Assignment 6090

00:17 JOHN SOMMERS-FLANAGAN: Welcome to00:19 our clinical interviewing DVD. 00:21 In this video, we describe and demonstrate 00:25 a wide range of different clinical 00:27 interviewing responses. 00:29 Our goal is to help you further develop 00:33 your clinical interviewing repertoire. 00:37 The material in this DVD is based on our textbook, cleverly 00:42 titled clinical interviewing. 00:45 RITA SOMMERS-FLANAGAN: In our life as professors, 00:47 we really have come to believe in that old kindergarten 00:51 activity called show and tell. 00:53 So in this video, we're obviously 00:55 going to be telling you about clinical interviewing skills, 00:59 but we also will be showing you video clips that 01:02 illustrate these. 01:03 And we really hope that together they'll 01:06 combine to help you become excellent clinical 01:10 interviewers. 01:12 JOHN SOMMERS-FLANAGAN: And we begin 01:13 with a focus on very basic interviewing and listening 01:17 skills, skills that everyone needs 01:21 to do a really good clinical interview. 01:24 These skills include attending behavior, 01:27 non-directive listening, directive listening, and action 01:32 responses, as well as the skill the use of questions. 01:36 Later, we move to demonstrating more complex assessment 01:40 interviews, including intake, mental status, and suicide 01:44 assessment interviewing. 01:47 RITA SOMMERS-FLANAGAN: You know, our overall goal in this DVD 01:51 is to help you become aware of how to do the skills 01:56 and when to do the skills. 01:58 Awareness isn't under-girding. 02:01 That's very important in conducting 02:04 professional clinical interviews and in being a mental health 02:07 professional. 02:09 JOHN SOMMERS-FLANAGAN: You know, just a few years ago, Rita, 02:11 although I might be underestimating 02:13 that, we had a clinical supervisor who 02:16 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 saying 02:27 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 direction 02:38 so you become a little bit more intentional in your clinical 02:41 interviewing activities. 02:52 In the next four parts of this interviewing DVD, 02:56 we focus on what we call the continuum 02:59 of listening responses, beginning with the less 03:03 directive, almost non-directive listening approaches 03:07 and extending to the more complex and directive 03:10 interviewing or even action skills. 03:13 RITA SOMMERS-FLANAGAN: I think it's important 03:15 before we actually talk about the techniques 03:17 that we take a minute to think about a couple 03:21 of things that are across techniques in interviewing. 03:25 One is that because there's a power 03:29 differential in the relationship, 03:31 and we can never not communicate, 03:34 the interviewer can be seen as directive even when 03:39 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 culture 03:49 and the individual characteristics of the client 03:53 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 things 04:09 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 looking 04:25 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 subjectivity 04:36 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 understand 04:48 the deep experience of another person, 04:53 especially if the person's from another race 04:55 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 ways 05:07 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, interrupting 05:23 could be one of those negative behaviors. 05:24 RITA SOMMERS-FLANAGAN: Yeah, I agree. 05:26 I think that across cultures, people 05:30 have some kind of awareness or radar that tells them 05:34 when they're not being listened to 05:36 and they're not being respected, yeah. 05:38 JOHN SOMMERS-FLANAGAN: So I guess 05:40 the bottom line is listen well, listen authentically for you, 05:43 but also try to calibrate or adjust the way 05:46 you're listening for the specific individual 05:49 who you're with in the room. 05:50 RITA SOMMERS-FLANAGAN: Yeah, I think 05:52 too I want to underline something 05:53 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 interviewing 06:11 skills, non-directive listening responses. 06:14 JOHN SOMMERS-FLANAGAN: Right. 06:15 RITA SOMMERS-FLANAGAN: So the first one 06:17 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 wrote 06:30 about those as basic micro skills that 06:32 are always present in the interviewing interaction. 06:36 In addition to those, there are also 06:38 some non-directive listening responses. 06:41 These include silence, clarifications, paraphrasing... 06:46 And there's several different kinds 06:48 of paraphrases people can use... 06:50 Reflection of feeling, and summarization. 06:54 RITA SOMMERS-FLANAGAN: Silence can be a very compassionate 06:57 response. 06:58 Just sitting quietly after somebody has shared 07:02 their pain or their story can be difficult but very powerful. 07:08 The important thing is, John, you've 07:10 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 with 07:30 has wished that they had exactly the right thing to say 07:34 at the right time. 07:35 RITA SOMMERS-FLANAGAN: Right. 07:36 JOHN SOMMERS-FLANAGAN: And sometimes silence is exactly 07:38 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 noticed 07:51 I should put my hand over my mouth 07:54 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 tool 08:01 and an important one. 08:02 But of course, we also need some other non-directive techniques 08:08 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 saying 08:39 is that although you think paraphrasing is very important, 08:43 you really don't like it when it's done in kind 08:45 of a mimicky or robotic way. 08:47 RITA SOMMERS-FLANAGAN: Thank you, John Carl 08:49 Rogers Sommers-Flanagan. 08:52 I hate when you do that. 08:53 So what you're saying is you really 08:54 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'll 09:05 demonstrate a clarification. 09:07 JOHN SOMMERS-FLANAGAN: Sounds good. 09:08 You know, one of the things that is 09:10 I think true for me is that sometimes in my students, 09:14 I have observed them having naturally good listening 09:17 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 everyone 09:28 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 saying 09:40 is that listening skills and abilities 09:44 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 can 09:54 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 minutes 10:10 into a session where the client, Jessie, is talking 10:14 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 paraphrase 10:30 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 times 10:53 while talking that she doesn't listen to you 10:57 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 comes 11:19 and they talk to you for like half an hour 11:21 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 just 11:50 go off about her own story. 11:56 I care about our friendship, because it's 11:59 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 part 12:14 has to be crucial. 12:16 Yeah. 12:17 MEGAN: Yeah, it seems like you've 12:20 talked a lot about the different things 12:25 that you're dealing with within this relationship with her, 12:29 in terms of not being heard and not enjoying, just 12:37 not enjoying, being around her anymore 12:40 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 not 12:51 sure what to do about it. 12:52 JESSIE: Yeah. 12:54 I guess I'm just not sure how to bring up 12:57 not living together anymore. 13:03 I'll be gone for the summer, so part of me 13:05 thinks that would be a way. 13:07 Because like she has to find a new place 13:10 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 place 13:24 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 confronting 13:33 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 defensive 14:11 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 really 14:49 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 main 15:03 points that you've just heard. 