IS PATH WARM – An Acronym to Guide Suicide Risk Assessment

Suicide Risk Factors, Acronyms, and the Evidence Base

[This is adapted from our forthcoming 5th edition of Clinical Interviewing]

In 2003, the American Association of Suicidology brought together a group of suicidologists to examine existing research and develop an evidence-based set of near-term signs or signals of immediate suicide intent and risk. These suicidologists came up with an acronym to help professionals and the public better anticipate and address heightened suicide risk. The acronym is: IS PATH WARM and it’s outlined below:

I = Ideation

S = Substance Use

P = Purposelessness

A = Anxiety

T = Trapped

H = Hopelessness

W = Withdrawal

A = Anger

R = Recklessness

M = Mood Change

        IS PATH WARM is typically referred to as evidence-based and, in fact, it was developed based on known risk factors and warning signs. Unfortunately, reminiscent of other acronyms used to help providers identify clients at high risk for suicide, in the only published study we could find that tested this acronym, IS PATH WARM failed to differentiate between genuine and simulated suicide notes (Lester, McSwain, & Gunn, 2011). Although this is hardly convincing evidence against the use of this acronym, it illustrates the inevitably humbling process of trying to predict or anticipate suicidal behavior. In conclusion, we encourage you to use the acronym in conjunction with the comprehensive and collaborative suicide assessment interviewing process described in our chapter in the Clinical Interviewing textbook. See: http://www.amazon.com/Clinical-Interviewing-2012-2013-John-Sommers-Flanagan/dp/1118390113/ref=sr_1_1?s=books&ie=UTF8&qid=1373655813&sr=1-1

After talking about IS PATH WARM in workshops over the past year or so, it seems important to emphasize that these “risk” factors are near-term risk factors. Other, very important longer-term risk factors, are not included. For example, previous attempts and clinical depression aren’t even on the list. And, although they include withdrawal, it seems that words like isolation or loneliness capture this dimension of risk at least as well.

The point of my criticism is to emphasize that even the best suicidologists on the planet struggle in their efforts to identify the most important immediate and longer-term suicide risk factors. This is primarily because suicide is nearly always unpredictable and one of the reasons that it’s unpredictable is because it occurs, on average in the U.S. in 13 people per 100,000. The other side of this dialectical coin is that, of course, we need to try to predict it and prevent it anyway.

You can check out more details about IS PATH WARM on many different internet sites, including a description of its origin provided by the American Association of Suicidology: http://www.suicidology.org/c/document_library/get_file?folderId=231&name=DLFE-598.pdf

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My New Favorite Book (for now) and Why I Love Quiche

In elementary school in the 1960s, my reading almost exclusively included comics. I didn’t just love Captain America, I wanted to BE Captain America.

Unfortunately, I was in high school in the early 1970s, when reading books was apparently in disfavor. We used the SRA Laboratory Reading System and the only real “book” I recall reading in all of high school was “The Andromeda Strain.” Of course, the problem was likely partly due to my preoccupation with athletics over academics, but that’s a different story.

What this means is that most of my book reading has occurred after 1975, which is when my football buddy Barry and I read, “Real Men Don’t Eat Quiche.” The problem with that was that I happened to like quiche . . . a lot . . . and consequently, rather than questioning my sexual identity, I began questioning what society tells real men that they should do and not do.

This leads me to my book pick of the week.

As some of you already know, I’m working on a writing project related to sexual development in young males. This work led me to discover the book “Delusions of Gender” by Cordelia Fine, Ph.D. Dr. Fine is a psychologist in Australia and has written an absolutely awesome book that slices through many of the silly connections people are making between neuroscience and gender. For example, as an opening to chapter 14 “Brain Scams,” she wrote:

“My husband would probably like you to know that, for the sake of my research for this chapter, he has had to put up with an awful lot of contemptuous snorting. For several weeks, our normally quiet hour of reading in bed before lights out became more like dinnertime in the pigsty as I worked my way through popular books about gender difference. As the result of my research, I have come up with four basic pieces of advice for anyone considering incorporating neuroscientific findings into a popular book or article about gender” (p. 155).

