Here are links to citations from Understanding Baffling Psychotherapy Clients. You will also find a copy of the references on this webpage.

Chapter 3

Genesight is one of several companies that do genetic testing. Their website explains more. https://genesight.com/for-clinicians/

Chapter 4

Self-injury is not synonymous with suicidal behavior. Here is a comprehensive discussion of non-suicidal self-injurious behavior. Hooley,et al (2020) https://pmc.ncbi.nlm.nih.gov/articles/PMC6959491/

Assessing violence risk is critical but beyond the scope of this book. You may add to your knowledge about the risk of violence by reading this article by Drummond: Assessing Violence Risk Practice. https://div12.org/assessing-violence/ Drummond (2022)

Chapter 5

Ask about medical illnesses or situations that are associated with psychosis. Here is a link to an article on psychosis from The Cleveland Clinic that addresses these: https://my.clevelandclinic.org/health/symptoms/23012-psychosis

Chapter 6

Suppose you suspect your client has been chronically exposed to toxins from work or living situations. In that case, you may want the doctor to test for heavy metals and other environmental and industrial toxins. According to Ecowatch, there are several environmental and industrial toxins. They include persistent organic pollutants (POPs) like dioxin, volatile organic compounds (VOCs), phthates, polybrominated diphenyl ethers (PBDEs), polychlorinated biphenyls (PCBs), polyfluoroalkyl substances (PFASs), and some metals like lead, arsenic, copper, aluminum, cadmium, and mercury. https://www.ecowatch.com/environmental-toxins-guide.html

Chapter 11

Listen for evidence that might suggest they have attention deficit hyperactivity disorder. For more on this, go to my YouTube video Disastrous Fallacies about ADHD https://www.youtube.com/watch?v=V3V9sjIwyEI

You will find an explanation of how to take an alcohol history in this work on the medical school website about alcohol history taking: https://medschool.co/history/basics/alcohol-history-taking

The Foundations of Clinical Medicine of the University of Washington discusses how to take a substance use history here: https://uw.pressbooks.pub/fcmtextbook/chapter/substance-use-history/

If your history is suggestive of your client having an antisocial personality disorder, you may get some further clues by giving them the Disgust Scale. Find more about it on the Disgust Scale Home Page: https://people.stern.nyu.edu/jhaidt/disgustscale.html.

Familiarize yourself with the typical symptoms of these common mental disorders. This book assumes you already have this foundation of knowledge. This knowledge helps you understand the many clients whose presentations are not baffling and who more easily fit into diagnostic categories. Review them in the Diagnostic and Statistical Manual V. The Cleveland Clinic discusses the DSM-5 here: https://my.clevelandclinic.org/health/articles/24291-diagnostic-and-statistical-manual-dsm-5

Chapter 12

Evaluating mental status is most crucial in deciding suicidal risk, violence risk, and the presence of psychosis or mania. Jeffrey P. Kahn and Andre Barciela Veras, in their March 2022 article in Current Psychiatry, proposed different subtypes of psychosis and identified early mental status changes to help you identify psychosis early: https://www.mdedge.com/psychiatry/article/252208/schizophrenia-other-psychotic-disorders/psychoses-5-comorbidity-defined/page/0/4

Dr Ziad Nasreddine of Moca Cognition invented the Montreal Test of Cognitive Ability, the MOCA, which is helpful when you have questions about your client’s cognition. (https://www.mocacognition.com/the-moca-test/).

Dr. Marshal Folstein and Dr. Susan Folstein created the Mini-Mental State Exam, the MMSE (https://meded.temertymedicine.utoronto.ca/sites/default/files/assets/resource/document/mini-mental-state-examinationmmse.pdf), as another standardized screening instrument.

Chapter 14

Arlin Cuncic with Verywellmind has written an interesting article about the Imposter Syndrome: Is Imposter Syndrome Holding You Back from Living Your Best Life? Here is the link: https://www.verywellmind.com/imposter-syndrome-and-social-anxiety-disorder-4156469 (2024).

According to Arlin Cuncic, if you have imposter syndrome, aren’t perfect, don’t know everything about the subject, need help, or aren’t superbly accomplished, you may feel like an imposter and fear being exposed.

You also may link to Martin Huecker et al.’s article Imposter Phenomenon at

https://www.ncbi.nlm.nih.gov/books/NBK585058/ for additional information.

My pathology professor at the Medical College of Georgia, Dr. Luther Otkin

Chapter 15

Clients use different defense mechanisms to avoid the anxiety of becoming aware. These defenses include some combination of denial, projection, displacement, regression, rationalization, reaction formation, repression, or sublimation.

