From Suicidal Crisis to Calm: How people move through suicidal crisis with Johanna Mickelson

In this conversation, Dan talks with Johanna Mickelson about the Distress-Processing Model for people in suicidal crisis. In this conversation, Johanna shares her experiences working in a crisis center and discusses the challenges and insights gained from her time in crisis management.

Most of the conversation focuses on the Distress-Processing Model for people in suicidal crisis: Its development and application. The Distress processing model consists of the stages that people go through to move through their suicidal crisis. The stages consist of:

• Unengaged with distress: Minimal or no engagement with distress.
• Distress awareness: Recognizing distressing behaviors, emotions, or thoughts.
• Distress connection: Linking distress to specific stressors or experiences.
• Distress insight: Gaining an understanding of why the distress is personally relevant.
• Applying distress insight: Using new insights to identify ways forward.

Special Guest: Johanna Mickelson

Links to the Article
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Chapters

• 0:00 Introduction and Episode Overview
• 2:20 The Therapist's Role in Suicidal Crises
• 7:45 Reflections on Crisis Intervention Training
• 12:15 Gaps in Existing Research
• 17:00 Developing the Distress Processing Model
• 21:30 Validating the Model
• 25:00 The Five Stages of Distress Processing
• 39:20 The Sequential Nature of Distress Processing
• 44:50 Conclusion

Transcript

0:00

[Music] Broadcasting from most beautiful city in the world, I'm your host, Dr. Dan Cox, a professor of counseling psychology at the University of British Columbia. Welcome to episode number 27 of psychotherapy and applied psychology, where we dive deep with the world's leading applied psychology researchers to uncover practical insights, pull back the curtain, and hopefully have some fun along the way. If you didn't already know, you can check us out on YouTube, just tap the link in the show notes. And while you're there, be sure to hit the like and subscribe buttons. Hitting those buttons on YouTube and subscribing to the show when your podcast app keeps you in the loop and helps others find us too. Following up the last two weeks of episodes being a little bit different, these next two episodes, this week and next week, are also going to be a little bit different. These two conversations are going to be conversations about a project that I was deeply involved in. After this, the following episodes will be right back to normal. I have some astounding guests and we are going to be covering such a breadth of topics from truly global leaders. So let me give you some general background before we dig in too much. And why I've decided to devote so much time to this particular project. I feel like this is probably the most significant work in terms of its contribution to the field, both practice and theory that I've been a part of. When we started this project, I didn't think that it was going to be as important as it ended up being. And maybe in a lot of ways, really what it did was it was one of the first dominoes that really fell that influenced my own thinking. And really what I have ended up spending so much of my time or the last few years doing, but this project was really the impetus for me really recognizing that as therapists, when it comes to working with all of the other types of folks that we work with, we're really trained in practice in ways that help them move through and progress on the challenges that they're facing. However, when it comes to working with folks in suicidal crisis, that is neither what we're trained to do nor is it what we do do. And doing the project that we're going to be talking about, I somewhat unintentionally came to realize that as a field, we're really engaging in a real sin of omission in that. When we have clients who are in suicidal crisis, we really aren't trained or do we practice to help them move through that crisis. And I've come to believe that therapists have the skill set. We are really uniquely positioned to have that skill set to help people in suicidal crisis move through that. This conversation centers around two studies that were published in an article in the journal crisis, the journal of crisis intervention and suicide prevention. I'll link to this in the show notes, but if you aren't at a institution where you have access to it, just let me know there are several ways of getting in touch with me that are linked in the show notes. So my guest today is Johanna Mikkelsen, she's a doctoral student at the University of British Columbia, and someone who worked as a crisis interventionist for nine years and the principal investigator of the project that we'll be discussing. In this conversation, we discussed the experiences and questions that Johanna had in her work with suicidal clients that led to this research. How focusing on suicide might actually get in the way of helping clients? Process of developing the distress processing model for clients in suicidal crisis, the five stages of that model, assumptions that we had going into this research that were proved incorrect and much more. This episode starts with Johanna responding to my question about how she thought about helping clients in suicidal crisis process their distress before we did this research. So without further ado. I don't know if I actually really conceptualized it as distress, I think. And what I like, I think kind of to pull it back and use that language like I knew somebody