Suicide Assessment and Intervention for the 21st Century

This past year, Alexander Street Press has been filming and producing a number of Ted-like talks focusing on counseling and psychotherapy. These are 15 minute talks, followed by a short Q & A on the topic. Below is a transcript from a talk I gave this summer in their studio at Governor’s State University in Chicago. I’m posting this talk in honor of National Suicide Prevention Day. This talk, and another couple dozen talks, should be available later this year or early next year from Alexander Street Press:

Here’s the transcript:

Ironically I usually feel happy when I’m asked to do a talk on suicide and then I start with great confidence. I think it’s because suicide is such an extremely important and stressful issue for mental health professionals. But once I dive into the content, I remember how difficult this topic is. During one public presentation a therapist-friend of mine walked out because, as he told me later, the content was hitting too close to home. So please, as you listen, take care of yourself and talk to friends and colleagues for support.

To be perfectly honest, I DON’T REALLY LIKE to talk about suicide, but I think it’s VERY IMPORTANT that we do so directly . . . with each other and with our clients . . . and so here we go.

Death by suicide is pretty rare. Every year, only about 1 in 10,000 Americans commit suicide.

Despite its low frequency, suicide is still a major social problem that affects nearly everyone in one way or another. Over the years you’ve probably heard of many famous people who died by suicide. Marilyn Monroe and Kurt Cobain are two prime examples.

Perhaps even more important is the problem of suicide attempts. About 10% of the human population has attempted suicide and about 20% report struggling with suicidal thoughts and impulses. In surveys of high school students about 50% report “thinking about suicide.”

To summarize what we know about suicide base rates we can say:
I. Death by suicide is infrequent
II. Suicide attempts are NOT infrequent. In fact, many people attempt suicide and then go on to lead happy and meaningful lives
III. Suicide ideation (thoughts) are common
IV. And this is what makes suicide prediction very difficult, because it occurs so infrequently, but this is also what makes suicide prevention very necessary.

In 1991, I worked with a young man who ended up killing himself. This was a tragedy and I remember feeling that gut-wrenching guilt and regret that really stays with you a long time. Afterwards, my consultation group quizzed me and declared that I had done what I could, following all the standard and customary professional suicide assessment procedures. But in my mind and in my heart, then and now, I know I could have done better.

You see back in 1991, professionals (and the public) lived by a big suicide-related myth. We generally viewed suicidal thoughts as DEVIANCE. And so, when clients talked of suicide, it was our job to take action to assess and intervene to eliminate the suicidal thoughts.

This way of thinking about suicide is unhelpful. It creates distance between the professional therapist and his or her client; it also takes power away from clients. And so it’s NOW TIME FOR US TO BUST THE BIG SUICIDE MYTH.

NO LONGER should we consider suicidal thoughts and impulses simply as SIGNS OF DEVIANCE. Instead, we should view suicidal thoughts and impulses as normal signs of human distress. THIS IS THE NEW – and the more accurate – REALITY

Let’s take a minute now to contrast traditional and contemporary or post-modern suicide assessment and intervention approaches. The old Narrative is sort of a checklist approach where we emphasize risk factors, diagnostic interviewing, and no-suicide contracts. The New Narrative is different; it involves looking for protective factors, client strengths, normalizing suicide ideation, and initiating a collaborative safety plan.

This is what I wish I’d understood back in 1991. And so I’d like to be more specific about what I would have done differently and what all mental health professionals should be doing differently.
I wish I had asked more about his protective factors. Protective factors are things like reasons for living and so I wish I’d been more courageous in sitting with him and exploring the reasons why he wanted to live. I wish I’d asked him, over and over, what would or what could help him want to live.

I wish I had asked him more directly about what would help him control his suicide impulses. I would have asked him who he wanted around to help him. I would have lingered on this and asked, who else, what if that person can’t be there, who else would be your next choice to turn to for help.

One of the big changes in the suicide intervention field is that we no longer ask clients to sign No-Suicide contracts. Instead, we work to collaboratively develop a safety plan. As a part of this different focus, I wish I had clearly and unequivocally said to him: “I WANT YOU TO LIVE.” This is different than arguing with clients about their right or need to commit suicide. We should never argue against suicide because that can activate client resistance and make the act even more likely. But the language, “I WANT YOU TO LIVE” is just a self-disclosure and is therefore unarguable. It clearly communicates the intent to help.

