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Clinical Interviewing, Counseling and Psychotherapy Theory and Practice

Five Stages of a Clinical Interview – Updated

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The following is an excerpt from a chapter I wrote with my colleagues Roni Johnson and Maegan Rides At The Door. The full chapter is in the Cambridge Handbook of Clinical Assessment and Diagnosis . . .

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The clinical interview is a fundamental assessment and intervention procedure that mental and behavioral health professionals learn and apply throughout their careers. Psychotherapists across all theoretical orientations, professional disciplines, and treatment settings employ different interviewing skills, including, but not limited to, nondirective listening, questioning, confrontation, interpretation, immediacy, and psychoeducation. As a process, the clinical interview functions as an assessment (e.g., neuropsychological or forensic examinations) or signals the initiation of counseling or psychotherapy. Either way, clinical interviewing involves formal or informal assessment. [For a short video on how to address client problems and goals in the clinical interview, see below]

Clinical interviewing is dynamic and flexible; every interview is a unique interpersonal interaction, with interviewers integrating cultural awareness, knowledge, and skills, as needed. It is difficult to imagine how clinicians could begin treatment without an initial clinical interview. In fact, clinicians who do not have competence in using clinical interviewing as a means to initiate and inform treatment would likely be considered unethical (Welfel, 2016).

Clinical interviewing has been defined as

“a complex and multidimensional interpersonal process that occurs between a professional service provider and client [or patient]. The primary goals are (1) assessment and (2) helping. To achieve these goals, individual clinicians may emphasize structured diagnostic questioning, spontaneous and collaborative talking and listening, or both. Clinicians use information obtained in an initial clinical interview to develop a [therapeutic relationship], case formulation, and treatment plan” (Sommers-Flanagan & Sommers-Flanagan, 2017, p. 6)

A Generic Clinical Interviewing Model

All clinical interviews follow a common process or outline. Shea (1998) offered a generic or atheoretical model, including five stages: (1) introduction, (2) opening, (3) body, (4) closing, and (5) termination. Each stage includes specific relational and technical tasks.

Introduction

The introduction stage begins at first contact. An introduction can occur via telephone, online, or when prospective clients read information about their therapist (e.g., online descriptions, informed consents, etc.). Client expectations, role induction, first impressions, and initial rapport-building are central issues and activities.

First impressions, whether developed through informed consent paperwork or initial greetings, can exert powerful influences on interview process and clinical outcomes. Mental health professionals who engage clients in ways that are respectful and culturally sensitive are likely to facilitate trust and collaboration, consequently resulting in more reliable and valid assessment data (Ganzini et al., 2013). Technical strategies include authentic opening statements that invite collaboration. For example, the clinician might say something like, “I’m looking forward to getting to know you better” and “I hope you’ll feel comfortable asking me whatever questions you like as we talk together today.” Using friendliness and small talk can be especially important to connecting with diverse clients (Hays, 2016; Sue & Sue, 2016). The introduction stage also includes discussions of (1) confidentiality, (2) therapist theoretical orientation, and (3) role induction (e.g., “Today I’ll be doing a diagnostic interview with you. That means I’ll be asking lots of questions. My goal is to better understand what’s been troubling you.”). The introduction ends when clinicians shift from paperwork and small talk to a focused inquiry into the client’s problems or goals.

Opening

The opening provides an initial focus. Most mental health practitioners begin clinical assessments by asking something like, “What concerns bring you to counseling today?” This question guides clients toward describing their presenting problem (i.e., psychiatrists refer to this as the “chief complaint”). Clinicians should be aware that opening with questions that are more social (e.g., “How are you today?” or “How was your week?”) prompt clients in ways that can unintentionally facilitate a less focused and more rambling opening stage. Similarly, beginning with direct questioning before establishing rapport and trust can elicit defensiveness and dissembling (Shea, 1998).

Many contemporary therapists prefer opening statements or questions with positive wording. For example, rather than asking about problems, therapists might ask, “What are your goals for our meeting today?” For clients with a diverse or minority identity, cultural adaptations may be needed to increase client comfort and make certain that opening questions are culturally appropriate and relevant. When focusing on diagnostic assessment and using a structured or semi-structured interview protocol, the formal opening statement may be scripted or geared toward obtaining an overview of potential psychiatric symptoms (e.g., “Does anyone in your family have a history of mental health problems?”; Tolin et al., 2018, p. 3).

Body

The interview purpose governs what happens during the body stage. If the purpose is to collect information pertaining to psychiatric diagnosis, the body includes diagnostic-focused questions. In contrast, if the purpose is to initiate psychotherapy, the focus could quickly turn toward the history of the problem and what specific behaviors, people, and experiences (including previous therapy) clients have found more or less helpful.

When the interview purpose is assessment, the body stage focuses on information gathering. Clinicians actively question clients about distressing symptoms, including their frequency, duration, intensity, and quality. During structured interviews, specific question protocols are followed. These protocols are designed to help clinicians stay focused and systematically collect reliable and valid assessment data.

Closing

As the interview progresses, it is the clinician’s responsibility to organize and close the session in ways that assure there is adequate time to accomplish the primary interview goals. Tasks and activities linked to the closing include (1) providing support and reassurance for clients, (2) returning to role induction and client expectations, (3) summarizing crucial themes and issues, (4) providing an early case formulation or mental disorder diagnosis, (5) instilling hope, and, as needed, (6) focusing on future homework, future sessions, and scheduling (Sommers-Flanagan & Sommers-Flanagan, 2017).

