Tag Archives: clinical interviewing

Clinical Interviewing, Suicide Assessment and Intervention

Suicide Risk Factors, Part III

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It’s been awhile since I started my holiday and post-holiday look at suicide risk factors. In previous posts I focused on Demographic and Ethnic Factors related to death by suicide and then on the broad category of Mental Disorders and Psychiatric Treatment. This post focuses on Personal and Social Factors that are linked to suicide.

Not to worry, soon I’ll be moving beyond this tragic but important topic.

The following is mostly an excerpt from our Clinical Interviewing text.

Social and Personal Factors

There are a number of social and personal factors linked to increased suicide risk. Many of these factors have been reviewed and integrated into Thomas Joiner’s interpersonal theory of suicide (Joiner & Silva, 2012; Van Orden et al., 2010).

Social Isolation/Loneliness
In a review of the literature, 34 research studies were identified that include support for social isolation as a suicide risk factor (Van Orden et al., 2010). These findings provide support for Joiner’s (Joiner & Silva, 2012) attachment-informed interpersonal theory of suicide. Van Orden et al (2008) described the two primary dimensions of Joiner’s interpersonal theory:

The theory proposes that the needs to belong and to contribute to the welfare of close others are so fundamental that the thwarting of these needs (i.e., thwarted belongingness and perceived burdensomeness) is a proximal cause of suicidal desire. (Van Orden et al., 2008, p. 72)

Interpersonal theory explains why a number of social factors, such as unemployment, social isolation, reduced productivity, and physical incapacitation are associated with increased suicide risk. Specifically, research indicates that divorced, widowed, and separated people are in a higher suicide-risk category and that single, never-married individuals have a suicide rate nearly double the rate of married individuals (Van Orden et al., 2010). Based on interpersonal theory, an underlying reason that these factors are linked to suicidality is because they involve thwarted belongingness and a self-perception of being a burden to family and friends, rather than contributing in a positive way to the lives of others.

In a fairly recent study, the suicide notes of 98 active duty U.S. Air Force (USAF) members were analyzed. Using Joiner’s interpersonal theory, results indicated strong themes of hopelessness, perceived burdensomeness, and thwarted belongingness. Overall, interpersonal risk factors were communicated more often than intrapsychic risk factors. (Cox et al., 2011).

Physical Illness

Many decades of research have established the link between physical illness and suicide. Specific illnesses that confer suicide risk include brain cancer, chronic pain, stroke, rheumatoid arthritis, hemodialysis, and HIV-AIDS (e.g., (Lin, Wu, & Lee, 2009; Martiny, de Oliveira e Silva, Neto, & Nardi, 2011). Overall, although physical illness is a major predictor, several social factors appear to mediate the relationship between illness and death by suicide. In particular, Joiner’s concept of becoming a social burden seems a likely contributor to suicidal behavior, regardless of specific diagnosis (Van Orden et al., 2010). Similar to previously hospitalized psychiatric patients, medical patients also exhibit higher suicidal behavior shortly after hospital discharge (McKenzie & Wurr, 2001).

Previous Attempts

Over 27 separate studies have indicated that suicide risk is higher for people who have previously attempted (Beghi & Rosenbaum, 2010). Van Orden et al. (2010) refer to previous attempts as “. . . one of the most reliable and potent predictors of future suicidal ideation, attempts, and death by suicide across the lifespan” (p. 577).

As one example, in a 15-year prospective British study of deliberate self-harm, repeated self-harm was a strong predictor of eventual suicide, especially in young women (Zahl & Hawton, 2004). By the study’s end, 4.7% of women who had repeatedly engaged in deliberate self-harm committed suicide as compared to 1.9% in the single episode group. In this study, deliberate self-harm was defined as intentionally poisoning or self-injuring that resulted in a hospital visit. The study concluded that repeated deliberate self-harm increases suicide risk in males and females, but is a particularly salient predictor in young females. This is the case despite the fact that some clients use cutting, burning, or other forms of self-harm to aid in emotional regulation. Overall the research suggests that self-harm that rises to the level of hospitalization is likely beyond that which enhances self-regulation and instead constitutes practicing or successive approximation toward suicide.

