Psychotherapy and Applied Psychology

Clinical Training, Supervision, and the Limits of Suicide Risk Prediction: Listener Feedback

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[Music] Hello and welcome to our second feedback episode of Psychotherapy and Applied Psychology, where I respond to comments, questions, corrections, and reflections from listeners and viewers of the podcast. In this episode I'm going to be responding to comments on a pretty wide range of topics, things like sadism, graduate school, maybe they're kind of similar there, teletherapy, clinical supervision, religion in psychotherapy, therapy with trans clients, and suicide. So you know, the typical kind of light fairer. And as usual, for any episodes that I mentioned, I'll include links in the show description. Also, I want to say that if you've left a comment, sent a question, challenge something I said or shared the podcast with someone, thank you. And to everyone who sent in feedback that I'm not getting to in this episode, thank you. I read and appreciate all of it, and even if I don't respond to yours here, it's helping shape how I think about the show going forward. So please keep the comments and questions coming. You can leave them on YouTube, send them through the podcast website, or reach out however you usually do. And a quick programming note, I'm headed off to Japan for a couple of weeks, so I'm not totally sure yet, but there are a couple of weeks without an episode. That's why. So I apologize in advance. And as usual, I'm your host, Dr. Dan Cox, Professor of Counseling Psychology at the University of British Columbia, and this is psychotherapy and applied psychology. So let's get to the first comment. I'm going to start with a quick correction to my previous feedback episode at Helios Play Games pointed out that I said hierarchical taxonomy of psychotherapy, which is not what high top stands for, it's the hierarchical taxonomy of psychopathology. I don't know how I missed that, I'll do because they're very similar sounding words. So I apologize and Helios, thank you for pointing that out. As usual, I got several comments about graduate school related stuff at JRC Sure, responded to the episode where we talked about tips for improving your counseling or clinical psychology grad school application. They said, I was lucky to get into a school that had less reliance on GRE scores and other BS admission processes. After graduating with a master and post-pass degree, I don't know exactly what that is, but you get the idea, more graduate school type degree. I took the understanding that most of what occurred in grad school was so much posturing and BS from faculty. I'm going to respond to the first part where he talks about, or they talk about, less reliance on GRE scores and other BS admission process stuff. This is something that we constantly struggle with, which is, how do you tell at the admissions level if someone's going to be a good therapist? But then it's further challenging because we're looking for good therapists, we're also looking for good students, and then depending on the program, we're also looking for good researchers. So we are trying to serve all three of those masters, which is a near impossibility. And then for many graduate programs, you also have the challenge of the number of applicants. So we have several hundred applicants a year. So there has to be a certain amount of consideration of how long it's going to take, or just the practical consideration of how long it takes to look at these applications, because it's just so much probably the best regarded tool for predicting who's going to be an effective therapist and who isn't, is based on Amanda Sins work on, and Phil's Cilitative Interpersonal Skills or FIS, which is where you have people watch simulated clients and then respond to those clients. And that's those responses are recorded. And then those therapist responses, if you will, are coded based on these Facilitative Interpersonal Skills. These are things like empathy and stuff like that. And that these have been found to longitudinally predict successful or effective therapists. So this is something that we've been working on and considering bringing into our admissions process. But for many reasons, practical reasons in terms of, so do you get all of the 300 applicants, 400 applicants to go online and go through this process? Do we evaluate? I mean, it would take hundreds of hours, maybe more, maybe thousands of hours to actually evaluate all of those recordings and then code them for the Facilitative Interpersonal Skills. So we're kind of trying to figure out kind of an in-between ground for doing this, but it's very difficult. And there's a literature on what predicts successful graduate students, but that's not really a literature based on clinical graduate students. You know, there are other types of programs and what it takes to be successful. Clinically is obviously not the same thing that it takes to be a successful graduate student in mathematics or something like that. So I really appreciate the comment and I know that I felt the same way when I, I mean, I still feel the same way with this person as saying. And when you're actually on this side of it, it's just so difficult to actually figure out how can we do this in a way that