· Review the media Clinical Interview: Intake, Assessment,& Therapeutic Alliance in your Learning Resources. · Select one nursing theory and one counseling theory to best guide your practice in psycho
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· Review the media Clinical Interview: Intake, Assessment,& Therapeutic Alliance in your Learning Resources.
· Select one nursing theory and one counseling theory to best guide your practice in psychotherapy.
For guidance on nursing and counseling theories, refer to the Wheeler textbook in this week’s Learning Resources.
· Explain why you selected these theories. Support your approach with evidence-based literature.
· Develop at least three goals and at least three objectives for the practicum experience in this course.
· Create a timeline of practicum activities based on your practicum requirements.
· Review the media Clinical Interview: Intake, Assessment,& Therapeutic Alliance in your Learning Resources. · Select one nursing theory and one counseling theory to best guide your practice in psycho
00:17 JOHN SOMMERS-FLANAGAN: Welcome to00:19 our clinical interviewing DVD.00:21 In this video, we describe and demonstrate00:25 a wide range of different clinical00:27 interviewing responses.00:29 Our goal is to help you further develop00:33 your clinical interviewing repertoire.00:37 The material in this DVD is based on our textbook, cleverly00:42 titled clinical interviewing.00:45 RITA SOMMERS-FLANAGAN: In our life as professors,00:47 we really have come to believe in that old kindergarten00:51 activity called show and tell.00:53 So in this video, we’re obviously00:55 going to be telling you about clinical interviewing skills,00:59 but we also will be showing you video clips that01:02 illustrate these.01:03 And we really hope that together they’ll01:06 combine to help you become excellent clinical01:10 interviewers.01:12 JOHN SOMMERS-FLANAGAN: And we begin01:13 with a focus on very basic interviewing and listening01:17 skills, skills that everyone needs01:21 to do a really good clinical interview.01:24 These skills include attending behavior,01:27 non-directive listening, directive listening, and action01:32 responses, as well as the skill the use of questions.01:36 Later, we move to demonstrating more complex assessment01:40 interviews, including intake, mental status, and suicide01:44 assessment interviewing.01:47 RITA SOMMERS-FLANAGAN: You know, our overall goal in this DVD01:51 is to help you become aware of how to do the skills01:56 and when to do the skills.01:58 Awareness isn’t under-girding.02:01 That’s very important in conducting02:04 professional clinical interviews and in being a mental health02:07 professional.02:09 JOHN SOMMERS-FLANAGAN: You know, just a few years ago, Rita,02:11 although I might be underestimating02:13 that, we had a clinical supervisor who02:16 used to always say, don’t fly by the seat of your pants.02:19 You need to know what you’re doing and why you’re doing it.02:22 You need to know where you’re going, basically.02:25 And I think what he also was saying02:27 is that as clinical interviewers,02:29 we need to become more intentional.02:32 And so that’s another goal that we have for this video.02:35 And that is we hope that it can move you in that direction02:38 so you become a little bit more intentional in your clinical02:41 interviewing activities.02:52 In the next four parts of this interviewing DVD,02:56 we focus on what we call the continuum02:59 of listening responses, beginning with the less03:03 directive, almost non-directive listening approaches03:07 and extending to the more complex and directive03:10 interviewing or even action skills.03:13 RITA SOMMERS-FLANAGAN: I think it’s important03:15 before we actually talk about the techniques03:17 that we take a minute to think about a couple03:21 of things that are across techniques in interviewing.03:25 One is that because there’s a power03:29 differential in the relationship,03:31 and we can never not communicate,03:34 the interviewer can be seen as directive even when03:39 they’re not doing anything.03:40 It’s just associated with the authority.03:42 JOHN SOMMERS-FLANAGAN: Yeah.03:43 Rita, that reminds me.03:45 And it goes without saying, but you know me,03:47 I’m going to say it anyway, that culture03:49 and the individual characteristics of the client03:53 are very important in the clinical interviewing process.03:57 For example, if you don’t consider race, sex, ethnicity,04:03 and many other background factors,04:05 it may be that you’ll be tuned out and insensitive to things04:09 that you’re doing that might be off putting to the client.04:13 For example, if you’re listening closely, and leaning forward,04:18 and nodding vigorously, making great eye contact,04:22 but your client is sort of leaning backwards, and looking04:25 awkward, and uncomfortable, it’s your problem.04:28 It is definitely not the client’s problem.04:30 And you need to make some changes in your approach.04:33 I also find that there’s a little subjectivity04:36 in how I respond personally to interviews.04:40 And for example, when you said, I understand,04:43 I just really kind of don’t like that at all.04:45 Because I think technically you can’t really understand04:48 the deep experience of another person,04:53 especially if the person’s from another race04:55 or another culture.04:56 RITA SOMMERS-FLANAGAN: Yeah, yeah, you’re right.04:58 It’s very subjective.05:00 And there are, I think, some bad or ineffective ways05:07 of listening that aren’t just ineffective.05:10 I think they are harmful.05:14 I think looking at your watch, glancing around, yawning…05:20 JOHN SOMMERS-FLANAGAN: Or maybe interrupting, interrupting05:23 could be one of those negative behaviors.05:24 RITA SOMMERS-FLANAGAN: Yeah, I agree.05:26 I think that across cultures, people05:30 have some kind of awareness or radar that tells them05:34 when they’re not being listened to05:36 and they’re not being respected, yeah.05:38 JOHN SOMMERS-FLANAGAN: So I guess05:40 the bottom line is listen well, listen authentically for you,05:43 but also try to calibrate or adjust the way05:46 you’re listening for the specific individual05:49 who you’re with in the room.05:50 RITA SOMMERS-FLANAGAN: Yeah, I think05:52 too I want to underline something05:53 I tell my students over and over again.05:56 Listening is a gift.05:59 Listening in our culture, being listened to very,06:01 very well, is really a rare and a helpful gift.06:05 Let’s talk about some of these listening techniques,06:08 the least directive set of interviewing06:11 skills, non-directive listening responses.06:14 JOHN SOMMERS-FLANAGAN: Right.06:15 RITA SOMMERS-FLANAGAN: So the first one06:17 is Allen Ivey’s attending behaviors.06:20 And these include eye contact, body posture, voice tone,06:27 and verbal tracking.06:29 JOHN SOMMERS-FLANAGAN: And Ivey wrote06:30 about those as basic micro skills that06:32 are always present in the interviewing interaction.06:36 In addition to those, there are also06:38 some non-directive listening responses.06:41 These include silence, clarifications, paraphrasing…06:46 And there’s several different kinds06:48 of paraphrases people can use…06:50 Reflection of feeling, and summarization.06:54 RITA SOMMERS-FLANAGAN: Silence can be a very compassionate06:57 response.06:58 Just sitting quietly after somebody has shared07:02 their pain or their story can be difficult but very powerful.07:08 The important thing is, John, you’ve07:10 got to have your body, and your mind,07:14 and your face all really connected to the client,07:17 really saying, I hear you.07:20 I’m right here in the room with you.07:23 I can handle this.07:25 JOHN SOMMERS-FLANAGAN: You know, I think that’s a great point.07:27 Almost every student I’ve ever worked with07:30 has wished that they had exactly the right thing to say07:34 at the right time.07:35 RITA SOMMERS-FLANAGAN: Right.07:36 JOHN SOMMERS-FLANAGAN: And sometimes silence is exactly07:38 the right thing to say.07:39 Although, I think especially for beginning interviewers,07:42 five or 10 seconds of silence can seem like an eternity.07:46 And so they can feel like they need to say something.07:49 And even myself, at times, I noticed07:51 I should put my hand over my mouth07:54 and try to stop myself from talking too much.07:57 RITA SOMMERS-FLANAGAN: Verbal output, yeah,07:59 so silence certainly is a skilled tool08:01 and an important one.08:02 But of course, we also need some other non-directive techniques08:08 that we can use.08:09 JOHN SOMMERS-FLANAGAN: Tell me more about that.08:11 RITA SOMMERS-FLANAGAN: Well, that was one,08:12 and verbal prompt.08:14 JOHN SOMMERS-FLANAGAN: Mmhmm.08:15 RITA SOMMERS-FLANAGAN: Mmhmm.08:16 And also we can use paraphrasing,08:20 which means just reflecting back the content that you’ve heard.08:25 Although, I have to say something about that.08:28 When paraphrasing is done in a clumsy way,08:32 I think it can seem like you’re mimicking the client.08:35 It can seem kind of robotic.08:38 JOHN SOMMERS-FLANAGAN: So what you’re saying08:39 is that although you think paraphrasing is very important,08:43 you really don’t like it when it’s done in kind08:45 of a mimicky or robotic way.08:47 RITA SOMMERS-FLANAGAN: Thank you, John Carl08:49 Rogers Sommers-Flanagan.08:52 I hate when you do that.08:53 So what you’re saying is you really08:54 don’t like it when I talk like Carl Rogers.08:58 RITA SOMMERS-FLANAGAN: Well, I like Carl Rogers,09:00 but so let’s move on.09:02 How about this.09:03 How about you say something, and I’ll09:05 demonstrate a clarification.09:07 JOHN SOMMERS-FLANAGAN: Sounds good.09:08 You know, one of the things that is09:10 I think true for me is that sometimes in my students,09:14 I have observed them having naturally good listening09:17 skills.09:18 It’s like they seem to be born to listen,09:21 while other students, it’s more of a challenge for them.09:23 And they need to work at it a little harder.09:25 But what I found is that the virtually everyone09:28 is able to increase or improve their listening skills.09:32 And so that kind of gives me hope for everyone.09:37 RITA SOMMERS-FLANAGAN: So what I think I hear you saying09:40 is that listening skills and abilities09:44 can be something someone naturally has, more or less of.09:48 But in the years you’ve worked in this area,09:52 you’ve realized that everyone can09:54 learn to be a better listener.09:57 Did I get that right?09:58 JOHN SOMMERS FLANAGAN: Absolutely right,10:00 and it feels good to be heard.10:01 And so now let’s watch the magic of listening skills in action.10:07 Now this video clip begins a couple of minutes10:10 into a session where the client, Jessie, is talking10:14 about a roommate problem.10:15 The therapist, Megan, has a very gentle and accepting style,10:20 which allows Jessie to explore her concerns in depth.10:25 Early on, you should especially watch for Megan’s paraphrase10:30 about Jesse having no time for herself.10:33 Because there’s not even a hint of a robot in the room.10:38 JESSIE: I just, I can’t.10:44 I feel like she uses me as like a sounding board,10:49 and I get nothing in return.10:51 RITA SOMMERS-FLANAGAN: You said several times10:53 while talking that she doesn’t listen to you10:57 or doesn’t even give you the opportunity to talk.11:00 It seems like she just talks, talks, talks.11:02 JESSIE: Yeah.11:03 MEGAN: And then you’re listening,11:04 and that’s exhausting.11:06 Or you’re kind of getting angry and irritated by it.11:14 JESSIE: Yeah, yeah, I do.11:17 It’s just frustrating when somebody comes11:19 and they talk to you for like half an hour11:21 about all of their problems.11:23 And then it’s like once they’re done, they’re like, OK.11:25 I don’t care about how you are, what you’re doing.11:27 So she’ll go off and do whatever,11:33 or watch TV, or something.11:34 And whenever I do try to talk to her,11:36 she’s like either playing a video game or on her phone.11:39 Or she’ll just start in with oh, did that happen to you?11:43 That happened to me.11:45 And it’s just like, oh my gosh.11:47 MEGAN: Then she’ll go on into it.11:49 JESSIE: Yeah, and then she’ll just11:50 go off about her own story.11:56 I care about our friendship, because it’s11:59 been like a five or six or something year-long friendship.12:03 And so I would like to continue that.12:07 And so I think we could still be friends,12:10 if we didn’t live together.12:11 But the whole not living together part12:14 has to be crucial.12:16 Yeah.12:17 MEGAN: Yeah, it seems like you’ve12:20 talked a lot about the different things12:25 that you’re dealing with within this relationship with her,12:29 in terms of not being heard and not enjoying, just12:37 not enjoying, being around her anymore12:40 and not wanting to go home.12:43 JESSIE: That’s the worst part.12:44 MEGAN: And feeling frustrated by it,12:47 but also just it almost seems like you’re not12:51 sure what to do about it.12:52 JESSIE: Yeah.12:54 I guess I’m just not sure how to bring up12:57 not living together anymore.13:03 I’ll be gone for the summer, so part of me13:05 thinks that would be a way.13:07 Because like she has to find a new place13:10 or continue to pay rent where we are.13:13 And I don’t want to have to do that.13:16 And so part of me wants to be like,13:17 well, I’m just not going to be here.13:19 So we can’t live together because of that.13:21 Because you need to get into a place13:24 and start paying before I’ll even be here.13:27 And so I kind of want to just approach it that way.13:31 But that’s definitely not confronting13:33 the real reason of why I don’t want to live with her.13:38 MEGAN: What’s hard about that, about confronting her?13:45 JESSIE: Because I like confrontations.13:48 And I don’t like making people feel upset.13:52 And I’m pretty sure that she would cry,13:55 and get defensive, and angry.13:57 And we couldn’t continue a friendship.14:00 It would be like I’m a horrible person for this,14:08 and she wouldn’t want to be my friend.14:10 I would just imagine her getting defensive14:11 and blame me or something.14:16 MEGAN: So when you think about confronting her,14:21 you think that it would end the relationship.14:23 Am I getting that right?14:25 Or that it would kind of lead to that?14:28 JESSIE: Yeah, that’s what I’m afraid of.14:30 Because honestly, I want to say I can’t stand your dogs,14:33 and I can’t stand your attitude.14:36 And I am so exhausted with you.14:40 And I can’t continue to live with her.14:42 That’s how I feel.14:43 RITA SOMMERS-FLANAGAN: That was really nice.14:45 You know, we showed that video, we didn’t really14:49 talk about summarizing or summarization.14:53 Summarizing can really be a great technique to use,14:57 partly because it forces you to listen so well.15:00 Because you’re going to list the main15:03 points that you’ve just heard.15:04 JOHN SOMMERS-FLANAGAN: Yeah, and I15:05 think Megan did a great job of that.15:06 Especially because for myself, and I think many people I know,15:10 it’s so easy for the points that you’re15:12 listening to kind of evaporate in your mind15:15 as you’re trying to formulate the summary.15:18 And she did a great job.15:19 She identified that the client was feeling very unhappy15:23 in the roommate situation, that she was not15:26 wanting to come home, that she didn’t feel heard,15:28 that but she really didn’t even like her roommate anymore.15:32 RITA SOMMERS-FLANAGAN: Yeah, that was a great summary.15:34 One warning is probably not to number15:38 the items that you’re going to say.15:40 Because you can get to number two and suddenly15:43 have no idea what number three was.15:45 So John there’s one last skill that I think maybe15:48 we should talk about before ending this segment.15:51 And that is called the reflection of feeling.15:54 JOHN SOMMERS FLANAGAN: Absolutely,15:55 and I’m really glad that you remembered that.15:59 I find myself just as we go through this production16:04 process, it’s sort of nerve wrecking.16:06 I feel nervous.16:08 I feel anxious.16:09 I try to keep an external composure.16:12 But on the inside, I feel pressure.16:14 I’m worried that we’ll make mistakes,16:16 and that maybe it’s going to be not hopeful, or even worthless,16:22 or even the worst possible scenario that I would just16:24 terribly embarrass myself.16:26 RITA