backfired.
Truth #4: Most individuals who struggle with thoughts of suicide resist outside efforts to make them stop thinking about suicide. Using direct persuasion to convince people they should cheer up, have hope, and embrace life is rarely effective. The take-home message associated with busting this myth is that the best approaches to working with clients who are suicidal are collaborative. Instead of taking the role of an esteemed authority who knows what’s best for clients, effective counselors and psychotherapists take a step back and seek to activate their client’s expertise as collaborators onagainst the suicidal problem.
Jon Sperry asked if I could write the foreword for a book he and his dad wrote with Oxford University Press.
Because the truth will set me free, I should admit, I’d never written a foreword before. More truth . . . I went ahead and said “Yes” to Jon because (a) I was honored and didn’t want the opportunity to write my first foreword slip away, (b) the book was (is) cool (it’s “The 15-Minute Case Conceptualization”), and (c) Jon Sperry is one of the nicest guys on the planet.
And for even more information about this excellent book, my first-ever foreword is below.
I’ve needed this book for 30 years.
Just last month (before reading this book), I was standing in front of a Zoom camera, trying to teach the basics of case conceptualization to a group of 23 master’s and doctoral students. All of my fine-grained case conceptualization wisdom was being channeled into a single visual and verbal performance.
“My left hand,” I said, “is the client’s problem.” Pausing briefly for dramatic effect, I then continued, “and my right hand is the client’s goal.”
My new-found nonverbal gestures are mostly a function of seeing myself onscreen, and therefore wanting to avoid seeing myself (and being seen by the class) as boring. To add spice to my case conceptualization gesturing. “Case conceptualization is simple,” I said. “All it is, is the path we take to help clients move from their problem state . . . toward their goal state (I finished with a flourish, by wiggling the fingers on my raised right hand).”
But boiled down truths are always partly lies. Despite my fabulous mix of the verbal and nonverbal, I was lying to my students. At the time, I had thought of it as a little white lie, all for the higher purpose of simplification. And although I still like what I said and still believe in the rough truth of my visual case conceptualization description, after reading Len and Jon Sperry’s illuminating work on case conceptualization, I better understand what I should have said.
Case conceptualization is not simple. As the Sperry’s describe in this book, case conceptualization—even when summarized well—includes multiple dimensions of human behavior along with clinician perception, judgment, and decision-making. I needed much more than a few wiggly fingers to communicate the detailed nuances of case conceptualization.
What these authors have done in this book is the gracious service that great writers do so well: They have done our homework for us. They’ve read extensively, taken notes, and gifted us with elegant summaries of dense and complex concepts. They’ve made it easy for us to understand and apply the principles and practices of case conceptualization.
What I might like best is how they transformed a bulky and inconsistent literature into simple, therapist-friendly principles. They emphasize the explanatory, tailoring, and predictive powers of case conceptualization. I’ve never organized case conceptualizations using those “powers” but doing so was like switching on a light-bulb. Of course, case conceptualizations should explain the relationships between client problems and client goals and shine a bright light along the path, but rarely do theorists or writers make this linkage so efficiently. Their second principle, “tailoring” case conceptualizations to individual and diverse clients, is an essential, idiographic, Adlerian idea. The whole idea of tailoring counters the all-too-frequent cook-book approach to case conceptualization. Tailoring breathes life into creating client-specific case conceptualizations. And of course, case conceptualizations need predictive power; Len and Jon equip us with enough foundational predictive language to improve how we evaluate our own work.
Many other examples of how elegantly the authors have done our homework are sprinkled throughout this book. Here’s another of my favorite examples.
In chapter 2, they take us (in a few succinct paragraphs) from what Theodore Millon described as eight evolutionarily-driven personality disorders to eight crisply described behavioral patterns. What I love about this is that Len and Jon’s wisdom transforms what might otherwise be viewed as a pathologizing personality disorder system into language that can be used collaboratively with clients to identify contextually maladaptive interpersonal patterns. This is a beautiful transformation because it spins psychopathology into something clients not only understand but will feel compelled to embrace. The process goes something like this:
Therapist and client engage in an assessment process that touches on the client’s repeating maladaptive behavior patterns. These behavior patterns are palpably troubling and far less than optimal for the client.
As all clinicians inherently know, touching upon clients’ repetitive maladaptive behavior patterns can activate client vulnerability. This is a primary challenge of all counseling and psychotherapy: How can we nudge clients toward awareness without simultaneously activating resistance? For decades, psychoanalysts managed this through cautious trial interpretations. Solution-focused therapists dealt with this by never speaking of problems. Gently coaxing ambivalent clients toward awareness and change is the whole point of motivational interviewing.
