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Initiating Conversations about Suicide . . .

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Street Sunrise

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

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

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

Showing Empathy, Building Rapport, and Staying Balanced

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

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

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

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

Empathic Reflections

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

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

Using the Client’s Language

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

Using Validation

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

Dealing with Irritability

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

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

Dealing with Ruptures

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

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

Using Balanced Questioning

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

Asking Directly about Suicide Ideation

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

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

Using a Normative Frame

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

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

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

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

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

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

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

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

Clinical Interviewing, Personal Reflections, Politics

More Musings on Donald Trump’s Personality: Spoiler Alert, We’re Not Talking Narcissism Anymore . . . Because it’s Worse than That

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Irrigation SunriseAs I mentioned in Part One, much of the focus on DJT has been on whether he meets the diagnostic criteria for Narcissistic Personality Disorder. Allen Francis, who helped write the personality disorder criteria, has expressed many times that DJT is “bad, not mad.” His reasoning is that DJT’s narcissistic traits don’t cause Trump personal distress and haven’t adversely affected his functioning; in fact, DJT was elected president! In diagnostic terminology, Dr. Frances is saying that DJT doesn’t meet either the distress or impairment criteria, at least one of which is needed to make a formal diagnosis.

Despite the objections of Dr. Francis, if you look at the DSM-5 criteria for NPD, it’s easy to see that DJT’s public behaviors could have served as the prototype for the DSM’s authors as they developed the NPD diagnostic criteria. But it still doesn’t mean DJT has NPD. In addition to not meeting the distress or impairment criteria, individuals (even DJT) cannot be diagnosed without a clinical interview, principally because all behaviors occur in context (or within a subculture). What’s even more interesting is that given DJT’s context of being a reality television star, running for president, and being elected president, who are we to say whether his apparent NPD characteristics are diagnosable. In those contexts, having NPD behaviors might be adaptive (at least sometimes).

In particular, the context of U.S. President is of special intrigue. Generally, anyone who runs for president probably has some (or many) narcissistic traits. I’m not saying that all U.S. Presidential candidates are, by definition, narcissistic. I am saying that narcissistic traits in a U.S. President are not especially distinguishing features. It’s sort of like saying, “Hey, I found this fish and I also discovered that it can swim!!” Narcissistic traits in a U.S. President does not a news-flash make.

Besides . . . and here’s where I go down a more frightening path. My sense is that what’s unique and distinguishing about DJT isn’t his narcissism (although his narcissism is palpable, but not diagnosable); instead, I think he behaves in ways consistent with individuals who have antisocial personalities. Again, I’m not making the claim here that DJT should be diagnosed with Antisocial Personality Disorder (APD). Below, I’ll elaborate on my thinking about this.

As I explore how DJT manifests an antisocial personality style (not APD), I’ll be quoting liberally from the amazing work of the late Theodore Millon (see: Disorders of Personality, 3rd ed., 2011). Millon was a psychologist famous for his writings on personology in general, and personality disorders, in particular.

Just FYI: The following quotations and comments don’t refer to APD diagnostic criteria. Millon (2011) believed those criteria were too concrete and simple and therefore inconsistent with the concept of personality. Instead, my focus is on individuals who think and behave in ways consistent with Millon’s formulation of “Aggrandizing-Devious-Antisocial Personality.” These individuals, although not necessarily diagnosable in the DSM or ICD sense, exhibit a style consistent with antisocial psychological and interpersonal dynamics.

Before I dive into Millon’s descriptions, which are fantastic, by the way, let’s take a brief historical tour.

Way back in Aristotle’s time, his student, Theophrastus (371 – 287 B.C.), wrote about specific personalities, one of which was “The Unscrupulous Man.” Here’s one of Theophrastus’s descriptions.

The Unscrupulous Man will go and borrow more money from a creditor he has never paid . . . . When marketing he reminds the butcher of some service he has rendered him and, standing near the scales, throws in some meat, if he can, and a soup-bone. If he succeeds, so much the better; if not, he will snatch a piece of tripe and go off laughing (from Widiger, Corbitt, & Millon, p. 63).

If you recall Aristotelian philosophy, Aristotle was big into virtues or virtuous behaviors. Here we have his student describing someone who isn’t especially virtuous. Theophrastus’s description involves a pattern of taking from others; The Unscrupulous Man apparently thinks that theft of others’ goods and property is acceptable, and perhaps laudable. Serendipitously, I’m reminded of a few examples of this attitude and unscrupulous behaviors in DJT. Specifically, there are well-publicized bankruptcies, reports of non-payment to contracted employees, and a statement in one of his debates with Hillary Clinton that not paying any federal income taxes “makes me smart.” Hardly anyone (other than Sarah Huckabee Sanders) would step up and contend that DJT is neglecting himself because of his interest and focus on the welfare of others. That DJT frequently works systems and people to his advantage is relatively unarguable.