Ryan Baily and Jose Pico discuss these and other defense mechanisms in Stat Pearls at https://www.ncbi.nlm.nih.gov/books/NBK559106/ (Bailey, R, Pico, J) 2025

Robert van Reekum et al. have written an excellent article on apathy entitled Apathy: Why Care? Reekum (2005). Here is the link: https://psychiatryonline.org/doi/full/10.1176/jnp.17.1.7)

Chapter 19

It’s challenging to end a relationship with a person with pathological narcissism. Here is an exceptional article by Perpetua Neo, DClinPsy, from Mindbodygreen, on how to leave a pathological narcissist. She gives 12 tips and tells you what to expect. https://www.mindbodygreen.com/articles/breaking-up-with-a-narcissist Neo (2023)

This article may help you understand the neuropsychiatric basis for borderline personality disorder: The Neurobiology of Borderline Personality Disorder by Katerine S. Pier, MD and Lea K. Marin, MD M.P.H. Pier (2016). Here is the link: https://www.psychiatrictimes.com/view/neurobiology-borderline-personality-disorder

Chapter 20

An article in Neurochemistry International by V. Sreeja and others is entitled Pharmacogenetics of selective serotonin reuptake inhibitors (SSRI): A serotonin reuptake transporter (SERT) based approach can be found here:

https://www.sciencedirect.com/science/article/abs/pii/S0197018623002000

The Expanded Biology of Serotonin, an article by M. Berger and others in the Annual Review of Medicine, can be found at https://pmc.ncbi.nlm.nih.gov/articles/PMC5864293/ .

Serotonin Transporter Gene Polymorphisms and Selective Serotonin Reuptake Inhibitor Tolerability: Review of Pharmacogenetic Evidence is an article in Pharmacotherapy by Zhu and others found at https://pubmed.ncbi.nlm.nih.gov/28654193/

Some clients have good ego strength

Consider the use of lithium, which has been shown to reduce suicidal ideas even at low doses. It is not advertised because it is so inexpensive. Here is an article by SK Sarai, HM Mekala, and S Lippmann entitled Lithium Suicide Prevention: A Brief Review and Reminder in Innov. Clin Neuroscience https://pmc.ncbi.nlm.nih.gov/articles/PMC6380616/

I want to add to this brief discussion of how clients with suicidal risk trigger feelings in therapists by referring you to these resources:

Colorado State University has a website with warning signs, links to other resources, and assessment tools. It is https://health.colostate.edu/suicide-prevention/

Clinical Manual for the Assessment and Treatment of Suicidal Patients by Dr. John Chiles, et al. https://psychiatryonline.org/doi/book/10.1176/appi.books.9781615378982

Stronger than Death by Sue Chance

Choosing to Live: How to Defeat Suicide Through Cognitive Therapy by Thomas E. Ellis.

The National Suicide Hotline 1-800-273-8255

The Transgender Suicide Prevention Hotline 1-877-565-8860

The American Association of Suicidology https://suicidology.org/

The American Foundation for Suicide Prevention https://afsp.org/about-afsp/

Suicide Prevention Resource Center https://sprc.org/

The Virtual Helpbox App https://www.research.va.gov/research_in_action/Virtual-Hope-Box-smartphone-app-to-prevent-suicide.cfm

Chapter 21

Variations in estrogen metabolism affect the brain. Just scanning this complex article may give you an idea of the importance of estrogen in brain function: Estrogen effects on the brain: actions beyond the hypothalamus via novel mechanisms by Bruce S. McEwen et al. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3480182/.

Chapter 23

I have found Thomas Fogarty’s concepts helpful in working with families. Below is a link to his collected papers: http://cflarchives.org/thomasfogartymdcollectedpapers.html

This article is one of his seminal articles: http://cflarchives.org/images/Triangles.pdf

Chapter 26

If you help fretful, anxious parents deal with their anxiety, you will free up their kids to make mistakes and discover they aren’t so fragile after all. You may explore the dynamics of this more by reading about the Good Enough Mother, a term coined by D.W. Winnicott, who in 1953 wrote an article entitled Transitional objects and transitional phenomena; a study of the first not-me possession in The International Journal of Psychoanalysis, 34, 89–97.

