Working with suicidal clients often involves working two sides at the same time. . . as in a dialectic or paradox. For example, it’s crucial to be able to move back and forth between empathic acceptance and active-collaborative problem-solving.
When working from a strengths-based model, clinicians shouldn’t shy away from focusing on pain, sadness, anger, or other aversive emotions and experiences. At the same time, we need to also focus on potential strengths. The following excerpt from our new suicide book illustrates how to explore previous attempts, while also looking for strengths.
Previous attempts are often considered the most significant suicide predictor (Brown et al., 2020; Fowler, 2012). You can gather information about previous attempts through your client’s medical or mental health records, from an intake form, or during the clinical interview. During clinical interviews, clients may spontaneously tell you about previous attempts; other times you’ll need to ask directly. Again, using a normalizing frame can be facilitative:
It’s not unusual for people who are feeling very down to have made a suicide attempt. I’m wondering if there have been times when you were so down that you tried to kill yourself?
Once you have knowledge about a client’s previous suicide attempt, you can explore several dimensions of the attempt:
What was happening that made you want to end your life?
When you discovered that your suicide attempt failed, what thoughts and feelings did you experience?
Some people report learning something important from attempting suicide. Did you learn anything important? If so, what did you learn?
Although the preceding questions are important for assessment, once you’re ready to move beyond exploration of a previous attempt, you should ask a therapeutic solution-focused question, similar to the following:
You’ve tried suicide before, but you’re here with me now . . . what has helped? (Sommers-Flanagan & Sommers-Flanagan, 2017, p. 373).
Asking “What helped?” is central to a strength-based or solution-focused model and sometimes illuminates a path forward toward living. However, if your client is depressed, you may hear,
In the context of an assessment protocol, the “What helped?” question and its side-kick, “What have you tried?” are important because they assess for two core cognitive problems associated with suicidality: hopelessness and problem-solving impairment. Clients who respond with “nothing ever helps” are communicating hopelessness. Clients who claim, “I’ve tried everything” or “There’s nothing left to do” are communicating hopelessness, plus the narrowing of cognitive problem-solving that Shneidman (1996) called mental constriction. Hopelessness and problem-solving impairments should be integrated into your suicide treatment plan.
On March 3, the publisher, John Wiley & Sons is offering a free day-long webinar. They’re calling it a “Psychology Thought Leadership Summit.”
Full disclosure, I’m presenting at the 2:30pm-3:15pm (Eastern) time-slot. My presentation is titled: “Interviewing for Happiness: How to Weave Positive Psychology Magic Into the Interview Process.” Here’s my presentation description:
Freud once said that “words were originally magic.” In this interactive presentation, John Sommers-Flanagan will describe how clinical interviewing involves a process of using word magic to shift clients from a locked constructivist state to receptive social constructionism. This presentation focuses on systematically integrating positive psychology (aka happiness interventions) into a standard initial clinical interview protocol. Intentionally and systematically weaving happiness interventions into initial interviews is especially important because many people are being adversely affected by social isolation and challenges associated with the global pandemic.
Some of the other presenters are very notable. For example, Derald Wing Sue is presenting “Microintervention Strategies: Disarming Individual and Systemic Racism and Bias” during the at the 9:45am to 10:45am (Eastern) time slot. Here’s Dr. Sue’s presentation description:
Microinterventions are the everyday words or deeds—whether intentional or unintentional—that communicate the following concepts to targets of microaggressions:
Validation of their experiential reality
Value as a person
Affirmation of their racial or group identity
Support and encouragement
Reassurance that they are not alone
More importantly, they serve to enhance psychological well-being, and provide targets, allies, and bystanders with a sense of control and self-efficacy.
This session provides participants with the opportunity to learn, practice, and rehearse microintervention strategies and tactics to disarm and neutralize expressions of bias by perpetrators while maintaining a respectful relationship.
In the following paragraph I’ve pasted the Wiley promo, which includes a link to sign yourself up. . . or just REGISTER HERE. It looks like you’re supposed to register very soon, so check it out.
