In the Room

Responding to Suicidal Clients

Kenneth Pope has a great site on Responding to Suicidal Risk. The site contains practical advice on risk factors and specific factors to consider with any suicidal client.

The evaluation and response to suicidal risk is a source of extraordinary stress for many therapists. This aspect of our work focuses virtually all of the troublesome issues that run through this book: questions of the therapist's influence, competence, efficacy, fallibility, over- or under-involvement, responsibility, and ability to make life-or-death decisions. Litman's (1965) study of over 200 clinicians soon after their clients had committed suicide found the experience to have had an almost nightmarish quality. Clinicians tended to have intense feelings of grief, loss, and sometimes depression as anyone—professional or nonprofessional—might at the death of someone they cared about. But they also had feelings associated with their professional role as psychotherapist: guilt, inadequacy, self-blame, and fears of being sued, investigated, or vilified in the media. In a similar study, both the short-term and permanent effects of a client's suicide upon the therapist were so intense that Goldstein and Buongiorno (1984) recommended providing support groups for surviving therapists.

As a therapist who has had one long term client suicide during therapy I can certainly say that I experienced all of the above. Avoiding this event is something I can certainly recommend but it is highly likely that many of us will experience this at least once in our professional lifetimes.

Pope provides comments from arrange of professionals on working with suicidal clients.

One of the two main problems in treating suicidal patients is our own anger and defensiveness when confronted by someone who does not respond positively--and perhaps appreciatively--to our therapeutic efforts. It can stir up very primitive and childish feelings in us--we can start to feel vengeful, withholding, and spiteful. The key is to become aware of these potential reactions and not to act them out in our relationship with the patient. The other main problem seems to be more prevalent among beginning therapists. When we are inexperienced, we may be very cowardly regarding the mention of suicide in our initial interviews. We passively wait for the patient to raise the subject and we may unconsciously communicate that the subject is "taboo." If the subject does come up, we avoid using "hot" language such as "murder yourself" or "blow your brains out." Our avoidance of clear and direct communication, our clinging to euphemisms implies to the patient that we are unable to cope with his or her destructive impulses.

What I found most helpful on this site was a section on special considerations. Things to be aware of and to do in these situations. Some of the ideas that stood out for me included:

Screen all clients for suicidal risk during initial contact and remain alert to this issue throughout the therapy. Even clients who are seriously thinking of taking their own life may not present the classic picture of agitated depression or openly grim determination that is stereotypically (and sometimes falsely) portrayed as characteristic of the suicidal individual. In some cases the suicidal client may seem, during initial sessions, calm, composed, and concerned with a seemingly minor presenting problem. Clients who may in fact not be suicidal during initial sessions and who may actually have sought therapy to help them cope with a relatively minor problem may, during the course of therapy, become suicidal. The increase in suicidal risk may be due to external events, such as the loss of a job or a loved one, or to internal events, such as setting aside psychological defenses or discovering traumatic incidents—for example, incest—that had been repressed.

Case Conceptualisation II

The previous post considered a number of cognitive behaviour models for case conceptualisation. Clearly, at the centre of all these models is a case conceptualisation built around core beliefs, and how these impact on day-to-day cognitions, emotions and behaviour. These case conceptualisations do not provide a lot of space for comment on the relationship with the client, the client’s motivation or examine factors that may indicate the prognosis of therapy in general.

Consideration of these types of factors can considerably enhance your case conceptualisation. For example, use of psychological tests such as the Millon Clinical Multiaxial Inventory (MCMI III) can provide an Axis II picture of how the client is likely to react in general situations in their life as well as predicting how they are likely to interact in the therapy room.

The following factors are useful to consider:

• Motivation
• Capacity (psychological mindedness or insight).
• Ego strength.
• Intellectual ability.
• What social and emotional resources are available for supporting the client's positive changes?

Understanding the above factors can have a significant impact on the type of treatment and techniques that you utilise to work with the client. For example, a client with low psychological mindedness or insight, low ego strength and low intellectual ability may not respond well to techniques such as Socratic questioning and active thought monitoring. They may find extremely difficult to keep a thought diary. Their low intellectual ability may make it difficult for them to understand the logic behind Socratic questioning and challenging dysfunctional thought processes. Utilising these techniques with this type of client is likely to lead to frustration both on the part of the client and therapist. The value in assessing these aspects in a case conceptualisation means that you pitch your therapy to what the client can cope with and understand.

Clearly, the level of case conceptualisation, you can undertake to some degree relates to how much information you have gathered. In some situations, we only have a short period of time to gather information before implementing treatment. Where we may only have five or six sessions, then we may only have one session to gather data on which to base a case conceptualisation.

