Tag Archives: clinical interviewing

What is Motivational Interviewing? A brief description and demonstration video

The following content is adapted from Clinical Interviewing (6th ed., 2017).

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

In their 2013 edition of Motivational Interviewing, Miller and Rollnick offer “Layperson’s,” Practitioner’s,” and “Technical” definitions of MI.  For practitioners, Motivational interviewing is:

. . . a person-centered counseling style for addressing the common problem of ambivalence about change. (p. 29)

As a person-centered approach to therapy, MI relies substantially on four central listening skills, referred to as OARS (open questions, affirming, reflecting, and summarizing). MI is designed to help clients change from less healthy to more healthy behavior patterns. However, consistent with PCT, MI practitioners don’t interpret, confront, or pressure clients in any way. Instead, they use listening skills to encourage clients to talk about reasons for engaging in healthy or positive behaviors.

Moving Away From Confrontation and Education

In his research with problem drinkers, William R. Miller was studying the efficacy of behavioral self-control techniques. To his surprise, he found that structured behavioral treatments were no more effective than an encouragement-based control group. When he explored the data for an explanation, he found that regardless of treatment protocol, therapist empathy ratings were the strongest predictors of positive outcomes at 6 months (r = .82), 12 months (r = .71), and 2 years (r = .51; W. R. Miller, 1978; W. R. Miller & Taylor, 1980). Consequently, he concluded that positive treatment outcomes with problem drinkers were less related to behavioral treatment and more related to reflective listening and empathy. He also found that active confrontation and education generally triggered client resistance. These discoveries led him to develop motivational interviewing (MI).

Miller met Stephen Rollnick while on sabbatical in Australia in 1989. Rollnick was enthused about MI and its popularity in the UK. Miller and Rollnick began collaborating and subsequently published the first edition of Motivational Interviewing in 1991. Rollnick is credited with identifying client ambivalence as a central focus for change (Jones-Smith, 2016, p. 320).

Client Ambivalence

Client ambivalence is a primary target of MI. Miller and Rollnick (2013) have consistently noted that ambivalence is a natural part of individual decision-making. They wrote: “Ambivalence is simultaneously wanting and not wanting something, or wanting both of two incompatible things. It has been human nature since the dawn of time” (2013, p. 6).

Although MI has been used as an intervention for a variety of problems and integrated into many different treatment protocols, it was originally a treatment approach for addictions and later became popular for influencing other health-related behaviors. This focus is important because ambivalence is especially prevalent among individuals who are contemplating their personal health. Smokers, problem drinkers, and sedentary individuals often recognize they could choose more healthy behaviors, but they also want to keep smoking, drinking, or being sedentary. This is the essence of ambivalence as it relates to health behaviors. When faced with clients who are ambivalent about whether to make changes, it’s not unusual for professional helpers to be tempted to push those clients toward health. Miller and Rollnick (2013) call this the “righting reflex” (p. 10). They described what happens when well-meaning helping professionals try to nudge clients toward healthy behaviors (note that this description is an apt rationale for a person-centered approach, but that it’s also consistent with the Gestalt therapy ideas of polarizing forces within individuals):

[The therapist] then proceeds to advise, teach, persuade, counsel or argue for this particular resolution to [the client’s] ambivalence. One does not need a doctorate in psychology to anticipate [how clients are likely to respond] in this situation. By virtue of ambivalence, [clients are] apt to argue the opposite, or at least point out problems and shortcomings of the proposed solution. It is natural for [clients] to do so, because [they] feels at least two ways about this or almost any prescribed solution. It is the very nature of ambivalence. (2002, pp. 20–21)

The ubiquity of ambivalence leads to Miller and Rollnick’s (2013) foundational person-centered principle of treatment:

Ideally, the client should be voicing the reasons for change (p. 9).

MI is both a set of techniques and a person-centered philosophy. The philosophical MI perspective emphasizes that motivation for change is not something therapists should impose on clients. Change must be drawn out from clients, gently, and with careful timing. Motivational interviewers do not use direct persuasion.

The Spirit of MI

The “underlying spirit” of MI “lies squarely within the long-standing tradition of person-centered care” (Miller & Rollnick, 2013, p. 22). They identified four overlapping components that the spirit of MI “emerges” from. These include:

  • Collaboration
  • Acceptance
  • Compassion
  • Evocation

MI involves partnership or collaboration. It’s described as dancing, not wrestling. Your goal is not to “pin” the client; in fact, you should even avoid stepping on their toes. This is consistent with the first principle of person-centered therapy. The counselor and client make contact, and in that contact there’s an inherent or implied partnership to work together on behalf of the client.