You’re probably wondering, what is her excellent advice for those of us considering writing in this area? Well, I’m resisting the temptation within my male brain to type out her advice, other than her fourth piece of advice, which reads: “Don’t make stuff up.”

But that’s exactly what many writers are doing. Here’s an example I found recently. It’s titled, “7 things he’ll never tell you” and written by “Dr.” Kevin Leman. He wrote, “Did you know that scientific studies prove why a woman tends to be more ‘relational” than her male counter part? A woman actually has more connecting fibers than a man does between the verbal and the emotional side of her brain. That means a woman’s feelings and thoughts zip along quickly, like they’re on an expressway, but a man’s tend to poke slowly as if he’s walking and dragging his feet on a dirt road.” (pp. 5-6).

Of course, this is sheer drivel . . . or as Dr. Fine might say, “He just made that up.”

Or as I might say: He’s really just talking about himself here . . . and it’s likely caused by the fact that he didn’t eat enough quiche growing up.

So what’s the evidence? If we look at one of the best relational factors upon which women are supposed to be better than men–empathy–what does the research say?

Well, as it turns out, using the best and most rigorous laboratory empathy measure available, empathy researcher William Ickes found no differences between males and females in seven consecutive studies. And then, when he did find differences, he found women did better only in situations where they are primed by “situational cues that remind them that they, as women, are expected to excel at empathy-related tasks.” (Fine, p. 21).

Anyway, it’s late and I’m going to stop writing . . . but not before I put in a link to a Cordelia Fine speech you can watch online. Here it is:  http://fora.tv/2010/10/02/Cordelia_Fine_Delusions_of_Gender

Now I’m off to bake myself a quiche.

A Summary Checklist of Strategies and Techniques for Managing Client Resistance

One friend of mine who is a therapist has a very deep voice. Years ago, we were both seeing lots of boys who were often angry. These boys were also, no big surprise, resisting the advice and direction of authority figures, like parents and teachers. Several times I got a chance to work with young male clients who had “blown out” of therapy with my friend.

They described him as frightening. They said he would joke about having a “rack” in the back room in his office building and threaten to take them there if they wouldn’t talk. For young clients who got his sense of humor and who could see past his deep voice, his style worked very well. But for other youth, a kinder and gentler approach with less room for misinterpretation was needed.

In the following excerpt from Clinical Interviewing (5th edition), Rita and I are just finishing our discussion of why clients lie and resist counseling. Most of our thinking in this are is based on a combination of motivational interviewing and our own counseling and psychotherapy experiences-like the one described above. Following the end of our brief comments about lying and resistance, we include a summary table listing strategies and techniques for dealing with resistant clients that might be helpful to you. If you want more information about this, feel free to email me at john.sf@mso.umt.edu and I can send you an article or a chapter on working with resistant youth. Here’s the excerpt:

. . . . There are many reasons why clients lie, most involving some form of self-protection or the belief that they profit from lying. As a general rule (with exceptions), people tend to lie more if they feel the need to lie and tend to lie less when they experience trust. As a consequence, your goal is to build an alliance that includes enough trust to facilitate honesty. Confrontation of obvious or subtle lying behavior may be less productive than waiting for rapport and trust to build and for honest disclosure to flow more naturally. This perspective or stance can be a relief; when in the role of therapist (and not judge) facts are usually less important than feelings. To summarize, resistance, or whatever we choose to call it, is a natural part of the change process. In fact, research suggests that client resistance is an opportunity for deeper work. When resistance is worked through, the likelihood for positive outcomes is increased (Mahalik, 2002).

In the end, it’s helpful to remember that resistance emanates from the very center of a person and is part of the force that gives people stability and predictability in their interactions with others. Resistance exists because change and pain are often frightening and more difficult to face than retaining the old ways of being, even when the old ways are maladaptive. Finally, with culturally or developmentally different clients, resistance may actually be caused when the therapist refuses or fails to make culturally or developmentally sensitive modifications in his or her approach (J. Sommers-Flanagan & Sommers-Flanagan, 2007b). Table 12.1 includes a summary of strategies and techniques for managing resistance.

