Reality Therapy: Developing Effective Plans

With Wubbolding

Thanks to Molly Molloy, the Montana Office of Rural Health, the Montana Flex Program, and the Montana Hospital Association, I had a chance to present as part of a “Rethinking Resiliency” series this morning. One question that came up had to do with how we can make better plans to facilitate our self-improvement. The best answer I could come up with was to follow Robert Wubbolding’s guidance on effective planning, from a reality therapy perspective. All of the preceding leads me to posting a section from our Counseling and Psychotherapy Theories textbook on Reality Therapy and Planning.

Here we go:

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Wubbolding (1988, 1991, 2000, 2011 . . . and pictured above) has written extensively about how reality therapists help clients develop plans for making positive life changes. Therapists help clients make positive and constructive plans. Wubbolding (1988) uses the acronym SAMI2C3 to outline the essential ingredients of an effective plan:

S = Simple: Effective plans are simple. If a plan generated in reality therapy is too complex, the client may become confused and therefore not follow through.

A = Attainable: Effective plans are attainable or realistic. If the plan is unattainable, the client can become discouraged.

M = Measurable: Effective plans are measurable. Clients need to know if the plan is working and if they’re making progress.

I = Immediate: Effective plans can be enacted immediately, or at least very soon. If clients have to wait too long to implement a plan, motivation may be compromised.

I = Involved: Helping professionals can be involved with their client’s or student’s planning. This should be done ethically and in ways that promote client independence.

C = Controlled: The planner has exclusive control over effective plans. Avoid having clients develop plans that are contingent on someone else’s behavior.

C = Committed: Clients need to commit to their plans. If a client is only half-heartedly invested in the plan, the plan is less likely to succeed.

C = Continuous: Effective plans are continuously implemented. When the process is going well, reality therapy clients have continuous awareness of what they want and of their plan for getting what they want. This high level of awareness reminds us of mindfulness or conscious-raising therapeutic techniques.

Wubbolding (1988) also recommended that individuals learning to conduct reality therapy develop a plan for themselves. He noted that to be effective reality therapists, practitioners should obtain consultation and/or supervision from certified reality therapists (in addition, we recommend that you practice living your life using choice theory rules; see Putting it in Practice 9.3).

Putting it in Practice 9.3

Living Choice Theory: The Four Big Questions

Four questions have been developed to help students and clients live the choice theory lifestyle (Wubbolding, 1988). These questions are derived from Wubbolding’s WDEP formula. During one full week, do your best to keep these four reality therapy questions on your mind:

  1. What do you want? (Wants)
  2. What are you doing? (Doing)
  3. Is it working? (Evaluation)
  4. Should you make a new plan? (Planning)

Every day you’re operating with a personal plan. The plan may or may not be any good and it may or may not be clear. The point is this: You’re thinking and doing things aimed toward getting your basic needs met. Therefore, consistently ask yourself the four preceding questions. This will help make your plan and choices more explicit.

Wubbolding’s four questions are powerful and practical. Think about how you might apply them when doing therapy with a teenager. Now think about how you might apply them as a consultant for a local business. Whether you’re consulting with a teenager or a business leader, there are hardly any other four questions that are more relevant and practical.

In the space that follows each question, answer the four questions for yourself today.

  1. What do you want? ________________________________________
  2. What are you doing? _______________________________________
  3. Is it working? _____________________________________________
  4. Should you make a new plan? _______________________________

After you’ve answered the questions, go back and think about what you’ve written as your answer for Question 1.

To Mask or Not to Mask: Making America Rational Again

Make America Rational Again

About 4 years ago, I made a MARA hat. MARA stands for “Make America Rational Again.” My hat was in honor of the late Albert Ellis, a famous psychologist who relentlessly advocated for rational thinking. Given that some folks are doubting Covid-19, while others are passionately accusing health officials of infringing on their God-given liberties, I’m thinking my MARA hat from the last presidential election is still in style.