Person centered (and MI) counselors de-emphasize their expertness. Miller and Rollnick refer to this as avoiding the expert trap. Expert traps occur when you communicate “that, based on your professional expertise, you have the answer to the person’s dilemma” (p. 16). In writing about collaboration, Miller and Rollnick (2013) sound very much like Carl Rogers, “Your purpose is to understand the life before you, to see the world through this person’s eyes rather than superimposing your own vision” (p.16).

Consistent with Rogerian philosophy, MI counselors hold an “attitude of profound acceptance of what the client brings” (p. 16). This profound acceptance includes four parts:

  1. Absolute Worth: This is Rogerian unconditional positive regard
  2. Accurate Empathy: This is pure Rogerian.
  3. Autonomy Support: This part of acceptance involves honoring each person’s “irrevocable right and capacity of self-direction” (p. 17)
  4. Affirmation: This involves an active search or focus on what’s right with people instead of what’s wrong or pathological about people.

In the third edition of Motivational Interviewing, Miller and Rollnick added compassion to their previous list of the three elements of MI spirit. Why? Their reasoning was that it was possible for practitioners to adopt the other three elements, but still be operating from a place of self-interest. In other words, practitioners could use collaboration, acceptance, and evocation to further their self-interest to get clients to change. By adding compassion and defining it as “a deliberate commitment to pursue the welfare and best interests of the other” Miller and Rollnick are protecting against practitioners confusing self-interest with the client’s best interests.

Evocation is somewhat unique, but also consistent with person-centered theory. Miller and Rollnick contend that clients have already explored both sides of their natural ambivalence. As a consequence, they know the arguments in both directions and know their own positive motivations for change. Additionally, they note, “From an MI perspective, the assumption is that there is a deep well of wisdom and experience within the person from which the counselor can draw” (p. 21). It’s the counselor’s job to use evocation to draw out (or evoke) client strengths so these strengths can be used to initiate and maintain change.

A Sampling of MI Techniques

One distinction between MI and classical PCT is that Miller and Rollnick (2013) identify techniques that practitioners can and should use. These techniques are generally designed to operate within the spirit of MI and to help clients engage in change talk instead of sustain talk. Change talk is defined as client talk that focuses on their desire, ability, reason, and need to change their behavior, as well as their commitment to change.  Sustain talk is the opposite; clients may be talking about lack of desire, ability, reason, and need to change. Overall, researchers have shown that clients who engage in more MI change talk are more likely to make efforts to enact positive change.

MI appears simple, but it’s a complicated approach and challenging to learn (Atkinson & Woods, 2017). Miller and Rollnick (2013) have noted that having a solid foundation of person-centered listening skills makes learning MI much easier. The following content is only a sampling of MI techniques.

MI practitioners use techniques from the OARS listening skills. In particular, there’s a strong emphasis on skillful and intentional use of reflections, instead of questions or directives. Here are examples.

Simple reflections stick very closely to what the client said.

Client: I’ve just been pretty anxious lately.

Simple Reflection: Seems like you’ve been feeling anxious.

 

Client: Being sober sucks.

Simple Reflection: You don’t like being sober.

Simple reflections have two primary functions. First, they convey to clients that you’ve heard what they said. This usually enhances rapport and interpersonal connection. Second, as you provide a simple reflection, it lets clients hear what they’ve said. Hearing their words back—from the outside in—can be illuminating for clients.

Complex reflections add meaning, focus, or a particular emphasis to what the client said.

Client: I haven’t had an HIV test for quite a while.

Complex reflection: Getting an HIV test has been on your mind.

 

Client: I only had a couple drinks. Even when I got pulled over, I didn’t think I was over the limit.

Complex reflection: That was a surprise to you. You might have assumed “I can tell when I’m over the limit” but in this case you couldn’t really tell.

Complex reflections go beyond the surface and make educated guesses about what clients are thinking, feeling, or doing. Clients tend to talk more and get deeper into their issues when MI therapists use complex reflections effectively. Also, if your complex reflection is correct, it’s likely to deepen rapport and might evoke change talk.

An amplified reflection involves an intentional overstatement of the client’s main message. Generally, when therapists overstate, clients make an effort to correct the reflection.