Termination

Termination involves ending the session and parting ways. The termination stage requires excellent time management skills; it also requires intentional sensitivity and responsiveness to how clients might react to endings in general or leaving the therapy office in particular. Dealing with termination can be challenging. Often, at the end of an initial session, clinicians will not have enough information to establish a diagnosis. When diagnostic uncertainty exists, clinicians may need to continue gathering information about client symptoms during a second or third session. Including collateral informants to triangulate diagnostic information may be useful or necessary.

See the 7th edition of Clinical Interviewing for MUCH more on this topic:

https://www.wiley.com/en-sg/Clinical+Interviewing%2C+7th+Edition-p-9781119981985

Clinical Interviewing, Cool Counseling, Suicide Assessment and Intervention

Why You Should Open with a Focus on the Negative When Using a Strength-Based Suicide Treatment Model

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Keno Horse

I’m working on a book manuscript tentatively titled something like: Strength-Based Suicide Assessment and Treatment. As I do more work and professional training in this area, I’m struck by the natural dialectic involved in the whole area of suicide (I’m sure Marsha Linehan discovered this long ago).

One dialectic on my mind today involves the fact that although I’m calling the approach that I’m writing about “Strength-Based,” I often (but not always) advise clinicians to open their sessions with a focus on negative distress. The following excerpt takes a bit of content from my 7.5 hour (3-part) published video with Psychotherapy.net and explains my rationale for opening a session with a focus on negative or painful emotions. You can access the 3-part training video here: https://www.psychotherapy.net/video/suicidal-clients-series

Here’s the case example:

In the following excerpt, I’m working with Kennedy, a 15-year-old girl whose parents referred her to me for suicide ideation (see https://www.psychotherapy.net/video/suicidal-clients-series, Sommers-Flanagan, 2018). Although I might meet with her parents first, or with the whole family, in this case I chose to start therapy with her as an individual. My opening exchange with Kennedy is important because, in contrast to what you might expect from a “strength-based” approach, my focus with her is distinctly negative. Pay close attention to the italicized words and [bracketed explanation].

John:  Kennedy, thank you for meeting with me. Let me just tell you what I know, okay, because I know that you’re not exactly excited to be here. But the thing is that I know that your parents have said you’ve been talking about suicide off and on for a little while, and so they wanted me to talk with you. [I already know that suicide ideation is an issue with Kennedy, so I share that immediately. If I pretend that I don’t already know about her and her situation, it will adversely affect our rapport. This is a basic principle for working with teens, but also true for adults: Lead with a statement of what you know . . . and be clear about what you don’t know.]

And I don’t know exactly what’s happening in your life. I don’t know how you’re feeling. And I would like to be of help. And so I guess if you’re even willing to talk to me, the first thing I’d love to hear would be what’s going on in your life, and what’s making you feel bad or sad or miserable or whatever it is that you’re feeling? [You’ll notice that my opening question has a negative focus. The reason I’m starting with a question that focuses on Kennedy’s negative affect and pulls for what makes her feel bad or sad or miserable is because (a) I want to start with Kennedy’s emotional distress, because that’s what brings her to therapy, and (b) I want to immediately begin linking her emotional distress to situations or experiences that trigger her distress. By doing this, I’m focusing on the presumptive primary treatment goal (according to Shneidman) for all clients who are suicidal, and that is to reduce the perceived intolerable or excruciating emotional distress. In Kennedy’s case, one of my very first treatment targets is to reduce the frequency and intensity of whatever it is that’s triggering Kennedy’s suicide ideation. We’ll get to the positive, strength-based stuff later.]

Kennedy: I think I’m just like really busy every day. I am in volleyball, and I got a lot of homework, and I don’t get a lot of sleep. So, it’s really stressful getting up early, and my parents are always fighting, and sometimes I miss the bus, and they don’t want to drive me. So, I have to call one of my older friends to drive me, and sometimes I’m late, and I just – it’s stressful, and the teachers get mad, but it’s not my fault.

John:   Yeah. So, you’ve got some stress piling up, volleyball, school, sometimes being late, and your parents arguing. Of those, which one adds the most misery into your life? [Again, my focus is purposefully on the negative. I want to know what adds the most misery to Kennedy’s life so that I can work with her and her family or her and her school to decrease the stimulus or trigger for her misery.]

Kennedy: I think being at home is the hardest. In volleyball at least I find some joy. Like I like enjoy being on the court and playing with my team. They’re there to lift me up. But like my parents, I don’t like being at home.

John:  Okay. What do you hate about it? [When Kennedy says, “I don’t like being at home” she’s not providing me with specific information about the trigger for her distress, so I continue with that focus and stay with the negative and use a word (hate) that I think is a good match for how a teenage girl might sometimes feel about being with her family.]

Kennedy: I just – they’re always fighting. Sometimes my dad will leave, and my mom cries, and I’ll cry. And he’s just mean, and she’s mean, and they’re both mean to each other. And I just lock myself in my room.

