Helping People Move Though Suicidal Crisis: The distress-processing model with Johanna Mickelson

Dan welcomes back Johanna Mickelson as we dive back into the Distress-Processing Model and the significance of reflection and reading in developing insights and fostering better conversations.

Dan and Johanna explore the concept of the 'helper' in discussions, emphasizing the importance of clarity and nuance in communication. Then, they delve into how understanding these elements can enhance dialogue and lead to more meaningful exchanges.

The stages of the distress-processing model 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

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Chapters

• 0:00 Introduction & Welcome
• 1:42 Understanding Distress Processing
• 3:10 Sequential Nature of Distress Processing
• 6:35 Aligning Therapeutic Interventions with Client Needs
• 9:52 Importance of Addressing Client Distress Over Suicidal Thoughts
• 13:45 Practical Implications for Therapists
• 17:20 Safety Plans: Client-Centered Approaches
• 19:30 Closing Remarks and Key Takeaways

Transcript

0:00

[Music] Broadcasting from the 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 28 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 find our show helpful or interesting, it'd be much appreciated if you could share it with someone you know who might also enjoy it. It's a great way to spread the word and keep the conversation going. Today is the second part of my conversation with Johanna Michelson about distress processing with clients in suicidal crisis. In this conversation, we talk about the sequential aspects of distress processing, aligning therapeutic approaches with client needs, practical implications for therapists, safety plans, focusing on client distress over suicidal thoughts, and much more. This episode starts with Johanna talking about the step-by-step nature of distress processing with clients in suicidal crisis. So without further ado...[Music] So, yeah, so our second study was really looking at like both, you know, more processing, how does that really turn better outcomes, as well as does this actually move in sequential ways, so theoretically you would go from, you know, unengaged to distress awareness, distress awareness to connection, and so on. And so I think this is important for clinicians kind of more specifically to think about like, how am I supporting this client at this stage? Because I think, so actually going back to kind of my original, like, when I was trying to work through a problem around like, how do we do this work at the crisis center? Is that someone would come on and say, like, you know, I'm thinking about suicide or disclosing suicidal ideation, and oftentimes we would then jump to, or like the initial kind of trainees are like, oh, we got to get them to the hospital, they're thinking about suicide. And that to me is trying to go from like distress awareness, so a one to like a five, like, let's solve this problem of suicide. And so to me, that's jumping too far. And so the research has supported that if a client is at a certain stage, what's actually more helpful is to work with them at that stage, or just above like, how can we help them draw connections to themselves when they're aware of their distress, so that distress connection. And that's where we can actually really help them bring along. Whereas if you go too far away from that person, it doesn't make sense to them. And we also haven't actually taken the time ourselves to be like, what is their connection? Why is it important to them? Because that's where I think we can actually help tailor that insight. So if we don't even know why they're in distress, or like, what's what that experience is like for them, then I don't think we can allow them to bring that clarity. And I think we start maybe creating plans that aren't in alignment with that client. And so I think that's where it's really important. And vice versa. So we've had the opportunity to look through conversations that maybe didn't go as well. And we've seen somebody who's maybe on their own done more of that distress awareness. They're aware of their distress. They're starting to almost look at what's wise as important to me. And so they're looking over at stage for us for. And we're over here really just basic active listening skills that aren't necessarily tailored to them. The helper, the helper, yeah. Yeah. The helper, the helper's like the clients pretty far along. And the helper is still focusing on like, oh, you know, more focused. And focusing on like, what do you feel? How is that? Yes. And if the clients already made sense of that, that can actually feel very frustrating for the client because they want to help that help to move forward. And so I think the state, like our model is really helpful for clinicians to actually think about like, where is this client along this processing model, like along making sense? And therefore, how can I kind of align myself with that client to continue helping them through? Right. Yeah. And I think you to summarize some of that because I think it's particularly important because I think that this is where I guess a couple of things are happening. I think one is a lot of the training for working with folks in suicidal crisis gets in the way. And I think also our own, you know, fear or worry when we're working with clients in suicidal crisis can also get in the way. Which is that it's like, oh my god, this person's suicidal. What do I do? What do they do? Yes. So we want to push and get to, okay, what are you going to do? You know, how can we, what are you going to, how can you, and we saw this, you know, a bunch of times where helpers were jumping to, so, you know, now what? But if we think about, it's just like any problem that we have, before we can decide what we're going to do to deal with the problem, resolve the problem, move forward with the problem, whatever. And understand the problem, right? So I know this is not going well, but until I understand why it's not going well, why do I care? You know, we can't get to, so this is what we do next, right? So we have to help the client actually understand what's happening. Why does it matter to me? You know, why is it so frustrated? Like why is it, why does it hurt me so bad when my boss demeans me in that way? Right? Like if I have a better sense of that, then I can start to figure out, okay, so what can I do about it? So, and then Johanna gave the example also of when, you know, we would see folks sort of on the opposite end of the spectrum, which is that the clients move in along. They're making progress. They're, they