was in crisis and was in something that was clearly causing them suffering in some capacity. But I think I was thinking about it more, not about them making sense of like processing their distress. I think I was still almost thinking about it of like, I can support you with your like with the emotions. And I can support you in like showing that I'm here for you when I was working at the crisis center, I think I was really thinking about it through the lens of like, how can I show that I'm willing to be there for you? How can I really allow you to open up about this just like about the suffering, but I don't think I thought about it as helping them make sense of their distress. I think I saw it more as like me being almost like a bit of a social support through that as a, and by me connecting with that person, that's going to be a big help, which I think it still is like even after doing our work together. But I think I didn't think about even even that like I think I thought about it more of like me as as a support for that person as opposed to even now that I'm on the other side of it is like that might be them making sense of like, oh, I'm not alone in this situation. And that might actually be the the distress processing. But I don't think I thought about it in terms of I'm helping this client make sense of their crisis or their distress. So it would be reasonable to say that it was more focused on like what you could or should be doing rather than what you could or should be facilitating in the person you were talking to. It's a bit of a blend. I would actually I would say it's a bit of a blend. So I wish I could be like yes or no, but I think what it was is like there's certain aspects that I think are prevalent throughout a lot of different kind of suicidal support systems. And those are things that I think are still really embedded in like these are the things you should do. So like we should make sure that the person has a safety plan or we should make sure they have social supports or we should make sure that they're willing to call us again. And I think those are should that. I would argue or maybe not necessarily always the most helpful for the client. I think it's it can be but isn't always. So I think those parts were more of like what I should be doing that were very like problem equal is suicide. Therefore we need to try to fix that problem, which I think was taking away from the clients and ways but other parts felt more facilitative in terms of like helping them kind of share their story in a more conversational way like that felt more facilitative. And I think it was still facilitating like their disclosure, but I don't think I still had it with the same intention of like I'm doing this in order for them to understand their crisis. When you said you just said something like focusing on their suicide, which might have gotten in the way at all. Can you expand on that? Yeah, I think I don't want to normalize it because I think it can be a really like stressful experience for people who are working with people into a subtle crisis is it's it's scary to think about somebody could kill themselves and I think that is a scary thought for somebody and I think I really respect how much responsibility people hold around that when they're working with people into a subtle crisis. And while that is really stressful, I think oftentimes we end up focusing on how do we make sure that that person doesn't kill themselves. Which completely makes sense, we want to make sure that somebody doesn't die, but at the same time, I think then the focus of a lot of conversations tend to go towards the actual like means of suicide, how to make that person not kill themselves, which often can lead to maybe like a hospital intervention or something like that as opposed to actually having the conversation with person of how do we get here. And I think that is actually where the work is and would be in a lot of ways more helpful for the client because if that person's not experiencing that problem, whereas in that kind of distress, then I don't think suicide would be the common kind of presenting problem. And that's I think where we can be more facilitative. And if we helped to understand and work through how this person got here that that that those suicidal desires might the volume might be turned down on those exactly. Yeah. So once you started actually let me let's just sort of get into when we were doing this research, what was the primary question. Or that you were trying to answer the sort of the primary aim that you were going for and doing this work. Yeah, so I think and I'll caveat this a little bit. I think what was happening was when I was at the crisis center, both as of as somebody working with clients and crisis on the front lines and as well as training is that. There was almost like a certain point where I felt like we were really connecting with the client and like building those kind of empathy skills and act or like empathy and active listening. And I think I saw that really building, but then I'd see people saying like we got to get at the hospital or like we got to and almost like jumping to to solving around that crisis. And that's the reason I was totally again understand where that's coming from and I knew in my own in my votes. I was like I know that's not where we need to jump to, but then there'd be a really natural and obvious question of a of a training being like, well, why not like we don't want to kill themselves. Like well, we need we need to keep talking to them to help them like to help them