Way back when I was a full-time therapist working mostly with teenagers, I developed a method for talking with my teen-clients about their freedoms. When they complained about their parents infringing on their rights—those damn parents were pronouncing unreasonable curfews, alcohol prohibitions, and other silly mandates—I’d say something like this:

“Really, you only have three choices. You can do whatever your parents think you should do. That’s option #1. Or, you can do the opposite of what your parents think you should do. That’s option #2. Those are easy options. You don’t even have to think.”

Hoping to pique the teen’s interest, I’d pause and to let my profound comments linger. Sometimes I got stony silence, or an eye-roll. But usually curiosity won out, and my client would ask:

“What’s the third choice?”

“The third choice is for you to make an independent decision. But that’s way harder. You probably don’t want to go there.”

Actually, most of my teenage clients DID want to go there. They wanted to learn, grow, develop, and become capable of effective decision-making. Sadly, that doesn’t seem to be the case today. All too often, Americans are basing their decision-making on poor information. For example, when people are gathering the 411 on whether they should mask-up in public settings, to where do they turn? The rational choice would be medical professionals and virologists. But instead, people are turning to Facebook, Twitter, and even worse, Fox News, where misinformation from Tucker Carlson, Laura Ingraham, and Sean Hannity is offered up with nary a shred of journalistic ethics or integrity (for a fun and fabulous SNL Parody with Kate McKinnon as Laura Ingraham, check out this link: https://www.youtube.com/watch?v=XezLiezWN0E).

A related question that’s especially pressing right now is this: “How should we respond to coronavirus deniers and rabid anti-maskers?” Speaking for myself, I’ve been struggling to find the right words. Saying what I’m thinking—which usually starts with “WTF!? Have you been listening to Tucker Carlson instead of Dr. Fauci?”—seems too offensive and unhelpful. Instead, I’m making a commitment to letting go of the outrage, putting my 2016 campaign hat back on, and making myself rational again. Instead of being angry, my plan is to retreat to rationality. I’ll say things like this: “Hey, I’m curious, have you read the latest article in the New England Journal of Medicine titled, “Observational study of hydroxychloroquine in hospitalized patients with Covid-19?” or, “What are your thoughts about the chilblain-like lesions doctors are finding on patients with Covid-19?” or “According to the CDC and Dr. Fauci and the American Medical Association, the cloth face coverings—although imperfect—statistically reduce the likelihood of spreading the coronavirus.”

I invite you to join me in gathering good data for our personal and social decision-making. Together, we can Make America Rational Again.

Individualizing Suicide Risk Factors in the Context of a Clinical Interview

Spring 2020

In response to my recent post on “The Myth of Suicide Risk and Protective Factors” Mark, a clinical supervisor from Edmonton, wrote me and asked about how to make individualizing suicide risk factors with clients more concrete/practical and less abstract. I thought, “What a great question” and will try to answer it here.

Let’s start with two foundational prerequisites. First, clinical providers need to be able to ask about suicide in ways that don’t pathologize the patient/client. Specifically, if clients fear that disclosing suicide ideation will result in them being judged as “crazy” or in involuntary hospitalization, then they’re more likely to keep their suicidal thoughts to themselves. This fear dynamic is one reason why we emphasize using a normalizing frame when asking about suicide.

Second, both before and after suicide ideation disclosures, providers need to explicitly emphasize collaboration. Essentially, the message is: “All we’re doing is working together to better understand and address the distress or pain that underlies your suicidal thoughts.” In other words, the focus isn’t on getting rid of suicidal thoughts; the focus is on reduction of psychological pain or distress.

With these two foundational principles in place, then the provider can collaboratively explore the primary and secondary sources of the client’s psychological pain. In our seven-dimensional model, we recommend exploring emotional, cognitive, interpersonal, physical, cultural-spiritual, behavioral, and contextual sources of pain. Collaborative exploration is fundamental to individualizing risk factors. The general statistics showing that previous attempts, social isolation, physical illness, being male, and other factors predict suicide are mostly useless at that point. Instead, your job as a mental health provider is to pursue the distress. By pursuing the distress, you discover individualized risk factors. The following excerpt from our upcoming book illustrates how asking about “What’s bad” and “What feels worst?” results in individualized risk factors.