Unemployment

Individuals who have suffered any form of recent, significant personal loss should be considered higher suicide risk (Hall, Platt, & Hall, 1999). However, in particular, unemployment is a life situation that repeatedly has been linked to suicide attempts and death by suicide. Joiner’s (2005) interpersonal theory of suicide posits that unemployment confers suicide risk at least partly because of individuals experiencing an increased sense of themselves as a burden on others. Other losses that can increase risk include (a) status loss, (b) loss of a loved one, (c) loss of physical health or mobility, (d) loss of a pet loss, and (e) loss of face through recent shameful events (Beghi & Rosenbaum, 2010; Packman, Marlitt, Bongar, & Pennuto, 2004).

Sexual Orientation

Over the years the data have been mixed regarding whether gay, lesbian, bisexual, or transgender individuals constitute a high suicide risk group. More recently, a 2011 publication in the Journal of Homosexuality reported there is no clear and convincing evidence that GLBT individuals die by suicide at a rate greater than the general population (Haas et al., 2011).
Although this is good news, the data also show that GLB populations have significantly higher suicide attempt rates. Haas et al (2011) wrote:

Since the early 1990s, population-based surveys of U.S. adolescents that have included questions about sexual orientation have consistently found rates of reported suicide attempts to be two to seven times higher in high school students who identify as LGB, compared to those who describe themselves as heterosexual. (p. 17)

Overall, it’s likely that transgender people and youth questioning their sexuality may be at increased risk for suicide attempts or death by suicide. Additionally, GLBT youth who have experienced homosexual-related verbal abuse and parental rejection for their behaviors related to gender and sexuality are more likely to engage in suicidal behaviors (D’augelli et al., 2005).

In conclusion, as you can probably see from this and the two previous posts, there are many complex and potentially interacting factors associated with increased suicide risk, but no great predictors. This is unfortunate for those of us who would like to use prediction methods to prevent and reduce suicide rates. But, at the same time, the fact that many people who experience great suffering in their lives still choose life, is a testament to human strength and resiliency.

And, speaking of resiliency, maybe I’ll be focusing on an exciting and upbeat topic like that next time. Until then, I wish you all the best in your efforts to help your clients through difficult times in their lives. Your work may be more important than you think.

Clinical Interviewing, Multicultural, Personal Reflections

Cultural Adaptations in the DSM-5: Insert Foot in Mouth Here

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Sometimes it just seems easier to be snarky than balanced. This basic truth comes to mind because of a recent analysis I did of the Cultural Formulation Interview (CFI) from the DSM-5. As I read about the CFI and looked through its Introduction and 16 questions for “patients,” I kept thinking to myself things like,

“Seriously . . . could this really be the best cultural sensitivity that the American Psychiatric Association can manage when it comes to guidelines for interviewing minority cultures?”

And,

“Who wrote this and why didn’t they ask me for some help?” (insert smiley face here; please note that some of my colleagues at the University of Montana have noticed—and commented—on the fact that I tend to insert a smiley face icon right after texting or emailing my personal version of punchy, snarky, sarcasm).

Ha! is all I have to say to them (FYI: Ha! is my programmed default back up to my default smiley face snark signal).

Anyway . . . the point! It’s way easier for me to be critical of the American Psychiatric Association than balanced. In truth, the CFI is a reasonable effort. And, if you think about where the APA is coming from (and likely going to) then the CFI is a massive effort. I should be saying, “Cool! I’m so excited to see the CFI as part of the DSM-5.

All this is prologue for the excerpt I include below. This is an excerpt from a draft chapter I’m writing for the Handbook of Clinical Psychology . . . to be published at some point in the not too distant future. Here’s the excerpt; it focuses on cultural adaptations we can make when conducting initial clinical interviews with minority clients; forgive the roughness of the draft.