15:04 JOHN SOMMERS-FLANAGAN: Yeah, and I 15:05 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're 15:12 listening to kind of evaporate in your mind 15:15 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 unhappy 15:23 in the roommate situation, that she was not 15:26 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 number 15:38 the items that you're going to say. 15:40 Because you can get to number two and suddenly 15:43 have no idea what number three was. 15:45 So John there's one last skill that I think maybe 15:48 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 production 16:04 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 just 16:24 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 where 16:47 we might be wasting people's time 16:49 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 identifying 16:58 a range of different emotions that I'm feeling. 17:02 And I have to say I really appreciate 17:03 the fact that stayed with the basic non-directive reflection 17:07 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 action 17:25 responses. 17:35 JOHN SOMMERS FLANAGAN: Previously on this video, 17:37 we focused on listening skills and techniques that 17:39 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 beliefs 18:01 about the importance of listening 18:03 to one another respectfully. 18:06 And the extent to which you as a professional clinical 18:10 interviewer value listening may also 18:14 depend on your cultural background and even 18:17 on your personal experiences. 18:18 RITA SOMMERS-FLANAGAN: That's true. 18:20 You know, being able to stay non-directive and nonjudgmental 18:24 is an important part of interviewing. 18:26 But we also have to learn how to use more directive 18:30 interventions and actions in a way that maintains the therapy 18:35 relationship. 18:37 JOHN SOMMERS FLANAGAN: Absolutely. 18:38 In this next section, we begin moving further 18:42 along the continuum toward more complex and more directive 18:46 listening responses. 18:49 These responses are referred to as directive listening 18:52 responses, because they still primarily focus on listening. 18:56 But they also include components that are progressively more 19:01 directive. 19:02 And so they involve lots of listening, 19:04 and a little bit of directing, or pushing clients 19:07 to see or think about things a bit differently. 19:12 Directive listening responses are more judgmental. 19:15 And they include guidance or validation 19:18 from the interviewer. 19:19 For example, you might use a feeling validation 19:22 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 you 19:34 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 actually 19:44 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 observations 20:11 together and along with an attentive statement about how 20:15 they might be related or what they might mean. 20:18 These meanings that the interviewer picks up on 20:22 might relate to earlier life experiences of the client 20:25 or perhaps to some kind of unconscious processes. 20:29 RITA SOMMERS-FLANAGAN: Right, and of course 20:31 that is sort of theoretically laden. 20:33 And some people are little resistant to that kind 20:35 of interpretation. 20:37 But another way of thinking about it 20:39 is when you take information the client is giving you 20:43 and you link that to a different reality or different way 20:48 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 even 20:55 do a gentle confrontation. 20:57 At least I prefer gentle confrontations. 20:59 Because confrontations simply involve pointing out 21:02 inconsistencies or discrepancies between what 21:06 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 notice 21:23 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 style 21:35 when the interviewer's being slightly more 21:38 directive than the previous segment with Megan. 21:41 TRUDY: And I keep telling him, he 21:44 doesn't have to do it all today. 21:47 But then I think he thinks that I'm trying 21:53 to sabotage his good health. 21:57 I don't know. 21:58 It's just like everything that I do 22:02 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 mentioned 22:08 before you feel a little bit scared 22:10 at the idea of really being out there kind of on your own. 22:13 But also I hear maybe some sadness and some frustration 22:18 in the relationship now and that you're 22:20 not even sure where to start. 22:23 TRUDY: You know, I don't. 22:24 I sit and think about how our relationship 22:28 has been in the past. 22:31 And I realized that it wasn't just since Jamie's first heart 22:35 attack that things have been different. 22:41 I just remember a time when this friend of mine 22:45 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 things 23:13 that we might have talked about or anything like that. 23:17 It was just about kind of about Ross and trying to keep him 23:21 in the conversation, which isn't always easy because he 23:24 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 one 23:38 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 Jamie 23:44 says or wonders if you're trying to sabotage 23:47 some of his exercise. 23:49 TRUDY: Yeah. 23:51 JOHN SOMMERS-FLANAGAN: But I also hear you maybe sometimes 23:54 actively sabotaging the possibility of intimacy 24:00 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 Jamie 24:31 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 interpretation 24:57 was accurate. 24:59 And then we saw the confrontation, which 25:01 of course was very gentle. 25:03 We asked the client's permission, 25:06 then offered the interpretation, and then asked her 25:09 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 confrontation 25:17 was OK with her. 25:18 JOHN SOMMERS-FLANAGAN: One of the reasons 25:19 I think I like to ask client's permission 25:21 to do a confrontation is because I'm kind of naturally 25:24 averse to confronting people. 25:26 So it's a hard thing for me. 25:27 And I also think it helps to engage them 25:29 in a more collaborative way. 25:32 The other thing I noticed about that clip 25:34 was that although Trudy was talking about sabotaging 25:38 a lunch with a friend, I brought it back 25:41 with the confrontation to her presenting complaint, which 25:44 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 see 26:04 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 interpretation 26:21 and then offering the interpretation. 26:27 TJ: fights with family that don't fully 26:30 escalate physically, but kind of break you down. 26:36 JOHN SOMMERS-FLANAGAN: So you've had some fights 26:38 with your family that have been emotionally pretty 26:42 painful, maybe lasting emotional effects, not so much physical. 26:50 OK. 26:53 And when I hear you say that, it sounds 26:56 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 be 27:39 seen as having a weakness. 27:41 And so when your family or people 27:44 have some sympathy for you, that actually 27:46 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 feel 27:54 like they have to do something to make you feel better 27:58 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 when 28:10 we talk about anger and anger management stuff, 28:12 one of the things we do is we talk 28:14 about what are the triggers or the buttons they get 28:17 pushed that bring that anger up. 28:23 And it makes you wonder if maybe one of the buttons 28:28 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, you 28:45 were really working with TJ with his emotions 28:48 and the triggers that are associated with his aggression. 28:54 And you did have that attempt to do 28:58 an interpretation of feeling, and he was 29:00 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 even 29:13 the slightest whiff of weakness was 29:16 going to be a trigger for him. 29:18 JOHN SOMMERS-FLANAGAN: Yeah, I do 29:19 think it's good to follow the client's 29:22 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 well 29:40 are collaborative. 