John:   Yeah. So, even as I listen to you talk, it feels like this is a – just being around them – I don’t know what the feeling is, maybe of just being alone. Like they’re fighting, and you retreat to your room. Any other feelings coming up when that happens? [Although I’m trying to tune into specific feeling words to link to what’s happening for Kennedy, I’m also being tentative and vague and wanting to collaboratively explore the right words to use with Kennedy.]

Kennedy: I don’t know. Just sometimes I don’t feel like – I don’t feel like I have a home, or my family is not there for me, and sometimes I just don’t feel like living anymore. [Kennedy uses the term “feel like” which often is a signal that she’s talking about a cognition and not an emotion. For example, “I don’t feel like I have a home” is likely more of a cognition that leaves her with an emotion like sadness. But it’s too soon to be that emotionally nuanced with Kennedy and the important part of what she’s saying is that there’s a pattern that’s something like this: her parents’ fighting triggers a cognition, that triggers an unspecified emotion, and that triggers the cognition of “I just don’t feel like living anymore.”]

John:   Yeah. So, there are times when the family stuff feels so bad, that’s when you start to think about suicide?

Kennedy: Yeah.

Using Shneidman’s (1980) model to guide my initial interactions with Kennedy leads me to focus on her immediate emotional distress and the triggers for her distress. Exploring her distress and the triggers takes me to an early treatment plan (that will likely be revised and refined).

  1. I will focus on Kennedy’s immediate distress and collaboratively work with her on a plan to reduce her distress and create more positive affect.
  2. I will focus on specific situational variables that trigger Kennedy’s suicide ideation. Part of the treatment plan is likely to involve her parents and to try to get them to stop their intense “fighting” in her presence.
  3. As I aim toward distress reduction and reducing or eliminating the distress trigger, I will keep in mind that—like most teenagers—it may be very difficult for me to get Kennedy to agree to let me work directly with her parents on their fighting. Getting Kennedy on board for an intervention with her parents will test my therapeutic and relational skills.

While I’m working on this next book, I’ll be posting excerpts like this. As always, I would love your feedback and input on this content. Please post comments here, or email me directly at: john.sf@mso.umt.edu.

Personal Reflections, Suicide Assessment and Intervention

What Is a Strength-Based Approach to Suicide Prevention?

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Sommers FB 44

Suicide—as a thought, word, or action—usually triggers fear and judgment. Even though suicidal thoughts are common and suicidal behaviors have been part of humanity from as far back as anyone can recall, to think or talk of suicide is saturated with shame and judgment. A strength-based model for suicide prevention is about shifting attitudes toward suicide from negative judgment to compassion and lovingkindness.

Most people who think about suicide are sensitive, intelligent, and self-critical. Typically, they’re judging themselves in negative ways; sometimes they experience self-hatred. All this adds up to the main proposition underlying a strength-based approach to suicide prevention: Because individuals who feel suicidal are already burying themselves in harsh judgments and negativity, what they need from others is empathy for their pain, reassurance that suicidal thoughts are a nearly universal part of human experience, compassion, help for coping with their excruciating psychological distress, and a more or less relentless focus on the positive.

No More Mental Illness and No More Moral Shaming

In 1973, Edwin Shneidman, wrote the Encyclopedia Britannica’s definition of suicide: “Suicide is not a disease (although there are those who think so); it is not, in the view of the most detached observers, an immorality.” Shneidman—often referred to as the father of suicidology (the study of suicide)—capture two harsh judgments popularly linked to suicide: Mental or moral illness. As advocates for suicide prevention, we need to doggedly follow Shneidman’s lead, and show acceptance of the mental and moral condition of people experiencing suicidality.

I like this next quotation from Nanea Hoffman. I’m not sure it fits here, but because this post is about being strength-based when thinking and talking about suicide, and this is my blog and I can include what I want, here it is:

“None of us are getting out of here alive . . . so please stop treating yourself like an afterthought. Eat the delicious food. Walk in the sunshine. Jump in the ocean. Say the truth you’re carrying in your heart like hidden treasure. Be silly. Be kind. Be weird. There’s no time for anything else.” – Nanea Hoffman

Shame surrounding suicide has a long history. By 1000 B.C. most ancient city-states had criminalized suicide. People who died from suicide were sometimes dragged through the streets to enhance their shame and possibly as deterrence for others. Around 400 A.D., Saint Augustine declared suicide an unrepentable sin. I’m not quite sure how that works because I’m guessing that Christian theology would hold up God as the authority on what’s repentable and what’s not repentable.

Contemporary suicide-related policies continue to link shame and suicide. When students die from suicide, many U.S. schools follow a “no memorializing” policy. In New Zealand, the media is prohibited from using the word suicide when reporting on suicide deaths. Most families, when struggling to write obituaries for family members who died by suicide, replace the word suicide with “died suddenly” or some other vague explanation. In an online article, Charlotte Maya wrote of the first time she was able to speak of her husband’s suicide:

“The first time I spoke publicly was about a year and a half after Sam’s death. In many ways, I think Sam would have been appalled. After all, he did not speak a word of his struggles out loud – not to a therapist, not to his friends, not to me. There is so much shame.”

Charlotte is right; there is so much shame. To avoid shame, many people, institutions, and nations have decided that—like Lord Voldemort in the Harry Potter series—suicide is the thing that must not be named.