Wiley Psychology Thought Leadership Summit
March 3, 2021
As one of the world’s leading psychology publishers, Wiley offers trusted and vital resources written by leading subject matter experts in the field. Join colleagues from across North America for the Wiley Psychology Thought Leadership Summit featuring some of our top authors. Speakers will give inspiring talks and conduct breakout sessions where you’ll gain insight and ideas to bring back to your classroom or practice. Choose from multiple sessions on March 3, 2021.Sign Me Up
Because I’ve been getting plenty of questions about the Strengths-Based Approach as applied to suicide assessment and treatment, I’m re-posting a revised version of this blog from June, 2020. My apologies for the redundancy. On the other hand, as a friend and mental health professional has repeatedly told me, “Redundancy works.” So . . . I guess his redundancy worked on me.
Seven Dimensions of Being Human: Where Does It Hurt and How Can I Help?
We began this chapter describing the case of Alina. Mostly likely, what you remember about Alina is that she displayed several frightening suicide risk factors and openly shared her suicidal thoughts. However, Alina is not just a suicidal person—she’s a unique individual who also exhibited a delightful array of idiosyncratic quirks, problems, and strengths. Even her reasons for considering suicide are unique to her.
When working with suicidal clients or students, it’s easy to over-focus on suicidality. Suicide is such a huge issue that it overshadows nearly everything else and consumes your attention. Nevertheless, all clients—suicidal or not—are richly complex and have a fascinating mix of strengths and weaknesses that deserve attention. To help keep practitioners focused on the whole person—and not just on weaknesses or pathology—we’ve developed a seven-dimension model for understanding suicidal clients.
Suicide Treatment Models
In the book, Brief cognitive-behavioral therapy for suicide prevention, Bryan and Rudd (2018) describe three distinct models for working with suicidal clients. The risk factor model emphasizes correlates and predictors of suicidal ideation and behavior. Practitioners following the risk factor model aim their treatments toward reducing known risk factors and increasing protective factors. Unfortunately, a dizzying array of risk factors exist, some are relatively unchangeable, and in a large, 50-year, meta-analytic study, the authors concluded that risk factors, protective factors, and warning signs are largely inaccurate and not useful (Franklin et al., 2017). Consequently, treatments based on the risk factor model are not in favor.
The psychiatric model focuses on treating psychiatric illnesses to reduce or prevent suicidality. The presumption is that clients experiencing suicidality should be treated for the symptoms linked to their diagnosis. Clients with depression should be treated for depression; clients diagnosed with post-traumatic stress disorder should be treated for trauma; and so on. Bryan and Rudd (2018) note that “accumulating evidence has failed to support the effectiveness of this conceptual framework” (p. 4).
The third model is the functional model. Bryan and Rudd (2018) wrote: “According to this model, suicidal thoughts and behaviors are conceptualized as the outcome of underlying psychopathological processes that specifically precipitate and maintain suicidal thoughts and behaviors over time” (p. 4). The functional model targets suicidal thoughts and behaviors within the context of the individual’s history and present circumstances. Bryan and Rudd (2018) emphasize that the superiority of the functional model is “well established” (p. 5-6).
Our approach differs from the functional model in several ways. Due to our wellness and strength-based orientation, we studiously avoid presuming that suicidality is a “psychopathological process.” Consistent with social constructionist philosophy, we believe that locating psychopathological processes within clients, risks exacerbation and perpetuation of the psychopathology as an internalized phenomenon (Hansen, 2015; Lyddon, 1995). In addition to our wellness, strength-based, social constructionist foundation, we rely on an integration of robust suicide theory (we rely on works from Shneidman, Joiner, Klonsky & May, Linehan, and O’Connor). We also embrace parts of the functional model, especially the emphasis on individualized contextual factors. Overall, our goal is to provide counseling practitioners with a practical and strength-based model for working effectively with suicidal clients and students.
The Seven Dimensions
Thinking about clients using the seven life dimensions can organize and guide your assessment and treatment planning. Many authorities in many disciplines have articulated life dimensions. Some argue for three, others for five, seven, or even nine dimensions. We settled on seven that we believe reflect common sense, science, philosophy, and convenience. Each dimension is multifaceted, overlapping, dynamic, and interactive. Each dimension includes at least three underlying factors that have theoretical and empirical support as drivers of suicide ideation or behavior. The dimensions and their underlying factors are in Table 1.1.