SOMMERS-FLANAGAN: Yeah, so lots of feelings there…16:30 You feel anxious.16:32 You want this to go well.16:34 You have kind of this calm veneer,16:36 but underneath there’s anxiety.16:39 There’s a kind of worry that this won’t go well.16:44 And it just spirals down to the point where16:47 we might be wasting people’s time16:49 and really might just be embarrassed.16:52 JOHN SOMMERS-FLANAGAN: That is very nice.16:54 You did a great and accurate job of identifying16:58 a range of different emotions that I’m feeling.17:02 And I have to say I really appreciate17:03 the fact that stayed with the basic non-directive reflection17:07 of feeling.17:08 You didn’t interpret anything.17:09 You didn’t try to go for my deep-seated neuroses.17:13 RITA SOMMERS-FLANAGAN: Right, well no, it was tempting.17:16 And in the next sections, we’ll have opportunities for that.17:19 But our time’s up for this section.17:21 And we’ll move on to more directive listening and action17:25 responses.17:35 JOHN SOMMERS FLANAGAN: Previously on this video,17:37 we focused on listening skills and techniques that17:39 help the interviewer stay less directive.17:44 And our therapist on the proceeding video clip,17:48 Megan Hopkins, she is a member of the Sioux Assiniboine tribe.17:54 And that particular tribe has strong values and deep beliefs18:01 about the importance of listening18:03 to one another respectfully.18:06 And the extent to which you as a professional clinical18:10 interviewer value listening may also18:14 depend on your cultural background and even18:17 on your personal experiences.18:18 RITA SOMMERS-FLANAGAN: That’s true.18:20 You know, being able to stay non-directive and nonjudgmental18:24 is an important part of interviewing.18:26 But we also have to learn how to use more directive18:30 interventions and actions in a way that maintains the therapy18:35 relationship.18:37 JOHN SOMMERS FLANAGAN: Absolutely.18:38 In this next section, we begin moving further18:42 along the continuum toward more complex and more directive18:46 listening responses.18:49 These responses are referred to as directive listening18:52 responses, because they still primarily focus on listening.18:56 But they also include components that are progressively more19:01 directive.19:02 And so they involve lots of listening,19:04 and a little bit of directing, or pushing clients19:07 to see or think about things a bit differently.19:12 Directive listening responses are more judgmental.19:15 And they include guidance or validation19:18 from the interviewer.19:19 For example, you might use a feeling validation19:22 like, I can sure see why you would feel angry about that.19:28 And that’s sort of a validating response.19:30 It’s no longer non-directive.19:32 RITA SOMMERS-FLANAGAN: Right, and you19:34 might do an interpretive reflection of feeling,19:36 which takes it a little past the feeling that has been stated.19:41 And you might take a guess at a feeling that might actually19:44 be implied or just underneath what the client is saying.19:48 JOHN SOMMERS-FLANAGAN: Some people, Rita,19:49 refer to that as advanced empathy,19:52 because it goes beyond the client’s words.19:55 And speaking of going beyond the client’s words,19:58 from the psychoanalytic perspective,20:01 an even more directive listening response is interpretation.20:06 Interpretations are designed to put two different observations20:11 together and along with an attentive statement about how20:15 they might be related or what they might mean.20:18 These meanings that the interviewer picks up on20:22 might relate to earlier life experiences of the client20:25 or perhaps to some kind of unconscious processes.20:29 RITA SOMMERS-FLANAGAN: Right, and of course20:31 that is sort of theoretically laden.20:33 And some people are little resistant to that kind20:35 of interpretation.20:37 But another way of thinking about it20:39 is when you take information the client is giving you20:43 and you link that to a different reality or different way20:48 of seeing reality, and we call that a re-frame.20:51 It’s also quite directive.20:53 JOHN SOMMERS-FLANAGAN: Yeah, and you might even20:55 do a gentle confrontation.20:57 At least I prefer gentle confrontations.20:59 Because confrontations simply involve pointing out21:02 inconsistencies or discrepancies between what21:06 clients are saying they want and what they’re actually doing.21:11 RITA SOMMERS-FLANAGAN: In this next set,21:13 we’re going to see John working with Trudy,21:17 who’s struggling in her marriage with her husband named Jamie.21:22 And it’s also important to notice21:23 that they have a son named Ross who has a disability.21:28 And Ross is still living with them.21:30 It may be subtle, but notice the difference in tone and style21:35 when the interviewer’s being slightly more21:38 directive than the previous segment with Megan.21:41 TRUDY: And I keep telling him, he21:44 doesn’t have to do it all today.21:47 But then I think he thinks that I’m trying21:53 to sabotage his good health.21:57 I don’t know.21:58 It’s just like everything that I do22:02 that I think is going to be a good thing, a positive thing,22:06 doesn’t turn out that way.22:07 JOHN SOMMERS-FLANAGAN: Yeah, you mentioned22:08 before you feel a little bit scared22:10 at the idea of really being out there kind of on your own.22:13 But also I hear maybe some sadness and some frustration22:18 in the relationship now and that you’re22:20 not even sure where to start.22:23 TRUDY: You know, I don’t.22:24 I sit and think about how our relationship22:28 has been in the past.22:31 And I realized that it wasn’t just since Jamie’s first heart22:35 attack that things have been different.22:41 I just remember a time when this friend of mine22:45 that I was telling you about that is concerned about me,22:49 she called me for lunch one day.22:52 And so we made arrangements go to lunch.22:56 And you know what?22:57 I took Ross with me.23:00 And I remember her looking at me like, I invited you to lunch.23:05 And Ross was 17 years old.23:08 And so consequently, we never talked about girl things23:13 that we might have talked about or anything like that.23:17 It was just about kind of about Ross and trying to keep him23:21 in the conversation, which isn’t always easy because he23:24 has some autism problems.23:26 And I don’t know why I did that.23:32 JOHN SOMMERS-FLANAGAN: Is it OK with you,23:34 Trudy, if I just share with you a thought that I have about one23:38 of the dynamics that I think might be going on.23:41 TRUDY: Sure.23:41 JOHN SOMMERS-FLANAGAN: I hear you saying that sometimes Jamie23:44 says or wonders if you’re trying to sabotage23:47 some of his exercise.23:49 TRUDY: Yeah.23:51 JOHN SOMMERS-FLANAGAN: But I also hear you maybe sometimes23:54 actively sabotaging the possibility of intimacy24:00 with him.24:02 And I just wonder what your reaction is when I say that.24:06 TRUDY: It’s very possible.24:10 And you know, this is one thing, John.24:14 This just really upsets me about myself when I think about it.24:20 I don’t think I even know how to be intimate anymore.24:26 It would seem so foreign to me to spend time with just Jamie24:31 and to talk about our feelings.24:35 JOHN SOMMERS-FLANAGAN: Yeah.24:37 RITA SOMMERS-FLANAGAN: So in that last section,24:39 we saw two interesting things.24:41 We saw an interpretation of feeling,24:43 and we saw confrontation.24:46 The first, the interpretation of feeling,24:49 led Trudy to go into deeper material.24:54 And that’s often an indicator that the interpretation24:57 was accurate.24:59 And then we saw the confrontation, which25:01 of course was very gentle.25:03 We asked the client’s permission,25:06 then offered the interpretation, and then asked her25:09 what she thought about it.25:11 And again, we saw Trudy just go for it.25:14 And that’s an indication that the confrontation25:17 was OK with her.25:18 JOHN SOMMERS-FLANAGAN: One of the reasons25:19 I think I like to ask client’s permission25:21 to do a confrontation is because I’m kind of naturally25:24 averse to confronting people.25:26 So it’s a hard thing for me.25:27 And I also think it helps to engage them25:29 in a more collaborative way.25:32 The other thing I noticed about that clip25:34 was that although Trudy was talking about sabotaging25:38 a lunch with a friend, I brought it back25:41 with the confrontation to her presenting complaint, which25:44 was intimacy with her husband.25:48 RITA SOMMERS-FLANAGAN: Yeah, so in this next little clip,25:51 we’re going to watch John work with TJ.25:56 TJ is a 22-year-old young man with issues around anger,26:00 aggression, and social skills.26:03 This clip that you’re about to see26:04 focuses on TJ’s anger and aggression.26:07 And you’ll see a paraphrase, then an attempt,26:10 and an interpretive reflection of feeling, which TJ corrects,26:14 and then a reflection of feeling, and a clarification.26:17 You’ll see John creating a context for interpretation26:21 and then offering the interpretation.26:27 TJ: fights with family that don’t fully26:30 escalate physically, but kind of break you down.26:36 JOHN SOMMERS-FLANAGAN: So you’ve had some fights26:38 with your family that have been emotionally pretty26:42 painful, maybe lasting emotional effects, not so much physical.26:50 OK.26:53 And when I hear you say that, it sounds26:56 like one of the costs of that is you feel some regret.27:03 Have I got that right?27:04 Or is it something else?27:08 TJ: Not completely, more like sympathy.27:14 JOHN SOMMERS-FLANAGAN: Tell me about that.27:15 TJ: Well, I think emotions are a weakness.27:20 And if I have emotions that make me vulnerable,27:24 when people feel sympathetic of it, it doesn’t help me at all.27:29 JOHN SOMMERS-FLANAGAN: OK.27:34 So it is painful to you emotionally to be27:39 seen as having a weakness.27:41 And so when your family or people27:44 have some sympathy for you, that actually27:46 is something you don’t like?27:49 TJ: No.27:49 JOHN SOMMERS-FLANAGAN: No.27:50 TJ: No, because it’s like they feel27:54 like they have to do something to make you feel better27:58 to get you out of it.28:02 JOHN SOMMERS-FLANAGAN: OK.28:05 I’ve heard you use the word weakness at least three times.28:09 TJ: Yup.28:10 JOHN SOMMERS FLANAGAN: And sometimes when28:10 we talk about anger and anger management stuff,28:12 one of the things we do is we talk28:14 about what are the triggers or the buttons they get28:17 pushed that bring that anger up.28:23 And it makes you wonder if maybe one of the buttons28:28 or the triggers for you is a sense of feeling weak.28:33 Would you say at that might make you pretty pissed sometimes?28:39 TJ: Yeah.28:43 RITA SOMMERS-FLANAGAN: So John, you28:45 were really working with TJ with his emotions28:48 and the triggers that are associated with his aggression.28:54 And you did have that attempt to do28:58 an interpretation of feeling, and he was29:00 able to say, not quite right.29:03 Yeah.29:05 He also, I think, after you corrected,29:10 was starting to get some awareness that even29:13 the slightest whiff of weakness was29:16 going to be a trigger for him.29:18 JOHN SOMMERS-FLANAGAN: Yeah, I do29:19 think it’s good to follow the client’s29:22 lead on interpretive material in particular.29:24 And so when he clarified or told me that it wasn’t quite right,29:30 I wanted to go with his direction rather than mine.29:33 And you know, I think that’s really important,29:35 partly because interpretations when they go well29:40 are collaborative.29:41 And Otto Fenichel said this over 60 years ago,29:44 and that is, that we have to prepare clients29:47 for interpretations and that interpretations are really29:50 a way of us working on the edge of our client’s consciousness29:54 or awareness.29:55 RITA SOMMERS-FLANAGAN: Yeah, there’s29:56 nothing mysterious or woo-woo about interpretations.30:00 They’re not like mind reading.30:02 They really involve a lot of listening and a lot of work.30:05 So directive listening responses obviously30:11 depend more on the view of the interviewer,30:16 and the direction is this a little bit more30:18 related to where the interviewer wants to go than the client.30:22 JOHN SOMMERS-FLANAGAN: Yeah, directive listening responses30:25 are more advanced responses by clinical interviewers.30:29 RITA SOMMERS-FLANAGAN: Well, I agree with you in one sense.30:32 But I also think that actually listening really, really30:37 well is as hard as some of the more directive responses.30:41 JOHN SOMMERS-FLANAGAN: Well, you know, actually30:43 I totally agree with you.30:45 You’ve convinced me.30:46 And really what I was trying to say30:48 is I was trying to make the point30:49 that interviewing in a directive way is sometimes very tempting.30:55 And it’s very natural.30:57 It’s similar to the way we behave socially30:59 in social environments.31:00 And so I do think that to do it well,31:04 it really requires awareness of your goal.31:08 It requires sensitivity to the client,31:11 and it requires practice and probably some wisdom as well.31:23 RITA SOMMERS-FLANAGAN: So in this section,31:25 we’re going to be talking about directives and action31:29 responses, which actually move us31:30 a little further along the continuum of directive31:34 listening skills.31:36 JOHN SOMMERS FLANAGAN: Directives are really31:38 sort of like prescriptions in that they push or move31:42 clients a little bit toward acting, feeling, or thinking31:47 in certain particular ways.31:50 And so it’s really important when31:51 using these kinds of approaches that we weave back and forth31:55 or we integrate into the approach some less directive32:00 or non-directive listening skills… so32:02 a non-directive listening skill like a paraphrase,32:05 and then a directive action response, and then a check32:09 in or paraphrase to follow it.32:11 RITA SOMMERS-FLANAGAN: And you know32:13 we’re talking a lot it about the continuum32:15 as if it’s a linear sort of process.32:18 But actually, it’s sort of dimensional.32:21 Because something that seems very non-directive32:24 can be done in a way that was experienced32:28 as pretty directive.32:30 Raised eyebrow, a tone of voice, choice of words,32:33 posture those kinds of things can32:36 be experienced is as a pretty directive or not attractive.32:40 JOHN SOMMERS-FLANAGAN: I know, I’ve32:41 seen some people raise one eyebrow.32:43 And I’ve never been able to do that.32:45 RITA SOMMERS-FLANAGAN: Can you raise one nose nostril?32:47 JOHN SOMMERS-FLANAGAN: I don’t want to try, especially32:50 not on video.32:51 RITA SOMMERS-FLANAGAN: OK, fine.32:53 So in general, I think the truth is that non-directive things32:59 can be directive and directed things can come off33:03 as non-directive, really depending on how you use them.33:07 JOHN SOMMERS-FLANAGAN: Yeah, when interviewers start sharing33:11 information, or making suggestions,33:14 or expressing agreement, or disagreement,33:17 or approval or disapproval…33:18 RITA SOMMERS-FLANAGAN: Or giving advice…33:21 JOHN SOMMERS FLANAGAN: Self disclosing…33:22 RITA SOMMERS-FLANAGAN: Yeah, self-disclosing, urging…33:25 JOHN SOMMERS-FLANAGAN: When those kinds of things33:27 are happening, it’s obvious that the interviewer33:31 is moving toward action.33:35 And we’re trying to change in those situations33:38 the client’s way of thinking, or way of being, or behaving.33:44 We are in the realm of the directive, which33:47 may be one reason why directives are most effective with clients33:51 who are in Prochaska and DiClemente’s action stage33:57 in the transtheoretical model.33:58 These are people who are ready to engage and work hard34:01 toward change.34:03 RITA SOMMERS-FLANAGAN: Right, right, well,34:04 being directive is not a bad thing.34:06 It’s just that it comes very natural to some bossy firstborn34:12 people.34:13 And they might need, like you’ve been talking about,34:17 to tone it down, to be aware of when to use it.34:20 On the other hand, there are people who are very passive34:24 and the idea of offering something directive34:27 can be sort of terrifying.34:29 So in this next clip, we see John using agreement,34:35 suggestion, and he provides psychoeducational material34:39 effectively and appropriately.34:41 Watch how he engages his client Lisa34:44 with the information and the ideas he offers.34:48 LISA: Well, I don’t want to take drugs.34:51 