Clinical Interviewing, Counseling and Psychotherapy Theory and Practice, Writing

The Dialectics of Diagnosis at MFPE in Belgrade

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Waving

Today I’m in Bozeman on my way to present to the Montana School Counselors in Belgrade, MT. As my friends at the Big Sky Youth Empowerment Program like to say, “I’m stoked!” I’m stoked because there’s hardly anything much better than spending a day with Montana School Counselors. Woohoo!

My topic tomorrow is “Strategies for Supporting Students with Common Mental Health Conditions.” That means I’ll be reviewing some DSM/ICD diagnostic criteria and that brings me to reflect on the following. . . .

Not long ago (July, 2019), Allsopp, Read, Corcoran, & Kinderman published an article in Psychiatry Research, not so boldly titled, “Heterogeneity in psychiatric diagnostic classification.” Hmm, sounds fascinating (not!).

A few days later, a summary of the article appeared in the less academically and more media oriented, ScienceDaily. The ScienceDaily’s contrasting and much bolder title was, “Psychiatric diagnosis ‘scientifically meaningless.” Wow!

The ScienceDaily summary took the issue even further. They wrote: “A new study, published in Psychiatry Research, has concluded that psychiatric diagnoses are scientifically worthless as tools to identify discrete mental health disorders.”

Did you catch that? Scientifically worthless!

In an interview with ScienceDaily, Allsopp, Read, and Kinderman stoked the passion, and avoided any word-mincing.

Dr. Kate Allsopp said, “Although diagnostic labels create the illusion of an explanation they are scientifically meaningless and can create stigma and prejudice. I hope these findings will encourage mental health professionals to think beyond diagnoses and consider other explanations of mental distress, such as trauma and other adverse life experiences.”

Professor Peter Kinderman, University of Liverpool, said: “This study provides yet more evidence that the biomedical diagnostic approach in psychiatry is not fit for purpose. Diagnoses frequently and uncritically reported as ‘real illnesses’ are in fact made on the basis of internally inconsistent, confused and contradictory patterns of largely arbitrary criteria. The diagnostic system wrongly assumes that all distress results from disorder, and relies heavily on subjective judgments about what is normal.”

Professor John Read, University of East London, said: “Perhaps it is time we stopped pretending that medical-sounding labels contribute anything to our understanding of the complex causes of human distress or of what kind of help we need when distressed.”

In contrast to the authors’ conclusions, nearly every conventional psychiatrist believes the opposite–and emphasizes that psychiatric diagnosis is of great scientific and medical importance. For example, the Midtown Psychiatry and TMS Center website says, “A correct diagnosis helps the psychiatrist formulate the most effective treatment that will result in remission.”

No doubt there.

In addition, although I literally love that Allsopp, Read, and Kinderman are so outspoken about the potential deleterious effects of diagnosis, I think maybe they take it too far. For example, “Shall we pretend that we should provide the same intervention for panic attacks as we provide for conduct disorder, autism spectrum disorder, and gender dysphoria?”

That’s me talking now . . . and as I discussed this with Rita, she amplified that, of course, if you have a student who’s intentionally engaging in violent acts that harm others, we’re not treating them the same as a student who’s suffering panic attacks. Obviously.

Psychiatric diagnosis is a great example of a dialectic. Yes, in some ways it’s meaningless and overblown. And yes, in some ways it provides crucial information that informs our treatment approaches.

This leads me to my final point, and to my handouts.

What’s our School Counseling take-away message?

Let’s keep the baby and throw out with the bathwater.

Let’s de-emphasize labels – because labelling, whether accurate or inaccurate and whether self-inflicted or other inflicted, are possibly pathology-inducing.

Instead, let’s focus on specific behavior patterns, as well as abilities, impairments, stressors, and trauma experiences that interfere with academic achievement, personal and social functioning, and career potential.

In case you’re interested in more on this. My handouts for the workshop are below.