But it should be named; if we don’t talk about it, the shame linked to suicide grows more powerful, more frightening, and less well understood. It should be named because, hundreds of thousands of people around the world are dying by suicide every year, perhaps dying in shame, perhaps dying unnecessarily, and always leaving loved ones behind who pick up on the theme of shame and begin experiencing it themselves. If we don’t talk openly about suicide, we cannot address it effectively.

Shaming people for thinking about suicide, or for making a suicide attempt, or for completing suicide, magnifies the problem. Shaming people for their suicidal thoughts only makes them less likely to speak openly about their thoughts. And, as in the case of Charlotte Maya’s husband, remaining quiet about emotional pain is linked to tragic outcomes. When people who are suicidal shutter themselves in their private worlds, the suicidal pain and distress doesn’t diminish or evaporate; instead, being alone with suicidal thoughts usually deepens hopelessness and grows desperation, both of which contribute directly to death by suicide.

Shaming individuals who are suicidal is like pouring fuel on an open fire. Suicidal people already feel immense shame. There’s no need to add more. Besides, shaming isn’t an effective deterrent. Further, as I’ll elaborate on later, suicidal thoughts aren’t primarily about death anyway. If our goal is to save lives, there’s a different and more useful emotion to link with suicide.

Instead of shame, the word suicide should evoke compassion—compassion for people who were or are so distressed that they have contemplated or completed suicide; compassion for people who lost someone they loved to suicide; compassion for ourselves, during times when we’re in psychological pain and naturally have thoughts about suicide.

I’ll be writing more about this in the future and so I’ll summarize here. What people who are suicidal need from others includes:

  • Empathy for their pain
  • Reassurance that suicidal thoughts are a nearly universal part of human experience
  • Compassion
  • Help for coping with their excruciating psychological distress
  • A more or less relentless focus on the positive (to help counter their feelings of hopelessness)

Last night I had a chance to engage in a delightful discussion of the strength-based approach with a small group of amazing people at Big Sky, Montana. Thanks to Robin and Jacque for setting that up. As a part of our time together, I flipped through a set of powerpoints. Here are the powerpoints, in case you’re interested: Big Sky Public Lecture 2019

Clinical Interviewing, Suicide Assessment and Intervention

Advances in Suicide Assessment and Treatment . . . just published in the Jubilee Edition of Psychology Aotearoa

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Ocean View

Here’s the view from New Zealand.

The professional journal, Psychology Aotearoa is the flagship publication of the New Zealand Psychological Society. Just yesterday I received a copy of the Jubilee Edition of the journal. I’ve got a brief article on pp. 76-80, but the whole journal is an interesting glimpse of psychology, psychotherapy, and counseling at an international level. Here’s the pdf: 2018 November JSF New Zealand Pub

Clinical Interviewing, Suicide Assessment and Intervention

Last Call for the Suicide Assessment and Intervention Psychotherapy.net Video Training

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Hi All.

Below is the link for the $139 deal for the 7.5 hour Assessment and Intervention with Suicidal Clients training video with Psychotherapy.net.

Please share this information with other professionals who might want or need to sharpen their skills for working with clients who are or might become suicidal. This is a hard topic and I hope this resource can help clinicians feel more confident and competent in their suicide assessment and intervention skills.

https://academy.psychotherapy.net/p/suicide-promo?utm_source=ActiveCampaign&utm_medium=email&utm_content=LAST+CHANCE%3A+Suicide+Assessment+and+Intervention&utm_campaign=suicide+course+email%233

 

 

Suicide Assessment and Intervention

An Early Peek at the Suicide Assessment and Intervention Video Project

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Helicopter CroppedBack in March, 2012, I settled into a Starbucks in Vancouver, Washington to reflect on my experiences at the annual American Counseling Association conference in San Francisco. Memories of Dr. Irvin Yalom’s keynote bubbled up in my mind, so that’s what ended up in my fingers, on my screen, and in my blog.

Several days later, I got an email from a “Dr. Yalom.” Seeing the name, I immediately felt anxiety and anticipation. First thoughts, “I meant to be positive. I hope I didn’t write anything offensive?”

The email was from Dr. Victor Yalom. It was nice . . . and supportive . . . and positive . . . and a big relief.

Victor is the owner/publisher/president or grand sultan of psychotherapy.net. Psychotherapy.net is a publisher of psychotherapy training and continuing education materials, mostly videos. Over the past 6 years Victor and I have struck up a collegial friendship. He is the biggest fan and proponent of our Clinical Interviewing video series (which he sells through psychotherapy.net). After viewing the Clinical Interviewing video, he has repeatedly asked Rita and I about doing a video for psychotherapy.net. Unfortunately, the timing never worked out, until this past fall, when we agreed to collaborate on a six-hour suicide assessment and intervention training video.

As they say in the film industry, everything is in the can. We’re down to final editing and other details. We filmed in Missoula and Mill Valley. Rather than working directly with imminently suicidal clients, we got volunteers to channel previous or potential suicide-related experiences. All this is just my way of introducing this sneak peek into this upcoming video.

Of course, reading isn’t the same as watching, but the next 2,000 words can give you a glimpse of one of the cases featured on the video. The client is a young Native American man and veteran. Many cultural issues emerge during the session, along with suicide ideation. Here’s the clip, along with my side “commentary” in bold:

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John:            Cory, I know a little bit about you, but not very much. And so maybe the best place to start is for you to tell me some things about yourself, some things about how you’ve been feeling in your life, some things about the situations that you’ve been in, and maybe help me get a sense of how I might be of help.