I’ve tried a couple of glasses of wine at night, doesn’t34:55 seem to help.34:56 JOHN SOMMERS-FLANAGAN: That doesn’t help either.34:57 LISA: No.34:58 I’ve tried a good book, and that’s fine35:01 until I turn off the light.35:02 And then my mind starts racing again.35:06 I just feel overwhelmed and behind.35:15 All my life there have been times like that,35:18 but I’ve been able to see the big picture35:20 and know that it’s just a bump in the road.35:23 Now I’m swallowed up.35:26 JOHN SOMMERS-FLANAGAN: Yeah, that does sound really intense.35:30 Now let’s focus on the sleep just for a little while.35:33 There are three kinds of insomnia, mainly.35:37 One is difficulty falling asleep.35:39 And that’s when you lay there, oftentimes35:41 with racing thoughts, but you can’t35:43 get to sleep often for hours.35:46 The second type is early morning awakening.35:49 And that’s when you go to sleep, and you35:52 sleep most of the night.35:54 But maybe 2:00 or 3:00 in the morning,35:56 depending on when you went to bed,35:57 but way earlier than you want to wake up, you wake up36:01 and then you can’t get back to sleep.36:02 And so that’s early morning awakening.36:04 And the first one is difficulty falling asleep.36:07 And the third one is a thing called choppy sleep36:10 or intermittent insomnia.36:12 And that’s when maybe you have some difficulty falling asleep.36:15 You go to sleep.36:16 You wake up.36:16 You go to sleep.36:17 You wake up.36:18 And you kind of wake up intermittently36:20 through the night.36:21 Which do you think is the best description36:23 of the troubles you’re having?36:24 LISA: The first one.36:25 JOHN SOMMERS-FLANAGAN: OK.36:28 Are you interested if I might suggest36:31 to you a few ideas about how to approach the sleep issue?36:35 LISA: Sure.36:36 JOHN SOMMERS-FLANAGAN: I know that there36:38 are other things that we could and will talk about.36:42 But it seems like if we focus on the sleep for a little while36:45 that that might be useful.36:47 Is that OK?36:48 LISA: Yes.36:51 I think it’s all magnified by the fact36:54 that I have such a sleep deficit.36:56 And if I can sleep better, I’ll handle things better.37:00 JOHN SOMMERS-FLANAGAN: Yeah, I think37:02 that might be true for everybody.37:04 The lack of a good night’s sleep can37:06 make all of us a little less able to cope with things.37:10 And anything else you’ve tried to maybe37:13 push the thoughts aside or to speed the onset of sleep37:18 for you?37:18 LISA: No.37:20 JOHN SOMMERS-FLANAGAN: OK.37:21 Have you ever heard of mindfulness meditation37:25 or have you ever tried meditating?37:28 LISA: No, I never have.37:29 JOHN SOMMERS-FLANAGAN: No?37:30 OK.37:31 I’m just going to describe one approach to that.37:35 And actually I’ll probably describe several approaches.37:39 And what I’m going to do is I just37:40 want you to think about them and try them on as I’m talking.37:44 OK?37:44 LISA: OK.37:46 JOHN SOMMERS-FLANAGAN: So there’s37:47 a guy who did some research long ago.37:50 And he identified four things that people37:52 need to experience a relaxed state of mind.37:56 They need a comfortable position.37:58 I’m guessing in your bed it’s comfortable.38:00 They need a quiet place.38:02 Is it more or less quiet?38:04 LISA: More or less.38:05 JOHN SOMMERS-FLANAGAN: OK.38:06 Then they need a mental device.38:10 And what that means is a thought.38:14 It could be an image to focus on.38:16 It could be a word.38:18 You’ve tried counting sheep.38:19 That’s an example of a mental device.38:21 And we’ll talk more about that in a moment.38:24 And then the fourth thing you need is passive attitude.38:28 And a passive attitude, do you know what I mean by that?38:31 LISA: Well, go back to the one before.38:33 JOHN SOMMERS-FLANAGAN: Mental device.38:35 LISA: Yes, at some point I hope you’ll explain that one to me.38:38 And no, I’m not sure exactly what38:40 you mean by a passive attitude.38:42 JOHN SOMMERS-FLANAGAN: OK, well, let me try to explain both.38:44 Mental device, the sort of Zen people who are into meditation38:49 would say that your mind is like a barking dog…38:55 Bark, bark, bark, bark, bark.38:57 And it barks when you stop reading, and you lay down.39:02 And they sometimes say yapping, you know?39:05 But a barking or a yapping dog, and then in order39:08 to get that mind to stop barking at you,39:11 you need to give it a bone.39:13 You need to give it something to chew one.39:16 And that is what we refer to as a mental device, mental device39:20 being sometimes a mantra.39:24 People who do sort of Buddhist stuff39:27 might say the word ohm over and over.39:31 People who are religious, I know a guy who is religious,39:36 and he likes to say something they feels sort of spiritually39:40 right to him.39:41 And his mantra is to say, I am here.39:46 Here I am.39:47 So with his in breath he says, I am here.39:49 With his out breath, he says, here I am.39:52 And that sort of got some spiritual meaning for him.39:55 And so he finds that very soothing,39:58 and he can stick with it.40:02 RITA SOMMERS-FLANAGAN: So Lisa is obviously40:04 happy to get some information and help with her insomnia.40:08 She’s eager to try those ideas.40:10 JOHN SOMMERS-FLANAGAN: Yeah, I have40:12 to say it’s exciting, maybe little ego boosting,40:15 to have a client who’s really ready for action.40:18 And so I can provide her with a little scientifically based40:21 psychoeducation.40:22 She responds in a very positive way40:25 and is ready to get to work.40:27 RITA SOMMERS-FLANAGAN: Yeah, it’s so nice in fact40:30 that it can be a little bit seductive,40:32 and the interviewer who’s providing40:35 all that information and guidance40:37 can get a little too full of himself.40:41 And things can take a nasty turn.40:47 JOHN SOMMERS-FLANAGAN: Your son and your son’s family40:50 have moved into your home?40:51 LISA: Yes, and I do love them, and I love my grandbaby.40:57 But I’ve had many years of living alone, thinking41:03 I’ve paid my dues.41:04 I raised my children.41:06 I love having them come back for visits.41:09 But this, there’s always somebody under foot.41:13 And except for midnight and on, it’s41:16 hard to find quiet in the house.41:19 JOHN SOMMERS-FLANAGAN: Yeah, yeah.41:20 What great family time, though.41:25 It’s one of those things in life if you41:27 get the lemons, that sometimes you make lemonade.41:30 And it sounds to me like you’re probably41:32 getting lots of great time with your family41:35 that you maybe would’ve gotten before.41:38 LISA: Well, I thought that six months ago41:40 when they had to move in because of the unemployment situation.41:46 And they asked.41:47 And I said they could.41:48 I have room.41:50 I’d do anything to help them.41:52 But it’s been six months.41:55 And I don’t even like lemonade anymore.42:01 JOHN SOMMERS-FLANAGAN: But think of the six months,42:03 I mean, you wouldn’t have that wonderful family time42:06 if all this hadn’t happened.42:09 LISA: Now I’ve worked real hard at adjusting my attitude42:13 to accept what has happened in my life.42:17 I’m here to talk to you.42:18 I’m looking for help because I haven’t been doing so42:23 well over the last few months.42:28 How would you feel?42:29 How would you feel if suddenly you42:31 had three people who are noisy and move42:37 into your house, and your space, and impact your work?42:40 JOHN SOMMERS-FLANAGAN: I’m really glad you asked.42:42 I mean, I’ve actually been kind of lonely lately.42:45 And so it would actually feel nice to me42:48 to have a house full of children and people there.42:53 And so I guess what I’m trying to say to you42:54 is it’s really a matter of attitude.42:57 And I wonder if maybe you could consider shifting your attitude43:00 toward one that welcomes the company as43:04 opposed to fighting against it.43:05 You’re kind of fighting against it.43:09 LISA: I don’t think you’re remembering exactly what I43:11 told you last week.43:13 It was all rosy the first three weeks.43:17 I didn’t imagine it would go on this long.43:20 And I still don’t know how long it’s going to go on.43:23 And it is wearying.43:24 I can’t keep up my responsibilities with my job,43:30 without sleeping, with all this.43:33 I’ve talked to them.43:36 They’re very nice people, but the house isn’t that big.43:40 JOHN SOMMERS-FLANAGAN: Well it sounds to me like you would43:43 just like to get rid of them, maybe just get them completely43:46 out of the house…43:47 LISA: Well, I…43:48 JOHN SOMMERS-FLANAGAN: as soon as possible.43:52 RITA SOMMERS-FLANAGAN: Phew.43:53 Thank goodness that’s over with.43:56 That sort of deteriorated into a disagreement43:59 on how Lisa should view her own life.44:04 That was kind of like bad TV therapy.44:07 JOHN SOMMERS-FLANAGAN: Now as much44:08 as I would like to be a bad TV therapist,44:12 I want to emphasize I did that on purpose.44:13 RITA SOMMERS-FLANAGAN: OK.44:14 JOHN SOMMERS-FLANAGAN: Although I like the term44:16 you used before the clip of it’s seductive.44:18 It really is.44:19 When clients act so interested in what you have to offer,44:22 it’s seductive and that you start44:24 to think that they really want to know everything about you.44:26 RITA SOMMERS-FLANAGAN: Yeah.44:27 JOHN SOMMERS-FLANAGAN: And then you44:28 can go overboard with self-disclosure.44:30 And you can go overboard with I think44:32 I know what’s right for you.44:35 And in the clip where it ended, I44:38 could have even gone on and been even more44:41 of authoritarian or authoritative.44:42 RITA SOMMERS-FLANAGAN: I’m not sure you wouldn’t won though.44:45 JOHN SOMMERS-FLANAGAN: No, she was clearly44:47 showing a little push back.44:49 But I guess the main point is that even though we might have44:52 a really good point to make, or we might44:54 have a really interesting life story to tell,44:57 that’s really not the fault…44:59 RITA SOMMERS-FLANAGAN: It’s kind of like not the point.45:01 JOHN SOMMERS-FLANAGAN: That’s not45:01 the point we should be making.45:02 RITA SOMMERS-FLANAGAN: Right.45:04 So directive and action responses45:08 need to be developed collaboratively,45:11 and the client is always the final authority.45:24 JOHN SOMMERS-FLANAGAN: In this final section associated45:27 with listening continuum, we explore questions45:31 in general and therapeutic questions in particular.45:35 And we focus on these because questions can45:37 be so common, commonly used.45:40 They can also be very effective.45:42 But then I think oftentimes interviewers45:45 can misuse questions.45:47 RITA SOMMERS-FLANAGAN: Why do you feel that way, John?45:49 JOHN SOMMERS-FLANAGAN: Well, it’s because I…45:50 RITA SOMMERS-FLANAGAN: I mean, are you45:52 feeling kind of insecure about this section?45:54 JOHN SOMMERS-FLANAGAN: I think right now I am.45:55 RITA SOMMERS-FLANAGAN: Yeah, I don’t understand it.45:57 I wonder why you want this section right here anyway.46:01 JOHN SOMMERS-FLANAGAN: And right now I’m46:02 feeling very insecure about the whole thing.46:05 And I guess that’s the point.46:06 I mean I get the fact the questions can be very powerful.46:10 And they can be intimidating.46:12 They can be used in ways that make clients46:16 respond in a defensive way…46:19 Questions like, when did you stop lying to your employer?46:25 What are you really thinking about your mother?46:28 And those kinds of things can insinuate things.46:31 They can be used to wound people, definitely used46:35 to control the interview or the conversation.46:38 RITA SOMMERS-FLANAGAN: And, of course, our clients46:41 are not as skilled as your average politician at sliding46:45 away from a question.46:47 And so they’re stuck.46:48 They either have to answer the question46:50 or be seen as resistant.46:52 So questions can become kind of a no win situation for clients.46:56 JOHN SOMMERS-FLANAGAN: Yeah.46:58 That’s one of the reasons that in teaching I47:01 like to assign the students a pretty long interview47:05 where they can’t ask any questions47:07 or they just have to use active listening47:09 skills to gather information.47:11 And I think that can be a real learning experience for clients47:15 for students, maybe even up to 3047:17 minutes of non-directive listening without questions.47:19 RITA SOMMERS-FLANAGAN: Yeah.47:20 JOHN SOMMERS-FLANAGAN: There are many different types47:21 of questions.47:23 RITA SOMMERS-FLANAGAN: There are open, closed, indirect, swing,47:29 projective, and of course a group of questions47:32 that we just call therapeutic.47:33 JOHN SOMMERS-FLANAGAN: Now at this point,47:35 we’ve moved a little bit away from the listening47:38 continuum in that questions vary in their level47:41 of directiveness.47:43 They’re all directed, because questions47:45 come from the interviewer and are used to guide, or manage,47:49 or control what clients say.47:52 But some questions are much more leading.47:55 And others are much more gentle and less directive.48:00 RITA SOMMERS-FLANAGAN: In this next clip,48:01 our colleague from the University of Montana,48:03 Cris Fiore, demonstrates the use of questions48:07 as she works with Umit, who’s a graduate exchange48:11 student from Turkey.48:13 And you’ll see the skilled use of questions woven together48:16 with some other non-directive and directive listening48:20 responses.48:22 And you know, John, of course this is how48:25 a real clinical interview goes.48:27 You weave things together.48:29 You use more and less directive things.48:32 And you’ll notice that even sometimes Cris48:35 will do a paraphrase, but they’ll be a rise in her voice.48:38 They’ll be a little inflection change48:41 that works the same way as a question.48:44 CRIS FIORE: Hi, how can I help you today?48:48 UMIT: I don’t know, it’s kind of a long winter in Missoula48:52 And I’m not used to it.48:55 It’s my third year in Missoula.48:56 I’m not used to it.48:58 But it was the longest winter for me, I think.49:01 CRIS FIORE: So it’s not just the weather,49:04 because you’ve been here three years.49:05 It just feels long for you?49:08 UMIT: Yeah, maybe, because I didn’t see sunshine49:11 a long time.49:12 And I feel weak sometimes.49:13 I cannot get up.49:15 It makes me thing Missoula or what I’m doing.49:18 CRIS FIORE: Oh, so you feel bad enough that you can’t get up.49:23 Can you tell me more about that?49:25 UMIT: Where I’m from is more than 300 days of sunshine.49:29 And just you know, people are walking around a lot.49:34 And just it’s kind of crowded.49:36 People don’t go to bed early.49:38 I feel like I just miss sometimes them.49:40 RITA SOMMERS-FLANAGAN: So you’re missing home a lot49:43 and a big change from Missoula is49:46 we don’t have 300 days of sunshine.49:50 UMIT: Yeah, absolutely.49:51 You have in August and September,49:53 and I’m not here in august or September.49:56 CRIS FIORE: OK, so this is a big adjustment for you.50:00 But you’ve been here three years.50:02 UMIT: Yeah.50:03 CRIS FIORE: What’s it like for you during the winter?50:06 You mentioned a little bit that sometimes you50:10 don’t feel like getting up.50:11 UMIT: Yeah, six or seven hours of sleeping was enough for me.50:17 But now it feels like I’m sleeping more than 10 hours.50:20 CRIS FIORE: OK.50:21 UMIT: In my culture, we usually hang50:22 out a lot of times like three hours just chatting,50:25 four hours.50:26 But here, everybody’s busy, or at work.50:30 That’s fine.50:31 Even if I am free, how can I hang out with people?50:34 CRIS FIORE: OK, OK.50:36 So you and your friends have a different life here.50:40 UMIT: Yeah.50:41 CRIS FIORE: So in the best case scenario,50:44 how would you want your day to look like?50:47 What would it look like in the best case scenario?50:50 UMIT: Firstly, I want to finish my homework50:52 as early as possible.50:54 And in Turkey, usually my mom cooked for me.50:58 That’s why it’s that way.50:59 CRIS FIORE: It’s very different.51:01 It’s all very different here.51:03 Do you keep in contact with your family?51:05 UMIT: Yeah.51:06 CRIS FIORE: How often?51:07 UMIT: I call my mom almost every day.51:12 Yeah, because if I don’t call, she really misses me.51:17 I am the best for her.51:20 And I call her every day.51:22 And I call the other family members.51:24 I have six siblings, including me.51:27 And three of them have got married.51:32 I just call the others once or twice a week.51:37 My expectations are from friendship, relationship,51:42 is