helps us identify good therapists and is also a reasonable task for the graduate program to take on. So continued work, I think lots of other programs are dealing with this challenge as well, because we do ultimately have the same goal at the end. Van Jelene, who sent me an email said, "Dear Dr. Cox, I just want to say thank you for doing psychotherapy and a flight psychology podcast. I look forward to it every week. I have a question or topic that I be interested in for future episodes. Is how does research as a counseling psychologist differ from a clinical psychologist in terms of topics and methods?" Oh man, this is a great and very complicated question that's being asked. So the boring answer is that there's a lot of overlap between the two. And clinical psychology tends to be more focused on psychopathology, diagnostic assessment, severe clinical problems, treatment or intervention research, but yeah, even that. I say treatment or intervention research for more severe problems, health service systems, counseling psychology tends to be more focused on multiculturalism and diversity, identity, social justice, supervision, developmental and contextual approaches, vocational and career development. But these are all just generalities that what I encourage folks to do is actually look at specific programs and the specific faculty in those programs that they want to work with to help them figure out where they want to go and sort of have that be your guide. So for example, when I went up for a promotion to associate professor and then to full professor, one of the things that the dean's office does is they basically take all your publications and like get all sorts of metrics on them, but then also organize them and sort of put them into these categories. And so for me personally, mine were more likely or more of mine or in the classified as more clinical psychology kind of area than counseling psychology. So even though I'm in counseling psychology, my research tends to look more clinical on average. So this is where I think don't get overly hung up on the categories to really focus in on the specific type of training that you're going to get at this in this particular program or with this particular supervisor. What I was thinking about this question, I was thinking, you know, I have a colleague of mine, Rob Betty in my program who does a lot of work on like looking at the different areas of psychology, specifically in a Canadian context. So I think maybe I should have him and maybe somebody who's an expert on this stuff in the US context on talk about this because this is something that comes up over and over again and I totally understand why and I think it's worth digging into a little bit more. So next we have a very nice audio message that somebody left. Hi there, I really really love your podcast. I'd love to hear more in one of your episodes. I think one of your interviews mentioned this at one point that getting the best clinical supervision you can as early as you can is really key in your practice and I'm in my first year in grappling with that right now and finding it a bit of a challenge. How do I know who is the best? Do you know what I mean? Like my course leaders that I like a lot of them, but most of them wouldn't be supervisors. Yeah, so I guess it's figuring that bit out the how I would love to hear. Thanks again, thanks so much for your podcast. So thank you first for leaving a message. Anybody who wants to please feel free links are in the show notes on the website so you can do that if you would like. It's really great to hear a human voice of somebody who's listening. So this was in response to my episode with Rod Goodyear about clinical supervision where I learned a lot in that conversation. But this is specific to somebody who's in a graduate program. So a few thoughts. Obviously this is going to depend a lot on how your graduate program is set up. You know how much choice you have. The reality is probably you only have so much control. So don't you know be realistic about what is possible for you to actually influence and don't feel like, oh, I need to be able to do this, but really it's not flexible in those sorts of ways. Your program isn't that is. So a couple things that I suggest to folks, if you do have some control, some choice about where you're going to work or who your supervisor is going to be when you're in your program is to talk to for a year or two ahead of you because then you can talk to them to get a sense of what their experiences were like with different clinical supervisors. I think that's probably the best thing that you can do because that's how you're going to find out what their supervision style is like and what the value is. Now one of the things I often tell students is what's been more important than getting a really good supervisor is not having a really bad supervisor. So this again is the value in talking to folks, talking to fellow students, graduates who are year to ahead of you. And then when they say that they just had a terrible experience, make sure to write that down and just avoid that like the like. I think that that's more important than finding the optimal one. But otherwise it's talking people ahead of you. I mean, how is you going to find out and the people who are in your shoes, the ones who are