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     The opening exchange with Sophia is important because it shows how clinicians—even when operating from a strength-based foundation—address emotional distress. In the beginning the counselor drills down into the negative (e.g., “What’s making you feel bad?”), even though the plan is to develop client strengths and resilience. By drilling down into the client’s distress and emotional pain, and then later identifying what helps the client cope, the counselor is individualizing risk and protective factor assessment, rather than using a ubiquitous checklist.

Counselor: Sophia, thanks for meeting. I know you’re not super-excited to be here. I also know your parents said you’ve been talking about suicide off and on for a while, so they wanted me to talk with you. But I don’t know exactly what’s happening in your life. I don’t know how you’re feeling. And I would like to be of help. And so if you’re willing to talk to me, the first thing I’d love to hear would be what’s going on in your life, and what’s making you feel bad or sad or miserable or whatever it is you’re feeling?

The counselor began with an acknowledgement and quick summary of what he knew. This is a basic strategy for working with teens (Sommers-Flanagan & Sommers-Flanagan, 2007), but also can be true when working with adults. If counselors withhold what they know about clients, rapport and relationship development suffers.

The opening phrase “I don’t know. . .” acknowledges the limits of the counselor’s knowledge and offers an invitation for collaboration. Effective clinicians initially and intermittently offer invitations for collaboration to build the working alliance (Parrow, Sommers-Flanagan, Sky Cova, & Lungu, 2019). The underlying message is, “I want to help, but I can’t be helpful all on my own. I need your input so we can work together to address the distress you’re feeling.”

The opening question for Sophia is negative (i.e., What’s making you feel bad or sad or miserable or whatever it is you’re feeling?). This opening shows empathy for the emotional distress that triggers her suicidality and clarifies the link between her emotional distress and the triggering situations. By tuning into negative emotions, the counselor hones in on the presumptive primary treatment goal for all clients who are suicidal—to reduce the perceived intolerable or excruciating emotional distress (Shneidman, 1993).

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Collaborative exploration is the method through which risk and protective factors are individualized. If Sophia had a previous attempt, the reason to explore the previous attempt would be to discover what created the emotional distress that provoked the attempt, and how counseling or psychotherapy might address that particular factor. For example, if bullying and lack of social connection triggered Sophia’s attempt, then we would view bullying and social disconnection as Sophia’s particular individualized risk factors. We would then build treatments—in collaboration with Sophia and her family—that directly address the unique factors contributing to her pain, and provide her with palpable therapeutic support.

I hope this post has clarified how to individualize suicide risk factors and use them in treatment. Thanks for the question Mark!

A Strength-Based Suicide Assessment and Treatment Model

Bikes Snow 3

Over the past couple years, with feedback from workshop participants, supervisees, clients, and people with lived experiences around suicide, we’ve continued to refine our strength-based suicide assessment and treatment model. Below is a short excerpt from chapter 1 of our upcoming book. This excerpt gives you a glimpse at the strength-based model.

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)
    • Emotional dysregulation
  • The Cognitive Dimension consists of all forms of human thought. Empirically supported suicide-related problems in the cognitive dimension include:
    • Hopelessness
    • Problem-solving impairments
    • Maladaptive thoughts
    • 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
    • Meaninglessness
  • 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
    • Impulsivity
  • 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

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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.

Thanks for reading!

John S-F

A Glorious Moment

Pumpkins at birth

One nice thing about having my own blog is I get to post whatever I want. Sometimes that means I suffer from my own bad judgment. But not today.

Today, I’m posting a link to a fresh, new article in Democracy: A Journal of Ideas. The article is titled, “Our False Promise of Justice.” Not only is this article timely and compelling; not only is it well-reasoned and compassionate; not only is it balanced and beautiful prose; it’s also written by Rylee Sommers-Flanagan, my youngest daughter, who happens to be an attorney, a graduate of Stanford Law School, and a pretty fantastic person. Okay, so now I’m just bragging.