This link from the Seleni Institute explains the concept. https://seleni.org/advice-support/2018/3/14/the-gift-of-the-good-enough-mother

Chapter 27

I am reminded of the behavioral shaping techniques experimenters used to get a bird to peck for seeds in the left direction. They ignore every movement of the bird in the right direction and then drop grain each time the bird looks to the left. They shape the birds’ behavior by reinforcing the desired behavior and ignoring the negative. S.G. Friedman, Ph.D. explains this in Shaping New Behaviors in Good Bird Magazine reprinted on this site https://www.behaviorworks.org/files/articles/Shaping%20New%20Behaviors.pdf

This article from Positive Psychology covers using positive therapy in more detail and offers active listening and exercise techniques. How to Practice Active Listening:16 Examples and Techniques. https://positivepsychology.com/active-listening-techniques/ O’Bryan (2022)

Chapter 28

Another tell might be your choosing a diagnosis for your client that is considered pejorative in popular parlance. My residency program wisely made Dr. Thomas Main’s article The Ailment required reading for first-year residents. It shows how risky it can be for a patient to unwittingly frustrate the doctor’s expectation that the patient will get well. Here is the link: https://bpspsychub.onlinelibrary.wiley.com/doi/abs/10.1111/j.2044-8341.1957.tb01193.x

Main (1959)

It may take weeks or months to see the full effect of taking l-methylfolate, but clients tell me it makes such a difference. They are not as fearful of going into social situations. They don’t dread being a little anxious because they know they can calm down. To learn more about this, go to this link: https://genesight.com/genetic-insights/understanding-the-mthfr-gene-mutation/

Chapter 30

Understanding how the brain works can help you better understand unusual client situations. Below is a comprehensive video overview from Visceral.Labs69-wo7su: The Four Main Brain Networks (Salience, Default Mode, Central Executive, Task Positive) https://www.youtube.com/watch?v=cfwQDS8r80s 2023.

Chapter 31

People who overdo it have trouble taking vacations. You may remember going on vacation rates as a 13-point stress on the Social Readjustment Rating Scale, often called the Holmes and Rahee Stress Scale. Saul McLeod explains the Social Readjustment Rating Scale in Simple Psychology at this link: https://www.simplypsychology.org/srrs.html.

Chapter 32

In the European Journal of Psychotraumatology, Onno van der Hart’s article explores this more. It is entitled The Use of Imagery in Phase 1 Treatment of Clients with complex dissociative disorders. Here is the link https://pmc.ncbi.nlm.nih.gov/articles/PMC3402145/

Chapter 33

I encourage you to view my YouTube video called Misconceptions about People with high-functioning autism. Here is the link: https://www.youtube.com/watch?v=hLn6D4NujVU

In a July 2025 MDEdge article, Patricia Wendling discussed research published that same month in Nature Genetics. She noted that researchers had identified four clinically distinct autism subtypes and their underlying genetic signals. This research may lead to further changes in how autistic people are described. https://www.mdedge.com/psychiatry?summaryguid=2025a1000isl&ecd=WNL_PSYCH_250728_mdedge&uac=3006SK&sso=true (Wendling) 2025

In her Netflix Special called Nannette and her TED talk, Hannah Gadsby shared her insights into what it is like to be autistic and what her thought process is like. You can find her TED talk at https://www.ted.com/speakers/hannah_gadsby.

Explore the Pathological (or Extreme) Demand Avoidance concept and see if it applies to your clients. PDA is an unusual resistance to ordinary social demands and even to demands the client wants for themselves. The Extreme Demand Avoidance Questionnaire, which was used with children, has been adapted for use with adults. You can find it here at https://embrace-autism.com/eda-qa/

You will learn about penguin pebbling and other ways people with autism express their wish to connect with others when you read an excellent discussion by Myth@neurowonderful at this Stimpunks Foundation site: https://stimpunks.org/2022/01/22/the-five-neurodivergent-love-languages-2/.

Chapter 34

If a client misses several days of Lamictal and doesn’t start over with the small starting dose, they are putting themselves at risk for Stevens Johnson’s syndrome, which can be life-threatening. The Mayo Clinic discusses it here: https://www.mayoclinic.org/diseases-conditions/stevens-johnson-syndrome/symptoms-causes/syc-20355936 . It may be inconvenient to call pharmacies on the weekend or go the extra mile, but the consequences of not doing so are too significant. You may be tempted to set limits, but this is not the time.

Chapter 37

I have mentioned my dog, Sophie, and you may have seen her in my YouTube videos about college. You may click on this link https://www.youtube.com/playlist?list=PL8Hb1mIKF05i5KhUX_8zAs4LD783Rd3sH

or google YouTube How to Get Ready for College in Trying Times Duffey.

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