In the Room

Book Review: Suicide Risk Management A Manual for Health Professionals

Suicide Risk Management: A Manual for Health Professionals, by Stan Kutcher and Sonia Chehil is a good introduction to the subject of suicide assessment. This book in my view is geared to the beginning mental health professional. It is only 109 pages of well spaced text some of which is repeated in different layouts. Overall it is an extremely practical book which is written in easy to read language.

The book divides up into roughly four sections. The first section backgrounds and provides an  understanding of suicide. It has helpful little sections such as common myths about suicide. It covers a spectrum of disorders and situations where suicidal behaviour may be more prevalent and does a good job of covering and discussing a range of risk factors.

The second section looks directly at suicide risk assessment. They provide a practical four step process with a structured Suicide Risk Assessment Guide (SRAG) complete with flow diagrams to help you visualise each stage of this assessment process. I found this section quite useful even as an experienced clinician. Because I don’t deal with suicide on a daily basis in my practice it is easy to forget things and Kutcher and Chechil use of simple acronyms is very helpful. They emphasise the need to ask “the question” and provide a number of good ways to do this. Bottom line is you need to call a spade a spade but in a gentle and empathic way. Their suggestions include"

• Have you ever thought about harming yourself?
• Have you ever tried to do anything to yourself that could have seriously harmed you or killed you?
• Have you been thinking about killing yourself lately?

The third section deals with commonly encountered problems. This is one of the weaker sections in the book. It is only a few pages long and deals with complex issues such as countertransference and self harm or repeated low lethality clients in a brief and glib manner. Advice such as, avoid common traps such as manipulation and exploitation with no suggestion on how do this, is not helpful in my view.

The last section of the book focuses on what they call “Bringing it all together” and introduces a summary assessment tool on which to rate potential risk. Again they provide a nice structured way of doing this with their Tool for the Assessment of Suicide Risk (TASR). This is essentially a rating from for collating the information gathered with the Suicide Risk Assessment Guide (SRAG). Some practice using this with a range of vignettes is provided.

Overall a practical easy written book geared to the beginning professional. It is certainly a book I could recommend to my interns. Personally I would have liked more meat on the bones but then I don’t think I am necessarily this book's target market.

Received from the publisher 18^th December 2006.

Do We Unconsciously Invite Gifts?

With Christmas upon us, gifts from our clients can become an issue. I have posted on this earlier but was just revisiting a great paper on this by Helen Spandler and others. This paper is now free online.

The Spandler et al paper is a great one and covers the issue of gift giving in psychotherapy extensively. In rereading this, of particular interest to me, was the section on whether we as therapists unconsciously elicit gifts from our clients. Money quote:

It would appear that therapists generate their own specific gift patterns. While one respondent reported being offered what were the two ‘biggest’ gifts in the study, most respondents reported receiving gifts rarely. There were a number of examples of therapists reporting no gifts. One retired female therapist claimed she received no gifts after thirty-five years of therapeutic work, and another only twice in twenty years’ practice. Yet, on the other hand, some therapists reported a number of examples of gifts. We could speculate: are therapists who receive many gifts ‘better therapists’? Alternatively are therapists who rarely receive gifts those who are able to ‘contain’ the therapy so that the therapy itself is ‘enough’? As one therapist asked: ‘Do we unconsciously invite gifts?’ Clearly, such matters depend on the particular ‘take’ or interpretation of therapeutic approach, which in turn may relate to the personality/background of the therapist. However, responses highlighted other factors involved in evaluating the gift, including the mobilization of gender dynamics.

This can lead to complex unconscious patterns when groups of therapists work together. The person receiving the most gifts in the group practice can feel guilty, the rest can feel envious.

While we are on the topic, one of my favourite Christmas gift stories. I can remember one year receiving a book of crossword puzzles from one of my client’s prior to leaving for a three week Christmas holiday. Although we had explored the issue of how she felt about me being away she denied being angry at me. It took me a number of minutes to understand the real meaning of her gift: cross words = angry words.

What's on the Blogs

Catching my eye on the psychology blogs this week.

For those of you working in the health service then you are often part of a multidisciplinary team. Ever wondered why some of them worked and some of them didn’t. Sadly mostly didn’t in my experience. BPS Research Digest reports on a study looking at what makes these teams work. Money quote:

Teams with more professions on board only introduced innovations of greater quality when effective group processes were in place – including all team members being committed to the same cause; everyone in the team being listened to; the team reflecting on its own effectiveness; and there being plenty of contact between team members.

Psyblog has a great roundup on emotion, models of emotions and even unconscious emotion. This is useful stuff for us clinicians, given that working with affect is so much part of our day to day work.

The best known modern theory conceptualising emotional states concentrates on two dimensions: valence and arousal. Valence refers to whether you feel positive or negative and arousal refers to physiological 'excitement'. This model has been extremely popular probably because it provides a relatively simple way of researching emotions that can at least provide some answers. Rage, for example, can be considered an emotion that is high on both negative affect as well as arousal.

Read the rest

Psychsplash continues to provide reviews of a range of psychology blogs. Thanks by the way for the very positive review of In the Room. Thanks also for the positive plug at A Clinician’s Journal.