About 2000 years later, interest in The Unscrupulous Man re-emerged. The famous American physician, Benjamin Rush wrote about “perplexing cases characterized by lucidity of thought combined with socially deranged behavior. He spoke of these individuals as possessing an ‘innate, preternatural moral depravity’” (p. 425). Millon summarized Rush’s description: “He claimed that a lifelong pattern of irresponsibility was displayed by these individuals without a corresponding feeling of shame or hesitation over the . . . destructive consequences of their actions” (p. 425). Rush himself wrote: “Persons thus diseased cannot speak the truth upon any subject” (1812, p. 124).

Earlier this year, the Washington Post (May 31, 2018) reported, “President Trump has made 3,251 false or misleading claims in 497 days.” Of course, the Post limited their analysis to public statements, so their estimate is probably low. Rush’s description of someone who “cannot speak the truth on any subject,” has some surface validity in that it sometimes seems that DJT tells unnecessary lies. Given an opportunity to speak freely, it’s not unusual to hear DJT begin exaggerating about inaugural (or other) crowd sizes or to completely dissemble, “I never fired James Comey because of Russia!” or “I’m the only politician that produced more than I said I was going to produce, and we’re only 1 1/2 years in” or ________________. You can fill in the blank, I’m sure.

The history of APD as an entity is peppered with commentary of astonishment (an astonishment similar to the mainstream press) and their repeated surprise that DJT was behaving in ways that were unprecedented, over and over, and in a sense, normalizing combat between the  Office of the President and the Press Corps, who were quickly labeled as “the enemy of the people.” Historically, there was a similar repeated surprise over discovering (and rediscovering) that there was a “type” of mental patient who, in many ways seemed perfectly normal, but in the place where moral values existed for others, there was only emptiness. The usual signs of insanity were missing, but constructs of ethics and morals were viewed as quaint ideas existing only on other planets or in alternative universes. Given this moral lacunae, early on, the condition was referred to as “moral insanity.” This term emphasized the consistent observation that these people appeared sane in all other respects—and often charming. Henry Maudsley (1874), put it this way:

“As there are persons who cannot distinguish certain colours, having what is called colour blindness, so there are some who are congenitally deprived of moral sense” (p. 11).

In the early 1900s, Emil Kraepelin, upon whose work forms the foundation for modern diagnostic systems, described a personality type that he referred to as “morbid liars and swindlers.” These types “were glib and charming, but lacking in inner morality and as sense of responsibility to others; they made frequent use of aliases, were inclined to be fraudulent con men, and often accumulated heavy debts that were invariably unpaid” (Millon, 2011, p. 428). One of Kraepelin’s disciples, a German physician, later added, “. . . that many of these individuals were unusually successful in positions of either political or material power” (Millon, p. 429)

Obviously, DJT has been “unusually successful” both politically and materially. Of greater prescience is a quotation from Jimmy Kimmel Live (May 25, 2016) where DJT described his used of aliases. “Over the years I’ve used alias (sic), and when I’m in real estate and especially when I was out in Brooklyn with my father and I’d want to buy something . . . I would never want to use my name because you’d have to pay more money for the land. If you’re trying to buy land, you use different names.”

Also in 2016, but on a less grand stage, consistent with Kraepelin’s formulation of morbid liars and swindlers, my 90-year-old poker-playing father quickly identified DJT as “a con man” (https://johnsommersflanagan.com/2016/11/05/what-my-card-playing-genius-father-says-about-donald-trump/).

One final note before ending Part Two.

A Kraepelin disciple from Germany made an interesting point . . . and one that Millon repeatedly emphasizes. Not only is it that individuals with antisocial characteristics may not be disordered, in fact, they may be very successful: “Schneider observed that many of these individuals were unusually successful in positions of either political or material power.” (Millon, p. 429).

Part Three is coming . . . although I’m hoping that my Slate Magazine article is coming sooner.

Clinical Interviewing, Personal Reflections

On Psychiatric Diagnosis and Whether Donald J. Trump has a Personality Disorder

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IMG_3063Note — This is a three or four part series focusing on complexities of psychiatric diagnosis; then I ramble into an exploration of what specific psychological and interpersonal dynamics might be driving Donald Trump’s behaviors. This piece and the next two or three are a lead-up to an essay I’m doing for Slate Magazine.

Psychiatric diagnosis looks easy.

All you need is a diagnostic manual. In the U.S., you can use the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; published by the American Psychiatric Association) or the 10th edition of the International Classification of Diseases (ICD-10; published by the World Health Organization). Even easier, you can search for and find online diagnostic criteria for virtually every mental disorder. The power to diagnose is at your fingertips.

If you think your friend has panic disorder, you can type “panic disorder” into your favorite search engine, find the criteria, and confirm your suspicions. The same goes for diagnosing children. Finding the criteria for attention-deficit/hyperactivity disorder (ADHD) is simple. Of special convenience is the fact that if you look at the ADHD criteria, you’ll discover that nearly every child on the planet has ADHD. Odds are, if you look closely at the ADHD criteria, you’ll end up diagnosing yourself. I mean, who really likes waiting in lines?

