Motivational Interviewing (MI) is a widely used evidence-based technique to encourage behaviour change. According to clinical psychologists William R. Miller and Stephen Rollnick, “MI is a collaborative, goal-oriented style of communication with particular attention to the language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion.” In the clinical setting, it has been proven effective in tackling certain issues such as smoking, substance abuse, or other compulsive behaviour disorders including problem gambling, hypersexuality, or compulsive spending. In a way, MI serves as a decision aid and to guide clients towards making the necessary lifestyle changes. It assists clients in weighing the pros and cons of their respective situations, and encourages them to assess the benefits they can reap if they were to change their behaviour.
MI works best for individuals who fall within any one of these categories below. Of course, this is not to suggest that MI doesn’t work for conversations and discussions outside of these categories.
High ambivalence: These people are still experiencing mixed feelings about their situation. They sit on the fence, contemplating if they should make any changes.
Low confidence: These individuals are doubtful of their abilities to make the necessary lifestyle changes in order to overcome difficulties.
Low desire: These people are uncertain as to whether they really want to make a change.
Low importance: The line between the costs of the current situation and benefits of change is blurred, leaving the situation unclear.
In general, there are 4 fundamental processes to MI:
As with all other therapeutic methods, establishing a solid and productive therapist-client relationship is extremely important. This involves asking open-ended questions, affirming clients’ strengths, reflecting to clients what they may wish to express but have not yet spoken aloud and summarizing what has occurred in the therapeutic interaction. Having respect for the client’s autonomy is also a key aspect.
At the beginning, not all clients will have a clear goal in mind, and may lack direction and insight. This process gives the interviewer and the client the opportunity to narrow down on a shared goal or purpose that they can work towards. With that, the clinician is better able to steer the client into a directional conversation about change.
Essentially, the interviewer needs to be able to pick up on hints or cues which may suggest the client’s willingness to change. Oftentimes, clients may express their desire to change and their fear of the potential consequences if they do not. Interviewers will then employ more open-ended questions to guide the client, giving him a chance to elaborate on his attitudes, thoughts and motivations. Normalising ambivalence and ensuring that sensitive information is explored without judgement is also important.
Planning should come from the clients themselves based on their insights, self-knowledge, values and motivation. Typically, interviewers do not attempt to take full control and to force a commitment plan onto the client. Doing so will not only disempower the client, but also strips the client of his autonomy. However, they can step in when clients are stuck or unsure as to what they can do to make the necessary changes, as long as their advice is wanted.
In a MI, a decisional matrix is often used. This involves an open discussion of the situation at hand, allowing the client to assess the costs and benefits involved. What are the benefits of staying the same, versus the benefits that come with change? What costs are involved if they chose to stay where they are, than if they made changes? MI isn’t about having psychologists force their views on the client and having them follow their orders. By having an open discussion in a safe, non-judgemental space, clients are able to reflect on their behaviour and come to a decision based on a “fair” hearing. By getting clients to think about the costs of staying the same, this also allows for greater cognitive dissonance, making changes more likely.
Another common aspect of MI involves the Columbo approach, which can be characterised as deploying discrepancies. This technique was inspired by 1970s television series Columbo, in which TV detective Columbo would apply it to rationalise discrepancies and to seek additional supporting information. When contradictory information surfaces, the interviewer will then present a question in a way that makes the client reflect on their mindset. For example, a question could be phrased as, “How does your (risky behaviour) fit in with your goals?”
Motivational interviewing is sometimes used on its own or may be combined with other treatment approaches. In short, MI is a method of communication rather than an intervention, and it serves to help you attain greater confidence in self-improvement and to make crucial behavioural changes for the better. MI doesn’t force you to commit to a plan, nor involve scare tactics to pressure you into making decisions that you feel uncomfortable with. It does, however, motivate you and aims to help you achieve greater clarity on the importance of making a change. If you or a loved one needs to seek professional mental health support, do reach out to our team!
Caregivers with a family member affected by addiction problems are often exhausted, drained dry of their empathy and compassionate capacities.
