· 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.

Note:

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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