Technically, you should study the different diagnostic categories and the various checklists of symptoms for each disorder, do a formal observation or interview with the person you want to diagnose, match their behaviors to the checklist, and come to your diagnostic conclusion. But we’re living in a fast-paced world where, like our president, whatever you think must be true because you thought it; never mind that you should recuse yourself from diagnosing your friends, your family, and yourself. Who has time to fact check? Besides, you can just ask, “Siri, do I have obsessive-compulsive disorder?”

Contrary to popular solipsistic fantasies and what you’ll learn from Siri, psychiatric diagnosis may look easy, but in the real world, it’s complex and sticky.

Not only are there 300 different diagnoses (and 947 pages in the DSM-5), many psychiatric conditions overlap, meaning one symptom could be associated with several different diagnoses. For example, having a depressed or irritable mood could qualify your or your romantic partner for bipolar disorder or various depressive disorders, but because bad moods are also associated with ADHD, oppositional defiant disorder, substance use disorders, and many different physical/medical conditions, you’ll need to assess for and rule out these other possible disorders. Then again, there’s the likely chance that you and your romantic partner are bugging the hell out of each other and so your depressed and irritable moods are simply a natural product of your poor judgment, incompatibility, or desperate need for couple counseling.

Sorting out diagnostic signs and symptoms is especially difficult because people will often intentionally or unintentionally minimize or exaggerate their symptoms, depending on the setting and their motivation. Think about your son. He’s a hellion at home, but when you take him to the pediatrician, you come unglued trying to tell the doctor about your hyperactive child. All the while, he sits there, hands folded like a little cherub. You leave the office with a new prescription for valium for yourself.

If you make an effort to go beyond using the diagnosis-is-easy approach, in the end, or in the middle, or somewhere in the diagnostic process you may find the symptoms have changed. You mother may have seemed bipolar and you were closing in on a diagnosis of intermittent explosive disorder for your father, but suddenly, right after you move out, their symptoms vanish. Or maybe they just aged and became more mature or maybe they got out of their miserable jobs, and consequently became less emotionally volatile? This is the nature of working with humans; as much as you’d like them to hold still for a clear snapshot, they move, their relationships change, their employment situation shifts, and you end up with what the venerable psychologist Paul Meehl might have called, a fuzzy notion, rather than diagnostic certainty. Looking back, Meehl might have added that diagnosis is also a sticky notion because, once applied, psychiatric diagnoses are difficult to remove. This is why psychiatric diagnosis is best left to trained professionals. This is also why professionals often get it wrong, and someone ends up labeled with a sticky diagnosis that follows them into the future despite new and contradictory diagnostic information.

As an example, many people and some professionals have concluded that Donald J. Trump has a mental disorder called narcissistic personality disorder (NPD). As satisfying as it might feel to diagnose Donald Trump with NPD, the NPD conclusion is erroneous on two counts. First, no one can or should diagnose Trump without conducting a diagnostic interview. Even then, diagnosing him would be difficult. As Allen Francis, Chair of the DSM-IV Task Force wrote, diagnosticians should “be patient,” because accurate psychiatric diagnosis may take five minutes, five hours, five months, or five years. In the real world of psychiatric diagnosis, accurate and useful diagnoses take much longer and are much more involved than a 5 minute armchair social media diagnosis. Competent and ethical mental health professionals always go beyond diagnostic checklists.

Now, don’t get me wrong, labeling Trump with NPD feels good and feels right. Check it out. There are many, many obvious examples of how Trump fits the NPD criteria. However, other than being fun, entertaining, and gratifying (not to mention offensive), the process and outcome of armchair social media diagnosis is neither fair nor honest.

Beyond simply matching DJT’s behaviors with the NPD diagnostic criteria, over the past two years, many articles and books have been written about Donald J. Trump’s mental health. For some odd reason, I’ve been preoccupied with reading many of these articles and books lately. Although not “fun” content, reading about DJT’s mental state was a welcome shift away from my first impulse after his election—which was to start reading about the death instinct in Freud’s Civilization and It’s Discontents. I’m having way more fun now.

For another odd reason, after reading about DJT’s mental health, I found myself fantasizing that I might have something to add to the conversation.

To be continued . . .

Counseling and Psychotherapy Theory and Practice, Parenting, Personal Reflections

Feeling Anxious? Learn the One and Only Method for Self-Regulation

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Back in 1980, one of my supervisors at Woodside Hospital in Vancouver, WA, gave me a big compliment. At the time, I was a recreational therapist in a 22-bed psychiatric hospital. In a letter of recommendation, the supervisor described me as having a special knack for translating complex psychological phenomena into concrete activities from which patients could learn. To be honest, I really had no idea what I was doing.

But I think he was onto something about me and my personality. I like to integrate, summarize, and boil down information into digestible bits. Sometimes I have to get the facts to play Twister to get otherwise incompatible perspectives to fit together. This tendency is probably why I’ve written textbooks on clinical interviewing and counseling theories.

Today, I’m tackling anxiety, anxiety reduction, and self-regulation. This feels more personal than usual, mostly because I’ve been dysregulated, more or less, since November 9, 2016.