They recount countless cycles of suspended hope followed by just as many broken promises as they watch the affected person return time and again to their compulsive addiction despite a seemingly obvious trail of destruction behind them.
Caregivers learn to cope with the endless demands on their energies by blending the words uttered by the affected persons as a cocktail of lies, manipulation and attention-seeking antics to get what they want.In time, the cries for help from the affected person turn into cries for help by the boy who cried wolf and eventually fading into indistinguishable white noise.
Professor Lisa Firestone of the Glendon Association observes that there is a natural tendency for caregivers to minimise any suicide expressions in general.Responses such as, “Well, his past attempts weren’t serious.” or “He is just manipulating to get something.” are commonly observed.There is also a general tendency to not want the expressions to be true.In the case of addicts, words such as “I want to die” or “I am going to end my life” no longer convey the same meaning or gravity of their sense of desperation.
Why should we want to pay attention to an addict’s cry for help?
In Singapore, we lose 1.1 lives every day to suicide.It is still the leading cause of death for youths aged 10 to 29.While direct correlation evidence is still being researched on, studies in America have shown that more than 90% of people who kill themselves suffer from depression have a substance abuse disorder or both. Suicidality and addiction share a high concordance relationship.
When we overlay the statistics with a physiological lens, we note that both groups of persons have been observed in studies to have a dysfunctional hypothalamic-pituitary-adrenal (HPA) axis which essentially controls our body’s response to stress.
In a person with a normal functioning HPA axis, on the reception of a stressor, the hypothalamus in our brain instructs the secretion of the corticotropin-releasing factor (CRF) and vasopressin to stimulate our pituitary glands to produce the adrenocorticotropic hormone (ACTH).The ACTH, in turn, stimulates glucocorticoid synthesis and release (commonly referred to as cortisol) from the adrenal glands.This chain reaction provides a person the increased energy to handle the stress event and to do so without suffering from the pain and fatigue.When the stress event is gone, the body produces a negative feedback loop which then brings the body system back to homeostasis.
In a person exposed to a persistent or extreme level of stress, or in a person who frequently activates the HPA axis through substance use, the body starts to blunt the sensitivity of the HPA axis and blunt cell receptivity to cortisol in its efforts to return to and maintain homeostasis.This alteration to the sensitivity of the HPA axis affects our ability to tolerate physical and mental stresses and creates a need for a much bigger stimulus to activate the HPA axis (which may mean higher dosage of substance use); and when the HPA axis does react, produces a much bigger and exaggerated response (which may translate to more aggressive behaviours).
What Does This Mean In Practical Terms?
Many suicidal persons described having a voice in their head which is constantly there; telling them how much they need to seek fulfilment and comfort by reaching for the desired stimulus, whether it be a substance or a behaviour, of which one is killing themselves.Their mind starts to command them to constantly plan, to seek out and to take actions to soothe the unbearable lack that they are feeling.Eventually, the voice in the head goes from coaxing and persuading to being more intensive and aggressive towards the self to take immediate drastic actions.
The relief of death, a final refuge, becomes alluring and pleasurable and the fear of dying eventually transforms into the fear of not dying and becoming the loser, disappointment, and burden that they already believe themselves to be to their caregivers.This dual push towards drastic action and the need for an ever-increasing amount of substance in addicts leads to an increase in the risk level of suicidality.
What Can We Look Out For?
How then does the caregiver separate the wheat from the chaff amid the chaos that addiction has already wrought onto the family system to detect the risks of suicidality?
Below are some, though not exclusive, common markers to look out for. It is particularly useful to note changes in the content of the affected person’s expressions and any escalation or sudden extinction of intensity.
Intense Emotional Outbursts
Extreme Isolation or Withdrawal
The feeling of Being a Misfit in Every Way
Researching or Procuring Means of Suicide.
Self-Harm, Including Risky Substance Use or Behaviours.
Planning of Affairs.
Presence of Trigger Events
Loss of Primary Relationship.
Physical or Mental Health Conditions That Debilitate.
Abuse or Trauma Events.
What Can Caregivers Do On Observing The Signs?
Ask the Suicide Questions:
In the past few weeks, have you ever wished that you were dead?