Cory:            Yeah, I come from a small reservation in Eastern Montana, and I was kind of – it was a comfortable life growing up. I didn’t know anything different. And I remember sitting there with my family watching the war and kind of spurred us to want to help bring honor to our tribe. So, I signed up at 17.

John:            Yeah, what tribe?

Cory:            I’m from the Lakota Sioux tribe from the Fort Peck Indian Reservation.

John:            Okay. Great, thank you. Sorry.

Cory:            So, I left at 17, and it was kind of a big deal. We had a big honor, big gathering for me, big sendoff, and it was pretty great and feeling pretty good. Deployed when I was 18 years old over to Iraq. It was going great. I felt like I was doing something. I didn’t get to talk to my family much, maybe every three months. And I didn’t know what was going on at home. Had a fiancée when I left. Life was great. Eventually time to come home and came home. And my family’s kind of in disarray. My grandma died. I didn’t get to go to her funeral. They didn’t tell me.

John:            Yeah.

Cory:            So, kind of tore me up. My fiancée left me for one of my best friends, so that was the shock of my life.

John:            Yeah. So, at least at this point I’m hearing that you were on kind of a high and feeling good at 17, get a big sendoff from your tribe, from your family, and you go, and you go to Iraq. And you get back, and things are a mess.

Cory:            Yeah. Meth kind of hit our reservation pretty hard. And family members on meth and prison and kind of whole world changed, I guess. Eventually, I didn’t – just came back and started drinking. Not sure who I was anymore. So, that was difficult, didn’t have very many people to turn to anymore. Never had a father growing up. My mom was always raising us with a couple jobs. And eventually her and her boyfriend got into drugs, so that’s kind of pretty difficult. And I didn’t know what to do anymore. And I was kind of feeling down and just kept drinking, and I kind of don’t know what to do anymore. For us it’s a honor to serve and kind of makes us who we are.

John:            Yeah.

Cory:            We view it as becoming a warrior man.

John:            Yeah.

Cory:            And I felt like I did that, and I’d bring honor back to my culture, my tribe. Yeah, just I came home. Everything’s in disarray, and I thought I was pretty stable. Eventually – and one thing, on the reservation we don’t – or culturally we don’t talk about our feelings or emotions. So, every time we do, feel pretty shame. A lot of shame comes from it. So, it’s kind of you just deal with it.

John:            Yeah, yeah. Yeah, so a couple of cultural pieces. One is that sense of honor of serving, and you hooked onto that and were living that. And then another cultural thing is, it’s a little shameful to express emotions, sadness, that kind of emotion or others.

Cory:            Yeah, I mean, I guess I could just describe it as shame. Like I feel guilty talking about it because we’re supposed to be men.

John:            You’re warriors. You’re strong.

Cory:            Yeah.

John:            And so you keep it all –

Cory:            Yeah, it’s part of who we are, death, fighting, honor, celebrating together, just part of who we are.

John:            Yeah, yeah. And then as you get back, and you’re in this disarray, and the meth on your reservation is prevalent, and you start drinking, and it sounds like that could be connected with the emotional warrior. Is that one of the ways that you might cope?

Cory:            I guess I just – kind of just helped me feel nothing.

COMMENTARY: Cory has covered lots of ground quickly. He has articulated his collectivist identity. Knowing about his collectivist identity early in the session is a very good thing. He has also mentioned multiple stressors and losses; these stressors and losses are traditional risk factors and load onto the various risk dimensions. These include: coming back from war, being a veteran, loss and betrayal by his girlfriend, his grandmother’s death, the disarray of his tribal community from meth, and other issues. In addition, one immediate challenge that’s coming into my mind is how to address alcohol, because it’s a suicide desensitizer, but it’s also helping him “feel nothing” which is consistent with his cultural value of not expressing his feelings. At this point I’m choosing to build a relationship with Cory before jumping in and discussing alcohol directly.

John:            Okay.

Cory:            Just kind of, I guess, how I dealt with it because I couldn’t talk about stuff that happened over there, and I didn’t have no male role models in my life to kind of talk about culturally with or anything.

John:            Yeah. So, I’m aware of the fact that you’ve told me, and I really appreciate it, some cultural things about you, about being a Lakota Sioux, about the reservation that you grew up on and some of the things you experienced, about the honor, about the shame, about the warrior mentality. And I’m going to do my best to track all those things. Occasionally if you think I’m just not getting it from your cultural perspective, I would love it if you would tell me, but I don’t want to put all that responsibility on you. So, I will probably every once in a while just check in to see, am I getting this right? Is that okay with you if we –

Cory:            Yeah, that’s fine.

John:            Yeah, because I just don’t want to misunderstand things because of my lack of the same cultural experience as yours. And so as I’m imagining it, you’re back. You’re drinking. It’s part of being numb.

Cory:            Uh-huh.

John:            And getting rid of those emotions. And as you talk, one question that comes to mind to me, and my guess is that this would be a dishonorable thought to have, although not an abnormal thought because it’s not unusual when people come back and life is disappointing and hard, and you’re drinking, and you’re managing those emotions, it’s just not unusual to have a thought about suicide or about killing yourself. And my guess is that would be in opposition to your culture, too, but I don’t know.