After reading and thinking about anxiety and anxiety reduction for 30+ years, I’m strongly leaning toward the position that there’s only one, single, universal method to achieve self-regulation. The method is Mary Cover Jones’s counterconditioning. You probably already know that I think Mary Cover Jones is fabulous.

As a means of exploring this unifying method, I recently did a podcast on it with Sara Polanchek. I’ll write more later, but for now, if you’re interested, check out the podcast. It’s the latest episode (7/19/18 release date). You can listen on iTunes: https://itunes.apple.com/us/podcast/practically-perfect-parenting-podcast/id1170841304?mt=2

Or Libsyn: http://practicallyperfectparenting.libsyn.com/

If you do listen, please let me know what you think. That way I can continue with integration and synthesis by incorporating your thoughts into my thoughts. I’ll bet you can find many different ways to communicate with me.

If you don’t listen, no worries, I’ll just keep hanging out here in my personal echo chamber.

Clinical Interviewing, Personal Reflections

Mental Health or Mental Illness: Defining Mental Disorders

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East Rosebud

For a while, I’ve been engaged in a debate (sometimes just with myself) about the use of the term “mental illness.” [More on this at a later date]. Civil debates are good for the brain. There doesn’t have to be a winner or loser. Recently I remembered that we addressed this issue briefly in our 2017 revision (6th edition) of Clinical Interviewing. Here’s an excerpt, beginning on page 396:

Defining Mental Disorders

The concept of mental disorder, like many other concepts in medicine and science, lacks a consistent operational definition that covers all situations. From the DSM-IV-TR (American Psychiatric Association, 2000, p. xxx)

It’s often difficult to draw a clear line between mental problems and physical illness. When you become physically ill, it’s obvious that stress, lack of sleep, or mental state may be contributing factors. Other times, when experiencing psychological distress, your physical state can be making things worse (Witvliet et al., 2008).

Why Mental Disorder and not Mental Illness?

Many professionals, organizations, and media sources routinely use “mental illness” to describe diagnostic entities included in the ICD and DSM classification systems. This practice, although popular, is inconsistent with the ICD and DSM. Both manuals explicitly and intentionally use and plan to continue using the term mental disorder. From the ICD-10:

The term “disorder” is used throughout the classification, so as to avoid even greater problems inherent in the use of terms such as “disease” and “illness”. “Disorder” is not an exact term, but it is used here to imply the existence of a clinically recognizable set of symptoms or behaviour associated in most cases with distress and with interference with personal functions. (1992, p. 11)

The ICD and DSM systems are descriptive, atheoretical classification systems. They rely on the presence or absence of specific signs (observable indicators) and symptoms (subjective indicators) to establish diagnoses. Other than disorders in the F00-F09 ICD-10 block (e.g., F00: Dementia in Alzheimer’s disease, F01: Vascular Dementia, etc.), there is no assumption of any physical, organic, or genetic etiology among ICD mental disorders.

Consistent with the ICD and DSM, we don’t use the term mental illness in this text. We also believe mental illness to be a more problematic term than mental disorder. In fact, often we step even further away from an illness perspective and use the phrase “mental health problems” instead. However, in the end, no matter what we call them, mental disorders are fairly robust, cross-cultural concepts that can be identified and often treated effectively.

General Criteria for Mental Disorders

The DSM-5 includes a general definition of mental disorder:

A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. (American Psychiatric Association, 2013, p. 20)

This definition is consistent with ICD-10-CM. Nevertheless, significant vagueness remains. If you go back and read through the DSM-5 definition of mental disorder several times, you’ll find substantial lack of clarity. There’s room for debate regarding what constitutes “a clinically significant disturbance.” Additionally, how can it be determined if human behavior “reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning” (p. 20)? Perhaps the clearest components of mental disorder include one of two relatively observable phenomena:

  1. Subjective distress: Individuals themselves must feel distressed.
  2. Disability in social, occupational, or other important activities: The cognitive, emotional regulation, or behavioral disturbance must cause impairment.

Over the years the DSM system has received criticism for being socially and culturally oppressive (Eriksen & Kress, 2005; Horwitz & Wakefield, 2007). Beginning in the 1960s Thomas Szasz claimed that mental illness was a myth perpetuated by the psychiatric establishment. He wrote:

Which kinds of social deviance are regarded as mental illnesses? The answer is, those that entail personal conduct not conforming to psychiatrically defined and enforced rules of mental health. If narcotics-avoidance is a rule of mental health, narcotics ingestion will be a sign of mental illness; if even-temperedness is a rule of mental health, depression and elation will be signs of mental illness; and so forth. (1970, p. xxvi)

Szasz’s point is well taken. But what’s most fascinating is that the ICD and DSM systems basically agree with Szasz. The ICD includes this statement: “Social deviance or conflict alone, without personal dysfunction, should not be included in mental disorder as defined here” (p. 11). And the DSM-5 authors wrote:

Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual . . . . (p. 20)

The ICD’s and DSM’s general definitions of mental disorder and criteria for each individual mental disorder consist of carefully studied, meticulously outlined, and politically influenced subjective judgments. Science, logic, philosophy, and politics are involved. This is an important perspective to keep in mind as we continue down the road toward clinical interviewing as a method for diagnosis and treatment planning.

