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.
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.
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:
- 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.)
- Elaborate exceptions. (You do this with questions like “What’s usually happening when you feel a bit of hope peek through the dark clouds?”)
- Expand exceptions. (You move exceptions to new contexts and try to increase frequency, “What might help you feel hope just a tiny bit more?”)
- 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?”)
- 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.