students rather than faculty, although you can talk to faculty as well, of course, but a lot of what they're going to say is also going to be based on what they hear from students. So talking to students is the best way to do it often. I do want to make a real quick comment. And I think we talked I talked about this with Rod, but I'm not 100% sure if you're in a bad supervisor re-relationship, if you're in a situation where after a couple sessions with your supervisor, it's like, this is just not great. Talk to one of your faculty members, whoever would be most appropriate. Maybe it's your academic supervisor. Maybe it's the person leading your practicum class. Maybe you have a practicum coordinator or director. Well, whatever it happens to be, just talk to somebody about it. And even if you're like, well, this is just just be in contact with them about your experience. There certainly is the chance they're just going to say, yeah, you know, in this situation, hear some thoughts about how you might be able to make it a little bit better. Otherwise, this isn't terrible or anything. You kind of just have to suck it up. You can do that. But just start having those conversations because this is the first time you've done this. So how can you know what's normal or what's not normal? What's just like mediocre supervision? What is problematic supervision? Like, it's difficult to figure that out. So bring someone in to talk to about it is super important. So I very much encourage you to do that if you're in some sort of a, you know, not great supervisory experience. At Aristopause2672 said, and this was in response to my conversation with Katie, Ashess Van Dorn on his teletherapy effective. As person said, many clinicians and clients loud the convenience of online therapy, which may be especially important for those clients who are disabled, have a Gorphobia, live in rural areas, where skilled therapists are less available. However, there's a very real gap in the sense of emotional connectedness that exists. Definitely feel that in-person work would be far more optimal. Honestly, don't like doing therapy with a hologram. Like, it's very funny. What's next? An AI avatar? We're probably not too far from it. So I think this is a great comment. And, you know, my conversation with Katie with their research, it was sort of a, it seems like teletherapy is more or less as effective as in-person therapy. I think she did a nice job of articulating here the strengths of it, and for whom it might be more helpful, and here the downsides of it, and for whom it might be less helpful. So I think that she took a pretty even perspective on it, maybe more on the, I don't know if it's a pro-con. That doesn't seem like quite the right way to organize thinking about teletherapy. But I do think that this commenter has some really good points, and there is some research on that just the experience of being in person with a real human being is just substantially different. That there are other physiological, cognitive, emotional experiences that don't happen when you're talking to somebody remotely, or at least not to that extent. I tend to think of teletherapy is like, yeah, this is a useful tool because in some situations it's either the only possible way forward. It's a foot in the door. It's a, I just can't get to the session this week because it takes me 45 minutes to compute there, 45 minutes to get me back. I have this, but, but, but I could do it if I can just go in my office, close the door and have the therapy session, or find the corner of a library and put my headphones on and pull up my phone and have the session. And I think that that's great. But I do agree with the commenter, and there is data to support that like it is a qualitatively different experience, and that's certainly something that we shouldn't lose sight of. F2F. On my last feedback episode, they said, do you think a therapist must be empathic? I think we should begin there. You can throw the DSM at anyone, but empathy should be a requirement for a therapist. I find this is lacking in a lot of therapists. They're so lost in technical jargon and classification systems. They aren't able to see their clients as human beings. Many thoughts, many thoughts in response to this. Ferry, I guess what are we calling you ferries? That is at the appropriate way to respond to your handle or to address the handle. That, that, that ferry is very much on to something in that empathy empirically has the strongest and most robust link with client improvement relative to pretty much all of the process variables. So hands down empathy is super important. I think the one of the really interesting questions is how do we teach empathy? And a while ago, I tried to have somebody on the podcast who did some experimental work on this, and actually was able to turn up the volume on folks empathy. I always thought that this was super interesting in something that we don't directly address in as far as I know. I've never heard of a clinical training program that addresses this explicitly. How do we turn up the volume on empathy? We certainly focus on skills, but that's not the same thing and techniques and interventions, but that's not the same thing as empathy. So even though empathy is very well studied in a lot of regards, how we integrated into