In the past few weeks, have you felt that you or your family would be better off if you were dead?
In the past week, have you made plans about killing yourself?
Have you tried to kill yourself?
If the answers are yes to any or to all the questions, caregivers are encouraged to take the following first steps:
Be empathetic towards the suicidal wish.
The objective is not to agree with the act of suicide but to understand what has happened to lead the affected person to the conclusion that suicide is the only solution.
Find a genuine connection with the affected person.
However difficult that person might have been in your life, express what this person means to you personally and how the loss of this person would affect you.
Make a safety plan.
Ask the affected person to agree to not take or delay any action to harm themselves until they get to or you get them to professional help.
Professor Lisa Firestone observes that suicidal persons are generally ambivalent: a part of them wants to die but a part of them wants to live as well.There is often a process of the dividing up of the self within the person, between an aspect which is life affirming and engaging with the outer world; and the anti-self, which is self-critical, self-hating and ultimately suicidal.The key to recovery is to connect with and help strengthen that part of them that wants to keep on living.
6 Dazzi, T., Gribble, R., Wessely, S., & Fear, N. (2014). Does asking about suicide and related behaviours induce suicidal ideation? What is the evidence? Psychological Medicine, 44(16), 3361-3363. doi:10.1017/S0033291714001299
Stress is something we can never escape from, be it good (eustress) or bad (distress). From the small, tedious daily hassles to long-term occurrences that weigh on your mind, stress can impact us in different ways, and the experience varies for everyone. Just as how different individuals have differing levels of pain tolerance, the same applies for stress.
Stress comes in many forms, but they can be largely categorised under ‘environmental’ (e.g noise), ‘social’ (e.g family demands, friendship conflicts), ‘physiological’ (e.g sleep disturbance) and ‘cognitive’ stressors (e.g low self-esteem, high expectations of oneself). While a certain level of stress may be necessary to provide motivation and encourage positive growth, excessive and unhealthy levels of stress especially in the long-term may cause undesirable mental and physical health consequences:
Disrupted sleep patterns / insomnia
Undue anxiety or fear
Difficulty concentrating / forgetfulness
High blood pressure
Nervous behaviours such as teeth grinding or nail biting
Increased frustration and irritability
A racing mind / constant worrying
Poor eating / digestive upsets
Poor decision-making processes
Increased heart rate / rapid breathing
Sweating / sweaty palms
Sense of helplessness
Restlessness / fatigue
When stress becomes chronic, physical health consequences can definitely worsen, and an individual may also develop depression or anxiety disorders. As such, while there is no one-size-fits-all, this article aims to provide useful tips and suggestions on how you can better manage your stress levels, and to avoid being overwhelmed and giving in to chronic stress.
To guide us along, there are two main types of stress-coping mechanisms – ‘Problem-focused’ and ‘Emotion-focused’ coping. These are possibly the most basic approaches to healthy stress-coping, and aim to reduce or eliminate the causes of stress, apart from merely alleviating its symptoms.
Problem-focused coping is where action is taken to clarify and resolve the stressor directly, and hence addresses the demands of a given situation. An example of this method of coping is when a student who is worried over an upcoming examination copes by attending more review sessions and reading up on her course materials diligently. This serves to reduce her anxiety and increase her confidence to excel in her examination. A problem-focused mechanism is primarily used when one appraises a stressor to be within his capacity to change, and hence makes the appropriate adjustments and alterations to cope with the impending demands. As such, it is also important to learn how to identify the root cause of the direct stressor before responding to it accordingly.
Emotion-focused coping may be a concept that you find familiar. Unlike problem-focused coping, emotion-focused coping involves making efforts to regulate your emotional response to a stressor. This means identifying your feelings, focusing and working through them. According to Folkman and Lazarus (1980), such a mechanism can be extremely helpful especially when you need to work through your emotions before you can think clearly enough to act rationally. Emotion-focused coping can be done in various forms such as:
Venting or talking to a friend / close oneWhenever you feel stressed or overwhelmed, bottling up may not be the best way around. Talking to others about what’s bothering you could bring great relief, and perhaps they could also provide you with the constructive feedback or encouragement that you need. Physical affection, such as hand-holding and hugs can help combat stress too. Just as how others may come to you whenever they need support, don’t be afraid to lean into your social circle and find comfort in your friends. Of course, do also remember to be mindful of your friends’ emotions and needs while you’re busy venting!