Overall, I should have been MORE BALANCED and asked about what my client was doing when his depressive symptoms were gone. I should have asked about what he hoped for today and tomorrow and into the future. I should have asked him more about what brought a little light into his darkness. We should have brainstormed how to bring the light in when he was feeling down.
One problem with the old No-Suicide contracts is that clients sometimes viewed them as designed more to protect the counselor than the client. Obviously this is backward and not the sort of message we want to give clients who are suicidal. And so no-suicide contracts are out . . . and collaborative safety plans are in. What this requires is for counselors to dig in deeper and explore together specifically what the client is willing to do if the suicidal impulses come.

And now, because this talk is all about balancing negative and positive and I want to give an example of two suicide interventions, I’m going to share a positive story about suicide. Maybe I shouldn’t have said that, because now you already know there’s a happy ending. Oh well. Having a happy ending story is a good thing when you’re doing a suicide presentation.

About 5pm one evening I was about to head home and got a call from an alcohol and drug prevention organization across the street from where I was working. A suicidal 16-year-old had suddenly walked into their agency and they had no professional therapists on staff. They asked me to come over and help. I went right over and sat down with the girl in their lobby. We talked a while and she said she had left the local psychiatric unit and was planning to kill herself by jumping off a bridge about a quarter mile away. I listened and then began a specific suicide intervention developed by Edwin Shneidman, well-known as the father of suicidology. I said something like, “So you want to kill yourself. That’s one option, but let’s look at some others.” She said she wasn’t interested in any other options, but I got out a sheet of paper and wrote down “Kill myself” in the left hand column and asked her for other options. She said, “I don’t have any other options.” I said, how about going back to the hospital?” She said, “No way.” I said, that’s okay, we’re just making a list. Got any ideas? She said nothing. I said, “How about some family therapy?” She said, “No way.” I said, “Okay. I’ll write it down anyway because we’re just making a list. You don’t have to do any of these things.” Over time, I came up with about eight ideas of what she might do instead of kill herself, but she hadn’t come up with any. But the purpose of the intervention I was using was to address what Shneidman calls mental constriction. Mental constriction occurs when suicidal individuals are feeling so stressed and miserable that all they can consider is continued misery or death by suicide. With this intervention, I was working on opening up her mental blinders so she could see and consider alternatives to suicide. And so despite the fact that she didn’t generate or endorse any of the alternatives, I handed her the sheet of paper and asked her to rank order her preferences. And somewhat to my surprise, she ranked “Kill myself” as number three. There were two other options she preferred over suicide. I went for that and asked how I could help her get family therapy, which was her first choice. She re-escalated and headed out the door and down the street toward the bridge. I followed and walked with her and talked on and on about how “I want you to live.” She eventually got to the corner where we would cross the street to get on the bridge and I said I was stopping there. She stopped too and I reached out and grabbed her hand. She pulled back and yelled at me for touching her. Then I tried another specific suicide intervention, called Neodissociation. I said, “I know somewhere inside there’s a part of you that wants to live a happy and healthy life. Please, I want that part of you to just reach out and take my hand and walk with me back to the office so we can get you the help you deserve. She stared at me, reached out, took my hand, and then walked back to the office where I called the police and they took her back to the hospital.

[Insert big sigh here].

About two months later, I got a card from her that read, “The only bridges in my life now are bridges to health and happiness.” Now that’s a pretty good ending, but there’s more.

About six months later I asked her therapist if he thought it would be okay for me to interview her about what she thought was most helpful to her in choosing life over suicide. He asked her and then she came to my office for a short video interview. I remember asking her what was most helpful and she said she had a great student nurse at the hospital who was “Fresh” and genuine and that had helped a lot. Then I asked her what had helped her come with me on that first night we’d met. She said, “I’m not sure.” Eager for affirmation, I asked if it was when I used the neodissociation technique and she responded, “No way. That was really stupid.” Then she spontaneously said that she thought it was the look on my face, when I stopped and said I would go no further. She said that—in that moment—I looked like I really cared.

And so that’s the suicide story I prefer to remember.

Speaking of remembering, let’s review the main points.