The Powerpoints: MFPE 2019 Belgrade Final

Managing fear and anxiety:Childhood Fears Rev

Student de-escalation tips: De-escalation Handout REV

Why Kids Lie and What to Do About It

 

 

Suicide Assessment and Intervention

Happy Afternoon at ACES in Seattle: Now, Let’s Talk About Suicide Assessment and Treatment Planning

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IMG-4449

In a few minutes, along with Kelley McHugh, I’ll be doing my second ACES presentation today. This one is titled, “A New Model for Teaching and Learning about Suicide Assessment and Intervention.” Hana Meshesha was scheduled to join in the fun, but she wasn’t able to come today.

Along with our other doc students, Kelley and Hana are fabulous, focused, smart, and they contribute to my learning.

In the following powerpoints, you’ll see how Kelley, Hana, and I are thinking about how counseling students and professionals should be trained in suicide assessment and intervention. As always, we’re interested in your feedback. Here’s a link to the ppts: ACES Suicide Seattle 2019 Final

And here are a couple suicide assessment/treatment journal articles that might be helpful: Conversations About Suicide by JSF 2018 and SF and Shaw Suicide 2017

Counseling and Psychotherapy Theory and Practice, Personal Reflections

Happy Saturday Morning at ACES in Seattle

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Space_Needle_2011-07-04

The Association of Counselor Educators and Supervisors (ACES) conference is underway in Seattle. Seattle is a fabulous location. It’s great to be back in my home state.

It’s also great to be with so many fabulous people. Counselor educators are some of the nicest people on the planet. The conversations are intellectually stimulating, kind, compassionate, and positive relationship skills are on display everywhere.

Speaking of positive relationship skills, this morning, Kim Parrow (a fantastic doc student in our Counseling program at U of Montana) and I are presenting on Evidence-Based Relationship Factors (EBRFs). If you’re not sure what EBRFs are, or want to learn more, then check out the resources below.

The Powerpoints are here: ACES Seattle Kim and John Final REV

A previously published journal article from the Journal of Mental Health Counseling is here: JoMHC EB Article by John SF 2015

Personal Reflections, Politics, Writing

In My Great and Unmatched Wisdom

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One Wipe Charlies

In my great and unmatched wisdom I hereby proclaim that today is Opposite Day.

Never mind that Opposite Day is a fictional children’s holiday and that it’s officially celebrated on January 25. Just because today’s not January 25 and I’m not a child, doesn’t mean I don’t get to say opposite things. I get to say opposite things because I’ve said I get to say opposite things.

When my nephews were little, we never waited for Opposite Day. Instead, we’d suddenly start playing the Opposite Game. It’s just like Opposite Day, but spontaneous. We’d say hello when we meant goodbye. I’d say things like, “Tommy, you’re the smartest person I know!” Or, “Paul, you’re one good looking guy.” I was totally hilarious, maybe the funniest uncle ever to exist on planet Earth.

Sometimes our spontaneous opposite games got a little out of control, but that was the point. One time, when grandma showed up and Tommy and Paul rolled their eyes and said, “It’s terrible to not see you” she looked hurt. We had to call time-out and explain the game to her. Even after the explanation, she didn’t seem to get it.

Funny thing, even when you’re playing at saying things that are the opposite of the truth, sometimes people don’t catch on. People get confused. For example, if the media happened to be listening to us, they might get confused and literally report things we said, even though we meant the opposite. That’s especially funny. When that happens, whether it’s by accident or on purpose, the correct response is to say, “I was only joking.”

After a while, if you intermittently play the Opposite game and mix it with being normal, people won’t know when to take you seriously and when to not take you seriously. For example, the other day I made a phone call, it was a perfect phone call. I said, “Hey dude, I’ll bring you over some of that medicinal plant you’re needing for nausea. It really sucks to feel sick, and I want to help. I’d like you to do me a favor though. If you could spontaneously give my boss a call and tell him how much you appreciate my great and unmatched wisdom, that would be nice.”

To be certain that I’d communicated perfectly, I ended the conversation by saying, “I’m only joking you know. I’m quite the humorist. Never mind what I said before. You look really good today.”

The best thing about being in charge of the opposite game is that it keeps everybody else off balance. In comparison, I’m always on my game, because I’m the only one who knows when the opposite game rules are in effect. Sometimes I forget whether I’m playing the opposite game or not. Hey, not really. You and I both know I’m the most self-aware and evolved person ever to inhabit the planet. Me forgetting? Not possible. Or, maybe it’s possible, but I’d never forget the important things.