Client: I’m pissed at my roommate. She won’t pick up her clothes or do the dishes or anything.

Interviewer: You’d like to fire her as a roommate.

Client: No. Not that. There are lots of things I like about her, but her messiness really annoys me. (from Sommers-Flanagan & Sommers-Flanagan, 2017, p. 440)

 

Client: My child has a serious disability and so I have to be home for him.

Interviewer: You really need to be home 24/7 and have to turn off any needs you have to get out and take a break.

Client: Actually, that’s not totally true. Sometimes, I think I need to take some breaks so I can do a better job when I am home. (from Sommers-Flanagan & Sommers-Flanagan, 2017, p. 441)

Sometimes MI practitioners accidentally amplify a reflection. Other times amplification is intentional. When intentionally amplifying reflections, it’s important to be careful because it can feel manipulative.

The opposite of amplified reflection is undershooting. Undershooting involves intentionally understating what your client is saying.

Client: I can’t stand it when my mom criticizes my friends right in front of me.

Therapist: You find that a little annoying.

Client: It’s way more than annoying. It pisses me off.

Therapist: What is it that pisses you off when your mom criticizes your friends?

Client: It’s because she doesn’t trust me and my judgment. (from Sommers-Flanagan & Sommers-Flanagan, 2017, p. 441)

In this example, the therapist undershoots the client’s emotion and then follows with an open question. Clients often elaborate when therapists undershoot.

As noted, the preceding content is a small taste of MI technical strategies; if you want to become a competent MI practitioner, advanced training is needed (see Atkinson & Woods, 2017; Miller & Rollnick, 2013).

Now that you’ve read a brief summary of MI, check out the following video link. In this link, John S-F is using a few MI techniques/strategies with a client who has a history of excessive alcohol use. The video is part of our published video package accompanying our Clinical Interviewing textbook, and includes me weaving in a few more traditional clinical interviewing questions (e.g., the CAGE) along with the MI content. There’s also light commentary by Rita and me, as well as a short clip in the middle of me interviewing a Licensed Addictions Counselor on the topic of how to handle clients who are probably lying. Here’s the link to the approximately 22 minute video: https://youtu.be/rtN7kEk0Sv4

If you have questions, comments, praise, or constructive feedback on this blog or the video, I’d love to hear from you. You can post here, on Youtube, or email me directly at john.sf@mso.umt.edu.

Happy Tuesday.

John S-F

 

Mental Health or Mental Illness: Defining Mental Disorders

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).

 

Suicide Assessment: Mood Scaling with a Suicide Floor

IMG-2759

The following material is adapted from an article in the Journal of Health Service Psychology. You can access the whole article here: https://www.nationalregister.org/pub/the-national-register-report-pub/journal-of-health-service-psychology-winter-2018/conversations-about-suicide-strategies-for-detecting-and-assessing-suicide-risk/

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

My favorite suicide assessment procedure is to ask about suicide in the context of a mood assessment (as in a mental status examination). This procedure utilizes a scaling question to explore patient mood and possible suicide ideation (Sommers-Flanagan & Shaw, 2017). As you read through these steps, think about how you might apply this procedure with a recent or current patient of yours.

  1. Is it okay if I ask some questions about your mood? (This is an invitation for collaboration; patients can say “no,” but rarely do.)
  2. I’d like you to rate your mood right now, using a zero to 10 scale. Zero is the worst mood possible. 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 (you might hold your hand up high to illustrate the top of the scale). 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 is what psychoanalysts call binding affect; it links the internal mood to an external situation.) At this point, you might ask questions to have your patient elaborate, in greater detail, the reason for the current mood rating.
  4. What’s the worst or lowest mood rating you’ve ever had? (This question informs you about the patient’s lowest lows.)
  5. What was happening back then to make you feel so down? (This question binds the sad affect to an external situation; it may lead to discussing previous attempts.) Again, you might take time here to explore a previous attempt, in an effort to understand the (a) dynamics that led to it, (b) the seriousness of suicide intent, and (c) what happened to help the patient live and be with you to work on suicide.
  6. For you, what would be a normal mood rating on a normal day? (You can insert this question at any point where it fits. Often, the best point is after the first mood rating because patients will immediately tell you whether they’re a little more up or a little more down than normal. The purpose is to get your patients to 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.)