different than there.51:44 CRIS FIORE: Right.51:45 UMIT: That’s why it doesn’t work sometimes.51:47 CRIS FIORE: OK, OK.51:50 It sounds like you’re adjusting to a lot of different things.51:53 UMIT: Oh yeah.51:54 CRIS FIORE: Food, light, time, how51:57 you’re spending your time, and also this difference52:01 in how friends are, and even your communication…52:04 UMIT: Yes.52:05 CRIS FIORE: and that’s a lot to adjust52:07 to in the time you’re here.52:10 So what would be helpful for you at this point?52:13 What do you think you could do with the time52:16 that we have talking?52:17 How could I be helpful?52:19 UMIT: I don’t know.52:22 Maybe I have to learn more.52:25 I have to accept I am here in Missoula.52:28 And actually, I said all these bad things about living here.52:31 But there are some good things also.52:32 That’s why I’m staying here.52:34 I have a chance to go back.52:35 But in my culture, it’s so complicated.52:38 People just judge everything and just gossip.52:42 In here, nobody cares anything.52:44 That’s why I love here.52:48 You just do your business and go home.52:51 It’s the best part of living here.52:53 CRIS FIORE: OK.52:53 UMIT: And you can walk around just by yourself.52:57 It’s not crowded.52:59 There are advantages about living here also.53:05 If there’s a party at 8:00 PM, you can go 9:00 PM.53:08 And you can leave 9:40.53:09 Nobody said anything.53:11 But in Turkey, if you go at 9:00 PM.53:14 You might have trouble, because you are late.53:16 If you leave early, you will have trouble.53:19 Here is…53:20 CRIS FIORE: Different expectations,53:22 different expectations.53:23 RITA SOMMERS-FLANAGAN: You know, John,53:25 I’m struck by how graceful and skilled Cris is.53:31 In that tape, she’s simultaneously53:33 expressing interest, even her facial expressions53:37 and her mixing of directive, indirective, and questions.53:43 It was really very nice.53:44 JOHN SOMMERS-FLANAGAN: Yeah, her attending skills are fabulous.53:47 She’s very smooth.53:48 But I wonder if you can say which of the types of questions53:54 did she not use during her interview with Umit?53:58 RITA SOMMERS-FLANAGAN: And I can say that.54:00 It was the indirect question.54:02 Partly I noticed that because I don’t54:06 think that’s really a question.54:07 Grammatically, it’s not a question.54:09 JOHN SOMMERS-FLANAGAN: And I think you’re absolutely right.54:12 It’s not, although we use that language just because it54:14 sort of is an implied question.54:16 It kind of draws information out of clients.54:21 Another thing I wanted to comment on in Cris’s interview54:23 is that she uses a question about the best scenario that54:28 is possible for Umit.54:30 And I think that question is an example of a projected54:33 question, which is a therapeutic question, which54:37 in the solution-focused theoretical place,54:41 it would be referred to as a presuppositional question.54:46 Because it really asks Umit to project himself into a future54:50 place with a better or best scenario.54:53 RITA SOMMERS-FLANAGAN: You know, I54:55 want to say a little more about that.54:56 But first I also want to note that questions54:58 are another one of those techniques that have55:01 cultural meaning and valence.55:04 So cultures handle amounts of questions differently.55:08 The appropriateness of questions varies.55:11 People can feel very lost if they’re from a culture55:16 where they expect the person in authority to ask questions55:19 and you don’t, or pummeled if they’re not55:23 used to a lot of questions.55:24 JOHN SOMMERS-FLANAGAN: Exactly.55:26 RITA SOMMERS-FLANAGAN: And as you said,55:27 there’s a big theoretical link to some kinds of questions.55:31 There’s the big four in the reality therapy questions.55:35 Of course, that’s what do you want?55:37 JOHN SOMMERS-FLANAGAN: And what are you doing?55:40 Is it working?55:41 And should you make a new plan?55:42 RITA SOMMERS-FLANAGAN: Very good.55:44 JOHN SOMMERS-FLANAGAN: And those are very direct questions55:46 that help clients focus on problem solving as well.55:50 But really I think when it comes to therapeutic questions,55:53 those kinds of questions most squarely55:56 fall in the domain of solution focus theory in therapy.56:01 They’re really questions.56:02 And there are many different kinds.56:04 And they can be used well, and they can be overdone.56:06 But basically what they do is they have clients focus56:09 on positive scenarios, often the future, constructive things56:14 that are already working in their lives.56:16 RITA SOMMERS-FLANAGAN: Right, right.56:18 So I think there is a good example56:19 of that in a clip with TJ.56:21 So let’s watch just a couple more minutes of John with TJ.56:25 JOHN SOMMERS-FLANAGAN: I want to go back a little bit.56:27 I’ve got kind of a hard question for you.56:30 You have had times, 30 times or so,56:34 that you’ve gotten in fights.56:35 I’ll bet there have been some times when you almost56:38 got in a fight but then you chose not to,56:40 somehow, one way or another.56:44 Has that ever happened?56:46 And if so, how did you manage to choose not to fight?56:51 TJ: When it wasn’t worth.56:53 JOHN SOMMERS-FLANAGAN: OK, evaluate.56:56 TJ: Fighting for nothing is stupid.56:58 JOHN SOMMERS-FLANAGAN: Yeah.57:00 What do you think, in our last three57:03 minutes, what do you think as you look at the future for you?57:08 What do you think some of the most important things57:10 are that you’re going to learn about yourself,57:14 and about staying out of fights?57:21 TJ: I’m going to learn about myself.57:25 I’m definitely going to think about a lot of things57:27 I have done before, the bad things that happened57:33 and what’s led up to that.57:35 JOHN SOMMERS-FLANAGAN: OK.57:36 TJ: See the signs of where it’s going,57:40 stop it before it happens.57:42 RITA SOMMERS-FLANAGAN: So John, that was great.57:44 I really like how you used the exception question57:47 and framed it as saying, this is kind of a hard question.57:50 Because that hooks a kid like TJ to maybe pay attention and see57:55 if he can get it right.57:56 JOHN SOMMERS-FLANAGAN: Yeah, thank you.57:58 I think it’s a good example of how58:00 it’s important to gear the therapeutic question58:03 to the individual client.58:05 And questions, therapeutic questions,58:08 solution-focused questions can be58:09 asked in many different ways.58:11 And yet they almost always focus on moving the client58:14 toward the future and toward a more positive future.58:19 RITA SOMMERS-FLANAGAN: So John, if you woke up tomorrow58:24 morning…58:24 JOHN SOMMERS-FLANAGAN: And a miracle occurred…58:28 RITA SOMMERS-FLANAGAN: And you suddenly had58:30 more spare time, what would that look like?58:33 JOHN SOMMERS-FLANAGAN: Well, I think my wife58:35 and I would be spending a lot of time in a video production.58:39 RITA SOMMERS-FLANAGAN: Yeah, well, I58:40 guess we can see where this is going.58:42 Obviously you can see the importance58:45 of using those solution-focused questions.58:48 JOHN SOMMERS-FLANAGAN: And the power of questions, I think,58:50 should not be underestimated.58:52 RITA SOMMERS-FLANAGAN: That’s right.58:59 JOHN SOMMERS-FLANAGAN: In this section,59:01 Rita is demonstrating an intake interview.59:06 And of course, intake interviews are shaped by the client,59:10 by the interviewer, by the setting,59:12 and by just about every factor that you can imagine.59:16 In this particular intake example,59:19 the client, Michelle, comes in and has filled out a form.59:23 But it only identified in a general in a way59:26 that she was struggling with anxiety in her life.59:30 And so you should watch at the very beginning59:32 of this video clip at how quickly Michelle59:35 jumps into her specific problem, describes her symptoms.59:39 And then Rita does a nice job both exploring and sticking59:43 with the chief complaint but also59:44 staying with the format or structure of an intake59:48 interview.59:49 Keep in mind that some clients will not59:51 jump so quickly into their presenting complaint.59:55 I remember back in the day, well maybe just a few years ago59:58 when we were younger, that we might01:00:00 take three or four sessions just to deeply identify01:00:05 a presenting complaint and develop a problem formulation.01:00:09 RITA SOMMERS-FLANAGAN: OK, so let’s01:00:11 watch the beginning of this work with Michelle.01:00:15 RITA SOMMERS-FLANAGAN: So Michelle, it’s01:00:17 nice to meet you.01:00:17 MICHELLE: It’s nice meeting you too.01:00:19 RITA SOMMERS-FLANAGAN: And I would01:00:20 like to start today by just checking in01:00:22 with you on what brought you in today for the counseling.01:00:25 MICHELLE: OK.01:00:27 This feels a little bit weird.01:00:28 I’ve never gone to see a counselor before.01:00:30 So I’m not exactly sure how to start.01:00:34 But I had a couple of, I guess what they called panic attacks.01:00:39 I went to the hospital for one, because I01:00:41 didn’t know what was wrong.01:00:42 And I was kind of freaking out.01:00:44 So I went there.01:00:45 I thought there’s something wrong with me.01:00:47 And they said that there wasn’t anything physically wrong01:00:50 with me.01:00:50 But I was having some anxiety issues.01:00:52 So they said to come here to the clinic.01:00:55 And so I did.01:00:56 RITA SOMMERS-FLANAGAN: Wow.01:00:57 MICHELLE: So I really don’t know other than that.01:01:00 RITA SOMMERS-FLANAGAN: Wow.01:01:01 So you had a couple of those happen?01:01:04 MICHELLE: Yeah, well the first one01:01:06 was the one that I went… well, I01:01:07 had a couple littler ones before that.01:01:09 But the first big one was the one I went to the hospital for.01:01:13 Because I just felt like my chest was hurting.01:01:16 I couldn’t breathe.01:01:17 And I thought maybe, I don’t know.01:01:19 I didn’t know what to think.01:01:21 So I went there, and they ran a battery of tests, and blood01:01:24 pressure, and all that kind of stuff.01:01:27 And so then they said that I was OK.01:01:29 But I should probably check in with a mental health person.01:01:33 And that kind of made me feel weird,01:01:35 because I’ve never had anything like this happen before.01:01:38 RITA SOMMERS-FLANAGAN: Yeah, so it kind of like uh-oh.01:01:41 They’re telling me something’s in my head.01:01:44 And you felt weird about it.01:01:45 But here you are, decided to go after it.01:01:49 So is it OK if I ask you a little bit about what led up01:01:52 to those experiences?01:01:53 MICHELLE: Sure.01:01:56 Well, a couple of them seemed like that came out of the blue.01:01:59 But I’ve been having some stress at school.01:02:04 I’m a second year at the university up here.01:02:08 RITA SOMMERS-FLANAGAN: Yeah, so you01:02:10 had a couple of those classroom-based sort of uhh.01:02:14 MICHELLE: Well, the other one I was at a concert,01:02:16 like at a bar.01:02:18 And there was lots of people there.01:02:20 And I was kind of right in the middle of the crowd.01:02:22 So it wasn’t at school, but it kind of01:02:26 seemed like when there was a lot of people it made me…01:02:29 RITA SOMMERS-FLANAGAN: Just that crowded feeling, and then…01:02:31 MICHELLE: Like I can’t get out, and I need to get out.01:02:33 And I can’t get out.01:02:34 RITA SOMMERS-FLANAGAN: OK, what’s01:02:36 the first physical symptom or thought?01:02:39 Which comes first?01:02:40 MICHELLE: Usually it’s the chest heaviness.01:02:42 RITA SOMMERS-FLANAGAN: So right here?01:02:43 MICHELLE: I can’t breathe.01:02:45 And then just kind of then it feels like I can’t get out.01:02:47 And I need to.01:02:49 Then I freak myself out I think at that point.01:02:52 RITA SOMMERS-FLANAGAN: What starts to go on in your head?01:02:54 MICHELLE: I think that I can’t get out.01:02:56 I’m not going to be able to get out.01:02:57 I need to be able to get out.01:02:58 What happens if I can’t get out?01:03:00 And then it just sort of feeds on itself from there.01:03:03 And I start breathing heavy.01:03:04 My chest starts hurting more.01:03:06 Then it just kind of gets worse, and worse, and worse.01:03:09 RITA SOMMERS-FLANAGAN: I’m guessing about that point01:03:11 you thought, OK, fine.01:03:12 I’ll go see somebody.01:03:14 MICHELLE: I know, I kind of tried to play it off like,01:03:16 if the bad one doesn’t happen again,01:03:18 then I can probably deal with the other one.01:03:23 Like I said, I’ve never talked to a counselor.01:03:25 So I wasn’t really sure I wanted to or not.01:03:28 But at this point, I was like, well, if it works, great.01:03:32 If not, then I guess I’m not any worse off than I was before.01:03:35 RITA SOMMERS FLANAGAN: All right.01:03:36 OK.01:03:38 So I think what I’d like to do, if it’s all right with you,01:03:41 is kind of go backwards for a few minutes.01:03:43 But I do want to note that we’re pretty01:03:46 clear on what our goal would be in working together.01:03:49 MICHELLE: Yeah.01:03:50 RITA SOMMERS-FLANAGAN: And that would be…01:03:51 MICHELLE: No more panicking, which would be delightful.01:03:53 RITA SOMMERS-FLANAGAN: Yeah, yeah.01:03:54 And we may not be able to go right to no more panic,01:03:58 but maybe an intermediate goal would01:03:59 be how to handle when that heaviness comes,01:04:05 when those thoughts start, how to handle that.01:04:08 And maybe in some way we gradually get control of it01:04:14 as sort of steps toward the ultimate goal of no more panic01:04:19 attacks.01:04:20 Does that seem OK?01:04:21 MICHELLE: Anything’s better than what’s going on now, I think.01:04:23 RITA SOMMERS-FLANAGAN: Yeah, yeah.01:04:24 MICHELLE: So I’m pretty much game for whatever.01:04:26 RITA SOMMERS-FLANAGAN: You know, I01:04:26 do want to notice a couple things, though,01:04:28 and that is you’ve coped with some things that01:04:35 are pretty scary.01:04:36 And you had a lot of common sense,01:04:38 sort of got yourself out of the situation.01:04:40 You breathed.01:04:41 You walked.01:04:42 You gave yourself permission not to go back to class.01:04:46 And so I’m just noticing that you’ve got a lot of skills01:04:50 already…01:04:51 MICHELLE: Cool.01:04:51 RITA SOMMERS-FLANAGAN: that we’ll probably notice again.01:04:56 RITA SOMMERS-FLANAGAN: So, John, it’s a little bit startling01:04:58 when he client arrives and has already got a diagnosis01:05:02 and is ready to begin fixing the problem.01:05:05 JOHN SOMMERS FLANAGAN: Absolutely, you01:05:07 can feel, I think, like you have a lot of pressure on you01:05:10 to jump immediately into fixing the problem.01:05:13 But I’m glad that instead that you01:05:15 kept exploring the presenting complaint01:05:18 or the chief complaint, and then you01:05:19 went a little bit into other areas01:05:23 and really were building and gathering01:05:25 information that helped with establishing the beginning01:05:28 of a treatment plan.01:05:29 In particular, I liked the fact that you identified01:05:32 for the client, for Michelle, what01:05:35 was heaviness in your chest.01:05:38 And that seemed to be a trigger for her panic attacks.01:05:40 RITA SOMMERS-FLANAGAN: Right, right.01:05:42 I did intentionally transition to history.01:05:45 But before I went there, I really01:05:48 had noticed some strengths in Michelle01:05:50 and wanted to reflect those before we01:05:53 went into history taking.01:05:55 JOHN SOMMERS-FLANAGAN: At the risk01:05:56 of complimenting you too much, I really did like the way01:05:59 that you focused on her strengths.01:06:03 And I liked the way you developed with her01:06:06 some intermediate goals rather than sort01:06:09 of feeding into the idea that the goal is01:06:12 to eliminate all panic attacks.01:06:15 In fact, it can be very discouraging for clients01:06:18 if that’s their only goal.01:06:19 And you helped her see that there01:06:21 might be some intermediate goals along the way.01:06:24 RITA SOMMERS-FLANAGAN: Yeah, I did explicitly01:06:26 foreshadow that shift.01:06:29 Then we did do some history taking.01:06:31 And that was important, I think, to signal01:06:36 that we were going to make that shift, especially01:06:39 in an intake interview.01:06:40 Because clients don’t know where things are going.01:06:42 JOHN SOMMERS-FLANAGAN: And you know,01:06:44 gathering at least a little information01:06:45 about personal history is important.01:06:47 I think it’s important from the client’s perspective.01:06:50 And there are many different ways of doing it.01:06:53 But clients often