Cory:            Yes and no. One way we look at is from we’ve had everything taken from us. That’s one thing you can’t take from us. Our life is ours to give to the Creator, to Wakan Tanka which is our God. So, when it’s our time, it’s kind of our choice.

John:            Okay.

Cory:            The sad thing about it is, I’m feeling down, and a lot of times like as I grew up I had – I was probably nine years old. My first friend committed suicide. And it brings the community together. We have big honoring, big feast for his family, for him, and just days of celebrating. It’s kind of like bring the family back together. I had another friend do it after that because he was – couldn’t graduate high school and didn’t have nobody there, and he wanted his family to come back together, so he committed suicide, just felt like it’s going to bring his family back together. And it did for a bit, but meth came in again, so it kind of tore it apart.

John:            Uh-huh.

John:            So, I’m hearing two suicides of people that you knew well around the time that you graduated high school?

Cory:            Oh, one was when I was 9, and a good friend was 16. And by the time I was 18, I probably lost maybe 7 friends from drinking and driving, drugs, stabbings. So, I guess to us, I mean, death is death, so it wasn’t really a big deal, kind of a celebration and we’ll see them again.

John:            Yeah. So, for each one the family celebrates, the community celebrates –

Cory:            Uh-huh.

John:            – the life. And sometimes it almost sounds like somebody might choose suicide as an effort, it sounds like, to pull the family together to get everybody closer.

Cory:            Yeah, I guess, too, they know people will care. Pretty big sense of hopelessness there. Not many people know where to turn.

John:            Yeah. Yeah, so that’s a lot of death that you saw even by the time you graduated high school. Have you had some thoughts of suicide yourself?

Cory:            Originally when I first came back, I did. I just didn’t know what to do anymore. Then I came to college, thought I was going to – wanted to do something honorable again. Again, big celebration and sent us off to college. And I get here, and things are going well at first. Then just the culture differences, like nobody understood me, didn’t know what to do. I was doing all right in classes, but I just kind of couldn’t fit in, didn’t feel like anybody understood me. I mean, they’re all pretty nice guys and gals. I could tell they were trying to, but just something I knew they didn’t.

And then now things are getting bad again. I’m trying to sleep at night. Yeah, just every time I go to sleep, I remember one time in Iraq we were sitting there, and they decided – well, I guess Al-Qaeda, they blew a whole street, whole city block, and it just – I mean, every building came down. And we were there trying to help, and you had kids with missing arms and missing eyes and moms with no legs and crying, screaming. We were trying help as best we can, and same time people shooting at us and just didn’t know what to do.

My friend’s crying. Like why the fuck are we here? Like what are we doing here? Like this isn’t what we – not what we’re here for. Yeah, I just remember a mom with no leg carrying her helpless child just in her arms, and the child was dead. I mean, just every time I go to sleep, I just remember that kid helpless laying there. And so I’m not sleeping much, a lot of drinking still. I guess I don’t know what to do anymore.

COMMENTARY: It’s not unusual for suicidal clients to present with a vast array of psychological pain. That can be overwhelming to the client and to the therapist. Cory has shared several layers of unresolved grief, traumatic war memories. The number of people whom he has known who have died by suicide is immense. Additionally, because of his cultural norms of stoicism, I’m wanting to address these parts of his experience, while not activating intense emotions. my strategy has been and will be to use reflection of content, to avoid reflecting back strong emotions like sadness or anger, to keep his collectivist perspective in mind, and to take notes in a way so that he and I can take a more intellectual and problem-solving approach to working with him on his experiences.

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If you made it this far, a big congratulations. Acquiring skills to work effectively with clients who are suicidal is challenging, but dealing with the emotions that come up is probably even more difficult. The purpose of this training video (when it becomes available) is to help practitioners obtain knowledge, learn skills, and refine their awareness of the inner and interpersonal dynamics associated with suicide assessment and intervention. When I have more information on the video’s availability, I’ll let you know.

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice, Suicide Assessment and Intervention

More Methods for Discussing Suicide with Mental Health Clients

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nick-nacksNearly everyone agrees that asking clients directly about suicide is the right thing. However, because every client situation is unique, there are also many different strategies for asking about suicide. In this short excerpt from Clinical Interviewing, we discuss how to bring up suicide using information from outside of the counseling or assessment session.

Using Outside Information to initiate Risk and Protective Factor Assessment

Outside of the formal suicide assessment interview, three main sources of information can be used to initiate a discussion with clients about suicide risk and protective factors:

  1. Client Records
  2. Assessment Instruments
  3. Collateral Informants

Client Records

If available, your client’s previous medical or mental health (med-psych) records are a quick and efficient source for client risk and protective factor information. Many risk factors listed in this chapter won’t be in your client’s records, but you should look closely for factors, such as: (a) previous suicide ideation and attempts; (b) a history of a depression diagnosis; and (c) familial suicide. After your standard intake interviewing opening and rapport building, you can use the records to broach these issues.

I saw in your records that you attempted suicide back in 2012. Could you tell me what was going on in your life back then to trigger that attempt? 

When exploring previous suicide attempts, it’s important to do so in a constructive manner that can contribute to treatment (see Case Example 10.2). Using psychoeducation to explain to clients why you’re asking about the past helps frame and facilitate the process.