Why Diagnose?

Like Szasz (1961, 1970), many of our students want to reject diagnosis. They’re critical of and cynical about diagnostic systems and believe that applying diagnoses dehumanizes clients, ignoring their individual qualities. We empathize with our students’ complaints, commiserate about problems associated with diagnosing unique individuals, and criticize inappropriate diagnostic proliferation (e.g., bipolar disorder in young people). But, in the end, we continue to value and teach diagnostic assessment strategies and procedures, justifying ourselves with both philosophical and practical arguments.

Some of the benefits of education and training in diagnosis follow:

  • Clinicians are encouraged to closely observe and monitor specific client symptoms and diagnostic indicators
  • Accurate diagnosis improves prediction of client prognosis
  • Treatments can be developed for specific diagnoses
  • Communication with other professionals and third-party payers can be more efficient
  • Research on the detection, prevention, and treatment of mental disorders is facilitated

Although we advise maintaining skepticism regarding diagnostic labels, having knowledge about mental disorders is a professional requirement.

It seems ironic, but sometimes labels are a great relief for clients. When clients experience confusing and frightening symptoms, they often feel alone and uniquely troubled. It can be a big relief to be diagnosed, to have their problems named, categorized, and defined. It can be comforting to realize that others—many others—have reacted to trauma in similar ways, experienced depression in similar ways, or developed similar irrational thoughts or problematic compulsions. Diagnosis can imply hope (Mulligan, MacCulloch, Good, & Nicholas, 2012).

 

Parenting, Personal Reflections, Writing

Everything You Already Knew About Sex (But were afraid to talk about)

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SistersI’ll never forget the night my sisters saved my life. I was 12-years-old. My sisters were babysitting me while my parents were out. They said, “Sit down, we’ve got something serious to talk about.”

I was a compliant little brother. But because my sisters enjoyed dressing me up like a girl, as I sat down, I was hoping I wouldn’t have to get all dressed up again. To my surprise, their serious topic had nothing to do with girls’ clothing and everything to do with what’s underneath girls’ clothing.

They pulled out a gigantic book. In our family, it was called the DOCTOR book; we only got it out when someone was sick. I started to worry, mostly because I wasn’t feeling sick.

They opened the book and showed me anatomically correct pictures of naked men and women. Then I started feeling sick. While looking at various body parts they explained the relationship between male and female sexual organs. I remember thinking “There’s no way this is true.” My sisters, one 17 and the other 14, suddenly looked much older and wiser. I quickly I was not the smartest person in the room (but I already knew that). They explained: “Mom says it’s Dad’s job to tell you about sex stuff. But Dad’s too shy to talk about it. So tonight, we’re telling you everything.” And they did.

At some point in their explanation that night they explained that a “rubber” was a condom and a condom was a method of birth control and that my penis could get big and send out little invisible tadpoles that could get girls pregnant. Suddenly, I understood several jokes that my fellow seventh graders had been laughing about the week before. My sisters were providing knowledge that was essential to the social life of adolescence. But maybe more than anything else, I remember them saying: “Sexual intercourse is very special. You only have sex with someone you really love.” That philosophy may not fit for everyone, but it’s worked out pretty well for me.

If you’ve got children, you should put your fears and shyness aside and directly discuss sex and sexuality with them on an ongoing basis. If you don’t, you can bet they’ll learn about sex anyway, indirectly and from other people, like their cousin Sal or a pornography website. Given this choice, most parents decide, despite their discomfort, to talk about sex with their children.

In contrast to what I got from my sisters, sex education in America is generally a crapshoot. With social media, the internet, and television’s preoccupation with sexual innuendo, it’s easy for children to absorb less-than-optimal sexual ideas. In a National Public Radio interview, the Pulitzer Prize winning poet, Andrew Hudgins spoke about his sex education from jokes:

“One of the things I talk about in the book [The Joker] is what I learned from the taboo subjects my parents never told me about: sex. So I learned about it from jokes and had to figure it out backwards. … It’s very much a hazard. And because you get a ton of misinformation, you get a ton of misogyny built into your brain at a very early age when your brain is still forming and it can cause long-term complications.” (from NPR interview, Weekend Edition, Saturday, June 8, 2013)

In contrast to Hudgins, I got lucky one evening 49 years ago. I didn’t get any misogyny built into my brain. Instead, I learned about sexuality and relationships from two people who deeply cared about me and whom I respected. I’d love to be able to clone my sisters into universal sex educators so they could magically educate all the boys in the world on how to respect women, which, in the end, is much more important than being able to accurately find a vagina in the big DOCTOR book of life.