training programs explicitly to address it and try to increase it isn't really addressed in our training programs. So maybe this is good motivation for me to get back on the horse in terms of seeing if I can find somebody who can come in and talk about that. So thank you for here for the comment. At Zach Smith, on my conversation with PIM Kipers, love this interview. That's love with one, two, three, four O's. That's a lot of love. Dan also love that you included the effect sizes that were being referred to. I want to give a shout out so you know that it made a difference. Thanks. So what Zach is, I said Smith, maybe it's my SMYTH. I'm not sure. What Zach's referencing here is in that conversation, we were talking about, what was it that we were talking about? The effect sizes for something. Oh, it was on Mike Constantino's work on the effect sizes of matching therapists with clients who have the types of problems. That historically, those therapists have been good or effective at working with. After I recorded the conversation with Dr. Kipers, I went and looked up the exact effect size and sort of jumped back in with little audio note at that point in the conversation to explicitly say what the effect sizes were. So thank you, Zach, for pointing out that out. That little edit ends up being about an hour of work. So I appreciate that the shout out and the appreciation for it and sort of motivates me to do stuff like that again in the future. Then another nice thing that was said, Kerwin Wilson at Kerwin Wilson in my conversation about religion and psychotherapy with Dr. Stephen Lars Neilsen said, I'm a new subscriber. Thank you for touching on this topic. It was very informative. Why you're welcome, Kerwin. It's my pleasure. I do think that the religion thing is something that's kind of underrepresented in terms of our research and our training and our thinking in psychotherapy. Then another comment on that same episode from@heliosplaygames said, I think religious trauma and its effects should be acknowledged in videos talking about faith and psychotherapy. So what I'm taking from this comment is that what Helios, again, I guess is how you address folks is just by the first part of their handle. What Helios is saying is that if you're going to talk about religion in these contexts, then we should also talk about religious trauma in these conversations. Now I think it's a reasonable point. A couple thoughts. One, I do have this sort of reaction to the word traumatic reaction to the word trauma. I think it's that term has lost its effectiveness in terms of clearly indicating the qualitative experience of what that is. It's like what the threshold is. It's something needs to pass for it to be called traumatic. So I'm always hesitant just to use that word because it has different meanings to different people. Then so therefore its utility becomes lessened. I think it just adds to confusion. And reflecting on that episode, we were more focused on working with religious clients where their primary problem or challenge or the reason that they're in therapy is not necessarily religiously based. It's almost like the religious aspect while primary in their lives is a background to their human experience, not at the foreground of the problem or challenges why they came to therapy. And I think what the religious trauma idea is kind of an inverse of that that a certain part or certain experiences within the religious context are where the problems are coming from. And I think that that actually hadn't really thought about that too much in terms of having somebody on to talk about that. I've certainly worked with clients where that's been the case, but it's an interesting point, Delios, and is something that I'm going to see if I can find somebody to come on and talk about because I think it's pretty interesting. Thank you for the comment. So another comment about my episode with Dr. Stephanie Budge on therapy with trans clients at Floral Starks wrote, "As someone currently in therapy for this, I appreciate the care you have for it. My therapist has never messed it up, but mistakes can happen. The biggest thing for me is that it's not treated as a big scary thing never to be mentioned." Boy, what a great comment. So I love this. And I think that what this commenter is hitting on is an important thing. And I noticed this particularly for early career therapists, or I think that early career therapists when thinking about working with any sort of minoritized client, that my experience of it is that 40% of their attention is an arbitrary number, but something. Some substantial amount of their attention is focused on not saying the wrong thing. I think that, consistent with what this commenter is saying, I think that instead 99% of their attention should be on being a good therapist. And 1% of their attention should be on not saying the wrong thing. First of all, if they're focused on being a good therapist, they most likely won't say the wrong thing. But if they're focused on being a good therapist and are a good therapist, then if they do make some sort of a gap, then they'd be able to recognize their error because they're a good therapist. They can pick up on their responses from their client, or because their client feels comfortable, they'll be able to point it out. And they'll