This procedure is a general map that can be used more or less creatively. No doubt, when you start the process with an individual patient, there will be opportunities to stray from the procedure. For example, when exploring the low end of her mood, your patient may begin sharing a traumatic experience. If so, you are at a key choice point. Should you continue with the next step in the procedure or focus in more detail on the trauma? Either option may be appropriate and will depend on one or more of the following factors:

  • Based on your best judgment, does your client want to talk about trauma in more detail? If so, you should move in that direction and come back to the procedure later.
  • Do you have time to immediately explore the trauma? If not, then you should say so and let your patient know that when you do have time, you will be interested in hearing details.
  • Do you sense that your rapport is minimal and your client is uncomfortable sharing details? If so, then the best option is to continue with the procedure, making a mental note to check back later when your client is more comfortable.

Numbers can be useful in rating patient mood, but because every patient is unique, the meaning of specific numbers will be subjectively variable. I have interviewed teenagers and young adults who emphasize their distress by saying something like, “I’m a negative three!” Despite the fact that having a negative three rating on the suicide scale indicates—in a quantitative sense—suicide certainty, these patients are typically making a point, and may or may not be an especially high suicide risk. In contrast, I have also worked with cases where adult patients burst into tears and admit to suicide ideation after giving themselves a current mood rating of 8 or 9. One patient who rated herself as “9” explained that she always thought of herself as being a 10. For her, anything outside of a perfect mood rating as terribly disturbing.

            Several of my supervisees who work with teenagers have creatively transformed the scaling method to eliminate numbers. One supervisee engaged a patient in mood scaling using musical genres. After a collaborative conversation, they established that listening to opera 24/7 was equivalent to zero and imminent suicide, while listening to heavy metal was a solid 10. When working with a middle school boy, another former student used Yoga as zero and pizza as 10. The point of these examples is that practitioners can collaborate with patients to identify a method to discuss mood. Collaborative rating systems makes the method personally meaningful to the patient; it also involves interpersonal connection, implying that the assessment method has become simultaneously therapeutic.

The mood scaling procedure offers several advantages. First, it is a process that facilitates engagement, and engagement or interpersonal connection is central part of suicide interventions. Second, when patients bind their low and high moods to concrete external situations, you gain knowledge about the themes and triggers that lift and depress your patient’s mood. Third, as illustrated in the case where a client begins talking about trauma, the mood scaling procedure can be abandoned (temporarily or permanently) in favor of more salient therapeutic opportunities. Fourth, mood scaling flows smoothly into safety planning or other suicide interventions (e.g., “When you say that being a zero always involves you being alone, it tells me that one thing we should talk about now or later is how you can reach out to others, and we should talk about who you want to reach out to, during those times when you’re feeling like a zero. It also tells me that we should talk some more about other methods you can use to move from a zero to a one.”).

One final note: The mood scaling technique is an indirect method for assessing suicidality. As such, it is not a replacement for using a normative frame and asking directly. In fact, you should be thinking about if and when you will weave asking directly into your mood scaling process. For example, if your client says “I’m a 3” you might follow that with a normative-based direct question: “It’s not unusual for people who rate themselves as a three to sometimes have thoughts about suicide. Has that been the case for you?”

Eight Core Conditions that Often Contribute to Suicide

Rainbow 2017Many professionals and media sources have proclaimed that suicide is a 100% preventable problem. Although I completely disagree with that message—and find it terribly offensive—I also believe that we should do what we can to prevent suicide.

Recently I was asked to write a journal article summarizing the conditions or dimensions that commonly contribute to suicide. To give you a flavor of these dimensions, below I’ve included brief descriptions of each one. However, I also want to emphasize that suicidologists and suicide researchers agree that death by suicide is nearly always unpredictable. Suicide is unpredictable despite the fact that, afterwards, many people and professionals will feel as though they should have “seen the signs” and done something more to prevent the death.

Knowing the following eight dimensions is useful when they’re used to enhance your compassion and capacity to collaborate with individual clients and persons. They’re not designed to be used as suicide risk factors or predictors.

Here are the eight dimensions.

Unbearable Psychological/Emotional Distress (Shneidman’s Psychache)

Shneidman (1985) originally identified “psychache” as the central psychological force leading to suicide. He defined psychache as negative emotions and psychological pain, referring to it as “the dark heart of suicide; no psychache, no suicide” (p. 200). In more modern patient-oriented language, psychache is aptly described as unbearable emotional distress. Unbearable distress can involve many factors, or center around one main trauma, loss, or other psychologically activating experiences; it may be accompanied by distinct cognitive, emotional, or physical symptoms.