Journaling In this digital age, perhaps Journaling may come across as a rather old-fashioned way of coping with your emotions. Many a time, people would rather distract themselves and destress by playing mobile games or browsing through social media as and when they are feeling stressed. Although those can be a possible methods of destressing, the beauty of journaling shines through when you give yourself some time to reflect and balance yourself by creating your very own safe space. Writing in a journal can help you clear your mind by releasing any pent-up feelings, to let go of negative thoughts, as well as to enhance your self-awareness as you write about your progress.
Meditation Practising mindful meditation is an effective strategy to combat stress, for it can help you eliminate the stream of jumbled thoughts that are contributing to your heightened stress levels. Studies have shown that training in mindfulness can potentially increase your awareness of your thoughts, emotions, and maladaptive ways of responding to stress, therefore allowing one to cope with stress in a healthier and more effective way (Bishop et al, 2004, in Shapiro et al, 2005). With guided meditations that can easily be found online, all you need to do is to set aside some time for some mental self-care.
Reframing the situation and finding meaning in it When we are stressed, we often only focus on the bad and how much we dread a particular situation. However, it can be helpful to look on the bright side and to find the benefit and meaning in a stressful event. By doing so, we can make these experiences a little more tolerable, as well as to grow and build resilience as we go along.
Other Means of Coping with Stress
Last but not least, pay more attention to your diet and nutrition intake. For some of you, caffeine is a must-have on a daily basis, with some people having four to five cups of coffee per day. However, when you combine stress with the artificial boost in stress hormones from caffeine, this creates a significantly compounded effect. While caffeine can be particularly effective in providing you with the short-term energy boost and increased alertness, it can potentially heighten stress levels in the long-term. As such, it is always good to consume it in moderation and to be mindful of your caffeine intake. In addition, you may want to consume foods rich in vitamin B, which can help to reduce stress responses in your body.
As previously mentioned, everyone experiences life events in their own unique way, and a strategy that works for you may not for others. With that said, we hope this article has helped you to understand the various ways to combat stress better, and that you find the strategy best suited for you. However, if you ever find yourself struggling to cope with stressful life events, do reach out to one of our psychotherapists or counsellors for help.
Zimbardo, P. G., Johnson, R. L., & McCann, V. (2017). Psychology: Core Concepts (8th ed.). Pearson. (Accessed 25/11/2020)
Shapiro, S.L., Astin, J.A., Bishop, S.R., & Cordova, M. (2005). Mindfulness-based stress reduction for health care professionals: results from a randomised trial. International Journal of Stress Management, 12 (2), 164-176. (Accessed 25/11/2020)
We are no strangers to feelings of anxiety – at certain stages of our lives or in particular situations, we would have experienced anxiousness and worry with relation to our careers, studies, relationships and even our environment. However, anxiety levels may go beyond the healthy norm for some people, and may instead develop into anxiety disorders that may have a debilitating effect on their lives. According to the American Psychology Association (APA), an individual who suffers from an anxiety disorder is described to have “recurring intrusive thoughts or concerns”, where the duration and severity in which the individual experiences anxiety could be blown out of proportion to the original stressor, resulting in undesirable tension and other physical alterations. In this article, we will be exploring a few types of anxiety disorders as well as how they can manifest within us.
Generalised Anxiety Disorder (GAD)
Generalised Anxiety Disorder is a psychological issue characterised by persistent and pervasive feelings of anxiety without any known external cause. People who are diagnosed with GAD tend to feel anxious on most days for at least six months, and could be plagued by worry over several factors such as social interactions, personal health and wellbeing, and their everyday routine tasks. For example, an individual with GAD may find himself experiencing headaches, cold sweats, increased irritability and frequent feelings of “free-floating” anxiety. Others may also experience muscle tension, sleep disruptions or having difficulty concentrating. Often, the sense of anxiety may seemingly come from nowhere and last for long periods of time, therefore interfering with daily activities and various life circumstances.