through it. That's not necessarily the appropriate solution. And I, but I didn't have the language to help them understand why that's maybe not the right place to go to or like we're moving too quickly for the client. Hospitalization you're talking about. Yeah, hospitalization or like they got in a fight with their mom will let's let talk to mom then like just kind of getting to the either the problem or the suicide. And so that felt like we were moving too quickly. And also maybe moving it appropriately like that might not actually be facilitated for the client. And I knew that, but I didn't really know how to explain it. And then I think that's really where our research came into is being able to actually understand like how. How does the client actually go from being in a real rough like in a lot of distress. How do they go from being there. Into being at the end of the call being in a much better place. So that does like volume on the suicidal crisis is turned down. They may not be completely gone, but I know I've had those calls or the or chats or however like different conversations where I can feel like wow we've done so much, but I can't necessarily articulate why like what actually happened there that the clients in a better state. So I think that was really what motivated me to do our work is to better understand like how did that client actually move through that how are they in a better state by the end of the conversation. And what when when we were getting into this work and you first started like digging into the literature on this. Yeah, because before this how long did you work at the crisis center. Before starting our research. Well, just in total how long did you work in the crisis center. Eight to nine years. Right. So. So you, but at that most of the time you're at the crisis center, you know, you're not doing this as part of a research project. You're, you know, you're not so you're generally, you know, you're learning a lot experientially and trainings and those sorts of things. But you're not digging into the literature on this. Once you started digging into the literature on this to try to get a sense of what folks how folks have talked about how clients and suicidal crisis move through that crisis and move through that distress. Like what did you find folks were saying in terms of how the actual clients process their distress. Not much like what I was seeing, which was actually really helpful was was a lot of the research was really more focused on what the counselors should be doing. So kind of even what I was talking about we should be doing active listening skills. We should be setting them up with appropriate resources. We should be making sure that they have a safety plan. And so it was really to me, counselor focus like what are the skills that we are doing. But not focused on the intention as to why we're doing that. So it was really more focus to me was a counselor centric lens as opposed to the client centric lens. Yeah, and that was very much my experiences to it too in terms of like really digging into this was it was sort of like, you know, folks would say things like, you know, and then, you know, by talking about this clients can, you know, clients will do better or whatever. Yeah, and it's like, but there's no, but how like what's the actual process that's unfolding for the clients. They're sort of this like big gap and it was sort of, you know, I don't know kind of jarring almost how much attention folks would would put on this is what the helper should do. But not what is the actual change that's happening in the client that this is facilitating. You know, and so then it sort of became well, if I don't know what the the changes, how do I know if what I like, I'm going to go through the steps. But how can I track if the client is moving along with me exactly exactly. And so that was I think the part that really stood out to me is like, there's all these skills and I think some of them are still very like productive like, you know, being able to actively listen and be able to sit in those situations really important. I'm not trying to take that away, but I think not knowing what the intention is or what we're trying to work towards in doing some of these skills. I think leads to like anyone who's kind of working with clients and suicidal stress is like, it's not helping us think about why what the intention is and what are the markers of change so that we can move to kind of the next stage with that client. So it's more about like the skills as opposed to like when and why like there's a lot of lack of the intention behind it. Right. Yeah, it was very like helper focused sort of very kind of like felt kind of like checklisty. Yes, yes. And and that's been something that I think about a lot like even with safety plans or something like that, which is really common is I think those could could be actually done in a really like conversational meaningful way and applied in a nuanced way. We approach it of like who are you going to call and just really like in those questions and I think we can make quite a checklisty kind of thing and I do think about the impact on the clients about how that maybe doesn't feel as tailored or could not feel as supported or meaningful if we're doing it at a time that doesn't align with what they're hoping to get out of the conversation. Yeah, totally. Yeah, yeah, that's sort of an interesting thing about a lot of the suicide intervention is particularly the crisis intervention stuff as I think it becomes much more counselor or helper therapist