Despite my bragging, the preceding information is all true. At least IMHO.

If you read it and like it, please do me the favor of sharing this article with your friends and on social media.

Here’s the link: https://democracyjournal.org/magazine/our-false-promise-of-justice/

 

The Myth of Suicide Risk and Protective Factors

 

HummingbirdMyths are fascinating, resilient ideas that openly defy reality.

Some people say, “All myths are based in truth.” Well, maybe so, but tracking down the myth’s truthful origins reminds me of my friends back in high school who used to take their dates snipe hunting. Maybe the idea that all myths are based in truth is a myth too?

Suicide is a troubling problem (this is an obvious understatement). To deal with this troubling problem, one of the tools that most well-intended prevention programs advocate is to watch for suicide risk factors and warning signs, and when you see them, intervene. This would be great guidance if only useful or accurate suicide risk factors and warning signs existed. Sadly, like the snipe, you can look all night for useful or accurate risk factors and still come up empty.

I’m writing about mythical risk factors and warning signs today because I just covered this content in our suicide assessment and treatment manuscript. In the following excerpt, we’re writing about suicide competencies for mental health professionals:

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Cramer and colleagues (2013) noted, “One of the clinician’s primary objectives in conducting a suicide risk assessment is to elicit risk and protective factors from the client” (p. 6). As we’ll discuss in greater detail later, this competency standard is problematic for at least three reasons. First, in an extensive meta-analysis covering 50-years of research, the authors concluded: “All [suicide thoughts and behavior] risk (and protective factors) are weak and inaccurate. This general pattern has not changed over the past 50 years” (Franklin, et al., 2017, p. 217).

Second, the number of potential risk and protective factors that counselors should be aware of is overwhelming. Granello (2010a) reported 75+ factors, we have a list of 25 (Sommers-Flanagan & Sommers-Flanagan, 2017), and even Cramer and colleagues lamented, “It would be impossible for clinicians to be familiar with every risk factor” (p. 6). Jobes (2016) referred to suicidology as “a field that has been remarkably obsessed with delineating countless suicide ‘risk factors’ (that do little for clinically understanding acute risk)” (p. 17).

Third, prominent suicide researchers have concluded that using risk and protective factors to categorize client risk is ill-advised (McHugh, Corderoy, Ryan, Hickie, & Large, 2019; Nielssen, Wallace, & Large, 2017). For example, even the most common suicide symptom and predictor (i.e., suicide ideation), is a poor predictor of suicide in clinical settings; this is because suicide ideation occurs at a very high frequency, but death by suicide occurs at a very low frequency. In one study, 80% of patients who died by suicide denied having suicidal thoughts, when asked directly by a general medical practitioner (McHugh et al., 2019). Even the oft-cited risk factor of previous suicide attempt has little bearing whether or not individuals die by suicide.

When AAS (2010) and Cramer and his colleagues (2013) described the risk and protective factor competency, eliciting risk and protective factors from clients was standard professional practice. However, in recent years, researchers have begun recommending that practitioners avoid using risk and protective factors to categorize client risk as low, medium, or high—principally because these categorizations are usually incorrect (Large, & Ryan, 2014). In a review of 17 studies examining 64 unique suicide prediction models, the authors reported that “These models would result in high false-positive rates and considerable false-negative rates if implemented in isolation” (Belsher et al., 2019, p. 642).

To summarize, this suicide competency boils down to four parts:

  1. Competent practitioners should still be aware of evidence-based suicide risk and protective factors.
  2. Competent practitioners are aware that evidence-based suicide risk and protective factors may not confer useful information during a clinical interview.
  3. Instead of over-relying on suicide risk and protective factor checklists, competent practitioners identify and explore client distress and then track client distress back to individualized factors that increase risk and enhance protection.
  4. Competent practitioners use skills to collaboratively develop safety plans that address each client’s unique risk and protective factors.

Although risk and protective factors don’t provide an equation that tell clinicians what to do, knowing and addressing each unique individual’s particular risks and strengths remains an important competency standard.