In contrast, Panic Disorders are characterised by the random occurrence of panic attacks that have no obvious connection with events that are co-occurring in the person’s present experience. This means that panic attacks could occur at any time, even when someone is casually enjoying a meal. Of course, panic attacks could also be brought on by a particular trigger in the environment, such as a much-feared object or situation. Some individuals have reported that panic attacks feel frighteningly similar to a heart attack, especially with the rapid increase in heart palpitations, and the accompanying shortness of breath. Other symptoms also include trembling, sweating, and feelings of being out of control. With these panic attacks bringing on sudden periods of intense fear and anxiety, it can be exceptionally terrifying when these attacks reach their peak within mere minutes. However, a notable difference between a panic disorder and GAD is that an individual diagnosed with panic disorder is usually free of anxiety in between panic attacks.
Obsessive-Compulsive Disorder is a disorder marked by patterns of persistent and unwanted thoughts and behaviours. Obsessions are recurrent thoughts, urges or mental images that cause anxiety. On the other hand, compulsions are the repetitive behaviours that a person feels the urge to do in response to an obsessive thought or image. One common example often exhibited in films is where an individual has an obsessive fear of germs. This person may avoid shaking hands with strangers, avoid using public restrooms or feel the urge to wash their hands way too frequently. However, OCD isn’t purely limited to feelings of anxiety due to germs. OCD can manifest in other ways as well, such as wanting things to be symmetrical or in perfect order, repeatedly checking on things (“Did I leave my stove on?”), or the compulsive counting of objects or possessions. While everyone double-checks their things and has their own habits, people with OCD generally cannot control their thoughts and behaviours, even if they are recognised to be rather excessive. They can spend at least 1 hour a day on these thoughts and behaviours, and will only feel the much-needed brief sense of relief from their anxiety when they perform their rituals. As such, OCD can be exceptionally debilitating to one’s mental health.
Social Anxiety Disorder
Persons with Social Anxiety Disorder, or SAD, experience high levels of anxiety and fear under particular or all social situations, depending on the severity of their condition. They are often afraid of being subjected to judgement, humiliation or rejection in public, causing them to feel embarrassed. As such, individuals with SAD may feel extra self-conscious and stressed out, and try to avoid social situations where they might be placed at the centre of attention.
A phobia involves a pathological fear of a specific object or a situation. This means that one may experience intense anxiety upon encountering their fears and will take active steps to avoid the feared object. Phobias may centre on heights(acrophobia), birds (ornithophobia), crowds and open spaces(agoraphobia), and many others. People with agoraphobia, in particular, may struggle to be themselves in public spaces, for they think that it would be difficult to leave in the event they have panic-like reactions or other embarrassing symptoms. In severe cases, agoraphobia can cause one to be housebound.
Originating from the Greek word ‘wound’, trauma is used to describe the unwelcome recollection of disturbing experiences – those which can cause one to relive horrifying, spine-chilling moments of a disaster or a tragic event which leaves a deep mark on a person’s life.
Flashbacks can be particularly frightening for people with Post-traumatic Stress Disorder (PTSD), which is a delayed stress reaction, where an individual involuntarily re-experiences the mental and physical responses (i.e emotional, cognitive and behavioural aspects) that accompanied the past trauma. Symptoms can be particularly intrusive, presenting themselves in the form of nightmares and emotional distress upon remembering upsetting memories, and even certain physical reactivity after the exposure to traumatic reminders. Additionally, depending on the severity of one’s condition, the negative alterations in mood and behaviours may vary. Alterations may comprise of (non-exhaustive):
Exaggerated self-blame or others for causing the trauma, and a sense of invalidation
Decreased interest in activities
Increased irritability or aggression
Hyper-vigilance, excessive paranoia or heightened startle reaction
Difficulty sleeping or concentrating
Risky or destructive behaviour (can include the development of maladaptive coping strategies such as substance abuse)
A sense of isolation
Avoiding trauma-related stimuli / reminders of the traumatic event (including places, activities, people, thoughts or feelings that may bring back unwanted memories).