The reason I’m asking about your previous suicide attempt is because the latest research indicates that the more we know about the specific stresses that triggered a past attempt, the better we can work together to help you cope with that stress now and in the future. 

Don’t forget to balance your questioning about previous suicide attempts with a focus on the positive.

Often, after a suicide attempt, people say they discovered some new strengths or resources or specific people who were especially helpful. How about for you? Did you have anything positive you discovered in the time after your suicide attempt.

It may be difficult to identify protective factors in your client’s med-psych records. However, if you find evidence of protective factors or personal strengths, you should bring them up in the appropriate context during a suicide assessment interview. For example, when interviewing a client who’s talking about despair associated with a current depressive episode, you might say something like:

I noticed in your records that you had a similar time a couple years ago when you were feeling very down and discouraged. And, according to your therapist back then, you worked very hard and managed to climb back up out of that depressing place. What worked for you back then?

Strive to use information from your clients’ records collaboratively. As illustrated, you can use the information to broach delicate issues (both positive and negative).

Traditionally, previous suicide attempts are considered one of the strongest predictors of future suicidal behaviors. However, as with all risk factors, previous attempts should be considered within the idiosyncratic context of each individual client. Case example 10.2 provides a glimpse of a case where a previous attempt ends up serving as a protective factor, rather than a risk factor.

Case Example 10.2

Exploring Previous Attempts as a Method for Understanding Client Stressors and Coping Strategies

Exploring previous suicide attempts is an assessment process. It can illuminate past stressors, but it’s equally useful for helping clients articulate past, present, and future coping responses.

Therapist: You wrote on your intake form that you attempted suicide about a year and a half ago. Can you tell me a bit about that?

Client: Right. I shot myself in the head. It’s obvious. You can see the scar right here.

Therapist: What was happening in your life that brought you to that point?

Client: I was getting bullied in school. I hated my step-father. Life was shit, so one day after school I took the pistol out of my mom’s room, aimed at my head and shot.

Therapist: What happened then?

Client: I woke up in the hospital with a bad fucking headache. And then there was rehab. It was a long road, but here I am.

Therapist: Right. Here you are. What do you make of that?

Client: I’m lucky. I’m bad at suicide. I don’t know. I suppose I took it to mean that I’m supposed to be alive.

Therapist: Have you had any thoughts about suicide recently?

Client: Nope. Nada. Not one.

Therapist: I guess from what you said that getting bullied or having family issues could still be hard for you. How do you cope with that now?

Client: I’ve got some friends. I’ve got my sister. I talk to them. You know, after you do what I did, you find out who really cares about you. Now I know.

 

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice, Suicide Assessment and Intervention

Talking with Clients about Suicidal Thoughts and Feelings

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Spring is coming to the Northern Hemisphere. Along with spring, there will also be a bump in death by suicide. To help prepare counselors and clinicians to talk directly with clients about suicide, I’m posting an excerpt from the Clinical Interviewing text. The purpose is to help everyone be more comfortable talking about suicidal thoughts and feelings because the more comfortable we are, the more likely clients are to openly share their suicidal thoughts and feelings and that gives us a chance to engage them as a collaborative helper.

Here’s a link to the text https://www.amazon.com/Clinical-Interviewing-Video-Resource-Center/dp/1119084237/ref=asap_bc?ie=UTF8

And here’s the excerpt:

Exploring Suicide Ideation

Unlike many other risk factors (e.g., demographic factors), suicide ideation is directly linked to potential suicide behavior. It’s difficult to imagine anyone ever dying by suicide without having first experienced suicide ideation.

Because of this, you may decide to systematically ask every client about suicide ideation during initial clinical interviews. This is a conservative approach and guarantees you won’t face a situation where you should have asked about suicide, but didn’t. Alternatively, you may decide to weave questions about suicide ideation into clinical interviews as appropriate. At least initially, for developing professionals, we recommend using the systematic approach. However, we recognize that this can se0em rote. From our perspective, it is better to learn to ask artfully by doing it over and over than to fail to ask and regret it.

The nonverbal nature of communication has direct implications for how and when you ask about suicide ideation, depressive symptoms, previous attempts, and other emotionally laden issues. For example, it’s possible to ask: “Have you ever thought about suicide?” while nonverbally communicating to the client: “Please, please say no!” Therefore, before you decide how you’ll ask about suicide ideation, you need the right attitude about asking the question.

Individuals who have suicidal thoughts can be extremely sensitive to social judgment. They may have avoided sharing suicidal thoughts out of fear of being judged as “insane” or some other stigma. They’re likely monitoring you closely and gauging whether you’re someone to trust with this deeply intimate information. To pass this unspoken test of trust, it’s important to endorse, and directly or indirectly communicate the following beliefs:

  • Suicide ideation is normal and natural and counseling is a good place for clients to share those thoughts.
  • I can be of better help to clients if they tell me their emotional pain, distress, and suicidal thoughts.
  • I want my clients to share their suicidal thoughts.
  • If my clients share their suicidal thoughts and plans, I can handle it!

If you don’t embrace these beliefs, clients experiencing suicide ideation may choose to be less open.