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As always, even though getting feedback on this blog is yet another mythical phenomenon,  please send me your thoughts and feedback!

 

 

 

Our Upcoming ACA Book on Suicide Assessment and Treatment Planning: Sneak Peek #2

River Rising 2020

Hey,

I hope you’re all okay and social distancing and mask wearing and hand-washing and staying healthy and well.

Today I’m working on Chapter 6 – The Cognitive Dimension in Suicide Assessment and Treatment Planning (or something like that).

As always, please share your feedback. Or, if you have no feedback and like what you read, just share the post, because, as we all know, acts of kindness grow happiness.

Here’s an excerpt on working with hopelessness.

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Working with Hopelessness as it Emerges During Sessions

Clinicians can address hopelessness in two ways. First, when hopelessness emerges in the here-and-now, clinicians need to be ready to respond empathically and effectively. Client hopelessness manifests in different ways. Sometimes hopelessness statements have depressing content (e.g., “I’ve never been happy and I’ll never be happy”); other times hopelessness statements include irritability (e.g., “Counseling has never worked for me. I hate this charade. It won’t help.”). Either way, in-session hopelessness statements can be provocative and can trigger unhelpful responses from counselors. Preparing yourself to respond therapeutically is important.

Second, hopelessness among clients who are depressed and suicidal manifests as an ongoing, long-term cognitive style. As with most cognitive styles, hopelessness is linked to cognitive distortions wherein clients have difficulty (a) recalling past successes, (b) noticing signs of hope in the immediate moment, or (c) believing that their emotional state or life situation could ever improve. We address in-session hopelessness next and hopelessness as a longer-term cognitive distortion in the subsequent section.

Expressing Empathy

Imagine you’re working with a new client. You want to be encouraging, and so you make a statement about the potential for counseling to be helpful. Consider the following exchange:

Counselor: After getting to know you a bit, and hearing what’s been happening in your life, I want to share with you that I think counseling can help.

Client: I know you mean well, but this is a waste of time. My life sucks and I want to end it. Popping in to chat with you once a week won’t change that.

When clients make hopelessness statements, you may feel tempted to counter with a rational rebuttal. After all, if client hopelessness represents a pervasive depression-related cognitive distortion or impairment, then it makes sense to offer a contrasting rational and accurate way of thinking. Although instant rational rebuttals worked for Albert Ellis, for most counselors, immediately disputing your clients’ global, internal, and hopeless cognitions will create resistance. Instead, you should return to an empathic response.

Counselor: I hear you saying that, right now, you don’t think counseling can help. You feel completely hopeless, like your life sucks and is never going to change and you just want it to end.

Staying empathic—even though you know that later you’ll be targeting your client’s hopeless distorted thinking—requires accurately reflecting your clients’ hopelessness. You may even use a tiny bit of motivational interviewing amplification (i.e., using the phrase, “never going to change” could function as an amplification). What’s important to remember about this strategy is that mirroring your clients’ hopelessness will likely stand in stark contrast to what your clients have been experiencing in their lives. In most situations, if your clients have spoken about their depression and suicidality with friends or family, they will have heard responses that include reassurance or emotional minimization (e.g., “I’m sure things will get better” or “You’re a wonderful person, you shouldn’t think about suicide” or “Let’s talk about all the blessings you have in your life”).

Remaining steadily empathic with clients as they express hopelessness is an intentionally different and courageous way to do counseling. Staying empathic means that you’re sticking with your clients in their despair. You’re not running from it; you’re not minimizing it; you’re not brushing it aside as insignificant. Instead, you’re resonating with your clients’ terribly depressive and suicidal cognitive and emotional experiences.

If you choose the courageous and empathic approach to counseling, you need to do so with the conscious intention of coming alongside your clients in their misery. Following the empathic path can take you deep into depressive ways of thinking and emoting. This can affect you personally; you may begin adopting your clients’ impaired depressive thinking and then feel depressed yourself. Part of being conscious and intentional means you’re choosing to temporarily step alongside and into your clients’ depressive mindset. You need to be clear with yourself: “I’m stepping into the pit of depression with my client, but even as I’m doing this, my intention is to initiate Socratic questioning or cognitive restructuring or collaborative problem-solving when the time is right.”