Cultural Adaptations

A clinical interview is a first impression, and first impressions are powerful influences on later relational interactions, which is why we need to make cultural adaptations when conducting clinical interviews. One of the best sources for cultural adaptations is the already-existing guidance from psychotherapy research on working multiculturally. These guidelines include: (a) using small talk and self-disclosure with some cultural groups, (b) when feasible, conducting initial interviews in the patient’s native language, (c) seeking professional consultations with professionals familiar with the patient’s culture; (d) avoiding the use of interpreters except in emergency situations; (e) providing services (e.g., childcare) that help increase patient retention, (f) oral administration of written materials to patients with limited literacy, (g) having awareness and sensitivity to client age and acculturation, (h) aligning assessment and treatment goals with client culturally-informed expectations and values, (i) regularly soliciting feedback regarding progress and client expectations and responding immediately to client feedback, and (j) explicitly incorporating cultural content and cultural values into the interview, especially with patients not acculturated to the dominant culture (see Griner & Smith, 2006; Hays, 2008; Smith, Rodriguez, & Bernal, 2011).

Cultural awareness, cross cultural sensitivity, and making cultural adaptations are especially important to assessment and diagnosis. This is partly because mental health professionals have a long history of inappropriately or inaccurately assigning psychiatric diagnoses to cultural minority groups (Paniagua, 2014). To address this challenge, in the latest edition of the Diagnostic and Statistical Manual (DSM-5; American Psychiatric Association, 2014), a Cultural Formulation Interview (CFI) protocol is included to aid the diagnostic interview process.

The CFI is a highly structured brief interview. It is not a method for assigning clinical diagnoses; instead, its purpose is to function as a supplementary interview that enhances the clinician’s understanding of potential cultural factors. It also may aid in the diagnostic decision-making process. The CFI includes an introduction and four sections (composed of 16 specific questions). The four sections include:

1. Cultural definition of the problem
2. Cultural perceptions of cause, context, and support
3. Cultural factors affecting self-coping and past help seeking
4. Cultural factors affecting current help seeking

Questions from each section are worded in ways to help clinicians gently explore cultural dimensions of their clients’ problems. Question 2 is a good representation: “Sometimes people have different ways of describing their problem to their family, friends, or others in their community. How would you describe your problem to them?” (American Psychiatric Association, 2014).

Clinicians are encouraged to use the CFI in research and clinical settings. There is also a mechanism for users to provide the American Psychiatric Association with feedback on the CFI’s utility. It may be reproduced for research and clinical work without permission, which is a cool thing.

If you Google: “Cultural Formulation Interview” the first non-advertised hit should be a .pdf of the CFI.

If you Google: “Clinical Interviewing” the first several hits will take you to some form or another of our text on the topic.

Here’s a photo of me “working” inter-culturally with my brother-in-law (insert smiley face here):

Rebekah.Johnson.photo_0451

 

 

Clinical Interviewing

A Brief History of the Clinical Interview

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This is a short excerpt (pre-publication) from the forthcoming Encyclopedia of Clinical Psychology, edited by R. Cautin and S. Lilienfeld. My coauthors on this were Waganesh Zeleke and Meredith Hood. Waganesh is now at Duquesne University and Meredith is busy working on her dissertation.

This section is an interesting–albeit academically oriented–description of the history of the clinical interview.

A Brief History of the Clinical Interview

The term “interview” was first used in the 1500s to refer to a formal conference or face-to-face meeting. The term “clinical” has origins from around 1780 and is linked to an objective or coldly dispassionate approach to bedside observations and treatment of hospital patients. Although difficult to determine the precise origin of the joining of clinical and interview in modern use, it appears that Jean Piaget (1896 – 1980) was the first psychologist to use a variant of the term clinical interview.

In 1920, as Piaget was working to develop a standardized French version of an English reasoning test with Theodore Simon in the Binet laboratory in Paris, he became more interested in the fundamental nature of children’s thinking than in the ranking of children’s intellectual ability on a standardized test. Realizing that existing psychological research methods were inadequate for studying cognitive development, he began using an interviewing approach that had much in common with psychiatric diagnostic interviews. He referred to his process as the “semiclinical interview” (Elkind 1964). Piaget’s semiclinical interview combined standard and nonstandard questioning as a means for exploring the richness of children’s thought.

Similar to Piaget’s initial efforts to combine a rigorously standardized protocol with spontaneous or unplanned questioning, the definition and implementation of the clinical interview has historically and presently been characterized by tension between a highly structured or protocol-driven interaction versus an unstructured or free-response process. In a report on structured clinical interviews, Abt (1949) provided an early articulation of this dialectical tension inherent to the clinical interview, noting that researchers did not want to lose the rich, projective, and idiosyncratic material obtained in a clinical interview, but also needed reliable interviewing procedures that were quantifiable.