I remember how me being in charge of the opposite game worked with my nephews. At the end of the day, sometimes I’d hug them and yell, “I hate you.” They knew what I really meant.

Oh, and BTW. Thanks for reading this. I value you as a person and I hope you love yourself. You know one thing that might help. If you’d just keep this blog post to yourself. Don’t share it. Seriously. I’m joking.

 

Clinical Interviewing, Personal Reflections, Writing

Hacking Affect and Mood in 325 Words

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Rita Wood Surfing

Affect is how you look to me.

Affect involves me (an outsider) judging your internal emotional state (as it looks from the outside). Whew.

Mood is how you feel to you.

Mood is inherently subjective and limited by your vocabulary, previous experiences, and inclination or disinclination toward feeling your feelings.

Independently, neither affect nor mood makes for a perfect assessment. But let’s be honest, there’s no such thing as a free lunch, and there’s no such thing as a perfect assessment. Even in elegant combination, affect and mood only provide us with limited information about a client’s emotional life.

Our information is limited and always falls short of truth because, not only is there always that pesky standard error of measurement, also, emotion is, by definition, phenomenologically subjective and elusive. Emotion, especially in the form of affect or mood, is a particularly fragile and quirky entrepreneur of physiology and cascading neurochemical caveats. Nothing and everything is or isn’t as it seems.

As an interviewer, even a simple emotional observation may be perceived as critical or inaccurate or offensive in ways we can only imagine. Saying, “You seem angry” might be experienced as critical or inaccurate and inspire the affect you’re watching and the mood your client is experiencing to hide, like Jonah, inside the belly of a whale.

Oddly, on another day with the same client, your emotional reflection—whether accurate or inaccurate—might facilitate emotional clarity; affect and mood may re-unite, and your client will experience insight and deepening emotional awareness.

As a clinician, despite your efforts to be a detached, objective observer, you might experience a parallel emotional process. Not only could your understanding of your client deepen, but ironically, because emotional lives resist isolation, you might experience your own emotional epiphany.

Rest assured, as with all emotional epiphanies—including our constitutionally guaranteed inevitable and unenviable pursuit of happiness—you’ll soon find yourself staring at your emotional epiphany through your rear view mirror.

*************************************

Just for fun, below I’ve included a link to a brief clip of me doing a mental status examination with a young man named Carl. A longer version of my interview with Carl is available with the 6th edition of Clinical Interviewing. https://www.youtube.com/watch?v=1lu50uciF5Y

 

 

 

Happiness, Personal Reflections, Suicide Assessment and Intervention, Writing

On the Road from Suicide to Happiness: Please Send Directions!

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IMG-5436

Buddhists often say that life is suffering. Some days, for many of us, that feels about right.

But on other days, the inverse also rings true. Life is joy. Joy is the dialectical sunshine that intermittently breaks through clouds of suffering to interrupt our melancholy.

Don’t worry. Even though there’s currently a September Winter Storm Warning happening in Montana, I’m not going all weather on you. Besides, there’s not much I love more than clouds, rain, and winter storms. Also, to be fair, Buddha and the Buddhists recognized long ago that there’s a road we can take to get away from storms of suffering.

Maybe it’s my penchant for bad weather that’s drawn me, for the past two years, deeply into the professional monsoon of clinical depression, suicide assessment, and suicide interventions. What’s odd about that is that I don’t believe that depression or suicidality should be as pathologized as they have been. I’m a proponent of the right to die. I also find light and hope in the existential perspective that encourages us to embrace and integrate our darker, depressive sides, so we can emerge more whole and, as the existentialist Kirk Schneider likes to say, experience a Rediscovery of Awe.

For the past two years, focusing on suicide has felt very important. Our society isn’t very good at discussing suicide in an open and balanced way. All too often, suicide gets inaccurately conflated with illness or shame or moral weakness. These inaccuracies have inspired me to talk openly about suicide whenever given the opportunity.