29:41 And Otto Fenichel said this over 60 years ago, 29:44 and that is, that we have to prepare clients 29:47 for interpretations and that interpretations are really 29:50 a way of us working on the edge of our client's consciousness 29:54 or awareness. 29:55 RITA SOMMERS-FLANAGAN: Yeah, there's 29:56 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 obviously 30:11 depend more on the view of the interviewer, 30:16 and the direction is this a little bit more 30:18 related to where the interviewer wants to go than the client. 30:22 JOHN SOMMERS-FLANAGAN: Yeah, directive listening responses 30:25 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, really 30:37 well is as hard as some of the more directive responses. 30:41 JOHN SOMMERS-FLANAGAN: Well, you know, actually 30:43 I totally agree with you. 30:45 You've convinced me. 30:46 And really what I was trying to say 30:48 is I was trying to make the point 30:49 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 socially 30:59 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 action 31:29 responses, which actually move us 31:30 a little further along the continuum of directive 31:34 listening skills. 31:36 JOHN SOMMERS FLANAGAN: Directives are really 31:38 sort of like prescriptions in that they push or move 31:42 clients a little bit toward acting, feeling, or thinking 31:47 in certain particular ways. 31:50 And so it's really important when 31:51 using these kinds of approaches that we weave back and forth 31:55 or we integrate into the approach some less directive 32:00 or non-directive listening skills... so 32:02 a non-directive listening skill like a paraphrase, 32:05 and then a directive action response, and then a check 32:09 in or paraphrase to follow it. 32:11 RITA SOMMERS-FLANAGAN: And you know 32:13 we're talking a lot it about the continuum 32:15 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-directive 32:24 can be done in a way that was experienced 32:28 as pretty directive. 32:30 Raised eyebrow, a tone of voice, choice of words, 32:33 posture those kinds of things can 32:36 be experienced is as a pretty directive or not attractive. 32:40 JOHN SOMMERS-FLANAGAN: I know, I've 32:41 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, especially 32:50 not on video. 32:51 RITA SOMMERS-FLANAGAN: OK, fine. 32:53 So in general, I think the truth is that non-directive things 32:59 can be directive and directed things can come off 33:03 as non-directive, really depending on how you use them. 33:07 JOHN SOMMERS-FLANAGAN: Yeah, when interviewers start sharing 33:11 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 things 33:27 are happening, it's obvious that the interviewer 33:31 is moving toward action. 33:35 And we're trying to change in those situations 33:38 the client's way of thinking, or way of being, or behaving. 33:44 We are in the realm of the directive, which 33:47 may be one reason why directives are most effective with clients 33:51 who are in Prochaska and DiClemente's action stage 33:57 in the transtheoretical model. 33:58 These are people who are ready to engage and work hard 34:01 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 firstborn 34:12 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 passive 34:24 and the idea of offering something directive 34:27 can be sort of terrifying. 34:29 So in this next clip, we see John using agreement, 34:35 suggestion, and he provides psychoeducational material 34:39 effectively and appropriately. 34:41 Watch how he engages his client Lisa 34:44 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't 34:55 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 fine 35:01 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 picture 35:20 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, oftentimes 35:41 with racing thoughts, but you can't 35:43 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 you 35:52 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 up 36:01 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 sleep 36:10 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 intermittently 36:20 through the night. 36:21 Which do you think is the best description 36:23 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 suggest 36:31 to you a few ideas about how to approach the sleep issue? 36:35 LISA: Sure. 36:36 JOHN SOMMERS-FLANAGAN: I know that there 36:38 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 while 36:45 that that might be useful. 36:47 Is that OK? 36:48 LISA: Yes. 36:51 I think it's all magnified by the fact 36:54 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 think 37:02 that might be true for everybody. 37:04 The lack of a good night's sleep can 37:06 make all of us a little less able to cope with things. 37:10 And anything else you've tried to maybe 37:13 push the thoughts aside or to speed the onset of sleep 37:18 for you? 37:18 LISA: No. 37:20 JOHN SOMMERS-FLANAGAN: OK. 37:21 Have you ever heard of mindfulness meditation 37:25 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 just 37:40 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's 37:47 a guy who did some research long ago. 37:50 And he identified four things that people 37:52 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 what 38:40 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 meditation 38:49 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 order 39:08 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 device 39:20 being sometimes a mantra. 39:24 People who do sort of Buddhist stuff 39:27 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 spiritually 39:40 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 obviously 40:04 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 have 40:12 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 based 40:21 psychoeducation. 40:22 She responds in a very positive way 40:25 and is ready to get to work. 40:27 RITA SOMMERS-FLANAGAN: Yeah, it's so nice in fact 40:30 that it can be a little bit seductive, 40:32 and the interviewer who's providing 40:35 all that information and guidance 40:37 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 family 40:50 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, thinking 41:03 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's 41:16 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 you 41:27 get the lemons, that sometimes you make lemonade. 41:30 And it sounds to me like you're probably 41:32 getting lots of great time with your family 41:35 that you maybe would've gotten before. 41:38 LISA: Well, I thought that six months ago 41:40 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 time 42:06 if all this hadn't happened. 42:09 LISA: Now I've worked real hard at adjusting my attitude 42:13 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 so 42:23 well over the last few months. 42:28 How would you feel? 42:29 How would you feel if suddenly you 42:31 had three people who are noisy and move 42:37 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 me 42:48 to have a house full of children and people there. 42:53 And so I guess what I'm trying to say to you 42:54 is it's really a matter of attitude. 42:57 And I wonder if maybe you could consider shifting your attitude 43:00 toward one that welcomes the company as 43:04 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 I 43:11 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 would 43:43 just like to get rid of them, maybe just get them completely 43:46 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 disagreement 43:59 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 much 44:08 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 term 44:16 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 start 44:24 to think that they really want to know everything about you. 44:26 RITA SOMMERS-FLANAGAN: Yeah. 44:27 JOHN SOMMERS-FLANAGAN: And then you 44:28 can go overboard with self-disclosure. 