have a sense of continuing from the past01:06:58 to the present to the future.01:07:00 Now let’s watch as Rita’s intake interview with Michelle01:07:04 continues.01:07:06 RITA SOMMERS-FLANAGAN: So let’s do a little bit of background.01:07:08 You can’t go see a shrink without a little background.01:07:11 MICHELLE: Do I have to lay down on the couch?01:07:12 RITA SOMMERS FLANAGAN: Yeah, yeah, if you would, please.01:07:13 MICHELLE: All right, that’d be awesome.01:07:14 RITA SOMMERS-FLANAGAN: Yeah.01:07:15 MICHELLE: My dad was around until I was about four,01:07:17 and then they divorced.01:07:18 And I didn’t really have a lot of contact with my dad01:07:23 after that.01:07:24 My mom was a single mom and took care of me.01:07:27 She was a nurse.01:07:28 And so she was working a lot, but she01:07:31 had somebody to watch me during the night,01:07:33 so she was there during the day a lot.01:07:35 But sometimes she had to sleep, but a lot of times01:07:38 she was re, especially after I went to school.01:07:41 Then she’d sleep while I was at school and be up when I was up.01:07:43 And then after she put me to bed,01:07:45 she’d go to work late night.01:07:46 RITA SOMMERS-FLANAGAN: Oh my gosh,01:07:48 she sounds like a pretty hardworking mom.01:07:49 MICHELLE: Yeah, she was very hardworking01:07:51 and very supportive.01:07:52 RITA SOMMERS-FLANAGAN: Is she still alive?01:07:53 MICHELLE: She is, yeah.01:07:54 RITA SOMMERS-FLANAGAN: How’s your relationship these days?01:07:56 MICHELLE: It’s good.01:07:57 She’s, like I said, very supportive and has always01:08:00 been there for me.01:08:03 RITA SOMMERS-FLANAGAN: Brothers, sisters?01:08:05 MICHELLE: I have two older brothers.01:08:06 One’s in the Navy, and he’s on deployment.01:08:09 So that’s kind of nerve wracking.01:08:10 And then the other one is at school01:08:13 at a university in California.01:08:15 So they’re both gone.01:08:18 And I’m kind of close with my mom01:08:21 and go over and visit her all the times, and stuff like that.01:08:24 They still keep in touch and things like that,01:08:26 but they’re obviously not around as much.01:08:29 RITA SOMMERS-FLANAGAN: So do you know if either of them01:08:33 have had anything like what you’re coping with?01:08:37 MICHELLE: I think that not the brother that’s in the Navy,01:08:40 because they wouldn’t allow him in with anything like that.01:08:44 But I think the one in California01:08:46 mentioned that he had been diagnosed01:08:49 with something like generalized something like with anxiety.01:08:53 Like he just was worried about a lot of stuff all the time.01:08:57 We talk sometimes, but not super often.01:09:01 But I think I remember him saying something like that.01:09:03 And then he’s on medication for it.01:09:05 RITA SOMMERS-FLANAGAN: OK.01:09:07 I should have asked this before, but did they give you01:09:09 any medication at the hospital?01:09:11 MICHELLE: No.01:09:12 RITA SOMMERS-FLANAGAN: OK.01:09:13 MICHELLE: Nope.01:09:14 RITA SOMMERS-FLANAGAN: So how about mom and anxiety?01:09:19 MICHELLE: I mean, she’s always seemed like a real worrier.01:09:21 But she’s never seen anybody for it or anything.01:09:26 She’s one of those kind of catastrophic thinkers01:09:28 that’s always like, what happens if this happens?01:09:31 And then you lose your car.01:09:32 Then you won’t have a job.01:09:33 And then you’ll be a bum.01:09:37 It’s kind of like that all the time with her, just a constant01:09:39 run it into the ground.01:09:41 I learned at an early age not to tell01:09:43 are things that I thought might be at all dangerous seeming.01:09:47 Because she wouldn’t let me do them.01:09:49 RITA SOMMERS-FLANAGAN: Just gets up in arms and yeah.01:09:50 MICHELLE: So I’d just do them and not tell her.01:09:52 RITA SOMMERS-FLANAGAN: Yeah, yeah, interesting.01:09:54 So you protect her a little bit from things01:09:56 that would make her anxious.01:09:59 So do you mind if I ask you about your drug and alcohol01:10:02 history a little?01:10:02 MICHELLE: Sure.01:10:06 I really used to like smoking pot a lot.01:10:09 I quit probably six months, eight months ago.01:10:13 The first year of pharmacy I was able to do it01:10:14 without really studying or being that concerned about getting01:10:19 buckled down.01:10:19 But now it’s getting harder, so I really01:10:22 felt like I needed to stop.01:10:24 But I’ve been smoking pot pretty much since I was 11 or 12.01:10:28 I started with one of my older brothers.01:10:32 I really liked it, because it mellowed me out.01:10:34 I was laid back.01:10:36 RITA SOMMERS-FLANAGAN: How long ago?01:10:38 What’s the last time?01:10:39 MICHELLE: About six, seven months ago, I would say.01:10:44 RITA SOMMERS-FLANAGAN: So you just kind of stopped01:10:46 cold turkey?01:10:47 MICHELLE: Yeah, I was just like this is not helpful for me01:10:51 right now.01:10:51 I don’t need to do this anymore.01:10:53 But my boyfriend kept something.01:10:54 And that, like I said, is part of…01:10:56 RITA SOMMERS-FLANAGAN: Problems, yeah, yeah.01:10:58 MICHELLE: And I mean, me being in the area that I’m01:11:01 going into, I really can’t have somebody with pot01:11:05 sitting in my house smoking.01:11:08 If he got busted, then my career is basically down the toilet.01:11:11 So, I don’t know if that’s something01:11:12 I want to be connected to for the rest of my life.01:11:14 And at this point, we’ve been together off and on01:11:17 for four years.01:11:20 I feel like either I need to be done01:11:21 or we need to do something.01:11:23 RITA SOMMERS-FLANAGAN: It’s kind of a point of stress right now01:11:26 or a point of concern?01:11:28 Yeah.01:11:29 OK, so I’m wondering about other drugs or caffeine, those kinds01:11:38 of substances in your life…01:11:41 MICHELLE: Right now?01:11:42 RITA SOMMERS-FLANAGAN: Right now, yeah.01:11:44 MICHELLE: I drink quite a bit of caffeine, probably,01:11:47 well it depends on what’s going on.01:11:49 Because if it’s like a time when an exam’s coming up,01:11:53 I end up drinking a crap load of it.01:11:56 I’ll drink a couple pots to cram for a test01:12:00 and stay up most of the night.01:12:01 On normal basis, I’ll probably have01:12:04 three, four cups of coffee in the morning01:12:06 and then maybe a soda in the afternoon.01:12:09 RITA SOMMERS-FLANAGAN: OK.01:12:10 Are you drinking that kind of heavily caffeinated sodas?01:12:14 Or energy drinks?01:12:15 MICHELLE: No, I don’t really go for those.01:12:17 They make me kind of crazy feeling.01:12:21 But mostly like definitely caffeinated,01:12:22 though, like Mountain Dew, I like Mountain Dew quite a bit,01:12:25 or Pepsi, Coke, those kinds of things.01:12:30 RITA SOMMERS FLANAGAN: All right.01:12:31 Any problems with the law in your history?01:12:35 MICHELLE: I did get a couple of minor possessions01:12:38 for alcohol when I was younger.01:12:39 And then I got a possession of marijuana also01:12:43 and paraphernalia when I was younger.01:12:46 RITA SOMMERS-FLANAGAN: OK.01:12:47 All right.01:12:49 One thing I like to ask people too01:12:51 is what are you doing to take care of yourself?01:12:55 MICHELLE: Well, it’s kind of hard when you work all the time01:12:57 and also are a student and kind of crazy relationship.01:13:03 But I’ve tried to start working out lately.01:13:05 I’ve been swimming some at the university pool.01:13:08 I’ve really gotten to like that.01:13:09 I never really had done that before.01:13:11 So that’s something that I’ve kind of liked.01:13:13 Just in the last couple months I’ve01:13:14 started doing that, kind of since this started.01:13:16 I was like, I need to maybe try to do something that’s going01:13:21 to slow this roll a little bit.01:13:24 RITA SOMMERS-FLANAGAN: So you are doing a little swimming01:13:27 and other things?01:13:29 MICHELLE: I pretty much just hang out with friends.01:13:31 Although now I kind of worry if we go somewhere01:13:34 that’s got a lot of people.01:13:35 Like that concert was out with friends.01:13:37 RITA SOMMERS-FLANAGAN: Right01:13:37 MICHELLE: So I’ve kind of curtailed01:13:39 some of my social engagements just because I’m01:13:43 worried about freaking out.01:13:45 And then what are my friends going to think?01:13:47 And then I don’t want to be weird.01:13:49 RITA SOMMERS-FLANAGAN: So it’s starting to kind of affect01:13:52 your friendships and social life, your work01:13:57 and school a little bit.01:13:59 MICHELLE: Yeah.01:14:00 RITA SOMMERS-FLANAGAN: So it’s kind01:14:01 of bleeding out into some places that make it difficult.01:14:06 MICHELLE: Yeah.01:14:07 RITA SOMMERS-FLANAGAN: Yeah.01:14:07 MICHELLE: Absolutely.01:14:08 Which is, like I said, part of the reason that I…01:14:10 RITA SOMMERS-FLANAGAN: Here you are.01:14:11 MICHELLE: bucked up and came to counseling.01:14:13 RITA SOMMERS-FLANAGAN: Yeah.01:14:14 JOHN SOMMERS-FLANAGAN: Rita, you did01:14:15 a nice job of exploring Michelle’s personal history.01:14:19 One of the things that I might say01:14:20 is that there are many different ways01:14:22 to explore personal history.01:14:24 And one of things I found really useful01:14:26 is to do an early memory, or sometimes in my work01:14:30 with young adults and adolescents,01:14:33 I will kind of jointly draw a family tree with them,01:14:37 sort of like an Adlerian family constellation01:14:39 or just a basic genogram.01:14:41 And doing that collaboratively to explore history01:14:44 seems to be a pretty effective way to go back into the past01:14:47 and identify some issues or themes that the client has01:14:51 faced.01:14:52 RITA SOMMERS-FLANAGAN: I do think working with the client01:14:56 to understand the family in some way,01:14:58 whether it’s a family tree or genogram.01:15:00 It helps a lot.01:15:01 I was trying to help Michelle take01:15:04 a look at the possibility of other family members01:15:07 having problems coping with anxiety or panic.01:15:11 And of course, I also wanted to convey to her that I saw her01:15:15 as coping with anxiety rather than being victimized by it01:15:19 or struggling with it.01:15:21 JOHN SOMMERS-FLANAGAN: And you really made a nice flow01:15:23 from the past back to the present,01:15:25 which is a key part of the intake interview.01:15:28 Every intake interview is unique and selective,01:15:32 and that you focus a little bit on slightly different content01:15:36 here and there, and emphasize different things.01:15:39 But most intakes include the coverage01:15:41 of the least these three main general areas,01:15:44 the first of which is the identification01:15:47 and exploration of the client’s chief complaint.01:15:50 That’s kind of the first general area.01:15:52 RITA SOMMERS-FLANAGAN: Right, and then01:15:53 of course, personal history and information related to that.01:15:56 JOHN SOMMERS-FLANAGAN: Right, and many ways01:15:58 to get that information and sometimes many areas01:16:00 within the personal history.01:16:02 And finally, there’s a transition back to01:16:04 or review of the client’s current functioning.01:16:07 How is the client doing now?01:16:09 RITA SOMMERS-FLANAGAN: Right.01:16:11 JOHN SOMMERS-FLANAGAN: Each of these areas01:16:12 can be expanded upon or minimized.01:16:15 For example, depending on your setting and your client’s01:16:18 presenting problem, it might be important to gather01:16:20 specific information about the client’s family01:16:23 history, or maybe military history, or maybe01:16:26 drug and alcohol history.01:16:28 RITA SOMMERS-FLANAGAN: Yeah, the purpose01:16:30 of the intake, the goals, the theoretical orientation,01:16:34 the resources, the length of time that you have,01:16:36 these are all can influence what the interviewer focuses01:16:41 and what amount of time you have to deal with it.01:16:44 JOHN SOMMERS-FLANAGAN: Right, Rita,01:16:45 you focused on the relevant historical and current coping01:16:49 issues that Michelle had.01:16:51 And I think you did a really nice job of that.01:16:52 I specially was glad that you focused on her caffeine01:16:55 use, which can trigger panic and also01:16:58 focusing on self-care and some of the medical issues, just01:17:02 really important and relevant pieces01:17:04 of the interview with Michelle.01:17:05 RITA SOMMERS-FLANAGAN: Right, right.01:17:06 You know, it was interesting.01:17:07 There was a part of the tape we didn’t show.01:17:10 But Michelle starts making any connection01:17:12 between her stopping the use of pot, which01:17:17 she had used since she was 11 or 12 and the onset of those panic01:17:23 symptoms.01:17:24 So the client herself was starting01:17:26 to make connections that might end up being very important.01:17:29 JOHN SOMMERS-FLANAGAN: Which is something01:17:30 that can happen in a good intake interview,01:17:32 because it provides the client with opportunities to reflect.01:17:35 RITA SOMMERS-FLANAGAN: Right.01:17:36 So in this next section, we’ll watch as the interview shifts01:17:40 toward case formulation, homework,01:17:44 and instilling the hope for change, making sure01:17:48 we take full advantage of that placebo effect.01:17:52 RITA SOMMERS-FLANAGAN: Well, let me do a little summary of what01:17:55 I’ve heard.01:17:57 And then maybe we can talk about some plans01:18:00 for our next sessions together.01:18:03 And if you don’t mind, I might even give you01:18:06 a little bit of homework.01:18:07 MICHELLE: OK.01:18:08 Do you think this is something that people get better from?01:18:11 RITA SOMMERS-FLANAGAN: Yeah.01:18:12 MICHELLE: OK, because I’m kind of worried about it.01:18:15 RITA SOMMERS-FLANAGAN: Yeah.01:18:17 And the good news is that actually the problem01:18:22 that you brought in today is one of those01:18:25 that shows really goo results.01:18:27 MICHELLE: Oh good, because I don’t like it at all.01:18:29 And it really scares me quite a bit.01:18:30 RITA SOMMERS-FLANAGAN: Yeah, yeah.01:18:32 So that’s kind of the good news.01:18:33 The bad news, of course, is that anything like this01:18:36 requires some work, and some time, and understanding.01:18:39 And it doesn’t go away magically.01:18:41 You already tried that.01:18:42 MICHELLE: Yeah, ignoring, ignoring it didn’t work.01:18:44 RITA SOMMERS-FLANAGAN: Denying, yeah.01:18:46 Yeah, but I think there’s a really good chance01:18:49 that we can make a big difference in this.01:18:52 And it’s certainly worth a try.01:18:57 MICHELLE: Can’t be any worse than I was before.01:19:00 The way that I am avoiding things already now,01:19:04 like going out with friends, like even when01:19:06 I have to go to big classes, I’m kind of like, ahh.01:19:08 I sit on the edges of the things or in the back.01:19:10 And sometimes I can’t hear as well.01:19:11 So I think that I’m worried like I’ve01:19:15 seen those shows of the shut-in people that stay in their house01:19:19 and never leave.01:19:19 And that scares me.01:19:23 I’m not by any means at that point,01:19:25 but I just worry if it’s getting worse and worse01:19:28 that things could get worse.01:19:29 And then I could end up with a grocery delivery01:19:33 and that’s the only people that talk to me.01:19:35 RITA SOMMERS-FLANAGAN: Yeah, or you’re01:19:37 sitting in the car at Walmart like a homeless person.01:19:39 MICHELLE: Yeah, exactly.01:19:40 RITA SOMMERS-FLANAGAN: Right, right.01:19:41 So does this remind you of anybody01:19:43 that we’ve talked about today?01:19:47 MICHELLE: Not really.01:19:48 RITA SOMMERS-FLANAGAN: That’s a trick question.01:19:50 You told me your mom catastrophizes.01:19:53 MICHELLE: Wow, I’m surprised I didn’t make that connection.01:19:56 RITA SOMMERS-FLANAGAN: It’s funny01:19:57 how we mirror our mothers sometimes.01:19:58 MICHELLE: I know, well it’s lalala01:19:59 and just like totally space it out after a while.01:20:02 But she does leave the house.01:20:03 So that I guess was the part.01:20:05 But yeah, I don’t want to end up like my mom either.01:20:08 That’d be terrible.01:20:09 I mean, she’s very nice.01:20:10 RITA SOMMERS-FLANAGAN: Oh, yeah, but that tendency01:20:12 to do to be able to take one difficult life event01:20:16 and go uh-oh.01:20:17 This is going to leave to this.01:20:18 MICHELLE: It’s going to blow up…01:20:19 RITA SOMMERS-FLANAGAN: This is going to lead to this.01:20:20 And then I’ll be homeless and shut-in.01:20:22 And then I won’t get a suntan anymore.01:20:24 MICHELLE: Yeah, I guess that’s where I was going with that.01:20:27 That sounds