The next question is: “How long do you need to stay alongside your client in the depressive mindset?” The answer varies. Sometimes, just as soon as you step alongside your clients’ hopelessness, they will rally and say something like, “It’s not like I’m completely hopeless” or “Sometimes I feel a little hope here or there.” When your client makes a small, positive statement, your next job is to gently nurture the statement with a reflection (e.g., “I hear you saying that once in a while, a bit of hope comes into your mind”), and then explore (and possibly grow) the positive statement with a solution-focused question designed to facilitate elaboration of the exceptional thought (e.g., “What was different about a time when you were feeling hopeful?”). Then, for as long as you can manage, you should follow Murphy’s (2015) solution-focused model for working with client exceptions. This includes:

  1. Elicit exceptions. (You can do this be asking questions like “What was different. . .” and by using the motivational interviewing techniques of coming alongside or amplified reflection.)
  2. Elaborate exceptions. (You do this with questions like “What’s usually happening when you feel a bit of hope peek through the dark clouds?”)
  3. Expand exceptions. (You move exceptions to new contexts and try to increase frequency, “What might help you feel hope just a tiny bit more?”)
  4. Evaluate exceptions. (You do this by collaboratively monitoring the utility or positivity of the exception, “If you were able to create reminders for being hopeful to use throughout the day, would you find that a plus or minus in your life?”)
  5. Empowering exceptions. (You do this by giving clients credit for their exceptions and asking them what they did to make the exceptions happen, “How did you manage to get yourself to think a few positive thoughts when you were in that conflict with your supervisor?”).

In other cases, you’ll need to stick with your clients’ misery and hopelessness longer. However, because this is a strength-based model and because the evidence suggests that clients who are suicidal sometimes need their counselor to explicitly lead them toward positive solutions, you will need to watch for opportunities to turn or nudge or push your clients away from abject hopelessness.

 

A Sneak Peek at Our Upcoming Suicide Assessment and Treatment Book with the American Counseling Association

Spring Sunrise and Hay

Rita and I are spending chunks of our social distancing time writing. In particular, we’ve signed a contract to write a professional book with American Counseling Association Publications on suicide assessment and treatment planning. We’ll be weaving a wellness and strength-oriented focus into strategies for assessing and treating suicidality.

Today, I’m working on Chapter 6, titled: The Cognitive Dimension. We open the chapter with a nice Aaron Beck quotation, and then discuss key cognitive issues to address with clients who are suicidal. These issues include: (a) hopelessness, (b) problem-solving impairments, (c) maladaptive thinking, and (d) negative core beliefs.

Then we shift to specific interventions that can be used to address the preceding cognitive issues. In the following excerpt, we focus on collaborative problem solving and illustrate the collaborative problem-solving process using a case example. As always, feel free to offer feedback on this draft content.

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Collaborative Problem-Solving

Though not a suicide-specific intervention, problem-solving therapy is an evidence-based approach to counseling and psychotherapy (Nezu, Nezu, & D’Zurilla, 2013). Components of problem-solving are useful for assessing and intervening with clients who are suicidal. As Reinecke (2006) noted, “From a problem-solving perspective, suicide reflects a breakdown in adaptive, rational problem solving. The suicidal individual is not able to generate, evaluate, and implement effective solutions and anticipates that his or her attempts will prove fruitless” (p. 240).

Extended Case Example: Sophia – Problem-Solving

In Chapter 5 we emphasized that clinicians should initially focus on and show empathy for clients’ excruciating distress and suicidal thoughts. However, there often comes a moment when a pivot toward the positive can occur. Questions that help with this pivot include:

  • What helps, even a tiny bit?
  • When you’ve felt bad in the past, what helped the most?
  • How have you been able to cope with your suicidal thoughts?