44:30 And you can go overboard with I think 44:32 I know what's right for you. 44:35 And in the clip where it ended, I 44:38 could have even gone on and been even more 44:41 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 clearly 44:47 showing a little push back. 44:49 But I guess the main point is that even though we might have 44:52 a really good point to make, or we might 44:54 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 not 45:01 the point we should be making. 45:02 RITA SOMMERS-FLANAGAN: Right. 45:04 So directive and action responses 45:08 need to be developed collaboratively, 45:11 and the client is always the final authority. 45:24 JOHN SOMMERS-FLANAGAN: In this final section associated 45:27 with listening continuum, we explore questions 45:31 in general and therapeutic questions in particular. 45:35 And we focus on these because questions can 45:37 be so common, commonly used. 45:40 They can also be very effective. 45:42 But then I think oftentimes interviewers 45:45 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 you 45:52 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'm 46:02 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 clients 46:16 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 used 46:35 to control the interview or the conversation. 46:38 RITA SOMMERS-FLANAGAN: And, of course, our clients 46:41 are not as skilled as your average politician at sliding 46:45 away from a question. 46:47 And so they're stuck. 46:48 They either have to answer the question 46:50 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 I 47:01 like to assign the students a pretty long interview 47:05 where they can't ask any questions 47:07 or they just have to use active listening 47:09 skills to gather information. 47:11 And I think that can be a real learning experience for clients 47:15 for students, maybe even up to 30 47:17 minutes of non-directive listening without questions. 47:19 RITA SOMMERS-FLANAGAN: Yeah. 47:20 JOHN SOMMERS-FLANAGAN: There are many different types 47:21 of questions. 47:23 RITA SOMMERS-FLANAGAN: There are open, closed, indirect, swing, 47:29 projective, and of course a group of questions 47:32 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 listening 47:38 continuum in that questions vary in their level 47:41 of directiveness. 47:43 They're all directed, because questions 47:45 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 questions 48:07 as she works with Umit, who's a graduate exchange 48:11 student from Turkey. 48:13 And you'll see the skilled use of questions woven together 48:16 with some other non-directive and directive listening 48:20 responses. 48:22 And you know, John, of course this is how 48:25 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 Cris 48:35 will do a paraphrase, but they'll be a rise in her voice. 48:38 They'll be a little inflection change 48:41 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 Missoula 48:52 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 sunshine 49:11 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 lot 49:43 and a big change from Missoula is 49:46 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 you 50:10 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 hang 50:22 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 homework 50:52 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, how 51:57 you're spending your time, and also this difference 52:01 in how friends are, and even your communication... 52:04 UMIT: Yes. 52:05 CRIS FIORE: and that's a lot to adjust 52:07 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 time 52:16 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 simultaneously 53:33 expressing interest, even her facial expressions 53:37 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 questions 53:54 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't 54:06 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 it 54:14 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 interview 54:23 is that she uses a question about the best scenario that 54:28 is possible for Umit. 54:30 And I think that question is an example of a projected 54:33 question, which is a therapeutic question, which 54:37 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 future 54:50 place with a better or best scenario. 54:53 RITA SOMMERS-FLANAGAN: You know, I 54:55 want to say a little more about that. 54:56 But first I also want to note that questions 54:58 are another one of those techniques that have 55:01 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 culture 55:16 where they expect the person in authority to ask questions 55:19 and you don't, or pummeled if they're not 55:23 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 questions 55:46 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 squarely 55:56 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 focus 56:09 on positive scenarios, often the future, constructive things 56:14 that are already working in their lives. 56:16 RITA SOMMERS-FLANAGAN: Right, right. 56:18 So I think there is a good example 56:19 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 almost 56:38 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 three 57:03 minutes, what do you think as you look at the future for you? 57:08 What do you think some of the most important things 57:10 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 things 57:27 I have done before, the bad things that happened 57:33 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 question 57:47 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 see 57:55 if he can get it right. 57:56 JOHN SOMMERS-FLANAGAN: Yeah, thank you. 57:58 I think it's a good example of how 58:00 it's important to gear the therapeutic question 58:03 to the individual client. 58:05 And questions, therapeutic questions, 58:08 solution-focused questions can be 58:09 asked in many different ways. 58:11 And yet they almost always focus on moving the client 58:14 toward the future and toward a more positive future. 58:19 RITA SOMMERS-FLANAGAN: So John, if you woke up tomorrow 58:24 morning... 58:24 JOHN SOMMERS-FLANAGAN: And a miracle occurred... 58:28 RITA SOMMERS-FLANAGAN: And you suddenly had 58:30 more spare time, what would that look like? 58:33 JOHN SOMMERS-FLANAGAN: Well, I think my wife 58:35 and I would be spending a lot of time in a video production. 58:39 RITA SOMMERS-FLANAGAN: Yeah, well, I 58:40 guess we can see where this is going. 58:42 Obviously you can see the importance 58:45 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 way 59:26 that she was struggling with anxiety in her life. 59:30 And so you should watch at the very beginning 59:32 of this video clip at how quickly Michelle 59:35 jumps into her specific problem, describes her symptoms. 59:39 And then Rita does a nice job both exploring and sticking 59:43 with the chief complaint but also 59:44 staying with the format or structure of an intake 59:48 interview. 59:49 Keep in mind that some clients will not 59:51 jump so quickly into their presenting complaint. 59:55 I remember back in the day, well maybe just a few years ago 59:58 when we were younger, that we might 01:00:00 take three or four sessions just to deeply identify 01:00:05 a presenting complaint and develop a problem formulation. 01:00:09 RITA SOMMERS-FLANAGAN: OK, so let's 01:00:11 watch the beginning of this work with Michelle. 