But, to be honest, talking and writing about suicide—even from a professional perspective—isn’t all that fun. Those who know me know how much I like to tell funny stories. For years, I’ve had an untreated addiction to showing Far Side and Calvin and Hobbes cartoons during presentations. You wouldn’t believe how hard it is to find suicide cartoons that are workshop-worthy. When I show my cartoon with the white rat in the cage hanging itself and the lab scientist saying, “Looks like discouraging data on the antidepressant” if there’s any laughter it’s a painful and strained laughter, at best.

I do have one amazing depression cartoon; it’s a Gary Larson Far Side scene of a sad looking man on a bed in a messy room with the caption, “The bluebird of happiness long absent from his life, Ned is visited by the Chicken of Depression.”

But let me get out of my addiction and to the point. In my work on suicide prevention and intervention, I’ve slowly realized that we need to paddle upstream. I won’t stop talking about depression and suicide, but I want to more explicitly acknowledge that disabling depression and tragic suicides are often the inverse of well-being or happiness turned upside down. To address this effort at integration, I’m preparing materials to teach and present on the science of happiness. This is where I need your help. Yes, please send more suicide and depression cartoons, but even more importantly, send me happiness cartoons! I’m expanding my focus, and getting ready to spend more time talking about how we can all live happier and more meaningful lives. One way I’m doing this is by teaching a new “Happiness” course this spring at the University of Montana.

As background, I should let you know that I’m familiar with the Yale Happiness Class, the Penn Positive Psychology Center, and other popular resources. Although I’ll use this mainstream material, I want to do something different.

Here’s how you can help.

I’m looking for lecture material and happiness lab activities. Examples include,

Lecture content

  • Video clips
  • Songs with meaning
  • Demonstration activities
  • Quirky/meaningful stories

Lab activities

  • 30-60 minute specific experiential activities that can deepen student learning
  • Evidence-based experiential activities that demonstrate how to counter depression or embrace meaning

Because I’ll be delivering the course to undergraduates, as you contemplate sending me a map with directions to happiness, please put on your 19-year-old hat and help me find destinations with academic substance, but that will still appeal to the college-age generation.

As always, thanks for reading. I wish you a weekend (and life) filled (at least intermittently) with the sort of happiness and joy that’s palpable enough to sustain you until the next bluebird of happiness lands on your shoulder. And if you live in Montana, be sure to stay warm in the winter storm.

John S-F

Personal Reflections, Politics, Writing

Without a Trace of Shame: Looking Back at Trump’s Personality

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IMG-5443

Donald Trump told another joke today. Problem is, his jokes frequently include death threats. I recall back in the day when he implied that his 2nd amendment supporters might want to stop Hillary from appointing Supreme Court justices. He played that off as a joke. Today the joke was about how America used to treat spies.

Like most things Donald Trump, what he says is usually half-impulse, half-informed, half-truths, half-ass, but wholly designed to trumpet his dominance.

The focus right now is on Trump’s Mafioso-like negotiation with Ukraine’s President. The press and politicians call it a “quid pro quo.” I think they’re using their fancy Latin to refer to a shake-down, which, if you read the transcript is obviously happening. To be more accurate, the Latin refers to “this for that.” But the Urban Dictionary might put it clearer with, “I want something, you want something. You give me what I want, I’ll give you what you want.” Even better, if you want to really know what’s going on, check out Urban Dictionary’s definition for “Quid pro quo-job” (which, because of my PG-13 rating, I’m unable to share here).

Some people act surprised that Donald Trump’s behaviors are so reminiscent of the Godfather. I’d say Mafioso, but Trump’s not Italian and consequently cannot qualify . . . which is probably at least partly why he’s acting so much like he’s trying to gain Mafioso status without having it. As Alfred Adler would say, that’s the way psychological compensation works.

If you’re a conscious and sentient being, there’s nothing particularly surprising here. Trump was being Trump. To review (which us academics do all the time, mostly because we’re forgetful), let’s look at the personality traits I wrote about in Slate Magazine last year around this time.