Insert Table 1.1 About Here
Table 1.1: Brief Descriptions of the Seven Dimensions
The Emotional Dimension consists of all human emotions ranging from sadness to joy. Empirically supported suicide-related problems in the emotional dimension include:
Excruciating emotional distress
Specific disturbing emotions (i.e., guilt, shame, anger, or sadness)
The Cognitive Dimension consists of all forms of human thought. Empirically supported suicide-related problems in the cognitive dimension include:
Negative core beliefs and self-hatred
The Interpersonal Dimension consists of all human relationships. Empirically supported suicide-related problems in the interpersonal dimension include:
Social disconnection, alienation, and perceived burdensomeness
Interpersonal loss and grief
Social skill deficits
Repeating dysfunctional relationship patterns
The Physical Dimension consists of all human biogenetics and physiology. Empirically supported suicide-related problems in the physical dimension include:
Biogenetic predispositions and illness
Sedentary lifestyle (lack of movement)
Agitation, arousal, anxiety
Trauma, nightmares, insomnia
The Spiritual-Cultural Dimension consists of all religious, spiritual, or cultural values that provide meaning and purpose in life. Empirically supported suicide-related problems in the spiritual-cultural dimension include:
Religious or spiritual disconnection
Cultural disconnection or dislocation
The Behavioral Dimension consists of human action and activity. Empirically supported suicide-related problems in the behavioral dimension include:
Using substances or cutting for desensitization
Suicide planning, intent, and preparation
The Contextual Dimension consists of all factors outside of the individual that influence human behavior. Empirically supported suicide-related problems in the contextual dimension include:
No connection to place or nature
Chronic exposure to unhealthy environmental conditions
Socioeconomic oppression or resource scarcity (e.g., Poverty)
End of Table 1.1
This past week Rita and I submitted the final draft manuscript to the publisher. The next step is a peer review process. While the manuscript is out for review, there’s still time to make changes and so, as usual, please email me with feedback or post your thoughts here.
When taking our TOT-Long, keep some or all of the following in the back (or front) of your mind.
This questionnaire is for self-exploration; it’s not an “assessment” with established psychometrics. What that means–in the spirit of Adler–is that this so-called test is an idiographic assessment process.
I’m not a big fan of counselors and psychotherapists pigeon-holing themselves into strict theoretical positions. Instead, finding a compatible theory can help you align with ways you can transform your ideas into practical ways of being and ways of working with clients. Don’t let your theoretical orientation stop you from flexibly providing clients with the services they need and want.
All theory-based approaches work best from a relational foundation. If you question this basic assumption, try doing cold CBT with ambivalent or reluctant teenagers. . . or just imagining how that would go might be enough.
I hope you enjoy contemplating where our theoretical “sorting hat” sends you. As with all assessments, you’re the final authority of whether the shoe (or hat) fits.
Please let me know what you think of the test and, if you’re so inclined, post your theoretical orientation as a comment here. I look forward to hearing and seeing your reactions and results.
Recently someone mistook me for an Adlerian. This got me thinking, “Maybe I am an Adlerian?” Then again, if you look at the history of counseling and psychotherapy, most of us are Adlerians. At one presentation I attended back when we attended those things, the presenters started with, “In the beginning, there was Adler.”
As a Happy Birthday tribute to Alfred Adler, below is an excerpt from our Adlerian theories chapter. There’s much more, of course, like, for example, what Adlerian theory would have to say about the Super Bowl.
Happy Birthday Dr. Adler.
Freud and Adler met in 1902. According to Mosak and Maniacci (1999), Adler published a strong defense of Freud’s Interpretation of Dreams, and consequently Freud invited Adler over “on a Wednesday evening” for a discussion of psychological issues. “The Wednesday Night Meetings, as they became known, led to the development of the Psychoanalytic Society” (p. 3).
Adler was his own man with his own ideas before he met Freud. Prior to their meeting he’d published his first book, Healthbook for the Tailor’s Trade (Adler, 1898). In contrast to Freud, much of Adler’s medical practice was with the working poor. Early in his career, he worked extensively with tailors and circus performers.
In February 1911, Adler did the unthinkable (Bankart, 1997). As president of Vienna’s Psychoanalytic Society, he read a highly controversial paper, “The Masculine Protest,” at the group’s monthly meeting. It was at odds with Freudian theory. Instead of focusing on biological and psychological factors and their influence on excessively masculine behaviors in males and females, Adler emphasized culture and socialization (Carlson & Englar-Carlson, 2017). He claimed that women occupied a less privileged social and political position because of social coercion, not physical inferiority. Further, he noted that some women who reacted to this cultural situation by choosing to dress and act like men were suffering, not from penis envy, but from a social-psychological condition he referred to as the masculine protest. The masculine protest involved overvaluing masculinity to the point where it drove men and boys to give up and become passive or to engage in excessive aggressive behavior. In extreme cases, males who suffered from the masculine protest began dressing and acting like girls or women.