01:00:15 RITA SOMMERS-FLANAGAN: So Michelle, it's 01:00:17 nice to meet you. 01:00:17 MICHELLE: It's nice meeting you too. 01:00:19 RITA SOMMERS-FLANAGAN: And I would 01:00:20 like to start today by just checking in 01:00:22 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 I 01:00:41 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 wrong 01:00:50 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 one 01:01:06 was the one that I went... well, I 01:01:07 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 blood 01:01:24 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 up 01:01:52 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 you 01:02:10 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 of 01:02:26 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's 01:02:36 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 point 01:03:11 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 pretty 01:03:46 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 would 01:03:59 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 it 01:04:14 as sort of steps toward the ultimate goal of no more panic 01:04:19 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, I 01:04:26 do want to notice a couple things, though, 01:04:28 and that is you've coped with some things that 01:04:35 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 skills 01:04:50 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 startling 01:04:58 when he client arrives and has already got a diagnosis 01:05:02 and is ready to begin fixing the problem. 01:05:05 JOHN SOMMERS FLANAGAN: Absolutely, you 01:05:07 can feel, I think, like you have a lot of pressure on you 01:05:10 to jump immediately into fixing the problem. 01:05:13 But I'm glad that instead that you 01:05:15 kept exploring the presenting complaint 01:05:18 or the chief complaint, and then you 01:05:19 went a little bit into other areas 01:05:23 and really were building and gathering 01:05:25 information that helped with establishing the beginning 01:05:28 of a treatment plan. 01:05:29 In particular, I liked the fact that you identified 01:05:32 for the client, for Michelle, what 01:05:35 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 really 01:05:48 had noticed some strengths in Michelle 01:05:50 and wanted to reflect those before we 01:05:53 went into history taking. 01:05:55 JOHN SOMMERS-FLANAGAN: At the risk 01:05:56 of complimenting you too much, I really did like the way 01:05:59 that you focused on her strengths. 01:06:03 And I liked the way you developed with her 01:06:06 some intermediate goals rather than sort 01:06:09 of feeding into the idea that the goal is 01:06:12 to eliminate all panic attacks. 01:06:15 In fact, it can be very discouraging for clients 01:06:18 if that's their only goal. 01:06:19 And you helped her see that there 01:06:21 might be some intermediate goals along the way. 01:06:24 RITA SOMMERS-FLANAGAN: Yeah, I did explicitly 01:06:26 foreshadow that shift. 01:06:29 Then we did do some history taking. 01:06:31 And that was important, I think, to signal 01:06:36 that we were going to make that shift, especially 01:06:39 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 information 01:06:45 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 past 01:06:58 to the present to the future. 01:07:00 Now let's watch as Rita's intake interview with Michelle 01:07:04 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 dad 01:07:23 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 she 01:07:31 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 times 01:07:38 she was there, 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 hardworking 01:07:51 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 always 01:08:00 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 school 01:08:13 at a university in California. 01:08:15 So they're both gone. 01:08:18 And I'm kind of close with my mom 01:08:21 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 them 01:08:33 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 California 01:08:46 mentioned that he had been diagnosed 01:08:49 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 you 01:09:09 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 thinkers 01:09:28 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 constant 01:09:39 run it into the ground. 01:09:41 I learned at an early age not to tell 01:09:43 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 things 01:09:56 that would make her anxious. 01:09:59 So do you mind if I ask you about your drug and alcohol 01:10:02 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 it 01:10:14 without really studying or being that concerned about getting 01:10:19 buckled down. 01:10:19 But now it's getting harder, so I really 01:10:22 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 stopped 01:10:46 cold turkey? 01:10:47 MICHELLE: Yeah, I was just like this is not helpful for me 01:10:51 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'm 01:11:01 going into, I really can't have somebody with pot 01:11:05 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 something 01:11:12 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 on 01:11:17 for four years. 01:11:20 I feel like either I need to be done 01:11:21 or we need to do something. 01:11:23 RITA SOMMERS-FLANAGAN: It's kind of a point of stress right now 01:11:26 or a point of concern? 01:11:28 Yeah. 01:11:29 OK, so I'm wondering about other drugs or caffeine, those kinds 01:11:38 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 test 01:12:00 and stay up most of the night. 01:12:01 On normal basis, I'll probably have 01:12:04 three, four cups of coffee in the morning 01:12:06 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 possessions 01:12:38 for alcohol when I was younger. 01:12:39 And then I got a possession of marijuana also 01:12:43 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 too 01:12:51 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 time 01:12:57 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've 01:13:14 started doing that, kind of since this started. 01:13:16 I was like, I need to maybe try to do something that's going 01:13:21 to slow this roll a little bit. 01:13:24 RITA SOMMERS-FLANAGAN: So you are doing a little swimming 01:13:27 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 somewhere 01:13:34 that's got a lot of people. 01:13:35 Like that concert was out with friends. 01:13:37 RITA SOMMERS-FLANAGAN: Right 01:13:37 MICHELLE: So I've kind of curtailed 01:13:39 some of my social engagements just because I'm 01:13:43 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 affect 01:13:52 your friendships and social life, your work 01:13:57 and school a little bit. 01:13:59 MICHELLE: Yeah. 01:14:00 RITA SOMMERS-FLANAGAN: So it's kind 01:14:01 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 did 01:14:15 a nice job of exploring Michelle's personal history. 01:14:19 One of the things that I might say 01:14:20 is that there are many different ways 01:14:22 to explore personal history. 01:14:24 And one of things I found really useful 01:14:26 is to do an early memory, or sometimes in my work 01:14:30 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 constellation 01:14:39 or just a basic genogram. 01:14:41 And doing that collaboratively to explore history 01:14:44 seems to be a pretty effective way to go back into the past 01:14:47 and identify some issues or themes that the client has 01:14:51 faced. 01:14:52 RITA SOMMERS-FLANAGAN: I do think working with the client 01:14:56 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 take 01:15:04 a look at the possibility of other family members 01:15:07 having problems coping with anxiety or panic. 01:15:11 And of course, I also wanted to convey to her that I saw her 01:15:15 as coping with anxiety rather than being victimized by it 01:15:19 or struggling with it. 01:15:21 JOHN SOMMERS-FLANAGAN: And you really made a nice flow 01:15:23 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 content 01:15:36 here and there, and emphasize different things. 