Abt’s comments captured the qualitative vs. quantitative nature of most historical and contemporary controversies concerning the clinical interview. On the one side, adherents to the medical model view the clinical interview as a scientific assessment endeavor, emphasizing its quantitative nature and psychometrics (e.g., reliability and validity). On the other side, many practitioners view the clinical interview as a means for obtaining qualitative and idiosyncratic data about patients, using both the process and the data obtained to strengthen the therapeutic relationship and move toward a culturally and individually tailored intervention. Since the 1940s the clinical interview has been considered as either a method for gathering facts about symptoms that align with a scientifically valid diagnosis or a relational experience designed to understand the subjective world of another. There are some who contend that the clinical interview can and should be both a scientific and relational process (Sommers-Flanagan and Sommers-Flanagan 2012).

Clinical Interviewing, Cool Counseling, Therapy with Adolescents, Tough Kids, Tough Kids Cool Counseling

January is an Excellent Month to Attend Workshops in Cincinnati

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Just in case you’re planning to be in or around the Cincinnati area this weekend, the Greater Cincinnati Counseling Association (GCCA) is offering a day and a half of workshops starting on Friday afternoon, January 10 and two workshops with one of my favorite workshop presenters on Saturday, January 11. Here’s the info:

On Friday, January 10, there are two Ethics workshops to choose from:

2:00-5:15

School Counselor Ethics: Case

Discussions and Current Trends

Tanya Ficklin

Or

2:00-5:15

Ethical and Professional Issues:

Therapeutic Alliance Building and

Ethical Considerations When

Working with Children and

Families

Barbara Mahaffey

On Saturday, January 11, I’m doing two separate ½ day workshops:

Tough Kids, Cool Counseling

John Sommers-Flanagan

Saturday 8:45-12:00

Therapy with adolescents can be immensely frustrating or splendidly gratifying. The truth of this statement is so obvious that the supportive reference, at least according to many adolescents is, “Duh!” In this workshop participants will sharpen their therapy skills by viewing and discussing video clips from actual sessions and participating in live demonstrations. Over 20 specific cognitive, emotional, and constructive therapy techniques will be illustrated and/or demonstrated. Examples include acknowledging reality, informal assessment, the affect bridge, therapist spontaneity, early interpretations, asset flooding, externalizing language, and more. Countertransference and multicultural issues will be highlighted.

Suicide Assessment Interviewing

Saturday 1:00-4:15

John Sommers-Flanagan

Freud once said, “By words one person can make another blissfully happy or drive him to despair.” Ironically, traditional adolescent suicide assessment and intervention procedures overemphasize a pathology-based biomedical model that orients adolescents toward despair. In this workshop suicidal crises are reformulated as normal expressions of human suffering and a specific, positive, and practical approach to adolescent suicide assessment interviewing is described. This contemporary adolescent suicide assessment model has a constructive focus, addresses diversity issues, and integrates differential activation theory and Jobes’s approach to Collaborative Assessment and Management of Suicidality. Specific suicide intervention procedures will be described and reformulated.

You can register for these workshops by phone by calling: 513-688-0092

 

Clinical Interviewing, Therapy with Adolescents, Tough Kids Cool Counseling

The Therapist’s Opening Statement (or Question) with Adolescents

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           Working with adolescents or teenagers is different from working with adults. In this excerpt from a recently published article with Ty Bequette, we briefly focus on how the opening interaction with an adolescent client might look different than an opening interaction with an adult client. This is from: Sommers-Flanagan, J., & Bequette, T. (2013). The initial interview with adolescents. Journal of Contemporary Psychotherapy, 43(1), 13-22.

            When working with adults, therapists often open with a variation of, “What brings you for counseling” or “How can I be of help” (J. Sommers-Flanagan & Sommers-Flanagan, 2012). These openings are ill-fitted for psychotherapy with adolescents because they assume the presence of insight, motivation, and a desire for help—which may or may not be correct.