have a sense now of how I feel. They have a sense of what caused me to feel this way, and they want to keep going, but the helper is still there focused on how they feel. It's like, no, no, they got it. They're good. So sort of this, this idea, this sequential nature is like that it becomes a, you know, one of the tasks of the therapist to attend to where is my client and to meet them where they are to help pull them, push them, create a bridge for them to move to the next step or the next stage in the process. Yeah, exactly. Yeah. Okay, so what, when you think about the practical implications of this, so that's one of them right there, then in some ways, maybe that's one of the same, that one of the major ones, but what are your, do you have any other thoughts about practical implications? I think like, yeah, transparently that's like the biggest one to me is like to be able to help, to help helpers think about where that client is and then being able to meet them where they're at. I think that's really important. I think there can almost be an assistance too for even like, if this was to ever be kind of made more aware for clients, just because we just spoke about it like clients can, some people do this without even, again, maybe being conscious, this is the steps that they're going through, but even helping clients be able to be like, this is where I'm at. Like I, I think that can also actually be facilitative as well. This is actually like, giving clients like some language and understanding of like, I don't even know why this is important to me. It's like, okay, great, that's where we can maybe provide that support as well. So I think, I think it's kind of helpful on both, and then I mean, this is maybe implied, but I think this is also very helpful for trainers to be able to actually kind of help back up the therapist of like, where do we think we, where the client is and where do we think we're putting our focus on right now? And I think that can actually be used to help bring a little bit more reflectivity to what the, where the, the helper is, is and also helping the trainer actually have a language for helping that, helping that helper be aware where they're at. Yeah, I, you know, just this is sort of extending what you're saying is that like, so much of what we're trained to do with folks who are acutely suicidal is really not about helping, helping them, yeah, work through their experience. It's more of like, so now what do I do? Right? Like, like, you know, I need to assess them and for you, but it's just, I always find that this, this crazy thing, because therapists in general, professional helpers in general, are so good at helping people, you know, work through whatever it is that they're going through. And that, you know, this sort of processing framework, you know, pretty much doesn't matter what your theoretical orientation or approach is that this is common throughout all of them. And that, you know, with the distress processing model, we don't, you know, we, we tried to make it sort of trans theoretical with the idea, at least my thinking is that, you know, folks should be able to take their skills and ability and knowledge and experience from their particular approach and bring it into this context. And that, that, of working with suicidal, with, with clients and suicidal crisis, because they just are so skilled and so that they can work with clients and suicidal crisis using the skills that they have to help them work through that crisis, hopefully, rather than sort of like abandoning all of that and doing all sorts of other different stuff with their clients and suicidal crisis. Yeah, exactly. And I think that's, that's been actually something that's been enjoyable of like going to different conferences and even just talking about this is that hearing like somebody who's more from an EF, like emotion-focused therapy approach could be like, oh, I could see how, like, I could bring in emotions to that at this stage. And it's like, yeah, of course, it's the client. And then even just talking to them about like almost taking the suicide part away from, from this is like, they can see how like, if the client doesn't know what emotions they are actually feeling, they just know that this is bad. I hate this. Then the like, the therapist almost understands where to take this. And so I think if anything, it could also help people be almost more aware that they have a lot of these skills already and it's just that we can take, it doesn't just because somebody's in a suicidal crisis doesn't mean that we have to focus just on that suicide. I think we start, we stop necessarily like thinking about all of the, all the training we have to actually help that person make sense of the crisis. So same thing with like, I think we even talked about this a little bit in the paper is like, if somebody presents with depression, we don't just focus on like, well, let's make sure that the depression doesn't happen. We'd actually talk about like, what's leading up to that depression. And I think it's in the same vein around suicidality. And if we over focus on the suicide, I think one, we, the gate being able to actually help that client to the lead up to there. And I think sometimes I think it can be disconnecting based on conversations we've seen with the client if we're just focusing on like, how to make sure that they don't do that as opposed to actually helping them with their experience. Yeah, yeah, I think that's, yeah, I think that the, you know, the sort of this, you know, the saying of like, you know, the clients suicidal because they're in pain, they're not in pain because they're suicidal. Right. So this sort of like a lot of times the helper, as a helper, we're focusing on them being suicidal and not focusing on the pain that they're in. That's where it becomes therapist focused rather than client focused, right? Because I care about the suicide part because it freaks me out and I worry about it. And you know, some of it is, you know, some of it is more serving me in my own anxiety, but some of it is altruistic, which is, you know, I just don't want this person to die, which is, you know, it's great to have that intuition. But then we, but that's more our priority and not as much their priority, which is their priority is to stop feeling this pain, stop feeling this distress. Yeah. So since safety plans are more or less ubiquitous nowadays in the working with clients and suicidal crisis or suicidal clients, what are your thoughts about this model in the context of safety plans? I think, so I, we talked about it a little bit before is I think