Problem-Solving Impairment (Shneidman’s Mental Constriction)

Depression or low mood is commonly associated with problem-solving impairments. Originally, Shneidman called these impairments mental constriction, and defined them as “a pathological narrowing of the mind’s focus . . . which takes the form of seeing only two choices: either something painfully unsatisfactory or cessation” (1984, pp. 320–321). Researchers have reported support for Shneidman’s original ideas about mental constriction (Ghahramanlou-Holloway et al., 2012; Lau, Haigh, Christensen, Segal, & Taube-Schiff, 2012).

Agitation or Arousal (Shneidman’s Perturbation)

Agitation or arousal is consistently associated with death by suicide (Ribeiro, Silva, & Joiner, 2014). Shneidman (1985) originally used the term perturbation to refer to internal agitation that moves patients toward suicidal acts. When combined with high psychological distress and impaired problem-solving, agitation or arousal seems to push patients toward acting on suicide as a solution to their distress. Trauma, insomnia, drug use (including starting on a trial of serotonin-reuptake inhibitors), and many other factors can elevate agitation (Healy, 2009).

Thwarted Belongingness and Perceived Burdensomeness

Joiner (2005) developed an interpersonal theory of suicide. Part of his theory includes thwarted belongingness and perceived burdensomeness as contextual interpersonal factors linked to suicide. Thwarted belongingness involves unmet wishes for social connection. Perceived burdensomeness occurs when patients see themselves as flawed in ways that make them a burden to others.

Hopelessness

Hopelessness is a broad cognitive variable related to problem-solving impairment and linked to elevated suicide risk (Hagan, Podlogar, Chu, & Joiner, 2015; Strosahl, Chiles, & Linehan, 1992). Hopelessness is the belief that whatever distressing life conditions might be present will never improve. In many cases, patients hold a hopeless view—even when a rational justification for hope exists.

Suicide Desensitization

Joiner (2005) and Klonsky and May (2015) have described how fear of death or aversion to physical pain is a natural suicide deterrent present in most individuals. However, at least two situations or patterns can desensitize patients to suicide and reduce natural suicide deterrence. First, some patients may be predisposed to high pain tolerance. This predisposition is likely biogenetic, as in blood-injury phobias (Klonsky & May, 2015). Second, patients may acquire, through desensitization, a numbness that reduces natural fears of pain and suicide. Chronic pain, self-mutilation, and other experiences can be desensitizing.

Suicide Plan or Intent

In and of itself, suicide ideation is a poor predictor of suicide. Nevertheless, ideation is an important marker to explore with patients; exploring ideation can lead to asking directly about whether patients have a suicide plan. Suicide plans may or may not be associated with suicide intent. Some patients will keep a potential suicide plan on reserve, just in case their psychological pain grows unbearable. These patients do not intend to die by suicide, but they want the option and sometimes they have thought through the method(s) they might employ.

Lethal Means

Access to a lethal means is a situational dimension that substantially contributes to suicide risk. Firearms are far and away the most lethal suicide method. Specifically, Swanson, Bonnie, and Appelbaum (2015) reported that firearms result in an 84% case fatality rate. Although firearms can quickly become a politicized issue in the U.S., researchers have repeatedly found that access to firearms greatly magnifies suicide risk (Anestis & Houtsma, 2017).

 

Talking with Clients about Suicidal Thoughts and Feelings

fortunes

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.

 

The 6th Edition of Clinical Interviewing is Now Available

Way back in 1990, a university book salesman came by my faculty office at the University of Portland. He was trying to sell me some textbooks. When I balked at what he was offering, he asked, “Do you have any textbook ideas of your own?” I said something like, “Sure” or “As a matter of fact, I do.” He handed me his card and a paper copy of Allyn & Bacon’s proposal guidelines.

Not having ever written a book, I never thought they’d accept my proposal.

They did. But after three years, A & B dropped our text.

Lucky for us.

Two  years later, Rita and I decided to try to resurrect our Clinical Interviewing text. We polished up a proposal, sent it out to three excellent publishers, and immediately got contract offers from W. W. Norton, Guilford, and John Wiley & Sons.

We went with Wiley.