 

Table 12.1 Summary Checklist of Strategies and Techniques for Managing Resistance
____  1. Adopt an attitude of acceptance and understanding because developing a therapeutic alliance is almost always a higher priority than confrontation.
____  2. Recognize that clients will feel some ambivalence about working toward and achieving positive change.
____  3. Resist your impulses to teach, preach, and persuade clients to make “healthy” decisions.
____  4. In the beginning and throughout the session, ask open-ended questions that are linked to potential positive goals.
____  5. Look for positive goals that are underlying your clients emotional pain and discouragement—and then help your client be the one who articulates those goals.
____  6. Use simple reflection to reduce clients’ needs to exhibit resistance.
____   7. Use concession “You’re right. I can’t make you talk with me” to affirm to clients that they’re in control of what they say to you.
____  8. Use amplified reflection to encourage clients to discuss the healthier side of their ambivalence.
____  9. Use emotional validation when clients are angry or hostile.
____ 10. Use radical acceptance to compliment clients for their openness—even though the openness may be aggressive or disturbing.
____ 11. Reframe client hostility and negativity into more positive impulses whenever possible.
____ 12. Provide genuine feedback related to your concerns to your clients.
____ 13. Use paradox carefully to respectfully come up alongside clients’ resistance.
____ 14. If you’re concerned about truthfulness, get signed consent and then interview a significant other to help you get an accurate story.
____ 15. When clients ask “Do you believe me?” use a response that will encourage more disclosure, like, “I’m not here to judge the truth, but just to listen and try to be of help.”
____ 16. Remember (and be glad) that you’re a mental health professional and not a judge.

From Clinical Interviewing (5th edition). See: http://www.wiley.com/WileyCDA/Section/id-302475.html?query=John+Sommers-Flanagan

 

Ode to Haddad

This is a short tribute to the retiring chair of the University of Montana Psychology Department, Nabil Haddad. I took the Psychology of Learning from Nabil in 1982. Like most limericks, this one works best if read aloud to a large group of people who have been drinking.

Ode to Haddad

There once was a man named Nabil

He could have invented the wheel

But he came to Montana

With his pet rat Santana

Cause psychology was his big deal

 

You see Nabil had a deep down yearning

And a passion to teach psych of learning

He would trap rats in mazes

Then watch them for days-z

While his cigarettes, well, they were burning

 

Some say that Nabil, he was scary

With a temper that could be flary

But he held it all in

Till he could say, with a grin

I’ve got tenure just like my friend Larry

 

We knew old Nabil had passion

That overshadowed his poor sense of fashion

No more cigarettes smoked

A Jordanian cow-poke

He stopped smoking so as to not cash in

 

Now Nabil is quite keen and patrician

He’s retiring of his volition

There’s a secret he keeps

From all of his peeps

That he wants to become a clinician

 

This story it ends with a flair

With Nabil giving up the Psych chair

So calm and serene

His office now clean

Well wishes to him—if you dare

DSM-5 and the Universal Diagnostic Exclusion Criteria

Sometimes, even when someone appears to meet all the diagnostic criteria for a mental disorder, assigning a psychiatric diagnosis is still not the right thing to do.

In the following excerpt from the forthcoming 5th edition of Clinical Interviewing, we offer an example of when and why psychiatric diagnosis is inappropriate (see: http://lp.wileypub.com/SommersFlanagan/). We refer to this as the “Three-Dimensional Universal Exclusion Criterion” which is our highly esoteric way of saying, “Whoa on psychiatric diagnosis until you’ve checked to see if there’s an alternative explanation for the observed behaviors!”

Multicultural Highlight 6.2

The Three-Dimensional Universal Exclusion Criterion: Is the Behavior Rationally or Culturally Justifiable or Caused by a Medical Condition?