Following the Fallacy: Enhancing your Logical Analysis

Cognitive therapy involves assisting people to change their cognitions and in the longer run so does psychodynamic therapy. Part of our role as a therapist doing cognitive therapy is to recognise and to challenge dysfunctional thinking patterns. To do this we need to understand what is dysfunctional and illogical about the client’s thinking patterns

Most courses teaching cognitive behavioural therapy spend a limited amount of time, often only two to three lectures, on this component of cognitive therapy. Rarely if ever do students come away with an overview of deductive and inductive logic and particularly of logical fallacies. Here is a simple test for yourself: Can you define the difference between inductive and deductive logic? If you got that right then: What is a straw man argument? Not able to answer either of these questions? Maybe it is time for some review.

I have already discussed Socratic questioning as an area that takes considerable practice. This is another area where it takes constant practice to develop one’s skills. Because it is hard work developing these two skills, therapists often give up on continued development and tend to run with a limited number of cognitive distortions they are familiar with. These are often the easier one’s to recognise such as black and white thinking or selective attention. I think it enhances our power as a therapist when we are able to also pick up on the more subtle distortions in client thinking and highlight these gently for the client.

It raises the question for me as to how as a therapist we can enhance a client’s critical thinking and application of deductive logic to their situation if we do not fully understand these concepts ourselves. It adds a further question (the topic of a further post) of what it means if we are not familiar with our own favourite logical fallacies. To develop our ability to recognise logical fallacies involves firstly understanding what each one is and then practice and practice at spotting these.

Here is an excellent site outlining all the major logical fallacies people use in debate or argument either with others or with themselves. Another more in depth site here. Again this is from the critical thinking literature which in my view provides a much better overview than does the cognitive behavioural literature. Robert Leahy has some good stuff in his Cognitive Therapy Techniques but does not go beyond providing a single example of each logical fallacy. The value of the site above is that it provides a clear outline of why each fallacy is not logical and then provides numerous examples to make sense of it.

One of the best places to practice spotting logical fallacies is to listen to politicians. Or you can play spot the fallacy on the famous Monty Python sketch. Once the ability is developed to label the fallacy then the therapist can use this understanding to develop a set of Socratic questioning to help the client understand the fallacy. Simply pointing out the fallacy is rarely helpful to the client. It is a therapist fallacy that by presenting logic and evidence to a client who has not been using this in the past that the client will be immediately convinced.

As important as all this is we need to recognise as cognitive therapists that logic and reason fails to provide good understandings about a lot of what it means to be human. Love, sex death and poetry are just a few that come to mind. Oh and God as well before someone reminds me. The limits of logic are not better put than by Albert Einstein.

Gravitation cannot be held responsible for people falling in love. How on earth can you explain in terms of chemistry and physics so important a biological phenomenon as first love? Put your hand on a stove for a minute and it seems like an hour. Sit with that special girl for an hour and it seems like a minute. That's relativity.

Avoiding the Hemlock: Socratic Dialogue III

Socratic questioning is something that takes a lot of practice to do well. For many beginning therapists there is not enough time spent developing this technique particularly in getting observed feedback on what they are doing and not doing well. This skill cannot be developed without this feedback. Ideally it should be video feedback.

The second overarching problem that arises is not understanding what Socratic questioning is. Given the confusing array of definitions outlined in an earlier post this is not surprising. Without a model of what you are doing in your head it is very difficult to know whether you are actually delivering the product in a useful manner. Before you start using this technique define what it is for you. Are you going to use Padesky’s model or someone else’s?

On a more specific basis there are a vast number of ways that Socratic questioning can get derailed. So where do therapists go wrong?

Moving too quickly in general.

Sometimes a client may take some time to give up a cherished and long held dysfunctional belief. Not going at the client’s pace or slower usually leads to resistance. This is commonly seen by the use of the word “but” in the client’s responses. For me that first “but” is a sign I am going to fast and need to go back a stage or two. I observe for many clinicians that the first “but” leads to an increase in what I call “presenting the evidence” behaviour with a resulting argument/counterargument pattern that leaves both client and therapist frustrated.

In general I see moving too quickly as a reflection of the therapist’s need to control the process. To me it is important to remember that not only are we helping a client challenge and find news way to think about an aspect of themselves we are also teaching or modelling a critical thinking process.

Moving to the evidence to quickly

This is the most common mistake I see.  It is often compounded by the therapist presenting the evidence to counter a current belief rather than eliciting this from the client themselves.  In a worst case scenario the client states a dysfunctional belief that is then immediately countered by therapist.

But what about the following evidence? Therapist then proceeds to outline all the evidence against the belief.

Client either resentfully acquiesces or a but/counter but exchange follows. Our job is not to convince the client but enable a process where the client convinces themselves.

Sometimes a Cigar is not a Cigar

Dr X has a thoughtful post on my own post about self-disclosure in therapists. In the post, he laments the move of clinical psychology towards a focus on the manifest and on the surface content of what a client presents. He makes a direct comparison between simplistic and manifest approaches to psychotherapy such as congitve behavioural approaches and fundamentalist approaches to religion and the dangers inherent in this. It is a lament I share however my position on it is a little different.

His post highlights the difficulty that listening on a deeper level to a client demands much more of us as a therapist, not the least of which is that the client's own struggles with the less salutary aspect of themselves, their hatred, their pettiness, their shame and their despair emphasises these very aspects in us as a therapist.  It is easier, less demanding and less threatening to stick with content.

Money quote:

When we work in this way, we will fail often. It is only then that we can honestly appreciate the client's struggle and the nature of the obstacles we and our clients face in taking up the honest pursuit of meaning that all of us face as finite, limited human beings in a vast dynamic creation. No one ever said this job would be easy.

Read the whole thing.