focused and client focused. Okay, so I don't think we should dive too deep on the research methods part, but I probably think I think we should probably hit some of the high points of the project. And so you know this project consists of two studies. So I'm wondering perhaps you give us an overview of sort of like what the you know of study one sort of what the purpose what we did was and then study to. Well, hello there. This is Dan from the future and unfortunately we had a little bit of a technical glitch for the next couple minutes of our my conversation with Johanna. So I'm here from the future to give a brief overview of the study that Johanna and I and others did. So why are people in suicidal crisis one of the primary reasons that people are in suicidal crisis is because they're experiencing some sort of psychological pain. And for this project we call it distress and actually later on in this conversation Johanna and I get into why we call it distress instead of pain or any number of other things. So we'll just sort of hold off on that. But the idea is it's because they're in pain or distress is why they're suicidal. So lots of people in the suicidal crisis world have brought up that one of the roles of the person working with the person the helper working with the client in suicidal crisis is to help them to work through make sense of whatever the psychological distress that they're in. But nobody had created but nobody had done any empirical study of that process of how they get how they work through that distress. So that was really the purpose of this study was we wanted to take the existing research from the suicide world and from more the psychotherapy world where folks look at how people move through or process emotions and that sort of thing and sort of bring these things together to develop an empirical model of what does this sort of step by step process look like for the person in suicidal crisis as they move through that crisis as they make sense of that distress or process that distress which then in turn reduces their suicide and then the suicide reality reduces that crisis and brings them back to baseline. So this project I keep referring to it as this study but it was actually two studies. So let me just talk about study one because later on in our conversation we dig into study two a little bit for study one there were three parts to it. So what we developed is where we developed this and this is mostly pretty all this was mostly led by Johanna where we developed a what they call a theoretical model. So this is where you take the research and theory that's been developed over the decades. So you take that and then you develop a model like theoretically this is what these steps or stages in which somebody will process their distress when they're in suicidal crisis what that will look like. And you also then take that model and you get feedback from people in the field who are actually working with real folks in suicidal crisis to help them and to help their insights in form the model. So you take this what they call this theoretical model, so you then you take that model you put it on the shelf. Then you get a whole bunch of conversations with clients who are in suicidal crisis and you develop what they call an empirical model. Purely empirically based model of how people move through this process. So what we did is we got a bunch of conversations with folks in suicidal crisis where it turned out well. And then we got a bunch of conversation with folks in suicidal crisis where it didn't turn out well. So you get a whole process in which you do this, but the short of it is you get this purely empirically based model when you do this coding of all of these conversations of the steps that are necessary to move through suicidal crisis. And what you have so you have this empirical model that you based off of the conversations, then you have this theoretical model that we developed earlier that we based off of existing theory feedback from people in the field, blah, blah, blah. And you take that and you basically merge them. So you take the empirical model you use it to inform your theoretical model and voila you have your synthesized or your final. And then you have your final, your final, uh, distress processing model for folks in suicidal crisis. Okay, I think that more or less covers what we talked about hopefully I didn't miss anything. So now let me get you back to the present. So a couple of things that we thought would happen that didn't end up happening in the real conversation in those real sort of psychological processing experiences for clients. Could you could you hit on what those were? Yeah, totally. Thank you for bringing that up. I think one of the, honestly, one of the challenges for me that we've had conversations about in this process is in developing the theoretical model we had some of that was informed by crisis theory and I found what we found is that a lot of the crisis theory is quite focused on the an event. And so it was trying to blend that research with more like counseling, distress processing theories and how do we blend those so my initial theoretical model was very much informed by looking at like what was the. And so I think that that focused that caused that caused the suicidal crisis as opposed to like looking at how like the experience of that person. And so even like the different stages were looking at like the how well does the client know about the event how are they linking the event to to their own crisis, how are they going to solve this event. And