Let’s say you meet with a client for an initial interview. During the interview the client describes an unusual belief (e.g., she believes she is possessed because someone has given her the “evil eye”). This belief is clearly dysfunctional or maladaptive because it has caused her to stop going out of her house due to fears that an evil spirit will overtake her and she will lose control in public. She also acknowledges substantial distress and her staying-at-home-and-being-anxious behavior is disturbing her family. In this case it appears you’ve got a solid diagnostic trifecta—her belief-behavior is (a) maladaptive, (b) distressing, and (c) disturbing to others. How could you conclude anything other than that she’s suffering from a psychiatric disorder?

This situation illustrates why diagnosis (see Chapter 10) is a fascinating part of mental health work. In fact, if the client has a rational justification for her belief-behavior . . . or if there’s a reasonable cultural explanation . . . or if the belief-behavior is caused by a medical condition—then it would be inappropriate to conclude that she has a mental disorder. One source of support for a universal exclusion criterion is the DSM-5. It includes the statement: “The level of severity and meaning of the distressing experiences should be assessed in relation to the norms of the individual’s cultural reference groups” (American Psychiatric Association, 2013, p. 750).

To explore our three-dimensional “universal” exclusion principle in greater depth, partner up with one or more classmates and discuss the following questions:

Can you think of any rational explanations for the client’s belief-behavior?

Can you think of any reasonable cultural explanations for the client’s belief-behavior?

Can you think of any underlying medical conditions that might explain her belief-behavior?

After you’ve finished discussing the preceding questions, see how many new examples you can think of where a client presents with symptoms that are (a) dysfunctional/maladaptive, (b) distressing, and (c) disturbing to others. Then discuss potential rational explanations, cultural explanations, and medical conditions that could produce the symptoms (e.g., you could even use something as simple as major depressive symptoms and explore how rational, cultural, or medical explanations might account for the symptoms, thereby causing you to defer the diagnosis.

 

Praise or Encouragement or Something Else?

On the National Parenting Education Network listserv (go to: http://npen.org/ to check out their flashy upgraded website), there has been a very interesting recent discussion of the relative merits of praise and encouragement. In keeping with this topic, I’m posting a homework assignment for parents from “How to Talk so Parents will Listen and Listen so Parents will Talk.” (see: http://www.amazon.com/How-Listen-Parents-Will-Talk/dp/1118012968/ref=la_B0030LK6NM_1_5?ie=UTF8&qid=1370905715&sr=1-5). The following assignment is designed to help parents experience the nuances between praise, mirroring (one form of encouragement), character feedback, and solution-focused questions.

Parenting Homework Assignment 8-2

Exploring the Differences between Praise, Mirroring, Character Feedback, and Solution-Focused Questions

If you’ve been given this homework assignment, you’re probably already using many good parenting techniques with your child. This assignment will help you refine your parenting approach to intentionally include even more ways of being positive with your child.

Imagine that a father is busy taking care of household chores while he’s parenting his 5-year-old daughter. She’s creating some excellent 5-year-old crayon art and approaches her daddy with a finished product and a beaming smile. Dad looks up and takes a break from his chores to admire his daughter’s artwork. He returns her grin and says one of the following:

  • “This is beautiful!” (An example of praise—a form of direct power)
  • “Thanks for showing me your drawing. You look very happy with your picture.” (An example of emotional mirroring or encouragement—a form of indirect power)
  • “You love doing artwork!” (An example of character feedback—another form of indirect power)
  • “How did you manage to create this beautiful drawing?” (An example of a solution-focused question—a form of problem-solving power)

If you can increase your awareness of these different strategies, you’ll feel more capable of being intentional and positive when interacting with your children. The result usually includes fewer power struggles and more positive parent–child relationship dynamics.

Using Praise

Using praise is simple. For example, praise includes statements like: “Great work,”  “I’m proud of you,” and “Look at what a good job you’ve done cleaning the bathroom!” When you use praise, you are clearly communicating your expectations and your approval to your child.

Think about how much praise you use with your children. Are you being clear enough with them about what you want and are you letting them know when they’ve done well? As a part of this homework assignment, consider increasing how much you praise your child and then see how your child reacts.