exactly like her.01:20:28 I’ve become my mother.01:20:29 RITA SOMMERS-FLANAGAN: No, you haven’t, no, no, no.01:20:32 We learn a lot from our parents and their coping styles.01:20:36 And one coping style is to face right into it01:20:40 a tough potential reality and say,01:20:43 if I don’t do something about this, it could go there.01:20:46 So it’s not a bad or good thing.01:20:49 It’s just one of the ways you’ve learn to deal with things.01:20:54 And the good outcome of that is it brought you here.01:20:57 Because you kind of looked down that road and said, hmm.01:21:00 I think I don’t want to go there.01:21:02 So, here you are.01:21:05 JOHN SOMMERS-FLANAGAN: Rita, I really liked01:21:07 the way you made the connection between Michelle’s tendency01:21:10 to do a catastrophizing in her thinking01:21:13 with what she had identified herself before as her mom’s01:21:17 tendency to do the same thing.01:21:19 You also wove in something that was very smooth,01:21:23 and that is suggesting to Michelle01:21:26 that maybe the path of the catastrophizing01:21:31 was not very much pathology.01:21:33 And so I think by doing that, you kind of give her01:21:35 an opportunity to choose to work on it or not.01:21:39 RITA SOMMERS-FLANAGAN: Right, yeah,01:21:40 I think it kind of led to a little bit of an insight,01:21:44 which I think sometimes motivates people.01:21:48 When you have an insight into the way you are01:21:52 and a way you might want to change,01:21:53 you actually might have a little motivation01:21:55 to do things like homework.01:21:58 So we did have a homework assignment, as you saw.01:22:02 And then we had summary, enclosure,01:22:07 and we had a plan to get back together,01:22:09 including permission for her to call the clinic earlier.01:22:14 Because when you are dealing with panic attacks,01:22:16 sometimes you need that reassurance01:22:18 that you can make contact earlier.01:22:27 So in this section, we’re going to watch a mental status01:22:31 examination with a young man named Carl.01:22:35 This is a general check in.01:22:38 He was referred because of some odd ideation01:22:44 and bizarre behaviors.01:22:46 So his vocational instructors and educators01:22:49 were a little bit concerned.01:22:51 JOHN SOMMERS-FLANAGAN: A traditional mental status01:22:53 examination includes about nine domains.01:22:57 And the first three…01:22:58 Appearance, behavior or psychomotor activity,01:23:03 and attitudes toward the interviewer or examiner…01:23:07 Are always just inferred.01:23:09 In other words, you just observe the clients01:23:12 and then you make some inferences about those three01:23:15 categories.01:23:16 The remaining six categories are usually01:23:19 assessed in a little bit more of a direct way.01:23:22 And these other six categories include affect and mood01:23:25 together, speech and thought together,01:23:30 perceptual disturbances, orientation and consciousness,01:23:35 memory and intelligence, as well as reliability, judgment,01:23:40 and insight.01:23:42 RITA SOMMERS-FLANAGAN: As I look at that list,01:23:44 it seems to me that the client’s speech is something01:23:49 more inferred or observed.01:23:51 JOHN SOMMERS-FLANAGAN: I think you’re right.01:23:53 It’s usually inferred or observed more indirectly also.01:23:57 Although in the upcoming interview,01:23:58 I accidentally forgot to ask one of the speech01:24:03 assessment items, which is to ask Carl to repeat after me…01:24:08 No ifs, ands, or buts.01:24:11 RITA SOMMERS-FLANAGAN: So, well, no ifs, ands, or buts,01:24:15 let’s watch a little section of Carl.01:24:19 Carl is a 19-year-old young man who01:24:21 is a student at Trapper Creek Job Corps.01:24:24 He has a lot of adjustment struggles and eccentricities.01:24:29 And you’ll notice that he also has some tick-like mannerisms.01:24:34 We both met with Carl in earlier sessions.01:24:37 And we’ve talked about those mannerisms.01:24:39 So in this tape you won’t here us inquiring about those.01:24:42 JOHN SOMMERS-FLANAGAN: As you get01:24:44 ready to watch this mental status examination01:24:47 interview with Carl, it might be a good idea01:24:49 to pull out a piece of paper and jot down01:24:52 a few notes in each of the nine domains01:24:55 as you observe the interview.01:24:58 JOHN SOMMERS-FLANAGAN: Well, Carl, thank you for coming in.01:25:01 And what I would like to do with you today01:25:04 is just a very standard interview01:25:08 that is sort of a way for me to get to know01:25:11 how your brain is working.01:25:12 And so what I’m going to do is I’m going01:25:14 to ask you some questions.01:25:16 But first I just want to start off01:25:17 by sort of asking some very easy questions.01:25:22 And then some of the questions will get harder as we go.01:25:26 And so, does that sound OK to you?01:25:29 CARL: Yeah, that sounds OK.01:25:30 JOHN SOMMERS-FLANAGAN: First one is state your full name.01:25:36 CARL: I’ve actually had quite a few different names growing up.01:25:38 You want my current name?01:25:39 JOHN SOMMERS-FLANAGAN: Whatever you would like.01:25:42 CARL: Carl Dunn.01:25:43 JOHN SOMMERS-FLANAGAN: OK.01:25:47 You said you’ve had quite a few different names growing up.01:25:49 CARL: Yes, actually, my mother changed her name.01:25:51 I don’t know whether or not she legally01:25:53 changed them or anything.01:25:54 But she always changed our last name01:25:56 depending on what guy or girl she was dating at the time.01:25:59 And I was CJ once.01:26:01 I tried to be Todd the second time,01:26:04 but the name just kind of sounded ridiculous.01:26:07 I’ve got Warren, Jr., Raccoon because of the rings01:26:10 around my eyes.01:26:12 JOHN SOMMERS-FLANAGAN: What’s your favorite name01:26:14 for yourself?01:26:15 CARL: Just Carl Dunn.01:26:16 JOHN SOMMERS FLANAGAN: Carl Dunn, OK.01:26:17 CARL: I don’t really have a favorite name for myself,01:26:19 I just pick whichever one sticks better.01:26:20 JOHN SOMMERS-FLANAGAN: OK.01:26:21 Well, I’ll just stick with Carl if that’s OK.01:26:23 CARL: OK.01:26:24 JOHN SOMMERS-FLANAGAN: And what is today’s date, Carl?01:26:27 CARL: 3-29-2012, I believe.01:26:29 JOHN SOMMERS-FLANAGAN: OK.01:26:34 All right.01:26:35 What day of the week is it?01:26:36 CARL: No, it’s 3-20, and I don’t remember what day it is.01:26:39 OK, what?01:26:39 JOHN SOMMERS-FLANAGAN: What day of the week is it?01:26:41 CARL: OK, it’s Thursday.01:26:43 JOHN SOMMERS-FLANAGAN: Thursday, OK.01:26:46 And can you tell me what season of the year it is?01:26:50 CARL: It seems to be spring, going from winter into spring.01:26:53 But judged by the weather, it’s still kind of wintery.01:26:56 There’s a lot of snow.01:26:58 JOHN SOMMERS-FLANAGAN: So we’re going from winter into spring.01:27:02 CARL: Yeah.01:27:04 JOHN SOMMERS-FLANAGAN: Yeah.01:27:05 Which one do you think we’re in?01:27:08 CARL: Here spring, but back at Job Corps, winter.01:27:11 JOHN SOMMERS-FLANAGAN: OK.01:27:13 And what is the name of the town or city01:27:18 where you are living now?01:27:21 CARL: Darby.01:27:22 JOHN SOMMERS-FLANAGAN: Darby.01:27:23 OK.01:27:26 OK.01:27:28 Now this is a hard question.01:27:30 Do you know who the governor of Montana is?01:27:34 CARL: No.01:27:35 JOHN SOMMERS-FLANAGAN: No, OK.01:27:37 So my next question is going to be a test of your memory.01:27:40 Is that OK if we do that?01:27:41 CARL: Yeah.01:27:42 JOHN SOMMERS-FLANAGAN: So I’m going to say three things.01:27:44 And all you need to do is when I’m finished saying them,01:27:48 you repeat them back.01:27:49 CARL: OK.01:27:49 JOHN SOMMERS-FLANAGAN: OK.01:27:50 So the three things are cup, newspaper, banana.01:27:58 CARL: OK.01:27:59 JOHN SOMMERS-FLANAGAN: What are the three things?01:28:01 CARL: Cup, newspaper, banana.01:28:03 JOHN SOMMERS-FLANAGAN: OK.01:28:05 All right, good work.01:28:08 Now this one is a little bit harder.01:28:10 You ready for something a little bit more of a mental challenge?01:28:14 I’d like you to begin with the number 10001:28:17 and then count backwards by sevens.01:28:19 So it’s like 100…01:28:21 CARL: Oh yeah.01:28:23 100, 93, 86, 79, 72, 65, 58, 51, 44.01:28:36 JOHN SOMMERS-FLANAGAN: You can stop, good work.01:28:40 That seemed pretty easy for you.01:28:41 CARL: It was pretty easy.01:28:43 I used to be able to multiply double digit numbers.01:28:46 JOHN SOMMERS-FLANAGAN: Yeah, so you’re pretty good with math.01:28:48 You’re pretty good with numbers.01:28:50 CARL: Yeah, I used to be a lot better reading.01:28:52 In the second grade, I knew words01:28:54 that none of the college teachers I used to visit knew.01:28:57 And I was able to read beyond a college level and in a couple01:29:00 other languages.01:29:01 And then I forgot all that.01:29:03 But that’s another story.01:29:04 JOHN SOMMERS-FLANAGAN: Sure.01:29:05 So try this one.01:29:09 Spell the word “world” backwards.01:29:14 CARL: D-L-R-O-W.01:29:17 JOHN SOMMERS-FLANAGAN: OK.01:29:19 Now who is currently the president of the United States?01:29:22 CARL: I believe it’s still Obama.01:29:24 JOHN SOMMERS-FLANAGAN: OK.01:29:26 Do you know who was president before Obama?01:29:29 CARL: Bush, I believe.01:29:30 JOHN SOMMERS-FLANAGAN: OK, do you know01:29:32 who was president before Bush?01:29:36 CARL: No, I don’t remember who it was before Bush.01:29:38 I mean, I know who it is.01:29:39 I just don’t remember the name.01:29:40 JOHN SOMMERS-FLANAGAN: OK.01:29:41 Can you describe the person?01:29:44 CARL: A Christian white guy.01:29:46 JOHN SOMMERS-FLANAGAN: OK.01:29:49 CARL: I’ll know him when I see him.01:29:50 JOHN SOMMERS-FLANAGAN: OK.01:29:52 CARL: Then before that was Bush.01:29:55 JOHN SOMMERS-FLANAGAN: OK, so before the Christian white guy01:29:57 there was Bush.01:29:58 And then…01:29:59 CARL: Another Christian white guy.01:30:01 OK, I’ll remember the faces.01:30:06 If I see a face of the president,01:30:08 I’ll be able to recognize it.01:30:09 JOHN SOMMERS FLANAGAN: You can recognize…01:30:11 CARL: I don’t really know that much about the presidents.01:30:13 JOHN SOMMERS-FLANAGAN: Do who was before the first Bush?01:30:16 CARL: His father.01:30:17 JOHN SOMMERS-FLANAGAN: OK.01:30:20 CARL: Before Bush, it was his father Bush.01:30:24 Before him was the other Christian white guy.01:30:29 JOHN SOMMERS-FLANAGAN: OK.01:30:30 CARL: Why is it that all the presidents up until Obama01:30:33 were Christian white males?01:30:36 JOHN SOMMERS-FLANAGAN: I don’t know.01:30:38 CARL: You don’t know.01:30:39 JOHN SOMMERS-FLANAGAN: Why do you think?01:30:41 CARL: Because people are naturally judgmental,01:30:43 and there are a lot of racist people out there.01:30:47 Everything’s always going to be fair.01:30:49 It’s always going to have something01:30:50 to do with looks, religion, and ethnic national background,01:30:53 stuff like that.01:30:56 Christianity and stuff like that just01:30:58 happens to be one of the more powerful religions.01:31:00 So coming from that aspect, lots of people01:31:03 are compelled by their religious beliefs to do a lot of things.01:31:08 It would all make sense that the government in general01:31:11 would look for white Christian males.01:31:16 JOHN SOMMERS-FLANAGAN: OK.01:31:19 Sounds good.01:31:20 Now I’m going to ask you some questions that01:31:22 are a little different, questions about feelings.01:31:25 OK.01:31:25 CARL: Feelings, feelings, yes.01:31:27 JOHN SOMMERS-FLANAGAN: And my first question about that01:31:30 is how are you feeling right now?01:31:39 CARL: Calm, that’s about it.01:31:44 JOHN SOMMERS-FLANAGAN: OK.01:31:45 So you’re feeling calm.01:31:51 If you were to rate your mood, zero01:31:53 is the worst possible mood.01:31:56 It’s like you’re so down and depressed that you’re just01:31:59 going to kill yourself.01:32:01 It’s over.01:32:02 And 10 is the happiest you could possibly feel.01:32:07 You’re so happy maybe…01:32:08 I don’t know what you do when you’re really happy…01:32:10 But maybe you’re dancing, and singing,01:32:12 and you’re just super happy.01:32:15 On that scale of zero to 10, how would you01:32:17 rate your mood right now?01:32:23 CARL: Right down the middle.01:32:24 JOHN SOMMERS-FLANAGAN: You’re about a five, you think?01:32:26 Down the middle?01:32:27 CARL: Well, I had a pretty good day.01:32:28 But yesterday was pretty crappy.01:32:29 And I’ve got some stressful things on my mind.01:32:31 So it’s about a five.01:32:33 JOHN SOMMERS-FLANAGAN: So you’re about a five.01:32:34 CARL: Yeah, it’s right there in the middle.01:32:35 JOHN SOMMERS-FLANAGAN: OK.01:32:36 Now if you were to say the worst mood01:32:40 you’ve had for the last three months.01:32:45 JOHN SOMMERS-FLANAGAN: You know, Rita, many professionals01:32:47 I think are a little reluctant to do something01:32:50 as structured and evaluative as a mental status01:32:52 examination for fear that it might adversely01:32:55 affect the report or the therapeutic relationship.01:32:58 One thing that I found, and maybe it’s01:33:00 just because I’m a little bit weird,01:33:02 is that I actually find that using that kind of structure01:33:07 and the assessment parts of the mental status examination01:33:11 can be framed in a way that engages the clients01:33:14 and I think at least doesn’t adversely01:33:17 affect the relationship.01:33:20 And I think I try to frame questions01:33:21 as they might be difficult. And I01:33:23 try to respond empathically when clients have trouble01:33:27 or struggle with the questions.01:33:29 RITA SOMMERS-FLANAGAN: I think you do put people at ease.01:33:32 I like how you kind of ask permission.01:33:34 You tell them it’s going to be a hard question.01:33:36 But even with all of that reassurance,01:33:39 you can feel the anxiety that comes up in Carl when01:33:42 he can’t get something right.01:33:44 And then he says, he was able to multiply double digit numbers01:33:48 in second grade.01:33:50 But really, there is always that urge to ask about the past,01:33:54 to explore.01:33:56 And mental status exams are about the functioning01:33:59 of the client in the present.01:34:01 JOHN SOMMERS-FLANAGAN: So even Carl’s defensiveness01:34:04 that we saw, and maybe his exaggeration,01:34:07 and his use of humor, that’s all data01:34:09 that the mental status examiner or the clinical interviewer01:34:13 can use to make statements within those nine01:34:17 different domains.01:34:19 In particular, I think at the very least,01:34:21 we know Carl is a creative young man.01:34:23 RITA SOMMERS-FLANAGAN: Yes, we do.01:34:24 And one thing that has always been a little confusing for me01:34:27 in mental status exams is affect and mood.01:34:31 So the strategies for assessing those are important.01:34:34 Remember that affect is something that you infer,01:34:37 that you observe.01:34:39 And mood is something that you actually ask about.01:34:42 And you ask about the mood now with some rating form.01:34:47 And then you can also ask about mood the past three months,01:34:50 the highest, the lowest, do an average with that.01:34:52 JOHN SOMMERS-FLANAGAN: And you get01:34:54 a chance to compare where the client is now01:34:56 with previous highs and lows.01:34:59 In this next section…01:35:00 RITA SOMMERS-FLANAGAN: Yeah, let’s watch another one.01:35:01 JOHN SOMMERS-FLANAGAN: OK, in this next section,01:35:02 I start off by doing an assessment01:35:04 of Carl’s intermediate memory.01:35:07 And one thing I think that we’ll discover01:35:08 is he has an excellent intermediate memory.01:35:11 He also shows that he has a pretty darn good sense01:35:14 of humor.01:35:14 RITA SOMMERS FLANAGAN: All right.01:35:16 JOHN SOMMERS-FLANAGAN: Now I’ve got kind01:35:17 of a tricky question for you.01:35:19 You ready?01:35:20 CARL: Does this question do back flips?01:35:23 Then it’s not very tricky, is it?01:35:24 JOHN SOMMERS FLANAGAN: All right, I guess not.01:35:25 CARL: OK.01:35:26 JOHN SOMMERS-FLANAGAN: Remember a few minutes ago I01:35:28 asked you to remember three things that I said?01:35:30 Can you remember what those three things are?01:35:32 CARL: Cup, banana, and newspaper.01:35:34 JOHN SOMMERS-FLANAGAN: OK.01:35:38 You’ve got them.01:35:39 CARL: Well, it was cup, newspaper, banana,01:35:40 in that order.01:35:41 But still.01:35:42 JOHN SOMMERS-FLANAGAN: You got all three anyway.01:35:44 You even remember the order they came in.01:35:47 CARL: Of course, of course, I’m smarter01:35:48 than your average Job Corps kid, which is