so that focused on an actual like event as opposed to giving us like an example of what an event means. Yeah, so like an event might be I got in a in a fight with a partner in my now my partner's breaking up with me. So that would be the event so everything that the person would be doing in terms of the helper would be looking at how can we relate all this meaning making to that specific event. And how can we problem solve around that event to. And so what did the so that was sort of what we initially thought we would we would be seeing was a lot of sort of processing events, but what do we end up seeing instead. So a lot of the actual like work oftentimes ended up not really focusing on the event itself that might be part of the story, but really a lot of the focus ended up in the conversations when we're looking at it more from an empirical as opposed to theoretical lens. And so I was looking at what we were seeing is more of a focus on how the person was feeling, how the person's thinking and not necessarily about the event itself, but about the actual experience of being in a suicidal crisis. And so really that informed a lot of our model once we like integrated the theory and empirical was to focus less on the event and more on the client and their experience. And so I think that we were, we originally had like, I don't know, we probably like we, we eventually we got to like a distress processing model. But originally we had other terms in there other than distress. And memory is that one of the reasons we settled on distress was because it was that was sort of literally what was happening was that when clients were able to process their distress, which is very kind of broad right so that could be a specific inciting event. And so that feeling they're having about it that could be relational issues future things past things, whatever, just sort of like anything around the distress rather than you know so like rather than necessarily on the emotion like it could be on the emotion. Yeah, it could be on the event, but it doesn't have to be just talking about the distress and processing the distress in general was sort of the best depiction or encapsulation of what was actually happening and what was helpful for clients. Am I am I remembering that correctly? Yeah, absolutely. Yeah, so we I don't remember. I think at one point, I think it was even like the cognitive processing model like we were very focused on like thoughts at one point at one point. I think it was like an of like, oh, just like suicide process like each one was kind of not quite capturing. I think we would be talking about certain chats and I'd be like, well, this person really needed to focus more on their what they were bringing to their table was like the feelings about it and like other pieces were tied that like that's what was coming up for them. And for other people it was really specifically like that that that problematic event that might have occurred before that was maybe the focus and for other people it was like really around like their own thoughts about themselves or something like that. And being able to actually just to me when we renamed it to distress processing distress kind of covers all of that and I think to me that allows for the client to bring up what's most challenging for them as opposed to us really having to focus on like one specific aspect of their story or their experience. Yeah, exactly. Yeah, and I think that you know, because one of the things that I always struggle with and writing about this is sort of like the term distress like the word like pain or psychological pain, it's sort of like in some ways in some ways I feel like that better encapsulates. I don't really just more pointed in terms of like, you know, wire clients who decide well because they're in pain. You know, that's sort of the primary driver. So, but the and I remember going I think we probably went back and forth on this a thousand times. Yeah, but I think it was that what we really came down to is what was happening is yeah, a lot of times folks were talking about their pain, you know, but sometimes it wasn't so narrowly focused on just pain. It was other stuff as well. So that's where we ended up we sort of landed with the term distress. Yeah, like I think we even I psychic something that's used a lot in suicide terminology and that's something we even discussed. But then sometimes even in the conversations that were that were progressing is I would say they maybe are presenting with that initial suicidal crisis or like those ideas or like yes suicide ideation or something. But as they started talking further, you could almost see them bringing other aspects in that are maybe not suicide focus but are still distressing. And so I think this allowed for that full spectrum of experience that is in some ways causing yeah distress. So why don't we go through the five stages and that way folks will have context. And so what that looks like is there's five stages that the client should be moving through theoretically. And so what we did. So the first stage is what we call unengaged with distress and this could look in a couple of different ways, but essentially that the client isn't actually talking about what's distressing to them. And so that could either be that we give them the invite to discuss it and they're like it's too scary to talk about or it's too much to talk about or we give the invite and they maybe change the subject but either way we're giving that invite to discuss it and they're in some way marking that they're not ready