Unlike what most would perceive, PTSD does not solely affect individuals who have been through a tragic event personally. Apart from the direct exposure to a trauma, people can also develop PTSD through the witnessing of the event, or upon learning that a close one was exposed to the trauma. The indirect exposure to aversive details of the trauma in the course of professional duties (such as first responders or paramedics) can also make one prone to developing PTSD. With the effects lasting a lifetime for some individuals, PTSD can be debilitating to one’s mental health, robbing one of joy and freedom.
This is where Dialectical Behavioural Therapy (DBT) comes in. DBT is a comprehensive cognitive-behavioural treatment that can provide strong empirical support for individuals struggling with PTSD, Borderline Personality Disorder (BPD), Non-Suicidal Self-Injury (NSSI), and others. Intended to help persons with complex issues that place them at high risks of suicide or other self-destructive behaviours, DBT focuses on imparting the knowledge and skills to cope with PTSD and trauma reminders. Moreover, it also aims to assure the generalisation and application of skills learnt to the environment beyond the treatment setting, as well as to ensure that dysfunctional behaviours are not inadvertently reinforced. DBT consists of four stages, with the first two being the standard, essential stages for all clients.
Stage 1: Aiming to Achieve Better Stability and Behavioural Control
It is safe to say that most of the work is done at stage 1, where clients work hand-in-hand with their therapists to target behavioural dyscontrol and to address the chaos within them. When clients first take on DBT, they are often said to be at their lowest point in their lives. As such, stage 1 focuses on achieving control over life-threatening behaviours, therapy-interfering behaviours, as well as other factors that are causing a decline in their quality of life. At the same time, it will serve to increase one’s behavioural skills which can include mindfulness, interpersonal effectiveness , emotion regulation, distress tolerance and self-management. In short, this helps the individual to stabilise, and to reduce the frequency of impulsive and emotional outbursts.
However, stage 1 alone is insufficient. Although there are reductions in unwanted behaviours arising from the traumatic experience, these people may not have perfect control over their condition yet, and thus may still feel depressed, and anxious along with other PTSD symptoms.
In this stage, trauma-focused treatment is engaged, and past traumatic experiences are safely explored. Therapists will help clients to emotionally process them by approaching (gradually) the avoided trauma-related memories, as well as to help them continue applying the skills learnt in stage 1. With that said, the main objective of stage 2 is to discourage the client from silencing and burying the emotional pain.
Subsequently, this makes it easier for therapists to assess the severity of the problems, the relationships between the issues faced and to determine the hierarchy of needs based on the client’s goals.
Stage 3: Achieving Ordinary Happiness and Tackling Unhappiness
Upon ensuring that the individual is no longer suffocating under the same weight of fear that they once were, stage 3 aims to maintain progress and reasonable goal-setting. This establishes greater stability and addresses any other remaining problems in living. As the clients’ previous undesirable behaviours may have disrupted other aspects of their lives, stage 3 will also focus on improving relationships, and increasing valued daily activities.
Stage 4: Regaining the Capacity for Sustained Joy
Lastly, some people will choose to engage in stage 4 to find comfort in and to work towards spiritual fulfilment. This mainly helps to tackle any feelings of incompleteness as well as to ensure one’s capability to maintain an ongoing capacity for happiness.
DBT is an efficacious prototypic phase-based treatment of PTSD as it is a support-oriented approach to treatment, helping individuals to identify their own strengths and then building upon them to improve the person’s outlook on their life. By improving one’s ability to cultivate emotional regulation, increasing one’s ability to handle challenging emotions, and coping with conflict properly through interpersonal effectiveness, DBT can help traumatised individuals develop invaluable life skills that will allow them to achieve an overall improved quality of life.
Zimbardo, P. G., Johnson, R. L., & McCann, V. (2017). Psychology: Core Concepts (8th ed.). Pearson. (Accessed 22/11/2020)
Wagner, A. (2015). Applications of dialectical behaviour therapy to the treatment of trauma-related problems. Portland DBT Institute. https://adaa.org/sites/default/files/Wagner_MC.pdf (Accessed 22/11/2020)