Using Mirroring

Sometimes children don’t have a clear sense of how their behaviors look to others (which can also be true for adults). The purpose of mirroring is to help children see themselves through your eyes. After seeing (or hearing) their reflection, your child becomes more aware of his or her behavior and may choose to make changes.

For now, we recommend that you practice using mirroring only to reflect your child’s positive behaviors. For example, if your daughter has a play date and shares her toys with her friend, you could say, “I noticed you were sharing your toys.” Or if your son got home on time instead of breaking his curfew, you might say, “I noticed you were on time last night.” The hard part about using mirroring is to stay neutral, but staying neutral is important because mirroring allows your children to be the judge of their own behaviors. If you want to be the judge, you can use praise.

Using Character Feedback

Character feedback works well for helping your children see themselves as having positive character traits. For example, you might say, “You’re very honest with us,” or “You can really focus on and get your homework done quickly when you want to,” or “You’re very smart.”

Usually, as parents, instead of using character feedback to focus on our children’s positive qualities, we use it in a very negative way. Examples include: “Can’t you keep your hands to yourself?” “You’re always such a big baby,” and “You never do your homework.”

For your homework assignment, try using character feedback to comment on your children’s positive behaviors, while ignoring the negative. You can even use character feedback to encourage a new behavior—all you have to do is wait for a tiny sign of the new behavior to occur and then make a positive character feedback statement: “You’re really starting to pay attention to keeping your room clean.”

Using Solution-Focused Questions

Problem-focused questions include: “What’s wrong with you?” and “What were you thinking when you hit that other boy at school?” In contrast, solution-focused questions encourage children to focus on what they’re doing well. For example, “How did you manage to get that puzzle together?” “What were you thinking when you decided to share your toy with your friend?” and “What did you do to get yourself home on time?”

Solution-focused questions require us to look for the positive. For practice, try asking your child questions designed to get him or her to think about successes instead of failures. After all, it’s the successes that you want to see repeated. Of course, when you ask these questions, don’t expect your child to answer them well. Instead, your child will most likely say, “Huh? I don’t know.” The point is that you’re focusing on the positive and eventually these questions get your children to focus on the positive as well.

Tough Kids, Cool Counseling: Dealing with “Resistance” – Part 1

Working with challenging, tough, or naturally resistant youth is one of the most difficult situations a counselor or psychotherapist can face. In this excerpt from chapter 3 of “Tough Kids, Cool Counseling” (published by ACA, 2007), we begin discussing strategies for dealing with this difficult situation. Here’s a link to the Amazon page for this book: http://www.amazon.com/Tough-Kids-Cool-Counseling-User-Friendly/dp/1556202741/ref=la_B0030LK6NM_1_2?ie=UTF8&qid=1370790501&sr=1-2

Chapter 3

Resistance Busters: Quick Solutions and Longer-Term Strategies

As noted in preceding chapters, adolescents are well-known for their general distrust of adults and their striving for autonomy (Erikson, 1963; Saginak, 2003). Despite this distrust and independence-striving, in most cases, by using the strategies and techniques discussed in Chapter 2, counselors can manage resistance and initiate therapy with clients and their parents. However, upon entering a counseling situation, some young people will display extreme, provocative, or puzzling resistance behaviors that require more specialized approaches (Amatea, 1988; Richardson, 2001).

Imagine the following scenario:

You’re an intern scheduled to meet with a 15-year-old girl referred to a community clinic from a local group home. You’ve been in graduate school for about 18 months and so you’re not completely naïve, but because you’re only 23 years old yourself (and you went through a fair bit of emotional turmoil during your teen years), you’re especially excited about the opportunity to help a teenager who is obviously in a challenging life situation.

When you meet your client, Maya, in the waiting room, your enthusiasm begins to wane. Her jet-black and pink fringed hair hangs over her eyes and she reeks of cigarette smoke. When you greet her, she sneers, causing her lip-ring to flip upward. Her eyes (or at least what you can see of them) roll back as if she is disgusted at the sight of you.