The following descriptions are summarized or paraphrased from the famous personality psychologist, Theodore Millon. Millon’s work was immense and immensely interesting. Read the following descriptions and contemplate two things:

  1. Do they fit Trump?
  2. What might the future of a Trump Presidency hold?

As I said last year, Trump has virtually all the qualities of someone with narcissistic personality disorder. But that’s not particularly interesting because most big-time politicians, media personalities, and rock stars have at least some narcissistic qualities. What’s unusual (and dangerous) is that Trump also has antisocial personality traits.

Generally, Millon summarized antisocial personalities as:

“Driven by a need to . . . achieve superiority.” They act “to counter expectation of derogation and disloyalty at the hands of others,” and do this by “actively engaging in clever, duplicitous, or illegal behaviors in which they seek to exploit others for self-gain.”

With that general description as backdrop, here are specifics.

Impulsive Imprudence. Antisocial personalities are “. . . shortsighted, incautious, and imprudent. There is minimal planning, limited consideration of alternative actions, and consequences are rarely examined.”

Blaming Others for Shirked Obligations. Antisocial personalities “frequently fail to meet or intentionally negate obligations of a marital, parental, employment, or financial nature.” This is the equivalent of a personal philosophy in direct opposition to President Harry Truman’s, “The buck stops here.”

Pathological Lying. Millon wrote, “Untroubled by guilt and loyalty, they develop a talent for pathological lying. Unconstrained by honesty and truth, they weave impressive talks of competency and reliability. Many . . . become skillful swindlers and imposters.”

Declarations of Innocence. During times of trouble, antisocial personality types employ an innocence strategy. “When . . . caught in obvious and repeated lies and dishonesties, many will affect an air of total innocence, claiming without a trace of shame that they have been unfairly accused.”

Empathy Deficits. Antisocial personalities are devoid of empathy and compassion. Millon called this “A wide-ranging deficit in social charitability, in human compassion, and in personal remorse and sensitivity.” He added that “many have a seeming disdain for human compassion.”

Counterattacks. Millon noted that antisocial personalities are hyper-alert to criticism. He “sees himself as the victim, an indignant bystander subjected to unjust persecution and hostility” feeling “free to counterattack and gain restitution and vindication.”

Moral Emptiness. Antisocial personalities have no ethical or moral compass. As Millon described, they “are contemptuous of conventional ethics and values” and “right and wrong are irrelevant abstractions.” Antisocials may feign religiosity—when it suits their purpose. But the moral litmus test will always involve whether they stand to gain from a particular behavior, policy, or government action.

Whether you think Donald Trump’s personality is captured in this short list of descriptions probably depends on your politics. I should also add that it’s perfectly possible for someone to have all these qualities and still have positive qualities as well. We’ve known—probably since the beginning of time—that people with antisocial personalities can be quite charming and charismatic. What’s crucial, and also intuitive, is that we the people recognize that despite his intermittent charm and charisma, Donald Trump is not to be trusted . . . which is likely why one of his favorite lines is “Trust me.”

My perspective is precisely the opposite. Please don’t trust me. Do the work, think about Trump’s pattern of behavior. It’s about far more than this latest incident regarding Ukraine. Take a look at the long list of behaviors that are consistent with Millon’s criteria. And then decide where you stand on a future with Donald Trump.

*********

The views expressed here are my own. They’re not representative of anyone else. They’re also not part of a quid pro quo.

For the whole long version of the Millon and Trump’s personality article, go here: https://johnsommersflanagan.com/2018/09/03/the-long-version-of-the-trump-personality-slate-magazine-article/

Personal Reflections, Suicide Assessment and Intervention, Writing

When Happiness Ran Away: Thoughts on Suicide and the Pursuit of Happiness

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Elephant

Several days prior to driving across the state to a party with her family, a friend met up with Rita and me. We talked about happiness. She said she liked the word contentment, along with the image of hanging out in a recliner after a day of meaningful work.

Following the party, she wrote me an email, sharing, rather cryptically, that her party planning turned out just okay, because,

“Sigh. Some days happiness runs so fast!”

I loved her image of chasing happiness even more than the image of her reclining in contentment.

As it turns out, being naturally fleet, happiness prefers not being caught. Because happiness is in amazing shape, if you chase it, it will outrun you. Happiness never gets tired, but usually, before too long, it gets tired of you.