The Vienna Psychoanalytic Society members’ response to Adler was dramatic. Bankart (1997) described the scene:
After Adler’s address, the members of the society were in an uproar. There were pointed heckling and shouted abuse. Some were even threatening to come to blows. And then, almost majestically, Freud rose from his seat. He surveyed the room with his penetrating eyes. He told them there was no reason to brawl in the streets like uncivilized hooligans. The choice was simple. Either he or Dr. Adler would remain to guide the future of psychoanalysis. The choice was the members’ to make. He trusted them to do the right thing. (p. 130)
Freud likely anticipated the outcome. The group voted for Freud to lead them. Adler left the building quietly, joined by the Society’s vice president, William Stekel, and five other members. They moved their meeting to a local café and established the Society for Free Psychoanalytic Research. The Society soon changed its name to the Society for Individual Psychology. This group believed that social, familial, and cultural forces are dominant in shaping human behavior. Bankart (1997) summarized their perspective: “Their response to human problems was characteristically ethical and practical—an orientation that stood in dramatic contrast to the biological and theoretical focus of psychoanalysis” (p. 130).
Adler’s break from Freud gives an initial glimpse into his theoretical approach. Adler identified with common people. He was a feminist. These leanings reflect the influences of his upbringing and marriage. They reveal his compassion for the sick, oppressed, and downtrodden. Before examining Adlerian theoretical principles, let’s note what he had to say about gender politics well over 90 years ago:
All our institutions, our traditional attitudes, our laws, our morals, our customs, give evidence of the fact that they are determined and maintained by privileged males for the glory of male domination. (Adler, 1927, p. 123)
Raissa Epstein may have had a few discussions with her husband, exerting substantial influence on his thinking (Santiago-Valles, 2009).
To help practitioners focus on wellness within the whole person, Rita and I have been writing about seven life dimensions as they pertain to suicide assessment and treatment. Although treatments for individuals who are suicidal should focus on suicide, it’s also true that there’s much more to whole person in the room than suicidality. The seven dimensions we’re using include the following:
The emotional dimension
The cognitive dimension
The interpersonal dimension
The physical dimension
The cultural/spiritual dimension
The behavioral dimension
The contextual dimension
The visual excerpt from chapter 4 included with this post (above) focuses on the emotional dimension. In chapter 4 we discuss how to use empathy to emotionally connect with clients, but also on a variety of strategies for helping clients (and students) develop strengths, resiliency, and wellness within the emotional dimension.
In anticipation of my upcoming workshop, I’m posting this short excerpt from our book: How to Listen so Parents will Talk and Talk so Parents will Listen.
Theory into Practice: The Three Attitudes in Action
In the following example, Cassandra is discussing her son’s “strong-willed” behaviors with a parenting professional.
Case: “Wanna Piece of Me?”
Cassandra: My son is so stubborn. Everything is fine one minute, but if I ask him to do something, he goes ballistic. And then I can’t get him to do anything.
Consultant: Some kids seem built to focus on getting what they want. It sounds like your boy is very strong-willed. [A simple initial reflection using common language is used to quickly formulate the problem in a way that empathically resonates with the parent’s experience.]
Cassandra: He’s way beyond strong-willed. The other day I asked him to go upstairs and clean his room and he said “No!” [The mom wants the consultant to know that her son is not your ordinary strong-willed boy.]
Consultant: He just refused? What happened then? [The consultant shows appropriate interest and curiosity, which honors the parent’s perspective and helps build the collaborative relationship.]
Cassandra: I asked him again and then, while standing at the bottom of the stairs, he put his hands on his hips and yelled, “I said no! You wanna piece of me??!”
Consultant: Wow. You’re right. He is in the advanced class on how to be strong-willed. What did you do next? [The consultant accepts and validates the parent’s perception of having an exceptionally strong-willed child and continues with collaborative curiosity.]
Cassandra: I carried him upstairs and spanked his butt because, at that point, I did want a piece of him! [Mom discloses becoming angry and acting on her anger.]