safety plans can potentially sound quite checklusty and like, you know, who are you going to talk to? Like, what are the things you can do before you get into a crisis? What can you do after the crisis? What are self-care? Who do you talk to you? And I think that can come off as, I guess, less tailored to the client. But I think where our model actually fits in is, I think if we actually get to really understand this client's distress, like what, what they're actually experiencing, what emotions are coming up, what thoughts are coming up, etc. Like what's most pressing for them within their distress? Then I think the safety plan can come in in a more like nuanced and tailored way. So like, maybe, maybe this person that, like, needing to talk to somebody isn't actually part of their, they're safety plans. What's we've gotten to know them? So like, I think maybe pressing that we need to get every single one of those boxes filled out. I don't know if that's necessary. If that's necessary. I think that's where our having all of this conversation, I think, then going into the safety plan within our model is that allows us to actually pick and choose what would be most helpful for the client and having more of a conversation of like, how do you see this part playing in and like making sure that it's still tied to their actual distress? I think that's where it can be helpful. I think where it can be maybe unhelpful within the safety plan is if we're just focused on the suicidal behaviors. So like to me, if we would actually even have a safety plan of like, you know, these are, you're having this thought that you aren't loved right now. Who out there actually maybe challenges that or like being able to actually focus more on the problem or the distress of the thoughts as opposed to like, oh, you're thinking about killing yourself. Now we have to engage in the safety plan. I think that's where it feels more reactive as opposed to actually embedded in this client's presenting like distress. So like that this creates sort of thinking about the distress more broadly rather than just the desire to die or the plan for that that that could provide some really rich context. That could be integrated into a safety plan that could be more personally meaningful or that could be personally meaningful for a client and could be more beneficial for them or yes within the context of their safety plan. Yes, because I think that's where it's like if we can actually make those safety plans aligned and tailored to the distress because that's what's actually coming up as opposed to like, oh, the binary of now that you're thinking about suicide. Now we need to use it. I almost think there's ways to actually engage it in a more meaningful way, either before of course during, but like I think that would also allow the client to like more fully own that safety plan because if we're just doing it in service of the suicide, I don't know how necessarily utilize that client will actually engage in this safety plan. Yeah. It's interesting, you know, when you read about the folks who are really sort of developed the whole safety plan idea, they really do, I feel like, do a really nice job of talking about how this should be a process that you do with a client and how it is very like a client focused or client centered in how you do it and work with the client and it should be based on the client's motivations and how to do those sorts of things. And, you know, I think that in the context of suicide intervention stuff that that does get lost or not, no, that's not fair. That sometimes, and I would say more often than in a lot of other contexts, that that client centered, and I'm using that sort of as a, you know, not necessarily the proper noun of client centered, but that that sort of client centered approach does get lost. And like I've seen it in other stuff to other really great suicide intervention stuff where you look at the folks who developed it and it's like, wow, they are really attending to how can this be client focused and really, you know, be collaborative. But then you take a training and it's like, oh, this is just another checklist. This is just another to-do list. And it's like somehow that to me, what I read the original developers, what they intended versus what happens in practice, there's this discrepancy. Yes. And I think that one, that can come from like what we talked about the distress of the helper of this person's at this kind of level of suicidality. I really, I'm concerned is I think there's a certain, there's a certain safety in a safety plan where you're just filling it out and that's your task. And I think that can feel maybe productive for the therapists are safe because it's like, here's that checklist when I'm quite stressed out. But then I think that turns into then how, what's the meaning for the client and has that actually been articulated in a way where the client actually feels that that's going to be beneficial? Because you're right, like reading some of the more of the intention behind the safety plan, I think there's a lot of room for it to be more nuanced or even like getting to know the client. Like, it, I think some of them will be like name three social supports, but I think if you even bring that to talk to that more to the client about like what is supportive, I think you could tailor those two as opposed to needing it to be this exact checklist. I think we, we abandoned thoughts about like worse, I think helpers and counselors, et cetera, can be really great at getting to know the nuance of a client, but that's where sometimes I think the safety plan gets lost is like we can adapt that to be nuanced to the client's distress. Totally. Okay, so we've covered a lot. Is there anything that we haven't hit that you want to make sure we hit? I don't think so. I just, yeah, I think the biggest thing for me is like to me the big point is like being able to actually sit with the client and like explore the distress itself as opposed to just focusing on suicide. Like if that could be by like take home message, I think that would be the biggest piece. To sit with the client with the distress and to work with the client's distress rather than just rather than solely or primarily focusing on their suicidal thoughts. Exactly. Yeah. Great. Okay. Well, Johanna Mikkelson, thank you so much. Thanks for having me. Thanks a wrap on our conversation about distress processing with clients and suicidal crisis. As I noted at the top of the show, it would be much appreciated if you could spread the word to anyone else that you think might enjoy listening. Until next time.[Music]