In response to these questions, clients who are suicidal often display symptoms of hopelessness, mental constriction, problems with information processing, or selective memory retrieval. Statements like, “I’ve tried everything,” “Nothing helps,” and “I can’t remember ever feeling good,” represent cognitive impairments. Even though your clients may think they’ve tried everything, the truth is that no one could possibly try everything. Similarly, although it’s possible that “nothing” your client does helps very much, it’s doubtful that all their efforts to feel better have been equally ineffective. These statements indicate black-white or polarized thinking, as well as hopelessness and memory impairments (Beck et al., 1979; Reinecke, 2006; Sommers-Flanagan & Sommers-Flanagan, 2018).

Pivoting to the Positive

Picking up from where we left off in Chapter 5, after exploring the distress linked to Sophia’s suicide ideation in the emotional dimension, the counselor (John) pivots to asking about the positive (“What helps?”) and then proceeds into a problem-solving assessment and intervention strategy. One clearly identified trigger for Sophia’s suicidal thinking is her parent’s fighting. She cannot directly do anything about their fights, but she can potentially do other things to shield herself from the downward cognitive and emotional spiral that parental fighting activates in her.

John: Let’s say your parents are fighting and you’re feeling suicidal. You’re in your room by yourself. What could you do that’s helpful in that moment? [The intent is to shift Sophia into active problem-solving.]

Sophia: I have a cat. His name is Douglas. Sometimes he makes me feel better. He’s diabetic, so I don’t think he’ll live much longer, but he’s comforting right now.

John: Nice. My memory’s not perfect, so is it okay with you if I write a list of all the things that help a little bit? Douglas helps you be in a better mood. What else is helpful?

Sophia: I like music. Blasting music makes me feel better. And I play the guitar, so sometimes that helps. And volleyball is a comfort, but I can’t play volleyball in my room.

John: Yeah. Great. Let me jot those down: music, guitar, volleyball, and being with your cat. And volleyball, but not in your room! I guess you can think about volleyball, right? And how about friends? Do you have friends who are positive supports in your life?

Although the fact that Douglas the cat has diabetes includes a depressive tone, the good news is that Sophia immediately engages in problem-solving. She’s able to identify Douglas and other things that help her feel better.

Throughout problem-solving, regularly repeating positive coping strategies back to the client is important. In this case, John summarizes Sophia’s positive ideas, and then asks about friends and social support—a very important dimension in overall suicide safety planning.

Sophia: Yeah, but we’re all busy. My friend Liz and I hang out quite a bit. I can walk into her house, and it will feel like my house. But we’re both in volleyball, so we’re both really busy. But our season will end soon. Hopefully that will help.

John: Ok, the list of things that seem to help, especially when you’re in a hard place with your parents fighting: Douglas the cat, music, guitar, and volleyball, and friends. Anything else to add?

Sophia:  I don’t think so.

Often, the next step in collaborative problem-solving is to ask clients for permission to add to the list, thus turning the process into a shared brain-storming session. At no time during the brainstorming should you criticize any client-generated alternatives, even if they’re dangerous or destructive. In contrast, clients will sometimes criticize your ideas. When clients criticize, just agree with a statement like, “Yeah, you’re probably right, but we’re just brainstorming. We can rank and rate these as good or bad ideas later.”

Overall, the goal is to use brainstorming to assess for and intervene with mental constriction. During brainstorming, Sophia and John generated 13 things Sophia could do to make herself feel better. Sophia’s ability to brainstorm in session is a positive indicator of her responsiveness to treatment.

 

2020 Dreams from My Mother

Mom in Chair

By most estimates, moms have had it rough this year. Day care centers are closed and moms are working from home; at the same time they’re homeschooling, keeping their children from watching porn on the internet, and sanitizing everything. And then there’s that former reality television star who perpetually gets himself in the news, rambling in front of cameras about treating the novel coronavirus with disinfectants in the body. In an optimal world, mothers would get celebrated way more than once a year. In a decent world, they’d be able to protect their children from exposure to Donald Trump.