Based on clinical experience, we recommend opening statements or questions that are invitations to work together. Adolescent clients may or may not reject the invitation, but because adolescent clients typically did not select their psychotherapist, offering an invitation is a reasonable opening. We recommend invitations that emphasize disclosure, collaboration, and interest and that initiates a process of exploring client goals. For example,

I’d like to start by telling you how I like to work with teenagers. I’m interested in helping you be successful. That’s my goal, to help you be successful in here or out in the world. My goal is to help you accomplish your goals. But there’s a limit on that. My goals are your goals just as long as your goals are legal and healthy.

The messages imbedded in that sample opening include: (a) this is what I am about; (b) I want to work with you; (c) I am interested in you and your success; (d) there are limits regarding what I will help you with. It is very possible for adolescent clients to oppose this opening in one way or another, but no matter how they respond, a message that includes disclosure, collaboration, interest, and limits is a good beginning.

Some adolescent clients will respond to an opening like the preceding with a clear goal statement. We’ve had clients state: “I want to be happier.” Although “I want to be happier” is somewhat general, it is a good beginning for parsing out more specific goals with clients.    Other clients will be less clear or less cooperative in response to the invitation to collaborate. When asked to identify goals, some may say, “I don’t know” while others communicate “I don’t care.”

Concession and redirection are potentially helpful with clients who say they don’t care about therapy or about goal-setting. A concession and redirection response might look like this: “That’s okay. You don’t have to care. How about we just talk for a while about whatever you like to do. I’d be interested in hearing about the things you enjoy if you’re okay telling me.” Again, after conceding that the client does not have to care, the preceding response is an invitation to talk about something less threatening. If adolescent clients are willing to talk about something less threatening, psychotherapists then have a chance to listen well, express empathy, and build the positive emotional bond that A. Freud (1946, p. 31) considered a “prerequisite” to effective therapy with young clients.

Some adolescents may be unclear about limits to which psychotherapists influence and control others outside therapy. They may imbue therapists with greater power and authority than reality confers. Some adolescents may envision their therapist as a savior ready to provide rescue from antagonistic peers or oppressive administrators. Clarification is important:

Before starting, I want to make sure you understand my role. In therapy you and I work together to understand some of the things that might be bugging you and come up with solutions or ideas to try. But, even though I like to think I know everything and can solve any problem, there are limits to my power. For example, let’s say you’re having a conflict with peers. I would work with you to resolve these conflicts, but I’m not the police, and I can’t get them sent to jail or shipped to military school. I can’t get anyone fired, and I can’t help you break any laws. Does that make sense? Do you have any questions for me?

A clear explanation of the therapist’s role and an explanation about counseling process can allay uncertainties and fears about therapy. Inviting questions and allowing time for discussion helps empower adolescent clients, build rapport, and lower resistance.

Clinical Interviewing

Powerpoint Slides from the ACES Clinical Interviewing Presentation in Denver

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This post includes a link to the powerpoiint slides for our presentation at the Association for Counselor Education and Supervision in Denver, CO. For this we offer a BIG THANKS to Sidney Shaw, Ed.D. who presented on our behalf so we could be in Erie, PA for the birth of our new granddaughter, Nora Flanagan Bodnar. Thanks Sidney!!

ACES clinical interview

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice

Strategies for Working Effectively with Challenging Clients

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Working with clients who are reluctant or resistant to counseling can be very challenging . . . unless you use skills to help minimize resistance and maximize cooperation. The following is adapted from Chapter 12: Challenging Clients and Demanding Situations of the forthcoming 5th edition of Clinical Interviewing. Remember, these skills have to come from a foundation of therapist genuineness.

Using Emotional Validation, Radical Acceptance, Reframing, and Genuine Feedback

Clients sometimes begin interviews with expressions of hostility, anger, or resentment. If this is handled well, these clients may eventually open up and cooperate. The key is to refrain from lecturing, scolding, or retaliating when clients express hostility. Speaking from the consultation-liaison psychiatry perspective, Knesper (2007) noted: “Chastising and blaming the difficult patient for misbehavior seems only to make matters worse” (p. 246).

Instead, empathy, emotional validation, and concession are more effective responses. We often coach graduate students on how to use concession when power struggles emerge, especially when they’re working with adolescent clients (J. Sommers-Flanagan & Sommers-Flanagan, 2007b). For example, if a young client opens a session with, “I’m not talking and you can’t make me,” we recommend responding with complete concession of power and control: “You’re absolutely right. I can’t make you talk, and I definitely can’t make you talk about anything you don’t want to talk about.” This statement validates the client’s need for power and control and concedes an initial victory in what the client might be viewing as a struggle for power.