that they're not going to talk about it. So that's unengaged with distress and then there's distress awareness, which is the awareness that they're either like that there is something distressing that could be distressing thoughts that could be the event that happened or there could be emotions and they know about them but they're. And that's kind of how it's presenting. So sometimes that could even be like quite global. So like everything's terrible or I feel awful and they're aware of it and they're not going to be able to do that. And they're aware of it and they're open to talking about it. And then the next stage is distress connection, which is where they're able to start talking about how. Like how they're feeling and what that's maybe connected to so. I my partner broke up with me, I feel so sad, I feel heartbroken. So being able to draw the connections back to themselves. And then the next stage, the fourth stage is distress insight, which is more about actually like why is that important to that person. And so I like trying to explain this is that the same event could happen to two different people and they're going to take very different meanings about that event. And so that to me is really the distress insight is why is that important to you or how is that impacting you what what meaning are you making from that. So if it's I broke up with my partner broke up with me, I'm absolutely heartbroken. I don't I don't know if I'm going to be loved to get I don't know if I'll ever find somebody again. But that could be one person's reaction, whereas somebody else could be like a partner broke up with me, I'm really sad. But you know, I think there's other people out there for me and maybe I just need to take some time to figure out what's best for me. And so they can have very different reactions to the same event and that to me is distress insight. And then the last stage is application of distress is like, okay, so what do you want to do now that you're aware of that. Maybe that could be an actual action. So like, that could be maybe, you know, I want to talk to my partner or something like that or, you know, I want to talk to my other friends to get a sense of what they're thinking about what's best for me. Or it could be even just how they're making sense of the event like what do I want to take away from this that helps me make sense of the event. So that could be, or they're distressed, so that could be something as well as like, maybe maybe I really should kind of rethink about this. Maybe we weren't the best match in the first place, like something that helps them kind of see it even slightly differently, or maybe it gives them ideas of how they want to take action. And so that's the application distress and that's the full model. Yeah, and so the idea here is that when folks go through these distress processing stages, so they move through them. This is the processing of their distress that it will reduce their desire to die as they sort of process gain clarity insight. And so this was the, so the study one was very much like coming up with these stages. The study to was what they call the validation stage, or then we took this and we applied it to a bunch of other conversations with folks in suicidal crisis and found two things, one that that folks that clients who moved further along in this that they had better outcomes that they're suicidal desire and things like that were less. And that we also found that there was this sequential nature and what we'll get into that in a few minutes, but sort of this idea of that people move through these stages sequentially that you have to go from one before you go into the other before you go into the other. Okay, so why don't we do want to talk a little bit about the sort of going right at the beginning to sort of this stage one this unengaged with distress sort of what we thought initially and how we sort of modified that over time. Yeah, so there was a few kind of key ones. So the very first one was I called it distress avoidance. And actually, as we kind of got, as we started talking about this with other people, I think that's where that kind of started getting more clear is that it doesn't necessarily have to be direct. I'm intentionally avoiding this topic. But it's more like either way they're not discussing it, but it doesn't, it felt like a little bit too asumptive that they're actually avoiding it. They could be also like just talking about other things where there could be maybe discomfort, but I think avoidance was a little too. Yeah, I'm just going to say the same most of them here. I just want to just want to room an illness for a moment. So I think that one of the so with the unengaged with distress that you brought up talking, which is absolutely true. And part of this is also like that they are generally not engaged with their distress. It's not just that they're not disclosing it is that they just really don't have a sense of what's going on. So this would be just sort of feeling like they're tumbling around in a wave, but they don't really know what's happening. There's no things aren't okay. But if you said, tell me about the pain that they don't have a sense of that they're angry or that they're sad. Like it's not that differentiated. Right? Yeah, that's a that's a better way. Yeah, I actually agree with that. And that also allows for that person like because I to me, I think this model could kind of stand on its own without direct interaction. Right. And to be honest, I think you and I have even looked through a conversation where