about average.01:35:53 JOHN SOMMERS-FLANAGAN: OK.01:35:54 All right, now I have some questions.01:35:56 Those were questions about your feelings and emotions.01:36:01 And now have some questions that are more about your thinking,01:36:05 OK?01:36:05 And then we might come back to feeling a little bit too.01:36:08 But tell me, let’s see.01:36:16 Do you ever get any thoughts stuck in your head,01:36:20 they just kind of go over, and over, and over?01:36:23 CARL: I’ve got millions of those.01:36:24 Which one do you want?01:36:25 JOHN SOMMERS-FLANAGAN: What would be a typical that gets01:36:27 stuck in your head?01:36:29 CARL: Well, I sometimes whenever something happens,01:36:33 I picture another event happening as a result of it01:36:35 that gets stuck in my head.01:36:36 Songs get stuck in my head.01:36:38 Voices get stuck in my head.01:36:40 JOHN SOMMERS-FLANAGAN: Yeah.01:36:40 CARL: They don’t really [UNINTELLIGIBLE], ,01:36:41 but they just kind of sit there.01:36:42 And they used to tell me to do things,01:36:44 but now I get into arguments with them on occasion.01:36:46 JOHN SOMMERS-FLANAGAN: OK, so you01:36:48 have some songs that get stuck in your head01:36:50 and then some voices that get stuck in your head.01:36:52 CARL: Well, yeah, I like to make up the voices,01:36:53 because it helps drown out the music.01:36:54 I mean, the voice thing is intentional.01:36:56 Because it helps get the songs, and the thoughts,01:36:59 and memories out of my head.01:37:00 So that’s kind of like a self-help right there.01:37:02 JOHN SOMMERS-FLANAGAN: So one of the ways01:37:04 you get something that’s stuck in your head out of your head01:37:07 is maybe you sort of creative these voices in your head?01:37:11 And they kind…01:37:11 CARL: It’s kind of like an invisible imaginary friend.01:37:14 JOHN SOMMERS-FLANAGAN: OK.01:37:17 Do you have a consistent, invisible imaginary friend?01:37:20 CARL: No, not really, because they’re not technically01:37:22 imaginary friends.01:37:22 They’re just little bodily voices01:37:24 that I made up in my head.01:37:25 They’re like a little thoughts that I created,01:37:27 like I find a way create a thought that01:37:29 overpowers all the other noises and stuff01:37:31 that I hear in my head.01:37:32 They kind of just [UNINTELLIGIBLE] these other01:37:34 voices that…01:37:36 It’s pretty much I’m using my imagination.01:37:38 JOHN SOMMERS-FLANAGAN: Sure.01:37:41 This is just a different kind of question.01:37:43 Do you have any beliefs that other people01:37:45 think are strange or odd?01:37:49 Unusual beliefs?01:37:50 CARL: Quite a few, actually.01:37:52 JOHN SOMMERS-FLANAGAN: Well, give me an example.01:37:54 What would be an unusual belief?01:37:56 CARL: Well, I really don’t care if anybody’s into bestiality.01:38:02 I mean, for starters, there are guys out there01:38:07 that are raping little kids, people out there getting01:38:11 violated 24-7.01:38:12 There are necrophiliacs.01:38:13 There are all this other stuff.01:38:16 I mean, unless it’s like the most powerful out of the seven01:38:19 sins out there.01:38:21 And animals, for instance, for that example,01:38:24 they’re pretty much born to mate.01:38:26 I mean, I really don’t care.01:38:27 The only reason why it’s considered a bad thing01:38:30 is because people just didn’t understand it back then,01:38:32 which is nothing really to understand.01:38:34 The only risk is that they find a new kind of STD.01:38:39 JOHN SOMMERS-FLANAGAN: So one of your unusual beliefs might be01:38:42 that you don’t…01:38:43 CARL: I really don’t care about bestiality.01:38:45 I don’t think…01:38:45 JOHN SOMMERS-FLANAGAN: One way or another,01:38:46 It doesn’t matter to you much.01:38:48 Yeah.01:38:48 CARL: Yeah.01:38:49 JOHN SOMMERS-FLANAGAN: I have some more questions for you.01:38:50 Are you ready?01:38:51 Do you ever see or hear things that other people01:38:53 don’t see or hear?01:38:59 CARL: Sometimes I see ghosts.01:39:01 But other people see them too.01:39:02 JOHN SOMMERS-FLANAGAN: OK.01:39:04 And do you ever think that the radio or the television01:39:07 is speaking directly to you?01:39:10 CARL: Right.01:39:12 I don’t think that the radio or the television’s01:39:15 speaking directly to me.01:39:16 JOHN SOMMERS-FLANAGAN: That would be a no.01:39:17 CARL: No.01:39:18 JOHN SOMMERS FLANAGAN: Definitely not, OK.01:39:20 CARL: I mean, unless the TV turned on and the guy said…01:39:25 And I just happen to be sitting in my room, by myself,01:39:29 in my house.01:39:30 Let’s say I have a house, in my house and watching TV.01:39:33 And the TV magically comes on and I’m single at the time,01:39:41 and the guy goes, are you lonely?01:39:44 A little.01:39:45 Even a little lonely?01:39:47 Oh, yeah, yeah.01:39:48 Are you sitting underneath the covers with…01:39:51 I’m not going to get into that.01:39:52 I’m just saying, I’m probably not going01:39:54 to believe it unless some really weird stuff goes on.01:39:56 JOHN SOMMERS-FLANAGAN: OK.01:39:57 So for the most part, you’re saying probably absolutely not.01:40:01 CARL: I’m trying to watch my language here.01:40:02 JOHN SOMMERS-FLANAGAN: Yeah.01:40:04 Has anyone ever tried to steal your thoughts01:40:06 or read your mind?01:40:09 I know that’s kind of an unusual question.01:40:12 It’s OK.01:40:13 Some people think that.01:40:14 And that’s just mostly why I’m asking.01:40:16 CARL: People try to steal other thoughts or read their mind.01:40:19 So that’s original.01:40:25 Well, how do I answer this one?01:40:26 JOHN SOMMERS-FLANAGAN: Yes or no.01:40:28 CARL: I never thought that anybody was trying01:40:31 to steal or read my mind.01:40:34 But I used to have friends and family and stuff that01:40:37 were Wiccan.01:40:38 And I’ve met quite a few people…01:40:40 JOHN SOMMERS-FLANAGAN: Speaking of knowledge,01:40:42 I’ve got a few more questions for you.01:40:44 CARL: Yes, yes.01:40:45 JOHN SOMMERS-FLANAGAN: And these are a little more knowledge01:40:46 based.01:40:47 So in what way is a pencil and a computer alike?01:40:54 CARL: You write with them.01:40:58 You can transfer knowledge from one spot to another with it.01:41:01 Pretty much the only difference between a pencil and a computer01:41:04 is that the computer’s electrical and the pencil,01:41:06 you can’t store small bits of data01:41:08 on, except for the pencil’s entire system01:41:10 and [UNINTELLIGIBLE] the computer01:41:11 or across multiple components.01:41:13 So yeah, there’s a lot of differences in them two.01:41:15 But they’re pretty much the same thing.01:41:16 JOHN SOMMERS FLANAGAN: There are a lot of differences,01:41:17 but they can use some of the same purpose.01:41:19 CARL: Yes, the same purpose, they even01:41:21 have the same function.01:41:22 JOHN SOMMERS-FLANAGAN: Yeah.01:41:22 CARL: Don’t they?01:41:23 Just one’s one-handed.01:41:23 The other’s two-handed.01:41:24 There’s a lot of differences.01:41:26 JOHN SOMMERS-FLANAGAN: What if in the future some time…01:41:28 CARL: It’s pretty much the person01:41:29 doing the exact same thing.01:41:30 JOHN SOMMERS-FLANAGAN: OK.01:41:32 What if in the future some time you01:41:33 found a gun hidden in the bushes near your home.01:41:38 What would you do?01:41:39 CARL: If I found a gun in the bushes around my home,01:41:45 I would probably…01:41:48 Because I always have a friend like this that’s01:41:50 either in the police division or has worked for the government01:41:53 or something.01:41:54 I’d just get them to check the gun,01:41:55 see if there’s any signs that may have been used01:41:57 to harm somebody, if not, register the gun01:41:58 and keep it for myself.01:41:59 JOHN SOMMERS-FLANAGAN: So you’d get somebody01:42:01 to check the gun out?01:42:02 CARL: Yes.01:42:04 Then I’d see if I could get the gun registered01:42:07 so I could keep it.01:42:07 JOHN SOMMERS-FLANAGAN: And see if you could keep it.01:42:09 CARL: Because it’s a free gun.01:42:10 JOHN SOMMERS-FLANAGAN: Yeah, and the last question,01:42:13 and then if you have questions for me I’ll try to answer them.01:42:16 But what would you do if a close friend of yours01:42:19 obviously had a drug or an alcohol problem?01:42:23 CARL: Well, as far as the getting drunk part goes,01:42:26 I actually do care if they get drunk.01:42:29 So I would do what I can to take care of it.01:42:33 Well, if somebody, though, did do drugs01:42:36 but it didn’t affect them in a negative way,01:42:38 per se, like if it was like marijuana or hemp,01:42:41 I really wouldn’t care as long as they…01:42:44 JOHN SOMMERS-FLANAGAN: But let’s say they had a serious problem.01:42:47 CARL: Oh, an actual problem, then I’d01:42:48 try to help them with it.01:42:50 I’d try to get them off of it.01:42:51 JOHN SOMMERS-FLANAGAN: You’d try to be helpful?01:42:52 CARL: I’d try to tell them to [UNINTELLIGIBLE]01:42:53 down the doses, come up with strategies.01:42:55 But I wouldn’t really try to make01:42:56 anybody quit just cold turkey.01:42:58 I wouldn’t.01:42:59 JOHN SOMMERS FLANAGAN: Try to help them cut down.01:43:00 CARL: Yeah.01:43:00 JOHN SOMMERS-FLANAGAN: OK.01:43:01 CARL: Because I really don’t care.01:43:02 I mean, marijuana could help the world.01:43:04 But the lumber company got pissed.01:43:05 And then marijuana is illegalized01:43:08 because of all of its uses.01:43:11 JOHN SOMMERS-FLANAGAN: Well now, questions for me.01:43:14 JOHN SOMMERS-FLANAGAN: The purpose of the mental status01:43:16 examination is to gather data or observations on the client01:43:20 that you can then organize into the nine01:43:22 different mental status examination domains.01:43:25 But as you probably noticed, my preference01:43:28 is to try to do that in a way that01:43:30 is empathic and collaborative.01:43:33 RITA SOMMERS-FLANAGAN: Which I think is great,01:43:35 I really think that it’s a great relationship building thing.01:43:39 And you actually get more information that way.01:43:42 But of course, that accounts for some of the wide ranging01:43:44 and sometimes tangential content that you saw with Carl.01:43:49 But it is important information.01:43:52 JOHN SOMMERS-FLANAGAN: Although it01:43:53 would make the interview shorter if I stayed01:43:56 a little more structured.01:43:58 Now if you watched the mental status examination interview01:44:02 with Carl and you jotted down a few notes in those nine01:44:05 different areas, now would be a really good time01:44:08 for you to look back at those notes and the nine areas01:44:11 and to try to make a few statements that01:44:14 are a little more conclusive about what you saw01:44:17 in Carl during that interview.01:44:19 And even better, it would be a really good idea01:44:22 to compare those notes and those conclusions01:44:25 with your classmates so that you can get a little bit01:44:27 more objective in how you are evaluating the mental status01:44:32 examination data.01:44:41 RITA SOMMERS-FLANAGAN: In this section,01:44:43 we’re going to demonstrate a suicide assessment interview.01:44:46 We’re going to see John working with a young woman named Tommi,01:44:50 who’s been referred by staff at Trapper Creek Job Corps, where01:44:56 John has seen Tommi one another time in a group setting.01:45:00 So he doesn’t know her very well.01:45:01 The staff is worried about her because she’s moody.01:45:05 And she’s had intermittent suicidal ideation.01:45:08 So they want a mental status sort of check in on that.01:45:13 You will see as the tape begins that we’re01:45:16 a little ways into this session.01:45:18 John started an assessment of mood and depression.01:45:21 Because Tommi’s indicated she’s a little bit down.01:45:24 And also she’s talked a small amount about her family01:45:28 troubles and some other areas of concern,01:45:31 like personal insecurities, that are affecting her mood.01:45:35 So we’ll go ahead and watch some of this tape.01:45:39 JOHN SOMMERS-FLANAGAN: I know from our conversation01:45:41 before also that you’re Native Alaskan.01:45:45 TOMMI: Yes.01:45:46 JOHN SOMMERS-FLANAGAN: And you’re from a tribe in Alaska.01:45:49 That’s your main tribal connection.01:45:53 TOMMI: Yeah, yup.01:45:54 JOHN SOMMERS-FLANAGAN: And that’s the…01:45:56 TOMMI: Yupik.01:45:56 JOHN SOMMERS-FLANAGAN: Yupik.01:45:58 TOMMI: The Y-U-P-I-K.01:46:00 JOHN SOMMERS FLANAGAN: Y U P I K. And as we’re talking today,01:46:05 if there’s anything that maybe from your cultural background01:46:11 or from your tribal perspective that I maybe am not getting,01:46:18 I hope that you would feel free to say, hey, John.01:46:24 From my perspective or from my cultural perspective,01:46:28 this is the way we think about or this is the way we do it.01:46:32 And so would that be OK if you let01:46:35 me know if I’m going the wrong direction?01:46:40 TOMMI: That’d be fine.01:46:41 JOHN SOMMERS-FLANAGAN: OK.01:46:42 A All right.01:46:46 And sometimes when people are down,01:46:47 it affects them in a lot of different areas.01:46:51 And one of the places that it can affect you01:46:53 is the way you think.01:46:55 OK, it can affect some thoughts you have about yourself.01:46:59 CARL: Yeah.01:47:00 JOHN SOMMERS-FLANAGAN: Or about the world, or about the future.01:47:03 So I’m wondering if in particular you’re01:47:05 having any negative thoughts about yourself, or the world,01:47:10 or the future outlook of things.01:47:17 TOMMI: Sometimes I feel really hopeless.01:47:23 I don’t know, like things seem to get worse all the time.01:47:33 So I don’t really think about the future.01:47:41 JOHN SOMMERS-FLANAGAN: Sometimes people01:47:43 when they’re feeling down, they have01:47:44 some physical symptoms too.01:47:46 Like sometimes people have trouble sleeping.01:47:48 Sometimes they have trouble eating.01:47:50 Or then sometimes they sleep too much01:47:52 and sometimes they eat too much.01:47:54 Have you had anything like that going on?01:47:59 TOMMI: Yeah.01:48:01 I haven’t been sleeping.01:48:05 You can’t really sleep when you’re too busy thinking.01:48:10 JOHN SOMMERS-FLANAGAN: So your mind01:48:11 is kind of buzzing along at night,01:48:15 and so it’s hard to lay down and really01:48:18 get yourself to go to sleep?01:48:19 TOMMI: But once I do sleep, I don’t want to wake up.01:48:23 I’d rather stay asleep and dream and actually01:48:27 have to wake up and deal with reality.01:48:30 JOHN SOMMERS-FLANAGAN: Yeah.01:48:31 TOMMI: So.01:48:32 JOHN SOMMERS-FLANAGAN: Sometimes people01:48:33 have their social relationships sort of01:48:35 affected by when you’re down too.01:48:37 And I’m wondering how your social life is going.01:48:43 Is it going OK?01:48:44 You have some contacts and connections?01:48:49 TOMMI: I have friends, but it seems01:48:52 like everyone’s having fun.01:48:54 And I’m there just to be there.01:48:57 Like, they call me a zombie.01:49:01 JOHN SOMMERS-FLANAGAN: I’m going to just ask01:49:03 this question directly.01:49:07 Tell me because sometimes when people feel down,01:49:12 it’s really not unusual for people01:49:15 to also think about suicide or about death.01:49:19 And I’m wondering if you’ve had any thoughts about suicide,01:49:23 or about death, and stuff like that?01:49:30 TOMMI: There’s been some.01:49:31 JOHN SOMMERS-FLANAGAN: OK.01:49:32 So you had some thoughts.01:49:34 TOMMI: Yeah, more than some probably, daily basis.01:49:42 JOHN SOMMERS-FLANAGAN: Think about that most01:49:44 of the day, part of the day.01:49:51 TOMMI: Whenever, sometimes it’s never.01:49:55 But maybe sometimes it’s like throughout the day.01:50:01 JOHN SOMMERS-FLANAGAN: OK.01:50:06 What are some times when you’re not thinking01:50:08 about death or suicide?01:50:11 What’s usually going on when you’re01:50:13 free from those thoughts?01:50:20 TOMMI: When I’m not thinking about suicide?01:50:22 JOHN SOMMERS-FLANAGAN: Yeah.01:50:23 TOMMI: Probably singing.01:50:27 JOHN SOMMERS-FLANAGAN: OK, when you’re singing?01:50:29 OK.01:50:30 So kind of engaged in making music in some ways,01:50:34 and that sort of takes you away from those01:50:38 more negative and sad…01:50:42 TOMMI: Yeah, I write poetry too.01:50:45 JOHN SOMMERS-FLANAGAN: OK.01:50:46 And that’s helpful?01:50:48 TOMMI: Yeah.01:50:49 JOHN SOMMERS-FLANAGAN: OK.01:50:56 Sometimes when people think about suicide,01:51:02 they think about it in a very active way,01:51:06 like, oh here’s how I think I would kill myself.01:51:10 And sometimes people think about it in a less active way.01:51:14 