Her first spoken words to you are: “This is a fucking waste of my time.”

You’re not sure what to say and so the Carl Rogers voice inside of you says gently, “It sounds like you’re not very happy to be here.”

Maya’s response is to slip into a stony silence, a silence only occasionally broken with deep dramatic sighs. Eventually, when she finally speaks again, she says, “Oh my fucking God. And you’re supposed to help me?  That’s a joke.”

Some teenagers have a special talent for destroying their counselor’s confidence. Not surprisingly, our graduate students, when facing a client like Maya for the first time, are often stunned. They complain of having a blank-mind and not knowing what to say. Other common reactions to the Maya-prototype include overwhelming feelings of inadequacy (usually accompanied by anxiety) or strong impulses to retaliate with anger.

This chapter focuses on strategies and techniques for dealing with some of the most provocative behaviors you’re likely to see in counseling situations. Our belief is that counselors should prepare, plan, and look forward to aggressive resistance from teenage clients or students. Again, we emphasize that aggressive resistance is best viewed as a coping style brought into the counseling situation and directed towards anyone in authority—in Sullivan’s terms, a parataxic distortion (Sullivan, 1953). Therefore, when working with challenging youth, keep one key fact clearly in mind: Your client’s insults, disgust, and aggressive behavior, although aimed at you, have virtually nothing to do with you. There’s no point in taking your client’s comments personally, and in fact, if you can side-step the onslaught, it will provide you with all sorts of important diagnostic and clinical information about your client’s pain and defenses.

Getting Your Buttons Pushed

Despite our great advice about not taking your client’s degrading comments personally, in the real world, we all get our buttons pushed sometimes. A graphic example of counselor over-reaction to provocative client behavior was captured in the feature film, Good Will Hunting (Van Sant, 1997).

As a fan of counseling, you may recall the scene. The main character, Will, played by Matt Damon, is an extremely intelligent but emotionally disturbed young man with mathematical genius. His would-be mentor, in an effort to help Will fulfill his potential, sends him to several different counselors, none of whom are able to help Will. Finally, Will ends up in the office of Sean McGuire, played by Robin Williams.

During his initial session with McGuire, Will is his provocative and nasty self. He eventually, either accidentally, or via great intuition, begins insulting McGuire’s deceased wife and because he is still unresolved about his wife’s premature death, McGuire gets his emotional buttons pushed. The result: the counselor grabs Will around the neck and slams him up against the wall. Of course, McGuire also decides to take on Will as a client and successfully helps Will move forward in his life.

We would like to emphasize two key points related to this excellent example of resistance and countertransference from Good Will Hunting. First, be aware of your emotional buttons, seeking the support and counseling you need to be an effective and ethical counselor. Second, no matter how provocative your young clients may act, avoid using Robin Williams’s “Choking the client” technique.  It may play well in Hollywood, but physical contact with resistant, aggressive, and/or angry clients is highly ill-advised.

If you find you’re having your emotional buttons pushed occasionally by teenage clients or students, consider yourself normal. On the other hand, if the button pushing begins to cause you to contemplate acting on destructive impulses, it’s time to get therapy for yourself, and/or support from a collegial supervision group. Many psychoanalytically-oriented writers have warned about the powerful regressive countransference impulses that young clients can ignite in their counselors (Dass-Brailsford, 2003; Horne, 2001).

Pause for Reflection: How do you usually respond when you get your buttons pushed by someone? Do you instantly feel angry? Or, are you more likely to scrutinize yourself and decide that you really are just an inadequate and worthless piece of furniture? Of course, there’s no “right” response to these questions. The best guideline is to continually work at looking at yourself and your reactions to clients so that you are consistently cultivating your self-awareness.

[End of Pause for Reflection]

To work ethically and professionally with provocative clients requires general skill, personal insight, and a particular knowledge base that includes a range of potentially constructive automatic or formula responses.

The place to click if you want to learn about psychotherapy, counseling, or whatever John SF is thinking about.