I'm not even sure the the counselor said that much to be honest and this person was really actively doing that work. And I think this I think even having the unengaged with distress allows for that part where they're not even there's something that's maybe coming up for them, but they haven't even started to actually look at it. They haven't started wanting like that process of actually processing and making sense of their distress. Yeah, and I think, you know, getting back to I guess two things. So one, what you said earlier about the where we originally had distress avoidance. Yeah. When we change it to unengaged with distress, it's sort of, you know, avoidance does imply this, you know, volitional aspect of it. And it doesn't even necessarily have to be conscious, but there is this like, volitional. I'm avoiding it for, you know, and it just seemed like, you know, frankly, I kind of feel like probably most of the time that that's true. You know, and but it kind of felt like is it really is avoidance the best way, 100% of the time to communicate what people are doing. You know, I don't think so. I mean, it might be 95% of the time, but I don't think I just think sometimes they're just, you know, I mean, you know, it's sort of a bit of a trait example, but you know, sometimes you're avoiding something and sometimes you're just busy. Yeah. You know, so like things are, you know, you get bad news, but then you have to go teach a class or see a client or give a presentation or whatever it is. So you're just not engaged with that experience, but you're not avoiding it. So, and you know, maybe that may as not the best example for this particular context, but it just seemed like avoidance is not as precise as unengaged, which unengaged includes avoidance. And, you know, you, I think we both were on avoidance using the, and avoidance has been used historically in like processing models. Yeah. So that's where we sort of drew it from. And, you know, with my background doing a lot of PTSD related stuff, we talk about avoidance all the time. So I'm sure that I brought that into. So I just think that the, yeah, the unengaged was a better way to encapsulate what is going on with clients or with people at it. Sorry. So then the other thing that you said that I think is important is that we're talking about these steps in this process that, just like you said, like these are the steps that are stages that folks move through in therapy or, you know, in some sort of counseling or therapeutic context. But it doesn't have to be in that context. So this is, you know, people could do this just in their heads, people could do this in journaling, people could do this talking to their rabbi, like it, you know, in any of these context, it's the idea is that this is how people process the distress they experience when they're suicidal regardless of context. And they just happen to be looking at it in this context. Exactly. Yeah. I feel like you're about to say something about either distress awareness or distress connection. Oh, yeah. I think those two kind of generally stayed the same. And I think that I think that actually kind of makes sense in terms of, yeah. So like being able to connect like, or like being able to say, like, this doesn't feel good. I'm in some sort of distress or these are the thoughts that are coming up. Here's the event that happened. I think that's that awareness to like, and here's how, you know, this happened. And this is how I'm feeling so that connection and then the insight those to me also had the most kind of research supporting it in other less in the crisis, but more in the counseling research. So those stayed the same, but what did change for us is initially we said that people would do brainstorming of how to solve their problems and then apply their problems. Like, here's, I'm trying to figure out what I want to do. Here's all the different things I'm thinking about. We would be helping them, you know, brainstorm those or generate different ideas. And then they would decide on, and this is how I'm going to proceed. They would theoretically go and do that. And that's where we actually didn't see that in unfolding in the in the conversations we were looking at. And I think that I could go of one of two ways. I think one way that that could be looked at is again, if we're not looking at it so much as like, here's this problem event that we need to solve that brain-serving piece might not need to occur because they don't necessarily need to solve that event. I think sometimes they might be able to kind of see things differently, et cetera. And so we don't need to necessarily brainstorm all the different ways they could see it. The alternative that could be happening to is in the conversations given the crisis context as they could be doing that in their head. If like, here's the different ways I could go about this. You know what I've already decided and there that's how we're going to proceed. So, but we just we didn't see that as much. We just we didn't really see brainstorming occurring in most of the conversations we looked at. So then we ended up collapsing that into application of distress. Right. So originally we thought that folks would sort of say, OK, here are some different I could do this or I could do that or I could do this. And then they would apply it. But it sort of seemed like the thinking of things to do and the applying things to do was sort of all wrapped up into one. Yes. Process, if you will. Yeah, exactly. Or like, honestly, most of the conversations that we saw were like, this