QUOTE OF THE MONTH:

# 109 March 2009

"Verification is the only scientific criterion of reality. That does not mean that there may not be realities that are unverifiable. . . ."

John Fowles
from The Magus


(continues below)

mental health professional trainings
primary care professional trainings
psychological assessment supervision and consultations
Shawn Christopher Shea
links and recommended readings

INTERVIEWING TIP OF THE MONTH

# 109 March 2009

"Why Me, Why Now?": Pathways to Understanding the Client's Spirituality as a Powerful Component of Suicide Assessment

TISA Description of the Problem: While presenting down in San Antonio in January on "The Mysteries of the Human Matrix: the Quest for Happiness and its Role in Hope and the Prevention of Suicide" for the Department of Defense/VA's annual conference on suicide prevention (a wonderful event), I was approached by a military pastoral counselor, Doug Wigginton. Doug offered some keen insights on the role of happiness and spirituality in suicide assessment and promised me he would send them on for inclusion in our TISA "Clinical Interviewing Tip of the Month." His resulting e-mail is quite elegant, and I have little to add other than emphasizing the importance of spiritual investigation in assessing suicide (and treatment in general), one of my favorite topics for discussion and workshops. What is particularly clever in Doug's tips is the route with which he helps the client to feel comfortable discussing these complex and highly personal issues, for he uses the client's reasons for approaching him, specifically, as a wonderful gateway into spirituality. I think you are in for a treat with this set of superb clinical interviewing tips.

Tip: As a hospital chaplain, I conduct some short term pastoral counseling but rarely conduct a structured formal interview. Most often I provide pastoral care and on occasion short term pastoral counseling to patients who have already been identified as being at high risk for suicide. I also see patients that "happen" to stop by my office to talk.

Because of the transient nature of those who come to see me, I need to make the most of the little time I will have with them. As I listen to their story and presenting problem(s), there are three questions that I always ask myself and sometimes ask the patients. My questions are as follows:

Why me?
Why now?
What are your expectations?

The answers to my questions often are provided without my asking but there are times that it is important that I directly ask the patient. I normally phrase the "why me?" question something like the following:

"I am glad you came in to talk with me today. It is not always easy to talk about things that matter to us. I am curious about something. Out of all the people you could have talked with in the medical center you decided to talk with me. I am wondering why you came to see me as opposed to your doctor, psychologist, nurse or social worker."

The answers to my questions can be very telling especially depending upon their reason(s) for talking with me as a chaplain. Asking,"Why me?" can surface fears that their illness is punishment for a real or perceived "sin" that they have committed in the past. Sometimes the patients are attempting to "make sense" out of their illness and/or situation. Sometimes they are looking for an easy way out of a particular problem or difficulty. As one patient told me; "If you could help me get right with God things would be different for me." Further exploration made it clear that she believed her mental illness was a result of not "being right with God" and if she could "get right with God" she would be "discharged from the hospital."

Listening for and/or asking the patient "Why now?" will often provide me with an idea as to the patient's motivation for coming to see me. If I overtly ask the question, I usually phrase my question as follows: "You have come to see me today and I am glad you did. Out of all the times you could have come to talk with me you came today. Could you tell me why you came today as opposed to last week, month or even last year as opposed to next week or next month?"

The patient's reasons vary. Sometimes the patient has just received bad news or the reality of a life threatening illness just set in after weeks of disbelief, or the patient's wife just left him after years of fighting, or the patient is facing a jail sentence or a court hearing. Sometimes they are people who are near the "end of their rope" and are looking for a way out of their problems and/or pain. As one might imagine, the patient?s response to "Why now?" can be very helpful in understanding the patient.

The last question is, "What are your expectations?" "Is there a particular way that I as a chaplain can help/assist you?" is usually the way I ask about the patient's expectations of me as a chaplain. Most of the time people who come to me simply want to be heard, to feel as if someone cares, and for someone to pray for or with them. However, there are also times when, as in the situations mentioned above, they have clear expectations such as "Pray that God will remove my mental illness." Or in the case of the man whose wife had just left him, "Call her and tell her that I am now getting help from the chaplain." On occasion the patient's emotional pain has become so great that he/she sees no ways out of the pain and for reasons that may have been revealed in their answers to the first two questions are looking to their faith for help. In each of the examples I am left to make the decision as to what I am willing and unwilling to do, of what I can and cannot do, based upon what I believe would be helpful or harmful to the patient's overall wellbeing.

TISA Follow-up: What a wonderful set of clinical interviewing tips! I have nothing to add other than to remind readers of a reference that I mentioned in our last month's Interviewing Tip of the Month regarding what, to me, is one of the finest articles ever written (if not the finest) on how to actually explore the concepts of God/Goddess, spirituality, world view, and framework for meaning with our clients. The article is packed with specific examples of interviewing techniques and questions, that psychologists, counselors, social workers, and psychiatrists can use for sensitively exploring these important parts of the human matrix. The article is written by Allan Josephson and John Peteet and is entitled, Talking with Patients About Spirituality and Worldview: Practical Interviewing Techniques and Strategies. You can find the article in the June, 2007 issue of the Psychiatric Clinics of North America. Volume 30 (#2):181-197. Almost any medical library will carry this journal, and Allan's e-mail address (he might have reprints) is allan.josephson@louisville.edu.

Enjoy, and good-luck with your mission.

Tip provided by:

Chaplain Douglas A. Wigginton, M.Div.
Chief, Chaplain Service
Certified Supervisor, ACPE, Inc.
Department of Veterans Affairs Medical Center
Alexandria, LA

TISA is a site dedicated to advancing the science and art of preventing suicide and teaching clinical interviewing