Consultant: It’s funny how often when our kids challenge our authority so directly, like your son did, it really does make us want a piece of them. [The consultant is universalizing, validating, and accepting the mom’s anger as normal, but does not use the word anger.]
Cassandra: It sure gets me! [Mom acknowledges that her son can really get to her, but there’s still no mention of anger.]
Consultant: I know my next question is a cliché counseling question, but I can’t help but wonder how you feel about what happened in that situation. [This is a gentle and self-effacing effort to have the parent focus on herself and perhaps reflect on her behavior.]
Cassandra: I believe he got what he deserved. [Mom does not explore her feelings or question her behavior, but instead, shows a defensive side; this suggests the consultant may have been premature in trying to get the mom to critique her own behavior.]
Consultant: It sounds like you were pretty mad. You were thinking something like, “He’s being defiant and so I’m giving him what he deserves.” [The consultant provides a corrective empathic response and uses radical acceptance; there is no effort to judge or question whether the son “deserved” physical punishment, which might be a good question, but would be premature and would likely close down exploration; the consultant also uses the personal pronoun I when reflecting the mom’s perspective, which is an example of the Rogerian technique of “walking within.”]
Cassandra: Yes, I did. But I’m also here because I need to find other ways of dealing with him. I can’t keep hauling him up the stairs and spanking him forever. It’s unacceptable for him to be disrespectful to me, but I need other options. [Mom responds to radical acceptance and empathy by opening up and expressing her interest in exploring alternatives; Miller and Rollnick (2002) might classify the therapist’s strategy as a “coming alongside” response.]
Consultant: That’s a great reason for you to be here. Of course, he shouldn’t be disrespectful to you. You don’t deserve that. But I hear you saying that you want options beyond spanking and that’s exactly one of the things we can talk about today. [The consultant accepts and validates the mom’s perspective—both her reason for seeking a consultation and the fact that she doesn’t deserve disrespect; resonating with parents about their hurt over being disrespected can be very powerful.]
Cassandra: Thank you. It feels good to talk about this, but I do need other ideas for how to handle my wonderful little monster. [Mom expresses appreciation for the validation and continues to show interest in change.]
As noted previously, parents who come for professional help are often very ambivalent about their parenting behaviors. Although they feel insecure and want to do a better job, if parenting consultants are initially judgmental, parents can quickly become defensive and may sometimes make rather absurd declarations like, “This is a free country! I can parent any way I want!”
In Cassandra’s case, she needed to establish her right to be respected by her child (or at least not disrespected). Consequently, until the consultant demonstrated respect or unconditional positive regard or radical acceptance for Cassandra in the session, collaboration could not begin.
Another underlying principle in this example is that premature educational interventions can carry an inherently judgmental message. They convey, “I see you’re doing something wrong and, as an authority, I know what you should do instead.” Providing an educational intervention too early with parents violates the attitudes of empathy, radical acceptance, and collaboration. Even though parents usually say that educational information is exactly what they want, unless they first receive empathy and acceptance and perceive an attitude of collaboration, they will often resist the educational message.
To summarize, in Cassandra’s case, theory translates into practice in the following ways:
Nonjudgmental listening and empathy increase parent openness and parent–clinician collaboration.
Radical acceptance of undesirable parenting behaviors or attitudes strengthens the working relationship.
Premature efforts to provide educational information violate the core attitudes of empathy, radical acceptance, and collaboration and therefore are likely to increase defensiveness.
Without an adequate collaborative relationship built on empathy and acceptance, direct educational interventions with parents will be less effective.
My University of Montana COUN 195 Happiness class has compiled a “Happy Songs” playlist. I’m pasting it below, for your potential listening pleasure.
COUN 195 – Happiness Playlist
Each of these songs was selected by someone in our happiness class as contributing to happy feelings. Please be careful and use as directed because they could have the side effect of putting you in a good mood. [They’re listed alphabetically, and my apologies for typos.]
Just for fun, here’s a photo of a page from our Suicide Assessment and Treatment Planning book. This page is the lead in to a section that focuses in on how to work with clients who are suicidal, but whom also may be naturally also experiencing irritability, hostility, and hopelessness. For info, go to the publisher, ACA: https://imis.counseling.org/store/detail.aspx?id=78174
The place to click if you want to learn about psychotherapy, counseling, or whatever John SF is thinking about.