In the U.S., we’ve got an unhealthy preoccupation with happiness, as if it were an end-state we can eventually catch and convince to live with us. But happiness doesn’t believe in marriage—or even in shacking up. Happiness has commitment issues. Just as soon as you start thinking happiness might be around to stay, happiness suddenly disappears in the night.

Maybe our preoccupation with happiness is related to that revered line in the U.S. Declaration of Independence about the right to life, liberty, and the pursuit of happiness. Grandiose words indeed, because, at this point in the history of time, I’m not so sure any of us have an inalienable right to any of those three wondrous ideals.

But don’t let my pessimism get you down. Even though I’m not all that keen on pursuing happiness, I believe (a) once we’ve defined happiness appropriately, and (b) once we realize that instead of happiness, we should be pursuing meaningfulness, then, (c) ironically or paradoxically or dialectically, happiness will sneak back into our lives, sometimes landing on our shoulders like a delicate butterfly and other times trumpeting like a magnificent elephant.

Another reason not to feel down is because next Tuesday, October 1, I’ll be in Red Lodge, Montana as the speaker of the month for the Red Lodge Forum for Provocative Issues.

How cool is that?

My Red Lodge Forum presentation is: Suicide, Suicide Prevention, and the Pursuit of Happiness.

Just in case you’re passing through Red Lodge or happen to know someone in the general vicinity, below I’ve pasted the promotional email for the event. Please come if you can. There will be a fancy dinner, which inevitably involves a full stomach, which, even though I’m talking about suicide, might provide you with a twitch or two of happiness.

Here’s the promo:

From: Red Lodge Forum <redlodgemtforum@gmail.com>
Sent: Sunday, September 22, 2019 2:13 PM
To: ‘Red Lodge Forum’ <redlodgemtforum@gmail.com>
Subject: Tuesday October 1st Forum for Provocative Issues. Dinner reservations open

Forum for Provocative Issues

Suicide, Suicide Prevention, and the Pursuit of Happiness

Tuesday, October 1

PROGRAM

Beginning in 2005, death by suicide in the U.S. began rising, and despite vigorous national and local suicide prevention efforts, suicide rates have continued rising for 13 consecutive years. Depending on which metrics you prefer, suicide rates are up from somewhere between 33% and 61% from their levels at the turn of the century.

In Montana, we have the dubious distinction of the highest per-capita suicide rates in the U.S., at about 29.0 per 100,000 Montanans. Why? What is so peculiar about Montana?

But suicide is about much more than numbers. Join us on Tuesday, October 1 when Distinguished Professor at the University of Montana, John Sommers-Flanagan talks about what contributes to suicide, why Montana’s rate is so high, what’s wrong with suicide prevention efforts, and how we should talk with friends about suicide. Although suicide is a difficult, emotionally charged, subject, John will explore emotions that can create and sustain happiness.

FORUM CATERER CHANGE

In the next section, you will notice our caterer has changed. Martha Young, who has faithfully served our delicious meals for eight years, first at Café Regis, and more recently at the Senior Center, is unable to caterer our October meal. Prerogative Kitchen, an outstanding local restaurant,  has agreed to stand in.

DINNER RESERVATIONS NOW OPEN

Dinner at the Red Lodge Senior Center (13th St and Word Ave) will start at 5:30 pm and our program shortly after 6. If you plan to have dinner, email RedlodgeMtForum@gmail.com (no text or calls) with:

  • your reservation request,
  • your general meal choice (meat/fish, veggie, non-gluten), and
  • your cell number

If you don’t receive an email confirmation of your request promptly, please resubmit it. When I know specific dinner choices later this week, I will ask you to confirm your choice.

If you plan to attend the forum but not eat, come around six but donate $5 to help defray room rental and other expenses.

The price for this  dinner is $18. Please bring a check written prior to your arrival to Prerogative Kitchen for $18 per person. It will reduce traffic at the door, seat everyone faster, and make our cashier’s job easier.  If you want to leave an additional gratuity, simply leave cash on the table. Do not include gratuities in your check.

If you have friends who are interested in attending the forum, feel free to forward this message.