Teaching children about sex should begin early. There are many natural opportunities for discussing sex with your children – including television, grocery store magazines, and, more often than we like, politicians who engage in questionable sexual behaviors. Other opportunities occur around ages four or five, when young children begin talking, sometimes excessively and inappropriately, about poop, pee, penises, and vaginas. Although addressing such topics with your children can be uncomfortable, you should begin this process while your children are still interested in listening to you. About 10 years later, when your children begin thinking about sex from a different perspective, they may be slightly less impressed with what you have to say.

Of course if you’d rather not deal with the issue, you can always use the approach my parents used. Just give me a call. I’ll put you in touch with my sisters.

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For more information on sex education and parenting, you can check out our Practically Perfect Parenting Podcast episode on iTunes: https://itunes.apple.com/us/podcast/practically-perfect-parenting-podcast/id1170841304?mt=2 or Libsyn: http://practicallyperfectparenting.libsyn.com/

Personal Reflections, Suicide Assessment and Intervention

Bad News in Threes: Kate Spade, Anthony Bourdain, and the CDC Suicide Report

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Rainbow 2017

My mother always said, “Bad news comes in threes.” That concept, along with many of her other superstitions, never made much sense to me.

In truth, the bad news never stops. She knew that. I suppose that organizing bad news into groups of three offered hope that the suffering might soon end—at least until the next set of three bad things came round.

This week we’ve had bad news in waves, with three particular pieces distinctly linked to suicide. On Tuesday, there was fashion designer, Kate Spade. Yesterday, there was the release of a new CDC report on Suicide. And then this morning there was Anthony Bourdain.

When people like Kate Spade and Anthony Bourdain die by suicide, it’s hard not to be mystified. By all measures, both Spade and Bourdain were highly successful. They were passionate and fully alive. The dynamics that may have led them to choose death are opaque. We can’t see these dynamics. They’re not obvious.

Another thing that’s not easily seen or especially obvious is the fact that, along with Spade and Bourdain, 865 other Americans will die by suicide this week. Let that number sink in. Many of these other American suicides will be military veterans. These 865 Americans may choose suicide for reasons similar or different than Spade and Bourdain. We can’t know the deeply personal reasons why individuals choose suicide.

In honor of my mother’s desire to manage bad news in groups of three, I’ve got some other threes to share:

Three Things to Remember About Suicide

  1. As Spade and Bourdain’s deaths illustrate, suicide is unpredictable. Many respected suicidologists have thrown suicide risk factors and warning signs into the trash bin. Because we may not know if someone is suicidal, our best strategy is to treat everyone with kindness, compassion, and respect. This approach is all about connecting with others in ways that are meaningful and authentic. Then, from the context of your interpersonal connection, if you suspect or intuit that suicide is possible, ask directly in a way that normalizes suicidal thinking. You might ask something like, “It’s not unusual for people to think about suicide. Has that been true for you?”
  2. As the CDC report highlights, a person’s mental health may or may not be linked to suicide. In the CDC’s analysis, about 54% of suicides were not associated with a known mental disorder or pre-suicide warning signs. This implies that thinking about suicide or acting on suicidal impulses may be something that arises from challenging life stresses or circumstances. This information also means that you shouldn’t blame yourself for suicide deaths. We imagine suicide to be a terrible tragedy for the person who dies, but it’s also a palpable tragedy for many survivors. Of course, if you knew a person who died by suicide you deeply wish you could have known the right thing to say or do to save that person’s life. But the reality is, suicide is unpredictable, and so you and I shouldn’t beat ourselves up over not being able to effectively intervene. If you feel guilty after a suicide, talk about your feelings with someone you trust. Although it’s natural to blame yourself, there’s no point in being alone with your guilt, so please reach out for support for yourself.
  3. The deaths of Spade and Bourdain bring suicide to the front and center of our national consciousness. Although it’s good to shine a light on suicide, the deaths of Spade and Bourdain overshadow the 865 other Americans who have or will die by suicide this week. Many of these Americans will not have sought help. The irony of not seeking help is that there are several excellent talk-therapies that specifically target suicide risk. These therapies can be highly effective. Hotlines are a fine first step and medications might help, but the interpersonal connection that comes with evidence-based talk therapies, is profoundly important to positive outcomes. Effective help is available. Let’s bring the evidence-based talk therapies front and center in our national consciousness also.

Three Evidence-Based Therapies

Here are links to the three top evidence-based therapies for suicide.