Looking back 50 years or so, my own mother—she’s in a care facility now—was a mysteriously effective role model. She was more submissive than dominant, never hit me or raised her voice, didn’t directly boss anyone around, but indirectly gave my sisters and me VERY CLEAR guidance on what behaviors were expected in our home, and out in the world.

Rarely did my mother explicitly tell us how to behave. But once, when an African American family moved into our all-white neighborhood, she proactively, quietly, and firmly sat my sisters and me down and told us we would always treat them with respect. We did. When my mom got serious, we never questioned her authority.

One time, she was driving and a car squealed past us in a no-passing zone. She sighed, glanced over at me, and said, “I’ll be very disappointed if you ever drive like that.” For the next 5 decades, including my teen years, my friends and family have ridiculed me for my slow, conservative driving. I watch my speedometer, stop at yellow lights, and slow down at uncontrolled intersections. My mother said it once, I remembered what she said, and I still don’t want to disappoint her.

Without a stern word, my mother taught us to love our neighbors (even when they were annoying), showed us how to treat everyone with kindness and respect (even when they didn’t deserve it), and modeled how we could be generous with our time and energy by focusing on the needs and interests of others.

Once, when the family was out watching Paul Newman and Robert Redford in Butch Cassidy and the Sundance Kid, a sex scene started. Immediately, my mom elbowed my dad, and I was ushered from the theater. My mom didn’t want me to see or hear things that might lead me down the wrong path. She would cover my eyes and ears (literally) to stop me from being exposed to negative influences.

All this leads me to wonder how my mother would handle the disastrous role-model-in-chief. Mr. Trump is a mother’s nightmare, spewing out perverted values on a daily basis.

My mother’s first strategy would be to not let me hear whatever terrible ideas Trump gets out of his brain and into his mouth. She would have blocked me from watching news pieces about Mr. Trump’s playboy models, paid off porn stars, shitholes, Pocahontas, pussy-grabbing, gold star families, and references to women as pigs.

As much as my mother would have hated Mr. Trump’s sexist and racist words, she would be even more apoplectic about his poor character. If we saw or heard Mr. Trump counterattacking his critics, she would have sat us down, and talked about how an eye for an eye will leave us all blind.

If my mother caught us reading Trump’s tweets, she would have gathered us around the kitchen table for a spelling lesson. She would explain, “there’s no such word as unpresidented,” the phrase “twitter massages” makes no sense, “smocking guns” is just wrong, “the Prince of Whales” is from Wales, and journalists cannot win the “Noble prize.” She would never allow us to utter the word covfefe in our house.

My mother would be deeply offended by Mr. Trump’s incessant lying. If she were parenting us right now, every day she’d find a way to show us how we should admit our mistakes, take personal responsibility, and resist the temptation to blame others. She would talk about truth-telling. She would explain that Mr. Trump being President is a tragic mistake and that we should all work very hard to make sure this tragic mistake ends, so this malevolent man cannot continue to abuse women, minorities, and the American people.

But, for parents like my mother, Mr. Trump offers small advantages. As a teaching device, horrendous role models work quite well. In the end, and with one sentence, my mother would steal away all of Trump’s past and future influence. She would say, “I’ll be very disappointed if you ever act like that man.”

And we wouldn’t.

 

Happy Habits . . . Episodes 7 and 8

Big Turkey

Hi All,

As the turkeys were strutting around our house in Absarokee, Rita and I finished the final two episodes of Happy Habits for Hard Times. Please share these and the other Happy Habits episodes with people who you think might be interested. https://coehs.umt.edu/happy_habits_series_2020/default.php

Here’s Episode 7: Stop, Look, and Listenhttps://coehs.umt.edu/happy_habits_series_2020/hhs_module_seven.php

Here’s Episode 8: Persistence, Resilience, and Joyhttps://coehs.umt.edu/happy_habits_series_2020/hhs_module_eight.php

Our BIG thanks for inspiration and assistance on this project to Adrea Lawrence, Dean of the Phyllis J. Washington College of Education of the University of Montana, Eric Vorkoeper and Breanna Niekamp, both of UMOnline.

Have a fabulous weekend.

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