is what a great conversation. The person kind of had had by time we got to the insight. I actually found a lot of the what I actually assumed we would be doing more work in as a helper was going to be like, how do we want to resolve this? What are we thinking, etc. And that that was actually almost some of the faster things that would happen is the client kind of proceeding with like, here's how I'm going to go about it. Or like, actually, you should really just think about it this way. OK, thanks so much for your time. See you. So that that actually that stage actually tended to happen quite quickly. The application of distress insight. Yeah. So sort of the idea that once that once they understood why this mattered to them. Yeah. Right. Like, oh, when this happened, I feel like a complete failure. I feel like I can't succeed. That sort of insight piece that they sort of the solution, the next step, the what to do, sort of just like it was just sort of like, bam, yes. Yeah. When we did see it. And that's something that I don't know if we want to talk about. Is that also like a lot of our conversations, the person was in a really good state by three, four, like, so distress connection or once they've really been like, this is why it's personal to me. And sometimes they were in a pretty good place where we didn't end up actually having to explore. Here's all the solutions that you could be doing or like needing to have the chat have them tell us like this is my solution. Oftentimes they're like, this already feel a lot better. Like, thank you so much for your time. So we didn't necessarily always see application of distress in every positive outcome. And I think that I just think that that's worth highlighting. So, you know, we came up with these five stages, sort of this idea of here the five stages of person has to go through to process their distress. But what we ended up finding was that a lot of people who were doing really well at the end of the sessions that they didn't make it all the way through. And that they would make it to stage three or four and not to five. So sort of indicating that moving along this continuum is great. And that making it all way to all the way to five is not necessary to get a lot of benefit out of it. At least what we looked at and we looked at like short term outcomes, just like how was it at the end of the session, you know, over the course of the session. Because one of the things I think we talked about is like, you know, that application coming up with a plan of what to do next time or where to go next time. Maybe if we looked at more like long term outcome, maybe that would matter more where we're just talking about resolving that crisis in that moment. It doesn't for a good number of people getting all the way through the five stages doesn't it wasn't necessary. Exactly. Yeah. And that was interesting because I was actually I was just reviewing some of the models that we were kind of informed by from counseling context and like they do have like application and mastery. Like how can I apply this in other contexts. And so that one might be out of reach for us within the context we were looking at. So that could be happening. But in order to resolve that like initial suicidal crisis, getting to five isn't necessary isn't necessary. And my memory is that there was some work that I think Bill Stiles had done. Maybe some others sort of saying that are finding that sort of similarly that when they were looking at processing in other contexts that at what were that it didn't folks didn't have to make it all the way through all of the stages. So can you remind me of that and then also like what were some of the other contexts that processing has been looked at. Yeah. So the one that I think you're actually talking to is nervous get the name right. But past ball on was like the the global distress processing so processing emotions and how that was linked to outcome. And so they were actually finding and I think styles did one as well. So different slightly different models kind of similar ideas. Just different emphasis. I would say once a bit more cognitive with some emotional markers and once very emotion focused. But both of them kind of found that once you get to kind of that connection and insight that actually like the outcomes were quite positive as well. So looking at more of the kind of standard counseling outcome measures. Those were quite positive at that stage and then you didn't necessarily need to get to mastery in order to have positive outcomes. Like yeah, so this has been looked at or sort of the application of these processing models has been done in a bunch of psychotherapy to context using a bunch of different types of interventions for a bunch of different types of client problems. Which was really what we kind of a lot of what we drew from. And I do want to ask you sort of you know what we think about processing the suicidal clients. Yeah. How different you think that that is then processing with other types of clients. But before I do that. So can you maybe put a little bit of meat on the bone of the sequential nature of how this thing works and why that matters for a practitioner. Yeah, so I think so yeah, so our second study was really looking at it. That's a wrap on our conversation about distress processing with clients and suicidal crisis during this next time when we dig into how practitioners can bring this work into their practice. And as I noted at the top of the show, you can check us out on YouTube links in the show notes. Until next time.[Music]