Dialectical Behavior Therapy (DBT): https://www.amazon.com/DBT%C2%AE-Skills-Training-Manual-Second/dp/1462516998/ref=sr_1_1?s=books&ie=UTF8&qid=1528498109&sr=1-1&keywords=linehan+suicide

Collaborative Assessment and Management of Suicide (CAMS): https://www.amazon.com/Managing-Suicidal-Risk-Second-Collaborative/dp/146252690X/ref=sr_1_1?s=books&ie=UTF8&qid=1528498077&sr=1-1&keywords=jobes

Cognitive Therapy for Suicide: https://www.amazon.com/Cognitive-Therapy-Suicidal-Patients-Applications/dp/1433804077/ref=sr_1_4?s=books&ie=UTF8&qid=1528497986&sr=1-4&keywords=cognitive+therapy+suicide

Three More Resources

The CDC Report, although depressing, includes excellent information. You can read it here: https://www.cdc.gov/mmwr/volumes/67/wr/mm6722a1.htm?s_cid=mm6722a1_w  You can also listen to or read an NPR interview with the report’s lead author, Deborah Stone, here: https://www.npr.org/sections/health-shots/2018/06/07/617897261/cdc-u-s-suicide-rates-have-climbed-dramatically

A while back I wrote an Op-Ed piece for the Missoulian newspaper. This Op-Ed emphasized core factors or dimensions that often drive suicidal behavior. Reading the article can give you a better understanding of suicide dynamics and could help you help others, but in no way will it make you capable of successfully preventing suicide amongst all of your family and friends. This article is available through the Missoulian: https://missoulian.com/news/opinion/columnists/suicide-prevention-ignore-the-math/article_ce3c7f1e-ab86-587e-9505-310cc00b3355.html

In January I had a suicide assessment and intervention article published in the Journal of Health Service Psychology. This article is a good resource for professionals who work with suicidal clients. It’s an easy read and might also be of interest to non-professionals seeking to understand more about how professionals work with suicidal people. Conversations About Suicide by JSF 2018

I wish you all a weekend of connection and healing.

Parenting, Personal Reflections

Self-Regulation is Central

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Scarecrow

Self-regulation is central to nearly everything in life. I suppose maybe that’s why Dr. Sara Polanchek and I have been ruminating on it so much in our Practically Perfect Parenting Podcast series. In fact, the podcast that became available today is more general and less parent-focused than is usual. Again, that’s because self-regulation or self-control in the fact of outside forces or stressors is so important for everyone.

To read my more general self-regulation blogpost, click here: https://johnsommersflanagan.com/2018/06/04/the-secret-self-regulation-cure-seriously-this-time/

To listen to the podcast on iTunes, click here: https://itunes.apple.com/us/podcast/practically-perfect-parenting-podcast/id1170841304?mt=2

To listen on Libsysn, click here: http://practicallyperfectparenting.libsyn.com/

And finally, here’s a description of the podcast that’s live today!

The Secret Self-Regulation Cure (Seriously, this time)

For this Practically Perfect Parenting Podcast you should just let yourself relax, let go of all expectations, and tune in. You can even practice being bored, because one part of the secret to self-regulation is that it’s all about embracing your boringness (Spoiler alert, Sara gets bored at the end). Another way of putting this, is that the deep secret to self-regulation (which John shares in this episode) is to repeatedly focus on one comforting thing that is—or becomes—boring (for you science types, that means focusing in on one comforting stimulus). Another big part of the secret to self-regulation is mindful acceptance. Of course, you probably know that mindful acceptance is from Buddhist philosophy, but the concrete application of mindful acceptance involves accepting the fact that you will always get distracted and won’t ever be able to meditate or use progressive muscle relaxation perfectly. You can only strive to be imperfectly mindful (and you shouldn’t even strive to hard for that).

If you make it through this podcast episode without falling asleep, then you might be able to answer one of the following questions:

  1. According to Herbert Benson, What are the four parts of the “relaxation response.”
  2. What’s the problem with counting sheep as a method for dealing with insomnia?
  3. What was the spiritual mantra that John shared?

And if you can answer one of these questions and be the first person to post it on our Facebook page, then you will win something—something in addition to having that warm, positive feeling of having been the first person to post the answer.

Here’s the link to our Podcast Facebook Page: https://www.facebook.com/PracticallyPerfectParenting/?hc_ref=ARRyCtUkbbKwI1usTfQpgCtCAHB3Pi4EVR3fikiq3gd5A-C07BjG7mY7Lqtel9x2jiA&fref=nf

 

 

Counseling and Psychotherapy Theory and Practice, Parenting, Personal Reflections

The Secret Self-Regulation Cure (Seriously this time)

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The Road“I’m in suspense,” Sara said. “I’ve been in suspense since the last time we recorded, because John said he had this big secret and I don’t know what it is.”

Partly Sara was lying. She wasn’t in much suspense, mostly because the “last time we recorded” had been only five minutes earlier. But, as I’m sure you realize, capturing and magnifying in-the-moment excitement is the sort of behavior toward which we Hollywood podcasting stars are inclined.

Sara stayed enthusiastic. When I told her that I thought every self-regulation and anxiety reduction technique on the planet all boiled down to a single method that Mary Cover Jones developed in 1924, she said things like, “That’s exciting!” and “I love Mary Cover Jones.”

[Side note] If you end up needing a podcasting co-host, be sure to find someone like Sara who will express enthusiasm even when you’re talking about boring intellectual stuff. [End of side note.]

Mary Cover Jones was the first researcher to employ counterconditioning with humans (although she rarely gets the credit she deserves—but that’s another story). Counterconditioning involves the pairing a desirable (pleasant or comforting) stimulus with a stimulus that usually causes anxiety or dysregulation. Over time, with repeated pairing, the pleasant feelings linked with the desirable stimulus are substituted for the anxiety response. Eventually, the person who has experienced counterconditioning can more comfortably face the undesirable and previously anxiety-provoking stimulus.