01:15:39 But most intakes include the coverage 01:15:41 of the least these three main general areas, 01:15:44 the first of which is the identification 01:15:47 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 then 01:15:53 of course, personal history and information related to that. 01:15:56 JOHN SOMMERS-FLANAGAN: Right, and many ways 01:15:58 to get that information and sometimes many areas 01:16:00 within the personal history. 01:16:02 And finally, there's a transition back to 01:16:04 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 areas 01:16:12 can be expanded upon or minimized. 01:16:15 For example, depending on your setting and your client's 01:16:18 presenting problem, it might be important to gather 01:16:20 specific information about the client's family 01:16:23 history, or maybe military history, or maybe 01:16:26 drug and alcohol history. 01:16:28 RITA SOMMERS-FLANAGAN: Yeah, the purpose 01:16:30 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 focuses 01:16:41 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 coping 01:16:49 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 caffeine 01:16:55 use, which can trigger panic and also 01:16:58 focusing on self-care and some of the medical issues, just 01:17:02 really important and relevant pieces 01:17:04 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 connection 01:17:12 between her stopping the use of pot, which 01:17:17 she had used since she was 11 or 12 and the onset of those panic 01:17:23 symptoms. 01:17:24 So the client herself was starting 01:17:26 to make connections that might end up being very important. 01:17:29 JOHN SOMMERS-FLANAGAN: Which is something 01:17:30 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 shifts 01:17:40 toward case formulation, homework, 01:17:44 and instilling the hope for change, making sure 01:17:48 we take full advantage of that placebo effect. 01:17:52 RITA SOMMERS-FLANAGAN: Well, let me do a little summary of what 01:17:55 I've heard. 01:17:57 And then maybe we can talk about some plans 01:18:00 for our next sessions together. 01:18:03 And if you don't mind, I might even give you 01:18:06 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 problem 01:18:22 that you brought in today is one of those 01:18:25 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 this 01:18:36 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 chance 01:18:49 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 when 01:19:06 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've 01:19:15 seen those shows of the shut-in people that stay in their house 01:19:19 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 worse 01:19:28 that things could get worse. 01:19:29 And then I could end up with a grocery delivery 01:19:33 and that's the only people that talk to me. 01:19:35 RITA SOMMERS-FLANAGAN: Yeah, or you're 01:19:37 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 anybody 01:19:43 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 funny 01:19:57 how we mirror our mothers sometimes. 01:19:58 MICHELLE: I know, well it's lalala 01:19:59 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 tendency 01:20:12 to do to be able to take one difficult life event 01:20:16 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 it 01:20:40 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 liked 01:21:07 the way you made the connection between Michelle's tendency 01:21:10 to do a catastrophizing in her thinking 01:21:13 with what she had identified herself before as her mom's 01:21:17 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 Michelle 01:21:26 that maybe the path of the catastrophizing 01:21:31 was not very much pathology. 01:21:33 And so I think by doing that, you kind of give her 01:21:35 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 are 01:21:52 and a way you might want to change, 01:21:53 you actually might have a little motivation 01:21:55 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 reassurance 01:22:18 that you can make contact earlier. 01:22:27 So in this section, we're going to watch a mental status 01:22:31 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 ideation 01:22:44 and bizarre behaviors. 01:22:46 So his vocational instructors and educators 01:22:49 were a little bit concerned. 01:22:51 JOHN SOMMERS-FLANAGAN: A traditional mental status 01:22:53 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 clients 01:23:12 and then you make some inferences about those three 01:23:15 categories. 01:23:16 The remaining six categories are usually 01:23:19 assessed in a little bit more of a direct way. 01:23:22 And these other six categories include affect and mood 01:23:25 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 something 01:23:49 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 speech 01:24:03 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 who 01:24:21 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 get 01:24:44 ready to watch this mental status examination 01:24:47 interview with Carl, it might be a good idea 01:24:49 to pull out a piece of paper and jot down 01:24:52 a few notes in each of the nine domains 01:24:55 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 today 01:25:04 is just a very standard interview 01:25:08 that is sort of a way for me to get to know 01:25:11 how your brain is working. 01:25:12 And so what I'm going to do is I'm going 01:25:14 to ask you some questions. 01:25:16 But first I just want to start off 01:25:17 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 legally 01:25:53 changed them or anything. 01:25:54 But she always changed our last name 01:25:56 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 rings 01:26:10 around my eyes. 01:26:12 JOHN SOMMERS-FLANAGAN: What's your favorite name 01:26:14 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 city 01:27:18 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 100 01:28:17 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 words 01:28:54 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 couple 01:29:00 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 know 01:29:32 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 guy 01:29:57 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 Obama 01:30:33 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 something 01:30:50 to do with looks, religion, and ethnic national background, 01:30:53 stuff like that. 01:30:56 Christianity and stuff like that just 01:30:58 happens to be one of the more powerful religions. 01:31:00 So coming from that aspect, lots of people 01:31:03 are compelled by their religious beliefs to do a lot of things. 01:31:08 It would all make sense that the government in general 01:31:11 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 that 01:31:22 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 that 01:31:30 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, zero 01:31:53 is the worst possible mood. 01:31:56 It's like you're so down and depressed that you're just 01:31:59 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 you 01:32:17 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 mood 01:32:40 you've had for the last three months. 01:32:45 JOHN SOMMERS-FLANAGAN: You know, Rita, many professionals 01:32:47 I think are a little reluctant to do something 01:32:50 as structured and evaluative as a mental status 01:32:52 examination for fear that it might adversely 01:32:55 affect the report or the therapeutic relationship. 01:32:58 One thing that I found, and maybe it's 01:33:00 just because I'm a little bit weird, 01:33:02 is that I actually find that using that kind of structure 01:33:07 and the assessment parts of the mental status examination 01:33:11 can be framed in a way that engages the clients 01:33:14 and I think at least doesn't adversely 01:33:17 affect the relationship. 