It’s like, oh, I just kind of wish I was dead.01:51:18 But I don’t really have a plan or any specific ideas01:51:24 about how I might end my life.01:51:28 Which is more true for you?01:51:32 Do you have some specific ideas about a plan or a way01:51:37 that you would end your life?01:51:39 Or do you just sort of think, ah, I wish I…01:51:44 TOMMI: Well, I have a couple plans.01:51:50 But there’s days where it’s inactive.01:51:57 JOHN SOMMERS-FLANAGAN: Inactive in it’s not…01:52:00 TOMMI: It’s like I wish I was dead.01:52:02 JOHN SOMMERS-FLANAGAN: OK.01:52:02 TOMMI: Or the world would be better with me or something01:52:05 like that.01:52:06 JOHN SOMMERS-FLANAGAN: OK.01:52:07 TOMMI: So I could hurt the people in my family,01:52:14 and they would feel bad for it.01:52:18 But I was either going to shoot myself.01:52:22 But that was out of the plan, because there01:52:24 was no guns in the house.01:52:26 So I was going to hang myself in my room01:52:29 and write on the walls everything that ever hurt me01:52:35 to my parents.01:52:38 So whenever they decided, wow, she’s been in her room01:52:41 too long, they could go in there and tah-dah.01:52:48 Yeah.01:52:48 JOHN SOMMERS-FLANAGAN: So one parts01:52:50 for you is to send a message to your parents01:52:53 about how you feel.01:52:55 TOMMI: Yeah.01:52:56 JOHN SOMMERS-FLANAGAN: About how you’ve been treated.01:53:01 RITA SOMMERS-FLANAGAN: Well, it’s certainly clear01:53:03 that not all of these interactions01:53:06 are scripted or planned ahead of time.01:53:08 They’re very real.01:53:10 And so they’re not perfect.01:53:12 We’ll talk about some things that happened that went well01:53:15 and some things that maybe you wish you’d included.01:53:18 JOHN SOMMERS-FLANAGAN: Right.01:53:20 RITA SOMMERS-FLANAGAN: So one thing I noticed01:53:22 right away was a kind of interesting where she01:53:25 spelled the name of her tribe.01:53:28 And at that moment in the interview, her move lifted.01:53:31 She smiled.01:53:32 That’s kind of interesting.01:53:33 JOHN SOMMERS-FLANAGAN: Yeah, I notice that also.01:53:35 I thought it was interesting.01:53:37 I’m not sure what to make of it.01:53:39 It’s one of those things I kind of put in the back of my head.01:53:42 It might be worth exploring somewhat later.01:53:45 Maybe there’s something meaningful and affectively01:53:48 uplifting about her connection with her tribe.01:53:50 RITA SOMMERS-FLANAGAN: Yeah, there was something there.01:53:52 I also noticed that she was speaking and processing01:53:56 pretty slowly.01:53:57 She wasn’t at all agitated or hostile.01:54:00 But her tone was actually almost kind of flat.01:54:03 JOHN SOMMERS-FLANAGAN: Yeah, and that’s01:54:05 not very unusual for people who have01:54:07 sort of a unipolar depression that doesn’t01:54:11 have much agitation in it.01:54:14 And I noticed that when I was trying to do01:54:17 was to assess her cognitive, her physical,01:54:20 and her social depressive symptoms.01:54:23 I noticed she had some symptoms in each of those areas.01:54:26 And then I asked directly about suicide.01:54:27 And I was glad of that.01:54:28 But I felt a little bad that I never01:54:30 explored the frequency, duration,01:54:32 and intensity of her suicide ideation very completely.01:54:36 RITA SOMMERS-FLANAGAN: Right, frequency, duration…01:54:39 JOHN SOMMERS FLANAGAN: Intensity.01:54:41 RITA SOMMERS-FLANAGAN: But you did ask directly01:54:45 about suicide and about wanting to die or kill herself,01:54:48 which is very hard to do.01:54:50 And you did it in a way that I thought was acceptable.01:54:54 She went with it.01:54:55 She answered you.01:54:56 The other thing I liked is you asked about times that she’s01:54:59 free of any suicidal ideation.01:55:01 JOHN SOMMERS-FLANAGAN: Which I think01:55:02 is really important to sort of flow01:55:04 into some positive emotions or positive situations01:55:10 as much as possible during a suicide assessment interview.01:55:14 And you know, when someone admits to suicidal thoughts,01:55:18 it’s also important to check on suicidal plan.01:55:22 And the plan can be something that’s01:55:25 sort of underneath the surface that you need01:55:28 to ask directly about as well.01:55:30 TOMMI: I tried two times and I realized01:55:34 that I was being selfish.01:55:40 So I guess, I don’t know, mostly selfish.01:55:58 JOHN SOMMERS-FLANAGAN: So you tried a couple of times.01:56:01 And it sounds like after those, your conclusion,01:56:06 what you came to in your mind, was that feels selfish.01:56:10 And that you’re not really wanting to do that?01:56:14 TOMMI: Well, I tried two times to kill myself,01:56:19 two different occasions.01:56:21 So I just thought, well, two times01:56:33 of trying to kill yourself and you didn’t die.01:56:38 Why didn’t I die?01:56:42 Maybe I’m supposed to be here.01:56:44 So I don’t know.01:56:47 I’ve been trying to think positive, but I don’t know.01:56:50 JOHN SOMMERS-FLANAGAN: Maybe surviving means something.01:56:53 TOMMI: Yeah.01:56:53 JOHN SOMMERS-FLANAGAN: It’s maybe that’s a message from01:56:56 the universe or from…01:56:57 TOMMI: Something.01:57:00 RITA SOMMERS-FLANAGAN: Wow, that was an interesting exchange.01:57:03 You know, I had the feeling that she really01:57:05 wanted to ask her more about those two suicide attempts.01:57:09 JOHN SOMMERS-FLANAGAN: Yeah, I think you’re probably right.01:57:12 And it was a hard choice.01:57:14 I ended up deciding to go with exploring01:57:18 the meaning of her staying alive,01:57:21 which seemed also important to her.01:57:23 That’s one of the challenges in the suicide assessment01:57:26 interview is do you go more for deeper assessment of suicide,01:57:31 or suicidal plans, or thoughts, or even previous attempts,01:57:35 or do you focus a little more strategically on the positive01:57:39 and more hopeful parts of the interview?01:57:41 RITA SOMMERS-FLANAGAN: Yeah, OK, well,01:57:43 let’s watch a little bit more.01:57:46 TOMMI: Well, I guess there’s no good reason to commit suicide.01:57:49 But you know, I don’t know what I’m trying to say.01:57:57 My friend committed suicide because he01:58:00 got caught with a can of chew.01:58:02 He got kicked off the wrestling team.01:58:07 JOHN SOMMERS-FLANAGAN: OK.01:58:10 TOMMI: Yep, he shot himself in the head.01:58:16 JOHN SOMMERS-FLANAGAN: And as you say that to me,01:58:18 I think that it sounds like you feel both sad and a little bit01:58:22 angry that he killed himself.01:58:25 TOMMI: Well, I’m sad.01:58:27 Don’t get me wrong.01:58:28 He was a good kid.01:58:33 It makes me angry because you hurt a lot of people01:58:38 when you take your life.01:58:41 Like who are you to take your own life?01:58:44 Like you’re hurting your family, your friends.01:58:51 I don’t know.01:58:55 JOHN SOMMERS-FLANAGAN: Yeah.01:58:56 Yeah.01:58:57 So I hear you saying reasons to live,01:59:00 one is suicide you kind of hurt people,01:59:05 maybe even people you don’t intend to hurt.01:59:08 Another reason is you’ve got a brother who01:59:11 you think the world of you want to help him in his life.01:59:14 TOMMI: Yeah, I guess I don’t want him to end up like me.01:59:20 JOHN SOMMERS-FLANAGAN: I just want to check in with you01:59:23 on maybe a little plan you to stay safe.01:59:29 Because I know you’ve had some thoughts about suicide.01:59:32 It sounds like for the most part,01:59:34 and let me know if I’ve got this right, that for the most part01:59:37 you’re pretty clear that you want to live and move forward01:59:43 toward your dream and be a positive influence01:59:45 with your brother.01:59:45 Have I got that right?01:59:48 That’s the main thing.01:59:49 Now if you were in a situation and you were feeling suicidal,01:59:53 what would help you feel better?02:00:04 TOMMI: That’s a really hard question,02:00:05 because when something really gets me down,02:00:12 I don’t really think about what makes me happy.02:00:18 I’m kind of pessimistic in some way.02:00:23 JOHN SOMMERS-FLANAGAN: But the good thing is right now,02:00:25 you’re at a three or four.02:00:27 So you’re not all the way down there at a zero or one.02:00:29 TOMMI: Yeah.02:00:29 JOHN SOMMERS-FLANAGAN: So right now when you’re02:00:31 feeling a little better, what do you think,02:00:34 what could you remind yourself, oh, here’s02:00:36 what I think I should do when or if I02:00:40 start to feel more suicidal?02:00:42 What would be a healthy thing you could do.02:00:46 TOMMI: Well, I’d say eat, but that’s not too healthy.02:00:48 JOHN SOMMERS-FLANAGAN: Well, it depends on what you eat,02:00:50 I guess.02:00:50 TOMMI: Well, I binge eat sometimes.02:00:52 JOHN SOMMERS-FLANAGAN: So maybe having02:00:54 a small, nutritious meal.02:00:57 TOMMI: No, working out or singing karaoke or something.02:01:02 JOHN SOMMERS-FLANAGAN: Working out, singing, OK, those02:01:05 would help.02:01:05 Would it help to call somebody, talk with a friend?02:01:10 TOMMI: I don’t really like to talk to people about things02:01:13 they never went through.02:01:15 JOHN SOMMERS-FLANAGAN: OK.02:01:16 TOMMI: They don’t understand.02:01:18 They can sit there and be like yeah.02:01:21 JOHN SOMMERS-FLANAGAN: Anybody on your list of friends02:01:23 who might understand?02:01:25 TOMMI: Nope.02:01:25 JOHN SOMMERS-FLANAGAN: Nope.02:01:26 Not even the person who was on the phone with you02:01:28 for three hours?02:01:30 TOMMI: They’d be able to understand,02:01:32 but I’d rather call my sister.02:01:34 Because we grew up together.02:01:37 We know what we went through.02:01:42 JOHN SOMMERS-FLANAGAN: OK.02:01:43 So the possible things you might do is you might work out.02:01:46 You might sing.02:01:46 You might call your sister.02:01:48 Anything else that would help a tiny bit?02:01:59 Write some good poetry?02:02:00 TOMMI: Yeah.02:02:01 JOHN SOMMERS-FLANAGAN: Yeah?02:02:02 TOMMI: Write some poetry.02:02:03 JOHN SOMMERS-FLANAGAN: You know, one of the things02:02:05 I just want to say, and then we’ll probably stop here02:02:08 in just a minute, is that it’s hard to know when people02:02:13 are going to feel down, right?02:02:16 And so it’s good to have a plan ahead of time for what you’re02:02:21 going to do.02:02:21 Because when you’re feeling down, then sometimes02:02:24 you’re not very creative.02:02:25 And you can think of all the good options.02:02:28 So what I’m wondering is if you and I can agree02:02:30 that if you have a really down time that you will02:02:33 try working out, singing, calling your sister,02:02:35 writing poetry, and maybe even add that to,02:02:40 if you really were terribly suicidal, maybe even call 911,02:02:44 try to get some help?02:02:46 TOMMI: Yeah.02:02:49 RITA SOMMERS-FLANAGAN: So you know, this section02:02:51 is really tough.02:02:52 And this whole enterprise of suicide assessment is tough.02:02:56 People are unique.02:02:58 And there is no exact formula for assessing suicidality.02:03:04 I really appreciate the way you worked02:03:07 to make the assessment a positive therapeutic02:03:11 experience.02:03:13 But it’s also a scary endeavor.02:03:14 JOHN SOMMERS FLANAGAN: You know, it02:03:15 was stressful and challenging.02:03:18 Tommi, I think, is a very interesting and complicated02:03:21 young woman.02:03:22 It’s hard.02:03:23 I think at times she was very cooperative with me.02:03:27 And there are times when she was much more challenging.02:03:31 She’s a bright young woman.02:03:33 There are a lot of factors mixed in there.02:03:35 I think I probably, if I erred on one side,02:03:38 it was toward being more positive02:03:41 and focusing on maybe more therapeutic questions02:03:44 and what’s going well for her and maybe ignored02:03:47 a little bit of negative side.02:03:50 One interesting thing that I didn’t bring up earlier02:03:53 is that when she talked about her suicidal plan, which02:03:57 had been in the past, and that was a good thing,02:04:00 she also was talking about an underlying motive.02:04:03 And that’s often the case with a suicide plan.02:04:07 And for hers, it was a little bit02:04:09 of a revenge motive, a little bit of a send02:04:11 a message to my parents motive.02:04:14 And so I think that’s a place where02:04:16 you can take the opportunity to turn a discussion about a plan02:04:21 into something that’s more therapeutic02:04:23 and help her focus on how could she02:04:25 give that message to her parents without having it involve02:04:28 anything to do with suicide.02:04:31 RITA SOMMERS-FLANAGAN: So even though every suicide assessment02:04:36 is unique, there are some factors02:04:39 that should be considered in each interview.02:04:42 JOHN SOMMERS-FLANAGAN: That’s absolutely true.02:04:44 And now if you look at the slide,02:04:47 you can see that the first part of a comprehensive suicide02:04:51 assessment interview involves evaluating suicide risk02:04:55 factors.02:04:55 And oftentimes, you don’t do all that directly.02:04:58 But you find out about the different suicidal factors02:05:01 that may be operating.02:05:04 Typically, you do a depression assessment.02:05:06 Because almost always there are some depression symptoms.02:05:10 You do an exploration of the suicide ideation.02:05:13 You ask directly.02:05:15 You want to frame that in a way the client can02:05:17 answer truthfully.02:05:19 Also you explore the suicide plan and move02:05:22 on to trying to determine whether or not the client has02:05:26 a high level of suicide intent.02:05:27 And one of the ways of doing that02:05:29 is to check in to their reasons for living.02:05:33 And then the last categories are two02:05:35 try to infer the client’s level of self-control.02:05:38 And one way of doing that is to try02:05:41 to develop a collaborative and cooperative safety plan02:05:44 between you and your client.02:05:47 RITA SOMMERS-FLANAGAN: So if we were02:05:49 going to do a little summary, Tommi has tried suicide twice02:05:55 by her own account.02:05:56 She has a good friend who killed himself.02:05:59 Her family background includes some substance abuse,02:06:04 and probably some physical abuse,02:06:07 and a very serious addiction problem that Tommi herself has.02:06:13 So certainly, she’s in a high risk population.02:06:17 But on the other hand, she’s future-oriented.02:06:21 And she’s in a setting that’s structured and is providing her02:06:26 with the opportunity to work on vocational skills02:06:30 and on her sobriety.02:06:31 JOHN SOMMERS-FLANAGAN: What you’re saying02:06:32 reminds me of the fact that we need02:06:34 to talk about decision making.02:06:36 And that could be one of the most stressful and tormenting02:06:39 things I think for a mental health professional02:06:41 is deciding, well, how do I act in this particular situation?02:06:45 I think because of the things you02:06:46 said, including the fact that she has a pretty high mood02:06:49 rating and she collaborated on a safety plan,02:06:52 that in fact, I probably wouldn’t02:06:55 go toward hospitalization.02:06:56 RITA SOMMERS-FLANAGAN: Right, yeah.02:06:57 JOHN SOMMERS-FLANAGAN: But it’s really important02:06:59 to integrate or to weave in some documentation of what you’re02:07:03 doing and some consultation with other professionals02:07:06 in order to protect yourself from liability02:07:09 and to make sure you’re doing a thorough comprehensive suicide02:07:12 assessment.02:07:13 RITA SOMMERS-FLANAGAN: Right, yeah.02:07:14 And you know that not only brings us02:07:17 to the end of this section but to the end of the DVD.02:07:21 JOHN SOMMERS-FLANAGAN: You know one thing I’m02:07:23 struck at the end of this whole production02:07:27 is just how much there always is to learn,02:07:31 and how complicated individuals are,02:07:33 and how many different ways you can look at the clients02:07:37 with whom you’re working, and how many different ways there02:07:40 are two approach the clinical interview.02:07:41 RITA SOMMERS-FLANAGAN: Right.02:07:43 You know, if I was going to offer a summarization of that,02:07:46 I’d pretty much say, you think that it’s a lifelong learning02:07:51 process.02:07:52 JOHN SOMMERS-FLANAGAN: And you’d be02:07:54 pretty much right about that.02:07:55 RITA SOMMERS-FLANAGAN: And we both hope02:07:57 that this has been helpful to you in your journey02:08:00 toward becoming a really excellent clinical interviewer.02:08:04 Thanks.02:08:04 [MUSIC PLAYING]
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