My belief is that counterconditioning is the first, best, and only approach to self-regulation and anxiety reduction. Put another way, I’d say, “If it works for self-regulation, then what you’re doing is counterconditioning—even if you call it something else.”

I know that’s a radical statement. Rather than defend my belief and philosophy, let me move on and describe how you can begin using counterconditioning to make your life better.

Let’s say your goal is for you to experience more calmness and relaxation and less agitation and anxiety. That’s reasonable. According to Herbert Benson of Harvard University, you need four things to elicit the relaxation response.

  1. A quiet place
  2. A comfortable position
  3. A mental device
  4. A passive attitude

Benson was studying meditation way back in the early 1970s. Okay. I know I’m digging up lots of old moldy stuff from the past. But take a deep breath and stay with me.

Let’s say you’re able to find a quiet place and a comfortable position. If you’re a parent, that might be tough. However, even if you find it for 12 minutes as you lie in bed, waiting for sleep, that’s a start. And really, all you need is a start, because once you get going, you don’t really even need the quiet place and comfortable position. On airplanes, I use this all the time and it’s not quiet and I’m not physically comfortable.

The next question that most people ask is: “What’s a mental device?” or, “Is that something I have to strap on my head?”

A mental device is a mental point of focus. In Benson’s time and in transcendental meditation, the popular word for it was “Mantra,” but Benson’s research showed that it can be almost anything. One mental device (that’s actually physical) is deep breathing. Another one is to sit comfortably and to think (or chant) the word OM. Benson also found that simple words, like the numbers “one” or “nine” also were effective. But, as I mentioned on the podcast, you can use other words, as long as they are—or can become—comforting. For example, I know people who use the following words:

  1. I am here
  2. Here I am
  3. Peace
  4. Shalom
  5. Banana

For those of you with religious leanings, you might want to use a specific prayer as your mental device. For those of you who are more visually inclined, you could use a mental image as your mental device. For those of you who are physically-oriented, you could use progressive muscle relaxation or body scanning.

The point is that all you need is a point . . . of focus.

Now comes the hard part. Because we’re all human and therefore, imperfect, no matter how compelling or comforting or soothing your mental device might be, you won’t be able to focus on it perfectly. You will become distracted. At some point (and for me it’s usually very early in the process), you’ll find your mind wandering. Instead of focusing on your prayer, you’ll suddenly realize that you’re thinking about a recent movie you saw or a painful social interaction you had earlier in the day or your mind will drift toward a future social situation that you’re dreading.

What’s the solution to the wandering mind?

Well, one thing that’s not the solution is to try harder.

Instead, what Benson meant by a “passive attitude” is that we need to gently accept our mental wanderings and distractions. More commonly, the words we use for Benson’s passive attitude are “Mindful acceptance.” In other words, we accept in the moment of distraction and every moment of distraction, that we are humans who naturally become distracted. And then, after the noticing and after the acceptance, we bring ourselves back to the moment and to our chosen mental device.

On the podcast, Sara asked, “What if, as I try to focus on my mental device, I notice that all the while I have an inner voice talking to me in the background?”

What an excellent question! The first answer is, of course, mindful acceptance. For example, when you notice the inner voice, you might say to yourself, I notice my mind is chattering at me in the background as I focus on my mental device. Then, without judging yourself, you return to your mental device. A second option is for you to find a more engaging or more soothing mental device. Perhaps, you need two mental devices at once? For example, that might include a soft, silky blanket to touch, along with your “I am here” mantra.

As Mary Cover Jones illustrated over 90 years ago, the counterconditioning process is a powerful tool for anxiety reduction and self-regulation. I happen to think that it’s the only tool for anxiety reduction and self-regulation. Whether you agree with me or not isn’t important; either way, don’t let anything I’ve written here get in the way of you identifying and using your own cherished mental (or physical) device. At first, it might not work. It will never work perfectly. But, like Charles Shulz was thinking when he created Linus’s special blanket, life is way better when you live it with a comforting counterconditioning stimulus.

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For more information about Mary Cover Jones, you can go here: https://johnsommersflanagan.com/2011/11/25/a-black-friday-tribute-to-mary-cover-jones-and-her-evidence-based-cookies/

Or here: https://johnsommersflanagan.com/2017/07/17/brain-science-may-be-shiny-but-exposure-therapy-is-pure-gold/

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As I write this (6/4/18), the podcast isn’t quite up yet . . . but will be soon!

To listen to The Secret Self-Regulation Cure on iTunes, go here: https://itunes.apple.com/us/podcast/practically-perfect-parenting-podcast/id1170841304?mt=2

To listen to The Secret Self-Regulation Cure on Libsyn, go here: http://practicallyperfectparenting.libsyn.com/

To check out our podcast Facebook page, go here: https://www.facebook.com/PracticallyPerfectParenting/

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