In these types of situations, consider using a psychological test such as the Minnesota Multiphasic Personality Inventory (MMPI-2), the Millon Clinical Multiaxial Inventory (MCMI III) or the Personality Assessment Inventory. Any of these tests will provide a wealth of data that will considerably enhance your case conceptualisation. Personally, I really like the Millon Clinical Multiaxial Inventory.

In particular usign it with the book on interpretation by Choca and Van Denburg: Interpretive Guide to the Millon Clinical Multiaxial Inventory (3rd Edition). This book has interpretation on up to three combined highpoint scales of Axis II Scales. The book then provides an outline of the personality traits as well as likely responses that the client will have to therapy and suggestions for how the therapist can manage this. I find this particularly helpful as it gives me many useful ideas about how to work with and manage the client in the therapy room. My approach with a client with compulsive traits is going to be quite different from my approach to a client with passive aggressive traits.

With a client with compulsive traits my approach is likely to reflect this in ensuring that I'm always on time, always finish on time, that the same room is used every and  time that we arrange a meeting at the same time every week. I am likely to focus more on cognitions and take an intellectual approach to begin with as this more likely to engage the client. With a client with passive aggressive traits then I am likely to be focusing more on motivational issues, and usually utilising techniques such as cost benefit analysis to ensure that the client is fully engaged in therapy.

In the last year I have come across a couple of papers with some new ideas to consider in formulation. The first of these by Grosse Holtforth and Castonguay provides a framework for analysing the client's motivations. Their primary focus, on need satisfying experiences of the client, is based around one of my favourite therapeutic sayings.

Nobody does nothing for no reason.

In more scientific terms: Any repeated behaviour by an organism is an attempt to meet a need for that organism

Case Conceptualisation I

Case conceptualisation is one of the areas that many beginning therapists and interns seem to have difficulties with.

As with many concepts, we psychologists like to define case conceptualisation using a complex set of words:

Case conceptualisation is the process of using sound theoretical frameworks to organise interview data, observational data and assessment data to formulate hypotheses that may explain the underlying dynamics of presenting problem in order to formulate an appropriate treatment plan.

Another definition of case formulation:

Case formulation aims to describe a person is presenting problems, and his theory to make explanatory inferences about causes and maintaining factors that can inform interventions. First, there is a top-down process of cognitive behavioural theory providing clinically useful descriptive frameworks. Second the formulation enables practitioners and clients to make explanatory inferences about what caused and maintains the presenting issues. Thirdly case formulation explicitly and centrally informs intervention. Case formulation is a cornerstone of evidence-based CBT practice. For any particular case of CBT practice, formulation is the bridge between practice and theory and research. It is the crucible, where the individual particularities of a given case relevant theory and research synthesise into an understanding of the persons presenting issues in CBT.

In more simple terms. What's going on and what are we going to do about it.

The longer definition above is from a paper by Willem Kuyken and others, looks at the reliability and quality of cognitive case formulation. It is an interesting aside, that manualised approaches work better for beginning therapists than individualised case conceptualisation approaches and that there is not always a high degree of agreement on inferential aspects of case conceptualisation, even amongst experienced clinicians

There are a number of case conceptualisation models put out by various cognitive behavioural therapy writers. I have outlined a few of them below and provided a sample conceptualisation for some of the models.

The Fours Ps model is probably the simplest of all the case conceptualisation models. I don’t know where this comes from. If anybody knows the original reference or who conceived this one let me know.

• Predisposing factors.
• Precipitating factors.
• Perpetuating factors
• Protective factors

Predisposing factors are the historical or genetic elements that contribute to the current problem. The precipitating factors are the current triggers i.e. what sets off this problem or behaviours. Perpetuating factors are the internal and external thoughts and behaviours that maintain the problem. Protective factors are the strengths, social supports and positive patterns of behaviour.

The Ironies of Therapy

One of the more popular posts on this blog is on gifts in psychotherapy. This appears to be a frequent Google question for many therapists. Tracking back on one of these questions today it was somewhat ironic to see that the number one spot on Google for this question was ……

What is an appropriate Christmas gift for my psychotherapist?

While we therapists, and psychologists are busy searching for answers on how to deal with gifts, clients are out trying to find out what is the best gift to give us.

Cognitive Therapy Training Stress Disorder or the Joy of being a Psychology Intern

Scanning the journals today for some stuff on case conceptualisation today and came across this wonderfully humorous article on the stress of being a psychology intern entitled: Cognitive Therapy Training Stress Disorder.