In summary, there are three main modifications to the traditional approach, which I sometimes call the NEW MANTRA.
• There’s NO MORE BIG MYTH and so we normalize suicidal thoughts and impulses to counter our client’s feelings of deviance; they already feel deviant enough, we don’t need to add to that.
• Collaborate with clients. . . and be sure to do so from a place of genuine caring. It’s okay to say: “I WANT YOU TO LIVE” while collaboratively developing a safety plan.
• Use strength-based questioning, focusing on hope instead of hopelessness; meaning instead of meaninglessness.
• And of course, as always, like all good professionals, consult and document.

I’d like to end with a comment on self-care. As you can see in the final photo, my two daughters are engaged in what appears to be rather bizarre human behavior. I like to think of this as the one daughter performing a helpful “Pit-Check” for the other. We all need that and we especially need that when we’re working with clients who are suicidal. We need to keep talking and asking, “How am I doing?” We need to check up and check in with our colleagues and take very good care of ourselves because although the work we’re doing is essential . . . it can also be terribly stressful to face alone.

This reminds me of what another client once said to me. He said: The mind is a terrible place to go . . . alone . . . which is why we should keep on talking—directly to each other and to our clients—about suicide and suicide prevention.

Thanks for listening.


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A Plan for Maximizing Positive Counseling and Psychotherapy Outcomes

Sometimes I write things and then forget what I’ve written. Today, as I’m putting together an article for the Journal of Mental Health Counseling, I came across (and then read) a small section from Chapter 1 of our Counseling and Psychotherapy Theories textbook. It’s a little dense (and referenced) for blog material, but otherwise I think it’s a pretty good guide for improving counseling and psychotherapy outcomes. So here it is:

There’s nothing like a good plan to help with goal attainment (see Chapter 9). Using the following plan can help you minimize negative outcomes and maximize positive ones.

1. As appropriate, integrate empirically supported treatments (ESTs) or evidence-based principles (EBPs) into your therapy practice: There are many ESTs, but to use them, you’ll need advanced training, supervision, and it’s impossible to become proficient in the vast array of ESTs available. Therefore, you should learn a few that serve you well as you work with specific populations (e.g., if you want to work with individuals suffering from trauma, learning both Trauma-Focused Cognitive Behavioral Therapy [TF-CBT] and/or Eye Movement Desensitization Reprocessing [EMDR] would be useful). However, there will always be situations where clients don’t perfectly fit a diagnostic category with a specific EST or you don’t think a manualized approach is best, or the client will not want to work using certain approaches. In those cases you should follow EBPs. For example, using Beutler’s systematic treatment selection model, you can systematically select both general and specific approaches that are a good fit for the client and consistent with empirical knowledge about how to address particular problems (Beutler, 2011; Beutler, Harwood, Bertoni, & Thomann, 2006; Beutler, Moleiro, & Talebi, 2002).

2. Understand and capitalize on evidence-based (or empirically supported) relationships and other common factors: As the common factors advocates have articulated so well, evidence exists for much more than psychological interventions or procedures (Norcross & Lambert, 2011). For better or worse, psychological procedures tend to be implemented within the crucible of interpersonal relationships. Consequently, the ethical therapist intentionally attends to the therapeutic relationship in ways consistent with the research base (e.g., by collaboratively setting goals and obtaining consistent feedback from clients about their perceptions of therapy process and content).

3. Avoid pitfalls and procedures associated with negative outcomes: To address potential negative outcomes, ethical therapists should: (a) engage in activities to facilitate awareness including, but not limited to individual supervision, peer supervision, and consistent client feedback; (b) individualize therapy approaches to fit clients—rather than expecting all clients to benefit from a single approach; and (c) avoid using high risk approaches by knowing (and avoiding) potentially harmful therapy (PHT) approaches (Lilienfeld, 2007).

4. Use flexible, but systematic assessment approaches to tailor the treatment to the client and the client’s problem: Much like good mechanics assess the engine before initiating change, ethical therapists conduct some form of assessment prior to using specific therapy interventions. As discussed in each chapter, the particular assessment process you use will likely be more simple or more complex, depending on your theoretical orientation. Nevertheless, empathic, culturally sensitive, and ongoing collaborative assessment helps guide therapeutic processes (Finn, 2009).