be able to be humble and engage in a conversation, potentially apologize, but use it as a therapeutic opportunity, rather than some major gap that's screwed up everything. I also get into this in my conversation with Dr. Jesse Owen about the multicultural orientation framework, which I'll also link that below. So to add this feedback episode, we have a couple of comments in response to my episode with Matthew large on why suicide risk assessment is in helpful. At Claire Schmotzer, 9164 wrote very interesting research, depending on how it plays out, I wonder how it will trickle down to crisis lines and public outreach like mental health first aid. And then at platypus 2062 wrote, the fact that this is a news flash shows that most doctors are clueless. Suicide alities because people are in pain and they want to get out of it. So for those of you who've been long time listeners, you know that I do some research on this stuff, and I basically don't think that we should be doing suicide risk assessment. And by that, I mean pulling out forms and having people answer these sorts of questions, and then using that those forms as a predictive tool to predict how likely a person is to die by suicide or attempt suicide. And a couple of thoughts. So the question about trickle down. So as the effect of research demonstrating, which there is much demonstrating that risk assessment isn't useful for prediction, the trickle down effect of that research. The first research that was done that demonstrated this, I believe was done in the 60s. And it was really just based on the mathematics of prediction and suicide that if you look at the number of people who die by suicide, prediction in this area is clinically useless. And this has been out since the 60s. There have been task forces of experts, of suicide experts who have made these arguments that we should not be doing this. There's this great paper, a British, British group, NICE, nice, the national, something center for excellence. They did this report. I'm going to say I would be off on the years, but something like the first one they did was in 2012 or something like that. They had a bunch of suicide researchers who got together and then wrote this report to basically say, hey, Brits, stop doing risk assessment in these ways for these aims of prediction because it's clinically useless. And then a few years later, somebody wrote a paper and said, hey, this report came out telling clinicians to stop doing this and nobody stopped doing it. Basically, that's ineffective. And I think that's very much what my experience has been as well. That the trickle-down is very, very limited. It's like arguing against doing risk assessment, risk prediction, hospitalization in the ways that we often do it, that this sort of research and these arguments are like a bucket of water in the ocean, that there is an ocean full of folks talking about suicide risk assessment and trying to come with new predictors and better predictors for risk assessment and new tools for doing it and selling new tools and new trainings. And even though there's a lot of research arguing against risk assessment, it just can't keep up with the volume. And also to get to the point that platypus here made that most doctors are clueless, basically prioritizing risk assessment and these sorts of things, overattending to client's pain, I think that these physicians, psychologists, social workers, whomever, nurses, whatever the profession happens to be, was just in the water in all of these training programs that it just drowns out those other types of thoughts and feelings to not prioritize risk assessment and instead to prioritize the client in their experience. The only reason that I've really become familiar with this research and I push back against risk assessment is kind of coincidental that my graduate program was just like all the others that really prioritize this stuff and focus, you know, and say that we should be doing this. And so you kind of get brought up in that and that just becomes reality. So I think that making that sort of a sea change while it's certainly something that I would like to see us do, I don't know if it's realistic to expect that that's going to happen, that it's going to trick to trickle down in substantial ways. I hope that it does. I really, really hope that it does. I think that it will help to save people's lives if it does, but I'm not sure if it will. So, you know, that's one of my career goals is one of my career callings, if you will, is to stand up on that soap box and make those arguments to folks to try to influence thinking, to try to increase that possibility of trickle down. But, you know, we'll see, fingers crossed. So that is the end of our second feedback episode. Please follow up with me. Let me know how it was. Let me know if you want me to do it in different sorts of ways and just generally send your feedback. It makes my day to hear from you. So thank you so much my friends and I will see you all in the next episode. That's a wrap on our conversation. As I noted at the top of the show, it'd be much appreciated if you spread the word to anyone else who you think might enjoy it. Until next time.[Music]

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Dr. Dan Cox

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