Asking Directly about Suicide Ideation

Asking about suicide ideation may feel awkward. Learning to ask difficult questions in a deliberate, compassionate, professional, and calm manner requires practice. It also may help to know that, in a study by Hahn and Marks (1996), 97% of previously suicidal clients were either receptive or neutral about discussing suicide with their therapists during intake sessions. It also may help to know that you’re about to learn the three most effective approaches to asking about suicide that exist on this planet.

Use a normalizing frame. Most modern prevention and intervention programs recommend directly asking clients something like, “Have you been thinking about suicide recently?” This is an adequate approach if you’re in a situation with someone you know well and from whom you can expect an honest response.

A more nuanced approach is to ask about suicide along with a normalizing or universalizing statement about suicide ideation. Here’s the classic example:

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)

Three more examples of using a normalizing frame follow:

  • I’ve read that up to 50% of teenagers have thought about suicide. Is that true for you?
  • Sometimes when people are down or feeling miserable, they think about suicide and reject the idea or they think about suicide as a solution. Have you had either of these thoughts about suicide?
  • I have a practice of asking everyone I meet with about suicide and so I’m going to ask you: Have you had thoughts about death or suicide?

A common fear is that asking about suicide will put suicidal ideas in clients’ heads. There’s no evidence to support this  (Jobes, 2006). More likely, your invitation to share suicidal thoughts will reassure clients that you’re comfortable with the subject, in control of the situation, and capable of dealing with the problem.

Use gentle assumption. Based on over two decades of clinical experience with suicide assessment Shawn Shea (2002/ 2004/2015) recommends using a framing strategy referred to as gentle assumption. To use gentle assumption, the interviewer presumes that certain illegal or embarrassing behaviors are already occurring in the client’s life, and gently structures questions accordingly. For example, instead of asking “Have you been thinking about suicide?” you would ask:

When was the last time when you had thoughts about suicide?

Gentle assumption can make it easier for clients to disclose suicide ideation.

Use mood ratings with a suicidal floor. It can be helpful to ask about suicide in the context of a mood assessment (as in a mental status examination). Scaling questions such as those that follow can be used to empathically assess mood levels.

  1. Is it okay if I ask some questions about your mood? (This is an invitation for collaboration; clients can say “no,” but rarely do.)
  2. Please rate your mood right now, using a zero to 10 scale. Zero is the worst mood possible. In fact, zero would mean you’re totally depressed and so you’re just going to kill yourself. At the top, 10 is your best possible mood. A 10 would mean you’re as happy as you could possibly be. Maybe you would be dancing or singing or doing whatever you do when you’re extremely happy. Using that zero to 10 scale, what rating would you give your mood right now? (Each end of the scale must be anchored for mutual understanding.)
  3. What’s happening now that makes you give your mood that rating? (This links the mood rating to the external situation.)
  4. What’s the worst or lowest mood rating you’ve ever had? (This informs the interviewer about the lowest lows.)
  5. What was happening back then to make you feel so down? (This links the lowest rating to the external situation and may lead to discussing previous attempts.)
  6. For you, what would be a normal mood rating on a normal day? (Clients define their normal.)
  7. Now tell me, what’s the best mood rating you think you’ve ever had? (The process ends with a positive mood rating.)
  8. What was happening that helped you have such a high mood rating? (The positive rating is linked to an external situation.)

The preceding protocol assumes clients are minimally cooperative. More advanced interviewing procedures can be added when clients are resistant (see Chapter 12). The process facilitates a deeper understanding of life events linked to negative moods and suicide ideation. This can lead to formal counseling or psychotherapy, as well as safety planning.

Responding to Suicide Ideation

Let’s say you broach the question and your client openly discloses the presence of suicide ideation. What next?

First, remember that hearing about your client’s suicide ideation is good news. It reflects trust. Also remember that depressive and suicidal symptoms are part of a normal response to distress. Validate and normalize:

Given the stress you’re experiencing, it’s not unusual for you to sometimes think about suicide. It sounds like things have been really hard lately.

This validation is important because many suicidal individuals feel socially disconnected, emotionally invalidated, and as if they’re a social burden (Joiner, 2005). Your empathic reflection may be more or less specific, depending on how much detailed information your client has given you.

As you continue the assessment, collaboratively explore the frequency, triggers, duration, and intensity of your client’s suicidal thoughts.

  • Frequency: How often do you find yourself thinking about suicide?
  • Triggers: What seems to trigger your suicidal thoughts? What gets them started?
  • Duration: How long do these thoughts stay with you once they start?
  • Intensity: How intense are your thoughts about suicide? Do they gently pop into your head or do they have lots of power and sort of smack you down?

As you explore the suicide ideation, strive to emanate calmness, and curiosity, rather than judgment. Instead of thinking, “We need to get rid of these thoughts,” engage in collaborative and empathic exploration.

Some clients will deny suicidal thoughts. If this happens, and it feels genuine, acknowledge and accept the denial, while noting that you were just using your standard practice.

Okay. Thanks. Asking about suicidal thoughts is just something I think is important to do with everyone.

On the other hand, if the denial seems forced, or is combined with depressive symptoms or other risk factors, you’ll still want to use acknowledgement and acceptance, but then find a way to return to the topic later in the session.

 

Suicide Assessment and Intervention

A New Journal Article on Suicide Assessment Interviewing

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Article · Oct 2016 · Professional Psychology Research and Practice
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