HAS YOUR EMAIL CHANGED?

If you change your email address and want to continue receiving forum notices, remember to send the change to RedlodgeMtForum@gmail.com.

INFORMATION ABOUT UPCOMING AND PAST FORUMS

For quick access to all news about upcoming and past programs, become a member of our Facebook group page, which supports FPI programs.  To access the page, simply search “Forum for Provocative Issues.”  This is an open group, but we carefully screen applicants to avoid potential problems by asking three simple questions.

USE OF FORUM EMAILS

I never share the emails of forum members. However, I have on occasion sent information about community issues and events that I think members will find valuable.

FORUM SUGGESTIONS

If you have an idea for a forum, email it to RedlodgeMtForum@gmail.com.

FUTURE FORUMS

The dates for our 2019/2020 season follow. Mark them on your calendar now to avoid conflicts.

  • November 5, The Future of Nuclear Energy, Redfoot
  • December 10, Japanese American Internment Camp Conditions in WWII, Russell
  • January 14, Fighting Fires, Saving Homes, Trapp
  • February 4, Apollo 8 and the Race for Space, Dragon
  • March 3, Subject TBD, Darby
  • April 7, Dark Money in Politics, Adams
  • May 5, Genetics and the Future of the Human Race, Gunn

 

 

Counseling and Psychotherapy Theory and Practice, Suicide Assessment and Intervention

Trauma, Suicide, and Motivational Interviewing: A Handout for BYEP Mentors

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Sunset

Trauma may be the most common underlying factor contributing to mental disorders. Unfortunately, trauma is often overlooked, partly because it can manifest itself in so many different ways. That said, here are some common definitions. Trauma always involves a stressful trigger that activates a trauma response. Because, like everything, trauma responses are brain-based and involve the body, symptoms affect the whole person.

Old, informal, and useful definitions include:

  • A stressor outside the realm of normal human experience (but sadly, trauma is all-too-common)
  • A betrayal . . . (e.g., something that should not happen)
  • Occurrence of an event that’s emotionally overwhelming

Below I’ve listed the essence of the DSM-5 definition for Post-Traumatic Stress Disorder (note that the whole idea of PTSD centers on the chronic or long-lasting effects of trauma).

Exposure to a traumatic stressor that involves direct personal experience, witnessing, or learning about events involving threatened death, serious injury, or a threat to your physical integrity. The trauma response includes:

  • Intrusion symptoms (recurring unwanted memories, nightmares, flashbacks, and triggered distress)
  • Avoidance of trauma-related thoughts or external cues
  • Negative cognitive alternations (e.g., memory gaps, no joy, etc.)
  • Arousal and reactivity (e.g., irritability, risky behaviors, hypervigilance, insomnia, startle response)

Trauma and trauma responses can be big, medium, and small. Big traumas meet the DSM-5 diagnostic criteria for PTSD or acute stress disorder. Small traumas are usually disturbing and disruptive, but the body and brain adjust to them within 2-3 days. Medium size traumas have lasting effects, but don’t meet formal diagnostic criterial, and are usually referred to as subclinical.

I like to think of Trauma with an uppercase T (like in the DSM) and all other traumas that are difficult, challenging, and require adjustment as traumas with a lowercase t.

What to Say

Sometimes trauma responses or symptoms are visible and obvious. If so, it’s good to say and do some of the following:

  • Listen and show compassion
  • Reassure participants that physical/psychological responses are normal, take up energy & need soothing
  • Note that very effective treatments are available (e.g., This American Life)
  • Brainstorm on what helps
  • Remember: A pill is not a skill
  • Link and universalize (“It’s normal to have pleasant and unpleasant reactions to things we talk about”)
  • Brainstorm on more and less healthy reactions (Using substances is a quick distraction, but not a fix)
  • Share hopeful stories (what skills can be developed?)
  • Self-disclosure can help. But be careful with self-disclosure and remember that it’s not about you

Trauma is a normal and natural human response. You may experience trauma just by listening to people talk about trauma, or you may have your own direct experiences. When in the business of helping others, be sure to take good care of yourself.