Empathy and Emotional Validation

Empathic, emotionally validating statements are also important. If clients express anger at meeting with you, a reflection of feeling and/or feeling validation response can let them know you hear their emotional message loud and clear. In some cases, as in the following example, therapists might go beyond empathy and emotional validation and actually join clients with a parallel emotional response:

  • “Of course you feel angry about being here.”
  • “I don’t blame you for feeling pissed about having to see me.”
  • “I hear you saying you don’t trust me, which is totally normal. After all, I’m a stranger, and you shouldn’t trust me until you get to know me.”
  • “It pretty much sucks to have a judge require you to meet with me.”
  • “I know we’re being forced to meet, but we’re not being forced to have a bad time together.”

Radical Acceptance

Radical acceptance is a dialectical behavior therapy principle and technique based on person-centered theory (Linehan, 1993). It involves consciously accepting and actively welcoming any and all client comments—even odd, disturbing, or blatantly provocative comments (J. Sommers-Flanagan & Sommers-Flanagan, 2007a). For example, we’ve had experiences where clients begin their sessions with angry statements about the evils of psychology or counseling:

Opening Client Volley: I don’t need no stupid-ass counseling. I’m only here because my wife is forcing me. This counseling shit is worthless. It’s for pansy-ass wimps like you who need to sit around and talk rather than doing any real work.

Radical Acceptance Return: Wow. Thanks for being so honest about what you’re thinking. Lots of people really hate psychologists but they just sit here and pretend to cooperate. So I really appreciate you telling me exactly what you’re thinking.

Radical acceptance can be combined with reframing to communicate a deeper understanding about why clients have come for therapy. Our favorite version of this is the “Love reframe” (J. Sommers-Flanagan & Barr, 2005).

Client: This is total bullshit. I don’t need counseling. The judge required this. Otherwise, I can’t see my daughter for unsupervised visitation. So let’s just get this over with.

Therapist: I hear you saying this is bullshit. You must really love your daughter . . . to come here even when you think it’s a worthless waste of your time.

Client: (Softening) Yeah. I do love my daughter.

The magic of the love reframe is that clients nearly always agree with the positive observation about loving someone, which turns the interview toward a more pleasant focus.

Genuine Feedback

Often, when working with angry or hostile clients, there’s no better approach than reflecting and validating feelings . . . pausing . . . and then following with honest feedback and a solution-focused question.

“I hear you saying you hate the idea of talking with me, and I don’t blame you for that. I’d hate to be forced to talk to a stranger about my personal life too. But can I be honest with you for a minute? [Client nods in assent]. You know, you’re in legal trouble. I’d like to try to be helpful—even just a little. We’re stuck meeting together. We can either sit and stare at each other and have a miserable hour or we can talk about how you might dig yourself out of this legal hole you’re in. I can go either way. What do you think . . . if we had a good meeting today, what would we accomplish?”

Think about how you can incorporate, empathy, emotional validation, concession, radical acceptance, and genuine feedback into your clinical practice. For more on this, check out the 5th edition of Clinical Interviewing.

Clinical Interviewing

A General Guide to Using Stages of Change Principles in Clinical Interviewing

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This week I’ve been working on reading and editing the page proofs for the forthcoming 5th edition of Clinical Interviewing (John Wiley & Sons). The information below is from a “Putting It Into Practice” box from the 4th chapter. It focuses on a brief Q&A regarding the application of Prochaska and DiClemente’s “Stages of Change” concept in clinical interviewing and presupposes that you have basic knowledge of that particular piece of their Transtheoretical Model.

A General Guide to Using Stages of Change Principles in Clinical Interviewing

Below we pose and answer four basic questions about how to apply stages of change principles (Prochaska & DiClemente, 2005) to guide the techniques and responses you choose to use within a clinical interviewing context.

Q1: When should I use directive techniques like psychoeducation or advice?

A1: When clients are in the action or maintenance stages of change you’re free to be more directive (provided you have useful information to share that fits with what the client recognizes as his or her problem).