5. Use practice-based evidence to monitor your personal therapy outcomes: Practice-based evidence is a term used to describe when clinicians collect data, sometimes every session, pertaining to client symptoms and/or client satisfaction. Duncan, Miller, and Sparks (2004) refer to this process as client informed therapy. Regardless of the terminology, this is a process wherein clients are empowered to directly share their treatment progress (or lack thereof) with their therapists. This allows therapists to make modifications in their approach to facilitate more positive outcomes (Lambert, 2010a; Lambert, 2010b).

Working on positive family bowling outcomes



Talking with Parents about Positive Reinforcement

Before I head out to climb Mount Sentinel on this gloriously beautiful day in Missoula, I’m posting this short commentary with some ideas on how to talk with parents about positive reinforcement.

More often than not, children’s behavior can be understood in terms of contingencies. In fact, when parents are trying to persuade their children to do something (like chores), children and teens will make their awareness of behavioral contingencies clear with a one-word response: “Why?!”

Children and teenagers are notorious for asking why; they ask why they have to take out the garbage, why they have to be home by midnight, why they can’t go out and drink some beers with their friends, why they can’t experiment with drugs and why they can’t stay home alone when their parents go away for the weekend. It’s important for parents and therapists to be sensitive to children’s questions about why they should or should not engage in particular behaviors. This is because why questions are questions about contingency and motivation. When young clients ask why, they’re trying to understand: “What’s the payoff?” or “What’s the reason?” or “What’s in it for me?” or “How does this fit with our family values?” And, like most adults, they’re interested, to at least some degree, in obtaining external or intrinsic rewards or reinforcement in return for their cooperative behaviors.

Depending on their own values and upbringing, parents may insist children not be bribed to get good grades, complete their chores, or comply with curfew. They may insist that children of this generation are spoiled and too dependent on external rewards and in many ways, these parents are right; children are bombarded with messages about acquisition and materialism. However, complete denial of external motivators and rewards is impossible and ill-advised. The process by which external motivation becomes internal motivation is an important area of psychological research. Very generally, research shows that modest external rewards that convey performance information to children can contribute to the development of intrinsic motivation. In contrast, if rewards are used to control children’s behavior, children may work hard to obtain the reward, but intrinsic interest in the target behavior won’t be developed. Obviously, intrinsic motivation and/or self-reinforcement systems are crucial to the development of self-discipline. Consequently, as counselors, we preach moderate reinforcement strategies designed to provide performance feedback to young clients instead of large-scale reinforcements designed to control child behavior. However, before focusing on reinforcement, we suggest using a behavioral assessment technique: Analyze the existing contingencies.

Parents and children usually focus on different sets of behavioral contingencies. Parents focus on long-term contingencies (e.g., “Doing your homework will help you get good grades and getting good grades is important to getting into college”). In contrast, children and teenagers focus on short-term contingencies (e.g., “I need money for the movie tonight”). Therapists may need to help parents stop lecturing about the great benefits of long-term contingencies because these lectures aren’t typically well-received (Rarely do seven year olds say, “Hey mom, thanks for reminding me to save money for college). Instead, to be developmentally attuned to children and teens requires that parents and therapists be sensitive to short-term contingencies. In a sense, therapists function as developmental translators; they help parents understand the motivational language of children. Defining Bribery

Many parents mistakenly confuse positive reinforcement with bribery. They discount positive reinforcement strategies by saying things like: “Oh, we’ve tried bribery.” Or if the therapist uses an incentive to encourage a teenager to effectively communicate within a session, parents sometimes say: “You just bribed her to get her to do that. She won’t do it without being bribed.” Consequently, when using contingency programs or positive reinforcement techniques with young clients, we explain to parents the difference between bribery and positive reinforcement.

“Before we talk about using positive reinforcement techniques with Jennifer, let’s talk about the difference between positive reinforcement and bribery. Do you know the definition of bribery? (Short pause, usually parents just look at you.) The definition of bribery is to pay someone—in advance—to do something illegal. So if we come up with a plan to pay Jennifer something, whether it’s fruit snacks, a trip to the mall, or a new CD, for consistently completing her homework, it’s not the same as bribery . . . because there’s nothing illegal about Jennifer doing her homework and we won’t be rewarding her in advance.”