Three Suicide Myths

Myth #1: Suicidal thoughts are about death and dying.

Most people assume that suicidal thoughts are about death and dying. On the surface, it seems like a no-brainer: Someone has thoughts about death, therefore, the thoughts must 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.

Myth #2: Suicide and suicidal thinking are signs of mental illness.

Not true. 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.”

Myth #3: Scientific knowledge about suicide risk factors and warning signs allows for the prediction and prevention of suicide.

Believing in this myth can make surviving family members, friends, and helping professionals experience too much guilt and responsibility. In fact, even the most famous suicidologists say that it’s impossible to consistently and accurately predict suicide.

Tips for Talking about Suicide

We need to be able to talk directly about suicide with courage and calmness. But first, we should listen. Here’s what you should listen for in general

  • Emotional pain
  • A sense of feeling trapped or ashamed
  • Not believing that anything can possibly help to reduce the pain and misery

While listening, show acceptance, empathy, and compassion. Remember: suicidal thoughts are not signs of illness or moral failing; if you judge the person, it will make it harder for the person to be open. Also remember: when people talk with you about their suicidal thoughts, that’s a good thing, because you can’t help unless they’re comfortable enough with you to speak openly about their suicidal thoughts and feelings.

Traditional warning signs in particular

Although it’s good to know these warning signs, there’s not much research supporting the idea that anything predicts suicide.

  • Active suicidal thinking that includes planning and talk about wanting to die
  • Preparation and rehearsal behaviors (stockpiling pills, giving away belongings, etc.)
  • Hopelessness related to feeling that the excruciating distress will never end
  • Recklessness, impulsivity, dramatic mood changes
  • Anger, anxiety, and agitation
  • Feeling trapped
  • No reasons for living, no purpose in life, broken relationships
  • Increased alcohol or substance abuse
  • Immense shame or self-hatred

How should I ask about suicide?

The answer to this is always, “Ask directly.” But we can do even better than that. We need to de-shame suicidal thoughts and talk. Before asking, communicate that you know suicidal thoughts are a normal and natural response to emotional pain and disturbing situations. For example, you could ask it this way, “I know that it’s not unusual for people to think about suicide. Have you had any thoughts about suicide?”

What should I say if someone admits to thinking about suicide? You can say things like,

  • Thanks for telling me.
  • It sounds like things have been terribly hard.
  • Thanks for being so honest, that takes courage.
  • I know I can’t instantly make everything better, but I want you to live and I want to help.
  • How can I best support you right now?
  • What can we do together that would help?
  • When you want to give up, tell yourself to hold off for one more day, hour, minute—whatever you can.
  • Or . . . use your good listening skills and reflect back the feelings and thoughts that the person shared.

Resources for Help

  • National Suicide Prevention Lifeline: Call 800-273-TALK (800-273-8255)
  • Crisis Text Line: Text HOME to 741741
  • Bozeman Help Center – 24-Hour Crisis Line: (406) 586-3333

What is Motivational Interviewing?

Motivational interviewing (MI) is an evidence-based approach to treating substance problems, health concerns, and other mental health issues. MI is “person-centered” and based on the foundational principle that clients should be the ones who make the case for change in their lives. MI:

  • Focuses on the common problem of ambivalence about change.
  • Relies on four central listening skills (OARS): open questions, affirming, reflecting, and summarizing.
  • Helps clients transition from less healthy to more healthy behaviors

Four overlapping components combine to create the spirit of MI:

  • Collaboration (partnership; dancing, not wrestling)
  • Acceptance (UPR, accurate empathy, autonomy, affirmation)
  • Compassion (honoring the client’s best interest)
  • Evocation (tapping the client’s well of wisdom)

MI is a specific treatment approach that requires professional training. However, operating on a few basic MI principles can improve nearly anyone’s approach to helping others. For more information, see the book: Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change. New York, NY: Guilford Press.

This handout is from a mentor workshop for the Big Sky Youth Empowerment Program. These ideas are based on research and collected from professionals who have experience working with people who are feeling suicidal. These guidelines should not be considered medical advice and are no substitute for getting an appointment with a licensed health or mental health professional. See: johnsommersflanagan.com for more information.

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