Q2: When should I use less directive listening responses like paraphrasing, reflection of feeling, and summarization?

A2: As a general rule, if your client is in the precontemplative or contemplative stages of change, you should primarily use nondirective listening skills to help the client look at his or her own motivations for change. This would include: (a) attending behaviors, (b) paraphrasing, (c) clarification, (d) reflection of feeling, and (e) summarizing. Many questions, especially open questions and solution-focused or therapeutic questions, may be appropriate for clients who are precontemplative or contemplative. When you’re with clients who present as precontemplative or contemplative, your best theoretical orientation choices will likely be person-centered, motivational interviewing, and/or solution-focused. Using more directive approaches can produce defensiveness or resistance with clients in precontemplative or contemplative stages.

Q3: How do I know what stage of change my client is in?

A3: We’re tempted to suggest you’ll know it when you see it . . . and there’s some truth to that. If you try directly recommending a strategy for change and the client responds defensively, you may be moving forward too fast and it’s advisable to retreat to using reflective listening skills. Conversely, if your client seems frustrated with your nondirective listening and expresses interest in changing now, then you’ve got the green light to be more directive. Also, we recommend using George Kelly’s (1955) credulous approach to assessment, meaning you can always just directly ask clients what they prefer. In our work with parents we do this explicitly by stating something like:

“I want to emphasize that this is your consultation. And so if I’m talking too much, just tell me to be quiet and listen and I will. Or, if you start feeling like you want more advice and suggestions, let me know that as well.” (J. Sommers-Flanagan & Sommers-Flanagan, 2011, p. 60)

There are also standardized methods for assessing clients’ readiness for change. Interestingly, most of these involve asking clients very direct questions about their motivation to change, how difficult they expect change to be, and how ready they are to change (all of which seem in the spirit of George Kelly’s credulous approach; for example, see (Chung et al., 2011) for a study on the predictive validity of four different measures assessing client readiness to stop smoking cigarettes).

Q4: Is the stages of change concept supported by empirical evidence?

A4: The data are mixed on whether and how much attending to and using interventions that fit your clients’ stages of change makes a difference. Of course, this is true for nearly every phenomenon in counseling and psychotherapy.  Overall, some studies show strong support for gearing your interviewing techniques to your clients’ stage of change (Johnson et al., 2008). Other studies show that stages of change focused interventions do no better than interventions that don’t tune into clients’ particular motivational stage (Salmela, Poskiparta, Kasila, Vähäsarja, & Vanhala, 2009). We recognize this isn’t the clear and decisive research outcome you might hope for, but such is the nature of our profession.

For more information on Clinical Interviewing, 5th edition, go to: http://www.wiley.com/WileyCDA/WileyTitle/productCd-1118270045.html

 

Clinical Interviewing

IS PATH WARM – An Acronym to Guide Suicide Risk Assessment

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Suicide Risk Factors, Acronyms, and the Evidence Base

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

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

I = Ideation

S = Substance Use

P = Purposelessness

A = Anxiety

T = Trapped

H = Hopelessness

W = Withdrawal

A = Anger

R = Recklessness

M = Mood Change

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

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

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

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

Clinical Interviewing

The Exciting New Preface from Clinical Interviewing (5th edition)

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It’s hard to adequately express the excitement surrounding the upcoming publication of the DSM-5. Oops. I meant to write: “the 5th edition of Clinical Interviewing.” I knew there was a 5 in there somewhere.

To help the many world citizens eagerly anticipating this 5th edition, I’m including, hot off of my computer, the first part of the preface. I know . . . it really couldn’t get much more exciting than this.

Who knows, soon I might even be releasing the second part of the preface to this long-awaited masterpiece. [I hope you all can recognize the sarcasm I’m directing toward myself when you read this. It’s just that I’m working on the preface right now and I felt the need to post something on my blog . . . and these two things suddenly merged in space and time.]

Here it is.

Preface

Clinical interviewing is the cornerstone for virtually all mental health work. It involves integrating varying degrees of psychological or psychiatric assessment and treatment. The origins of clinical interviewing long precede the first edition of this text (published in 1993).