01:33:20 And I think I try to frame questions 01:33:21 as they might be difficult. And I 01:33:23 try to respond empathically when clients have trouble 01:33:27 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 when 01:33:42 he can't get something right. 01:33:44 And then he says, he was able to multiply double digit numbers 01:33:48 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 functioning 01:33:59 of the client in the present. 01:34:01 JOHN SOMMERS-FLANAGAN: So even Carl's defensiveness 01:34:04 that we saw, and maybe his exaggeration, 01:34:07 and his use of humor, that's all data 01:34:09 that the mental status examiner or the clinical interviewer 01:34:13 can use to make statements within those nine 01:34:17 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 me 01:34:27 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 get 01:34:54 a chance to compare where the client is now 01:34:56 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 assessment 01:35:04 of Carl's intermediate memory. 01:35:07 And one thing I think that we'll discover 01:35:08 is he has an excellent intermediate memory. 01:35:11 He also shows that he has a pretty darn good sense 01:35:14 of humor. 01:35:14 RITA SOMMERS FLANAGAN: All right. 01:35:16 JOHN SOMMERS-FLANAGAN: Now I've got kind 01:35:17 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 I 01:35:28 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 smarter 01:35:48 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 gets 01:36:27 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 it 01:36:35 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 you 01:36:48 have some songs that get stuck in your head 01:36:50 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 ways 01:37:04 you get something that's stuck in your head out of your head 01:37:07 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 technically 01:37:22 imaginary friends. 01:37:22 They're just little bodily voices 01:37:24 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 that 01:37:29 overpowers all the other noises and stuff 01:37:31 that I hear in my head. 01:37:32 They kind of just [UNINTELLIGIBLE] these other 01:37:34 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 people 01:37:45 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 there 01:38:07 that are raping little kids, people out there getting 01:38:11 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 seven 01:38:19 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 thing 01:38:30 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 be 01:38:42 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 people 01:38:53 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 television 01:39:07 is speaking directly to you? 01:39:10 CARL: Right. 01:39:12 I don't think that the radio or the television's 01:39:15 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 going 01:39:54 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 thoughts 01:40:06 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 trying 01:40:31 to steal or read my mind. 01:40:34 But I used to have friends and family and stuff that 01:40:37 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 knowledge 01:40:46 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 computer 01:41:04 is that the computer's electrical and the pencil, 01:41:06 you can't store small bits of data 01:41:08 on, except for the pencil's entire system 01:41:10 and [UNINTELLIGIBLE] the computer 01:41:11 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 even 01:41:21 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 person 01:41:29 doing the exact same thing. 01:41:30 JOHN SOMMERS-FLANAGAN: OK. 01:41:32 What if in the future some time you 01:41:33 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's 01:41:50 either in the police division or has worked for the government 01:41:53 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 used 01:41:57 to harm somebody, if not, register the gun 01:41:58 and keep it for myself. 01:41:59 JOHN SOMMERS-FLANAGAN: So you'd get somebody 01:42:01 to check the gun out? 01:42:02 CARL: Yes. 01:42:04 Then I'd see if I could get the gun registered 01:42:07 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 yours 01:42:19 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 drugs 01:42:36 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'd 01:42:48 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 make 01:42:56 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 illegalized 01:43:08 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 status 01:43:16 examination is to gather data or observations on the client 01:43:20 that you can then organize into the nine 01:43:22 different mental status examination domains. 01:43:25 But as you probably noticed, my preference 01:43:28 is to try to do that in a way that 01:43:30 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 ranging 01:43:44 and sometimes tangential content that you saw with Carl. 01:43:49 But it is important information. 01:43:52 JOHN SOMMERS-FLANAGAN: Although it 01:43:53 would make the interview shorter if I stayed 01:43:56 a little more structured. 01:43:58 Now if you watched the mental status examination interview 01:44:02 with Carl and you jotted down a few notes in those nine 01:44:05 different areas, now would be a really good time 01:44:08 for you to look back at those notes and the nine areas 01:44:11 and to try to make a few statements that 01:44:14 are a little more conclusive about what you saw 01:44:17 in Carl during that interview. 01:44:19 And even better, it would be a really good idea 01:44:22 to compare those notes and those conclusions 01:44:25 with your classmates so that you can get a little bit 01:44:27 more objective in how you are evaluating the mental status 01:44:32 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, where 01:44:56 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're 01:45:16 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 family 01:45:28 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 conversation 01:45:41 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 background 01:46:11 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 let 01:46:35 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 you 01:46:53 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're 01:47:05 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 people 01:47:43 when they're feeling down, they have 01:47:44 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 much 01:47:52 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 mind 01:48:11 is kind of buzzing along at night, 01:48:15 and so it's hard to lay down and really 01:48:18 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 actually 01:48:27 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 people 01:48:33 have their social relationships sort of 01:48:35 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 seems 01:48:52 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 ask 01:49:03 this question directly. 01:49:07 Tell me because sometimes when people feel down, 01:49:12 it's really not unusual for people 01:49:15 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 most 01:49:44 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 thinking 01:50:08 about death or suicide? 01:50:11 What's usually going on when you're 01:50:13 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 those 01:50:38 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 ideas 01:51:24 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 way 01:51:37 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 something 01:52:05 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 there 01:52:24 was no guns in the house. 