When addressed in a sensitive and non-pathologizing way, deep maladaptive behavior patterns can be discussed without activating resistance or excessive emotionality. This is a critical and not often discussed part of case conceptualization. Len and Jon illuminate a path for gentle, sensitive, and collaborative case conceptualization.
When clients can feel, recognize, and embrace their maladaptive behavioral patterns in the context of an accepting therapeutic relationship, insight is possible. In the tradition of Adlerian therapy, when insight happens, client interest is piqued and motivation to change spikes. Good case conceptualizations articulate problem patterns in ways that compel clients to invest in change.
I’m not surprised that Len and Jon Sperry have produced such a magnificently helpful book. If you dig into their backgrounds and conduct a case conceptualization of their personality patterns, you’ll discover they wholeheartedly embrace Alfred Adler’s work and consequently, much of what they do is all about social interest or Gemeinschaftsgefühl. Len and Jon Sperry are in the business of helping others. Reading their book has already helped me become better at teaching case conceptualization. I appreciate their work, and, no doubt, the next time I begin waving my hands in front of my Zoom camera, my students will appreciate their work too.
Apparently, video podcasts are the thing. Or maybe they’ve been a thing for a while. . . or at least since early 2020 and the onset of the Zoom age. I think we should call them vid-pods.
Two weeks ago, I promoted a vid-pod with Paula Fontenelle, Stacey Freedenthal, and me. It was Paula’s vid-pod, titled “Understand Suicide.” Paula is very experienced, very knowledgeable and produces great vid-pods. You can check out all her work, including her podcast (aka vid-pod) at: https://www.understandsuicide.com/
Late last year, Victor Yalom of Psychotherapy.net asked if he could connect me for a possible appearance on a vid-pod called “Normalize the Conversation.” Normalize the Conversation is the brain-child of Francesca Reicherter. Francesca is also the Founder and President of “Inspiring My Generation.” I think Victor wanted me to promote our 7.5-hour marathon Suicide Assessment and Treatment video training series with Psychotherapy.net. . . so here’s the link to that: https://www.psychotherapy.net/videos/expert/john-sommers-flanagan
Francesca and I did a recording together and she did a bunch of editing and promoting and this past week she sent me some video clips of our time together. What you’ll immediately notice in the video clips is that Francesca is an artist at getting people to talk. Throughout the clips, I’m talking and she’s not. Somehow, she got me to talk for about 47 minutes (although she did some nice summaries and commentary here and there). If my experience is at all representative, I suspect Francesca will be a talented therapist and fabulous listener.
You can check out the vid-pod clips below, but more importantly, check out all the amazing work of Paula, Stacey, Victor, and Francesca . . . all of whom are making the world a place where supportive and quality mental health services are more accessible.
While engaged in a little late-night Twitter scrolling, I came across a fascinating post and thread questioning the utility of suicide screening for low risk populations (e.g., schools). Having been mildly opposed (along with the UK and Canada), to general population suicide screenings, I felt validated, especially upon discovering that Craig Bryan was author of the Twitter thread. Dr. Bryan is one of the best and most authoritative resources on suicide in the world. As of two nights ago, I was only familiar with his professional book with David Rudd (Brief cognitive-behavior therapy for suicide prevention) and his excellent work with military veterans, suicide, and lethal means management. I also knew he had recently published a new book titled, “Rethinking Suicide.”
Then, today, I checked out Rethinking Suicide online. I was gob smacked. It’s fantastic.
This post is mostly to pitch Craig Bryan’s book.
Among other gems, Dr. Bryan frames suicide prevention as a “wicked problem” and tells us about the origin of the term, wicked problem. What’s not to love about that.
Here’s a quote from his introduction: “Consistent with the perspective of suicide as a wicked problem, I will argue in this book that we need to replace our solution-based approach to suicide prevention with a process-based approach focused on creating and building lives worth living” (p. 7). Wow. That’s like music to my ears.
Dr. Bryan also weaves in “confirmation bias” (more music) as part of his critique of using so-called “mental illness” as an explanatory mechanism in suicide (I know if you know me and this blog, you know I don’t even use the term mental illness unless I’m explaining why I don’t use the term mental illness, and so I’m destined to love Dr. Bryan’s deconstruction of that concept).
Anyway, you can find Rethinking Suicide through your favorite online bookseller. I recommend it highly. I’ve ordered my copy. It’s about time we all started rethinking suicide.
The place to click if you want to learn about psychotherapy, counseling, or whatever John SF is thinking about.