The term interview dates back to the 1500s, originally referring to a face-to-face meeting or formal conference. The term clinical originated around 1780; it was used to describe a dispassionate, supposedly objective bedside manner in the treatment of hospital patients. Although difficult to determine precisely when clinical and interview were joined in modern use, it appears that Jean Piaget used a variant of the term clinical interview in 1920 to describe his approach to exploring the nature and richness of children’s thinking. Piaget referred to his procedure as a semi-clinical interview (see Sommers-Flanagan, Zeleke, & Hood, in press).

Our initial exposure to clinical interviewing was in the early 1980s in a graduate course at the University of Montana. Our professor was highly observant and intuitive. We would huddle together around an old cassette player and listen to fresh new recordings of graduate students interviewing perfect strangers. Typically, after listening to about two sentences our professor would hit the pause button and prompt us: “Tell me about this person.”

We didn’t know anything, but would offer limited descriptions like “She sounds perky” or “He says he’s from West Virginia.” He would then regale us with predictions. “Listen to her voice,” he would say, “she’s had rough times.” “She’s depressed, she’s been traumatized, and she’s come to Montana to escape.”

The eerie thing about this process was that our professor was often correct in what seemed like wild predictions. These sessions taught us to respect the role of astute observations, experience, and intuition in clinical interviewing.

Good intuition is grounded on theoretical and practical knowledge, close observation, clinical experience, and scientific mindedness. Bad intuition involves personalized conclusions that typically end up being a disservice to clients. Upon reflection, perhaps one reason we ended up writing and revising this book is to provide a foundation for intuition. In fact, it’s interesting that we rarely mention intuition in this text. Although one of us likes to make wild predictions of the future (including predictions of the weather on a particular day in Missoula, Montana, about three months in advance), we still recognize our limitations and encourage you to learn the science of clinical interviewing before you start practicing the art.

Language Choices

We live in a postmodern world in which language is frequently used to construct and frame arguments. The words we choose to express ourselves cannot help but influence the message. Because language can be used to manipulate (as in advertising and politics), we want to take this opportunity to explain a few of our language choices so you can have insight into our biases and perspectives.

Patients or Clients or Visitor

Clinical interviewing is a cross-disciplinary phenomenon. While revising this text we sought feedback from physicians, psychologists, social workers, and professional counselors. Not surprisingly, physicians and psychologists suggested we stick with the term patient, whereas social workers and counselors expressed strong preferences for client. As a third option, in the Mandarin Chinese translation of the second edition of this text, the term used was visitor.

After briefly grappling with this dilemma, we decided to primarily use the word client in this text, except for cases in which patient is used in previously quoted material. Just as Carl Rogers drifted in his terminology from patient to client to person, we find ourselves moving away from some parts and pieces of the medical model. This doesn’t mean we don’t respect the medical model, but that we’re intentionally choosing to use more inclusive language that emphasizes wellness. We unanimously voted against using visitor—although thinking about the challenges of translating this text to Mandarin made us smile.

Sex and Gender

Consistent with Alfred Adler, Betty Freidan, contemporary feminist theorists, and American Psychological Association (APA) style, we like to think of ourselves as promoting an egalitarian world. As a consequence, we’ve dealt with gender in one of two ways: (1) when appropriate, we use the plural clients and their when referring to case examples; and (2) when necessary, we alternate our use between she and he.

Interviewer, Psychotherapist, Counselor or Therapist

While working at a psychiatric hospital in 1980, John once noticed that if you break down the word therapist it could be transformed into the-rapist. Shocked by his linguistic discovery, he pointed it out to the hospital social worker, who quipped back, “That’s why I always call myself a counselor!”

This is a confusing issue and difficult choice. For the preceding four editions of this text we used the word interviewer because it fit so perfectly with the text’s title, Clinical Interviewing. However, we’ve started getting negative feedback about the term. One reviewer noted that he “hated it.” Others complained “It’s too formal” and “It’s just a weird term to use in a text that’s really about counseling and psychotherapy.”

Given the preceding story, you might think that we’d choose the term counselor, but instead we’ve decided that exclusively choosing counselor or psychotherapist might inadvertently align us with one professional discipline over another. The conclusion: Mostly we use therapist and occasionally we leave in the term interviewer and also allow ourselves the freedom to occasionally use counselor, psychotherapist, and clinician.