All of us, especially adults, respond to positive reinforcement every day. Most of us go to work either because we get paid for it or because we enjoy it. And if we enjoy it, it’s because there’s something about going to work that we perceive as positively reinforcing. So if our goal is to have Jennifer consistently complete her homework, we’ve got to figure out how to make doing homework more rewarding (and less aversive) to her.

In addition to defining bribery, parents usually benefit from hearing how important it is to NOT give children excessively large or excessively frequent reinforcements designed to control behavior. Therefore, we usually inform them of research showing that providing children with too much reinforcement to control behavior can undermine development of intrinsic motivation.

This excerpt is adapted from the book: Tough Kids, Cool Counseling. The Amazon link is here:

Three grandchildren getting some natural positive reinforcement:



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Posted by on September 6, 2014 in Uncategorized


Paper Writing Tips for Grad Students in Counseling and Psychology


In honor of the beginning of Fall semester, I’m re-posting these writing tips. It also goes without saying that some people may not agree with these tips, but thinking about them is likely a good thing nonetheless. Happy Fall semester!

Originally posted on John Sommers-Flanagan:

I recently had the honor and privilege of reading the first set of papers submitted to me by graduate students this semester. The papers were generally of good quality, but a few repeating patterns inspired me to provide the following list of basic tips for graduate students seeking to become mental health professionals.

  1. There’s nothing quite like a clear and concise topic sentence in academic writing. The topic (or focus sentence) introduces the content included in the paragraph. When used well, it’s a beautiful organizing force that brings joy and comprehension to the hearts and minds of many a reader.
  2. Although I absolutely hate the saying “More is less” (because, in fact, “more” is always “more” even though “less” can better), it’s a good general rule to make your sentences shorter rather than longer because all too often I find students, like myself in this particular sentence, trying to fit…

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Posted by on September 3, 2014 in Uncategorized


The Long Road to Eagle Pass Texas


This is a re-blog because I’m back in Eagle Pass . . . one year later.

Originally posted on John Sommers-Flanagan:


I’m re-posting this because today, exactly one year since I made my long trek to Eagle Pass from Montana . . . I’m back again. The drive was just as long as before, but I’m back because the folks in the Eagle Pass School District are pretty darn fun to hang out with. And so here’s the original post from last year:

It’s a very long way from Missoula, Montana to Eagle Pass, Texas.

Just saying.

This epiphany swept over me after the early morning Missoula to Denver flight and after the Denver to San Antonio flight and right about when, after driving from San Antonio in a rental car for about an hour, I finally saw a green mileage sign that said: Eagle Pass – 95 miles. I just laughed out loud. And even though I was all by myself, I said, “It’s a long way from Missoula…

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Posted by on August 19, 2014 in Uncategorized


A Little Something I’ve Been Writing

Occasionally, against my better judgment, I (John) log into and read discussion boards in various online venues. These venues include sites where the public is invited to comment on newspaper or magazine articles, blog posts, books, and videos. Even worse than reading these discussion boards, I sometimes experience powerful emotions, emotions that draw me to the keyboard and into an internet discussion or debate. When I read something I find provocative or offensive, it can be very difficult to stop myself from commenting. But if I control this urge, after a few minutes, hours, or days, the impulse subsides and I’m then enlightened as to why my initial impulses to deliver a quick and clever retort were misguided. It also helps when I consult with wife on what it is that I’m wanting to write. Her sarcastic analysis of my juvenile impulses helps me inhibit my desire to make a fool of myself.

But there are times when I don’t wait long enough. And there are times when I don’t consult my wife. Instead, I channel the emotion I’m feeling (usually anger) into what I consider, in-the-moment, to be a pithy, clever, or creative retort.


The online world has a name for this phenomenon; it’s called flaming. Flaming is defined as a hostile and insulting interaction in an internet forum or discussion. It may include profanity and name-calling. I like to think I never stoop quite that low. Some internet users are intentional flamers who comment on specific topics in an effort to inflame or incite; others, like me, are occasionally drawn into an internet brawl.