01:52:26 So I was going to hang myself in my room 01:52:29 and write on the walls everything that ever hurt me 01:52:35 to my parents. 01:52:38 So whenever they decided, wow, she's been in her room 01:52:41 too long, they could go in there and tah-dah. 01:52:48 Yeah. 01:52:48 JOHN SOMMERS-FLANAGAN: So one parts 01:52:50 for you is to send a message to your parents 01:52:53 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 clear 01:53:03 that not all of these interactions 01:53:06 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 well 01:53:15 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 noticed 01:53:22 right away was a kind of interesting where she 01:53:25 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 affectively 01:53:48 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 processing 01:53:56 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's 01:54:05 not very unusual for people who have 01:54:07 sort of a unipolar depression that doesn't 01:54:11 have much agitation in it. 01:54:14 And I noticed that when I was trying to do 01:54:17 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 never 01:54:30 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 directly 01:54:45 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's 01:54:59 free of any suicidal ideation. 01:55:01 JOHN SOMMERS-FLANAGAN: Which I think 01:55:02 is really important to sort of flow 01:55:04 into some positive emotions or positive situations 01:55:10 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's 01:55:25 sort of underneath the surface that you need 01:55:28 to ask directly about as well. 01:55:30 TOMMI: I tried two times and I realized 01:55:34 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 times 01:56:33 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 from 01:56:56 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 really 01:57:05 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 exploring 01:57:18 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 assessment 01:57:26 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 positive 01:57:39 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 he 01:58:00 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 bit 01:58:22 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 people 01:58:38 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 who 01:59:11 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 you 01:59:23 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 part 01:59:37 you're pretty clear that you want to live and move forward 01:59:43 toward your dream and be a positive influence 01:59:45 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're 02:00:31 feeling a little better, what do you think, 02:00:34 what could you remind yourself, oh, here's 02:00:36 what I think I should do when or if I 02:00:40 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 having 02:00:54 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, those 02:01:05 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 things 02:01:13 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 friends 02:01:23 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 you 02:01:28 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 things 02:02:05 I just want to say, and then we'll probably stop here 02:02:08 in just a minute, is that it's hard to know when people 02:02:13 are going to feel down, right? 02:02:16 And so it's good to have a plan ahead of time for what you're 02:02:21 going to do. 02:02:21 Because when you're feeling down, then sometimes 02:02:24 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 agree 02:02:30 that if you have a really down time that you will 02:02:33 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 section 02:02:51 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 worked 02:03:07 to make the assessment a positive therapeutic 02:03:11 experience. 02:03:13 But it's also a scary endeavor. 02:03:14 JOHN SOMMERS FLANAGAN: You know, it 02:03:15 was stressful and challenging. 02:03:18 Tommi, I think, is a very interesting and complicated 02:03:21 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 positive 02:03:41 and focusing on maybe more therapeutic questions 02:03:44 and what's going well for her and maybe ignored 02:03:47 a little bit of negative side. 02:03:50 One interesting thing that I didn't bring up earlier 02:03:53 is that when she talked about her suicidal plan, which 02:03:57 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 bit 02:04:09 of a revenge motive, a little bit of a send 02:04:11 a message to my parents motive. 02:04:14 And so I think that's a place where 02:04:16 you can take the opportunity to turn a discussion about a plan 02:04:21 into something that's more therapeutic 02:04:23 and help her focus on how could she 02:04:25 give that message to her parents without having it involve 02:04:28 anything to do with suicide. 02:04:31 RITA SOMMERS-FLANAGAN: So even though every suicide assessment 02:04:36 is unique, there are some factors 02:04:39 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 suicide 02:04:51 assessment interview involves evaluating suicide risk 02:04:55 factors. 02:04:55 And oftentimes, you don't do all that directly. 02:04:58 But you find out about the different suicidal factors 02:05:01 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 can 02:05:17 answer truthfully. 02:05:19 Also you explore the suicide plan and move 02:05:22 on to trying to determine whether or not the client has 02:05:26 a high level of suicide intent. 02:05:27 And one of the ways of doing that 02:05:29 is to check in to their reasons for living. 02:05:33 And then the last categories are two 02:05:35 try to infer the client's level of self-control. 02:05:38 And one way of doing that is to try 02:05:41 to develop a collaborative and cooperative safety plan 02:05:44 between you and your client. 02:05:47 RITA SOMMERS-FLANAGAN: So if we were 02:05:49 going to do a little summary, Tommi has tried suicide twice 02:05:55 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 her 02:06:26 with the opportunity to work on vocational skills 02:06:30 and on her sobriety. 02:06:31 JOHN SOMMERS-FLANAGAN: What you're saying 02:06:32 reminds me of the fact that we need 02:06:34 to talk about decision making. 02:06:36 And that could be one of the most stressful and tormenting 02:06:39 things I think for a mental health professional 02:06:41 is deciding, well, how do I act in this particular situation? 02:06:45 I think because of the things you 02:06:46 said, including the fact that she has a pretty high mood 02:06:49 rating and she collaborated on a safety plan, 02:06:52 that in fact, I probably wouldn't 02:06:55 go toward hospitalization. 02:06:56 RITA SOMMERS-FLANAGAN: Right, yeah. 02:06:57 JOHN SOMMERS-FLANAGAN: But it's really important 02:06:59 to integrate or to weave in some documentation of what you're 02:07:03 doing and some consultation with other professionals 02:07:06 in order to protect yourself from liability 02:07:09 and to make sure you're doing a thorough comprehensive suicide 02:07:12 assessment. 02:07:13 RITA SOMMERS-FLANAGAN: Right, yeah. 02:07:14 And you know that not only brings us 02:07:17 to the end of this section but to the end of the DVD. 02:07:21 JOHN SOMMERS-FLANAGAN: You know one thing I'm 02:07:23 struck at the end of this whole production 02:07:27 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 clients 02:07:37 with whom you're working, and how many different ways there 02:07:40 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 learning 02:07:51 process. 02:07:52 JOHN SOMMERS-FLANAGAN: And you'd be 02:07:54 pretty much right about that. 02:07:55 RITA SOMMERS-FLANAGAN: And we both hope 02:07:57 that this has been helpful to you in your journey 02:08:00 toward becoming a really excellent clinical interviewer. 02:08:04 Thanks. 02:08:04 [MUSIC PLAYING]