Here we are 18 years later in the 6th edition. It’s been fun and a ton of work. Over the past five years we’ve started recording video clips and interviewing demonstrations to go along with the text. For the 6th edition, we got some pretty fantastic reviews from some pretty fancy (and fantastic) people. Here they are:

“I’m a huge admirer of the authors’ excellent work.  This book reflects their considerable clinical experience and provides great content, engaging writing, and enduring wisdom.”
John C. Norcross, Ph.D., ABPP, Distinguished Professor of Psychology, University of Scranton

“The most recent edition of Clinical Interviewing is simply outstanding.  It not only provides a complete skeletal outline of the interview process in sequential fashion, but fleshes out numerous suggestions, examples, and guidelines in conducting successful and therapeutic interviews.  Well-grounded in the theory, research and practice of clinical relationships, John and Rita Sommers-Flanagan bring to life for readers the real clinical challenges confronting beginning mental health trainees and professionals.  Not only do the authors provide a clear and conceptual description of the interview process from beginning to end, but they identify important areas of required mastery (suicide assessment, mental status exams, diagnosis and treatment electronic interviewing, and work with special populations).  Especially impressive is the authors’ ability to integrate cultural competence and cultural humility in the interview process.  Few texts on interview skills cover so thoroughly the need to attend to cultural dimensions of work with diverse clients.  This is an awesome book written in an engaging and interesting manner.  I plan to use this text in my own course on advanced professional issues.  Kudos to the authors for producing such a valuable text.”
—Derald Wing Sue, Ph.D., Professor of Psychology and Education, Teachers College, Columbia University

“This 6th edition of Clinical Interviewing is everything we’ve come to expect from the Sommers-Flanagan team, and more!  Readers will find all the essential information needed to conduct a clinical interview, presented in a clear, straightforward, and engaging style.  The infusion of multicultural sensitivity and humility prepares the budding clinician not only for contemporary practice, but well into the future.  Notable strengths of the book are its careful attention to ethical practice and counselor self-care. The case studies obviously are grounded in the authors’ extensive experience and bring to life the complexities of clinical interviewing.  This is a ‘must-have’ resource that belongs on the bookshelf of every mental health counselor trainee and practitioner.”
Barbara Herlihy, PhD. NCC, LPC-S, University Research Professor, Counselor Education Program, University of New Orleans

You can check out the text on Amazon https://www.amazon.com/Clinical-Interviewing-John-Sommers-Flanagan/dp/1119215587/ref=dp_ob_title_bk  or Wiley http://www.wiley.com/WileyCDA/WileyTitle/productCd-1119215587.html  or other major (and minor) booksellers.

 

 

Parallel Process in Clinical Supervision

This short case example from the forthcoming 6th edition of Clinical Interviewing is a small tribute to all the great supervisors I had over the years.

Case Example 7.2:

Intermittent Unconditional Positive Regard and Parallel Process

Abby is a 26-year-old graduate student. She identifies as a White Heterosexual female. After an initial clinical interview with Jorge, a 35-year-old who identifies as a male heterosexual Latino, she meets with her supervisor. During the meeting she expresses frustration about her judgmental feelings toward Jorge. She tells her supervisor that Jorge sees everyone as against him. He’s extremely angry at his ex-wife and he’s returning to college following his divorce and believes his poor grades are due to racial discrimination. Abby tells her supervisor that she just doesn’t get Jorge. She thinks she should refer him instead of having a second session.

Abby’s supervisor listens empathically and is accepting of Abby’s concerns and frustrations. The supervisor shares a brief story of a case where she had difficulty experiencing positive regard toward a client who had a disability. Then, she asks Abby to put herself in Jorge’s shoes and imagine what it would be like to return to college as a 35-year-old Latino man. She has Abby imagine what might be “under” Jorge’s palpable anger toward his ex-wife. The supervisor also tells Abby, “When you have a client who views everyone as against him, it’s all the more important for you to make an authentic effort to be with him.” At the end of supervision Abby agrees to meet with Jorge for a second session and to try to explore and understand his perspectives on a deeper level. During their next supervision session, Abby reports great progress at experiencing intermittent unconditional positive regard for Jorge and is enthused about working with him in the future.

One way to enhance your ability to experience unconditional positive regard is to have a supervisor who accepts your frustrations and intermittent judgmental-ness. If the issues that arise in therapy are similar (or parallel) to the issues that arise in supervision, it’s referred to as parallel process (Searles, 1955). This is one reason why when you get a dose of unconditional positive regard in supervision, it may help you pass it on to your client.

 

John Rap