In June, 2013, while perusing books about boys and male development, I came across the book: Raising Boys Feminists will Hate by Doug Giles. If the title of the book was a spark, the first page fanned my fire. Giles opened with:

Parent, if you have a young son and you want him to grow up to be a man, then you need to keep him away from pop culture, public school and a lot of Nancy Boy churches. If metrosexual pop culture, feminized public schools and the effeminate branches of evanjellycalism lay their sissy hands on him, you can kiss his masculinity good-bye because they will morph him into a dandy. (p. 1)

In this case, I could have taken a few deep breaths and waited. There was no hurry for me to respond. Why not wait? It also would have been advisable for me to consult my wife. But what fun would that have been? I knew what she would say. I also knew that instead of self-control or restraint, at that moment, mostly I wanted immediate gratification. Such is the nature of contemporary internet flaming. It’s about instant gratification; it’s not so much about thoughtful and reflective discourse. So, before I could fully contemplate my actions and while avoiding contact with anyone who might push me toward a more mature perspective, I quickly wrote a short book review:

This guy clearly has an ego of immeasurable proportions. I think the main problem is that he’s deluded himself to believe that just because he said it or wrote it, it must be true. I’m not sure anyone in the mainstream is against raising boys to be strong men with good character. But I suppose he’s just creating the image of Nazi-feminists so he can blast away at them and consequently increase his media attention. The real title of this book should be: “I hate feminists and because I’m a real man who knows everything, you should too.” I’d like to challenge him to a debate on Fox, but I’m afraid I’d lose control and get into fisticuffs and consequently damage my sissy-feminist reputation.

In retrospect, I see that this wasn’t my greatest moment. When I start a commentary with “This guy. . .” whatever follows isn’t pointed in the direction of intellectual sophistication. And when I deteriorate into mentioning “fisticuffs” well, then it just becomes a process of embarrassing myself.

Fortunately, I was posting on a relatively “quiet” discussion board. The first response to my post didn’t come until months later. Here’s a clipped version of what a person with the online handle “Jeffery Bozo” had to say about Giles’s book and my review of his work:

The Feminists stayed at the party too long and now they are just beating a dead horse. It’s time for them to find another hobby.

Doug’s comments concerning the Feminist takeover of education are spot-on. 90% of public school teachers are female and/or gay. Does that sound diverse and balanced to you? It seems these activists only concern themselves with their diversity pie charts when it favors their natural enemies. Sounds like female-Femi/Stasi-pigs to me. The height of hypocrisy.

What I took from Mr. Bozo’s post was that he was apparently unimpressed with my clever book review. And although much of what he wrote didn’t make any sense to me, I can see why he, and many others, might take offense to what I wrote. I was neither fair nor balanced. I didn’t focus on the book’s content. I was mocking and insulting Giles and his work. Even though it felt clever and gratifying in the moment, it wasn’t helpful or constructive (both of which are more valuable in a book review than offering clever insults).

You may want to come to my defense. After all, Giles was being intentionally provocative in his choice of book title and his opening paragraph. One great way to deny personal responsibility for immature behavior is to claim: “He started it!” And, although there’s truth to that, Giles’s being provocative is no excuse for my flaming response.

Interestingly, a few months later, another reader decided to enter into the discussion and share her feelings. Her post was directed to Mr. Bozo:

Wow, you are a truly special breed of stupid and ignorant, aren’t you? Your last name is perfectly fitting, because you’re a clown.

When this comment initially popped into my email I had the horrific thought that the posting was about me. Although I was relieved to discover that the commenter was on my side and referencing Mr. Bozo, this is still an excellent example of destructive flaming.

Here’s the main point: Flaming responses, whether online or in-person, nearly always have the intent of “teaching someone a lesson” or “putting someone in his or her place.” And here’s the corollary: It doesn’t work because the other person doesn’t want to hear the lesson and doesn’t want to be put in his or her place.


A Bill of Rights for Children of Divorce

Originally posted on John Sommers-Flanagan:

There are lots of different “Bills of Rights” for children and parents of divorce available online. I’m re-posting this one that Rita and I originally published in November, 2000, in Counseling Today, a publication of the American Counseling Association. It’s a slight revision and has been on this blog for a while, but here it is in honor of all the kiddos out there who end up with the challenge of transitioning between two homes. Feel free to share or use as you wish.

A Bill of Rights for Children of Divorce

By John and Rita Sommers-Flanagan

I am a child of divorce.  I hold these truths to be self-evident:

I have the right to be free from parent conflicts and hostilities.  When you badmouth each other in front of me, it tears me apart inside.  Don’t put me in the middle or try to play me against my…

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Posted by on August 3, 2014 in Uncategorized


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