I spend a lot of time talking about suicide with clients, and for many it’s the centerpiece of therapy agendas for months. In the case of DBT, it’s tracked on a diary card (log of symptoms, emotions, and skills used). During behavioral or CBT sessions, I usually do a verbal check-in and a PHQ-9 every four weeks. I have one client right now who isn’t experiencing suicidal thinking to some degree. That I’m aware of, anyway; this person could be keeping something from me.
I went to the Beck Institute training on CBT for Depression and Suicidality, which was very fabulous and worth attending if you are a clinician. Of the many things I learned, one was a protocol on suicide prevention. Part of the protocol – and we were told we often wouldn’t do this with folks due to time constraints and client readiness – is on treating suicide attempts as traumatic events
How we (therapists who use therapies related to CBT) treat traumatic events is through prolonged exposure – the person tells their story and listens to their story on recording over and over and over, amongst other things. The trainer said the process used is sort of like prolonged exposure and stressed we seek supervision should we decide to do it.
I’ve known attempting suicide is frequently traumatic for people. It doesn’t take much brain power to figure that out. What hadn’t clicked until then was my clients don’t describe suicide attempts as traumatic. They may bring up traumatic events during hospitalization, restraints in particular. The suicide itself, no. I’m not entirely sure why, and I plan on asking those who’ve made attempts about it.
I had a song stuck in my head the other evening. A couple snippets of circa 1992 Swedish pop that had bore into a space meant for a therapy manual I was trying to read. I tried to ignore it. I tried to mindfully observe it. I tried to purge it by listening to it. I tried to listen to a different pop song. Finally, I picked out something from a different genre and was able to get some work done.
Earworms are the common name for the “I have a song stuck in my head” phenomenon. They’re also known as intrusive musical imagery (IMI). Most people experience it and don’t find it particularly bothersome. A small number of people find them aversive and some these people may have obsessive-compulsive traits, frequently related to OCD.
IMI are not listed in the DSM-5’s section on Obsessive-Compulsive and Related Disorders. I’ve heard people with OCD comment on the presence of IMI and there is a question about it on the YBOCS (Young-Brown Obsessive Compulsive Scale, which is used to diagnose OCD, determine severity, for research purposes, etc). I’m not entirely sure why it didn’t make it into the DSM-5, but then again the DSM-5 is an example of what can happen when books are written by committee.
This is a fantastic review article on IMI:
Musical obsessions: A comprehensive review of neglected clinical phenomena
IMI Article Takeaways:
- It can be an obsession, and some sort of avoidance behavior (compulsion) may be accompanying it.
- It tends to co-occur with other obsessions, such as familiar ones like contamination or harm.
- It sometimes gets misdiagnosed as part of a psychotic disorder or just plain ignored by clinicians.
- Unlike other types of obsessions, use of distraction can be helpful – here is an opportunity to indulge in distraction, folks (I kid).