All posts by johnsommersflanagan

Clinical Interviewing, Cool Counseling, Suicide Assessment and Intervention

Building Hope from the Bottom Up

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One more freebie in honor of suicide prevention month.

Building hope from the bottom up is one of the strengths-based suicide assessment and treatment techniques clinicians like best. I may be forgetting that I’ve already posted this here, but the approach is so popular that I’ll take that risk. Here’s the section for our Strengths-Based Suicide book . . .

Working from the Bottom Up to Build a Continuum of Hope

When clients are depressed and suicidal, they often think and talk about depressing thoughts and feelings. We shouldn’t expect otherwise. Even so, when clients ruminate on the negative, it fogs the window through which positive feelings and experiences are viewed. Within counseling, a potential conflict emerges: although clinicians want clients to problem-solve, focus on their strengths, and have hope for the future, clients are unable to generate solutions, can’t focus on their strengths or positive attributes, and seem unable to shake their hopelessness.

As discussed earlier in the case of Sophia, after an initial discussion of suicidality, there may come a natural time to pivot to the positive. One common strength-based tool for exploring what helps clients overcome their suicidality is a solution-focused question (Sommers-Flanagan, 2018a). If you’re working with a client who has made a previous attempt, you might ask something like “You’ve tried suicide before, but you’re here with me now, so there’s still a chance for a better life. What helped in the past?”

Although this is a perfectly reasonable question, the question may fall flat, and your client might respond with a hopelessness statement, “Nothing really ever helps.” This puts you in a predicament. Should you use Socratic questioning to identify a cognitive distortion? Should you interpret the distorted thinking in the here-and-now? Or should you retreat to empathy?

No matter what theoretical model you’re using, the predicament of how to deal with client non-responsiveness, negativity, or cognitive distortions remains. Let’s say you’re operating from a solution-focused or strength-based model and you ask the miracle question:

I’m going to ask you a strange question. What if, after we get done talking, you go back to doing your usual things at home, go to bed, and get some sleep. But in the middle of the night, a miracle happens, and your feelings of depression and suicide go away. You were asleep, and so you don’t know about the miracle. When you wake up, what will be the first thing you notice that will make you say to yourself, “Wow. Something amazing happened. I’m no longer depressed and suicidal.” (adapted from Berg & Dolan, 2001, p. 7).

Although the miracle question might do its magic and your client will respond with something positive, it’s equally possible that your client will say something like, “Not possible” or “The only way that would happen would be if I died in the night.” When clients are pervasively negative and hopeless, one error clinicians often make is to get into a yes-no questioning process that looks something like this:

Counselor: I’m sure there must be something that helps you feel more positive.

Client: I can’t think of anything.

Counselor: How about time with friends, does that help?

Client: No. I don’t have any real friends left.

Counselor: How about exercise?

Client: I can’t even get myself to exercise.

Counselor: Being in the outdoors helps with depression. Does that help?

Client: Nope.

Counselor: Have you tried medications?

Client: I hate medications. They made me feel like a zombie.

Entering into this exchange is unhelpful. In the end, both you and your client will be more depressed. Rather than continuing to ask what helps, try changing the focus to what doesn’t help. This shift is useful because when clients are experiencing suicidal depression, they’re more likely to resonate with negativity, and connecting with your client at the negative bottom is better than not connecting at all. The goal is to collaboratively build a continuum from the bottom up. By starting at the bottom, you’re simultaneously assessing hopelessness and intervening on the “Black-black” (as opposed to black-white) distorted thinking that you’re witnessing in session. Here’s an example:

Counselor: You’ve tried lots of different strategies to deal with your suicidal thoughts, without success. You’ve tried medications, exercise, and you’ve talked to your rabbi. Let’s list these and other things you’ve tried, and see which strategies were the worst. Of all the things you’ve tried, what was worst?

Client: I really hated exercising. It felt like I was being coerced to do something I’ve always hated. And it made me sore.

Counselor: Okay then. Exercise was the worst. You hated that. Of the other things you’ve tried, what was a little less bad than exercising?

Client: The medications. I just didn’t feel like myself.

Counselor: So that didn’t work either. So, of those three things, talking with your rabbi was the least bad?

Client: Yeah. It didn’t help much. But she was nice and supportive. I felt a little better, but I didn’t want to keep talking because she’s busy and I was a burden.

Focusing on the worst option resonates with a negative emotional state. For clients who are unhappy with the results of previous therapeutic efforts, beginning with the most worthless strategy of all is an easier therapeutic and assessment task, provides useful information, and is usually answered quickly. Subsequently, clinicians can move upward toward strategies that are “just a little less bad.” Building a unique continuum of what’s more and less helpful is the goal. Later, you can add new ideas that you or your client identify, and put them in their place on the continuum. If this approach works well, together with your client you will have generated several ideas (some new and some old) that are worth experimenting with in the future.

Beginning from the bottom puts a different spin on the problem-solving process. Even extremely depressed clients can acknowledge that every attempt to address their symptoms isn’t equally bad. Using a continuum is a useful tool for working with hopelessness and is consistent with the CBT technique, “Thinking in shades of grey.”

Clinical Interviewing, Personal Reflections, Suicide Assessment and Intervention

Welcome to Enterprise, Oregon

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I’m in Enterprise, Oregon today and tomorrow morning. I got here Sunday evening after a winding ride through forests and mountains. Yes, I’m in Eastern Oregon. Even I, having attended Mount Hood Community College and Oregon State University, had no idea there were forests and mountains in Enterprise.

The scenes are seriously amazing, but the people at the Wallowa Valley Center for Wellness-where I’m doing a series of presentations on suicide assessment and prevention-are no less amazing. I’ve been VERY pleasantly surprised at the quality, competence, and kindness of the staff and community.

Just in case you’re interested, below I’m posting ppts for my three different presentations. They overlap, but are somewhat distinct.

Here’s the one-hour intro:

final-enterprise-suicide-one-hourDownload

Here’s the two-hour session for clinicians and staff:

final-enterprise-two-hours-9-20-22Download

Here’s the upcoming 90 minute session for the community:

final-community-happiness-for-enterprise-2022Download

And here’s a view!

Clinical Interviewing, Suicide Assessment and Intervention

A Free, One-Hour Video on the Strengths-Based Approach to Suicide Assessment and Treatment

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Earlier this year I was asked by a school district to create and record a one-hour training on strengths-based suicide assessment. I made the recording, shipped it off, got paid, and mostly forgot about it. However, because I have the recording and sometimes I think it’s good to give things away, I’m sharing the link here: https://youtu.be/kLlkh8nJ2pI

The video is about 62 minutes, recorded on Zoom, and slightly oriented toward school counselors and school psychologists. I’m sharing this video just in case it might be useful to you in your teaching or for your clinical group or personal knowledge, etc. Feel free to share the link.

If you feel you benefit from this video, I hope you’ll consider the “pay it forward” concept. No need to pay me . . . just notice opportunities where you can share your gifts and talents and resources with others and pay it forward.

Clinical Interviewing, Suicide Assessment and Intervention

Working in the Emotional Dimension with Clients who are Suicidal

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In honor of National Suicide Prevention Month, I’m offering another chunk of information about suicide assessment and treatment. This information is an excerpt from our book, Suicide Assessment and Treatment Planning: A Strengths-Based Approach. In the book, we discuss assessment and treatment planning using a dimensional approach. The first (and central) dimension for suicide assessment and treatment is the emotional dimension.

To get a bigger sense of the topic, you can read 33 pages of the book for free on Google Books: https://www.google.com/books/edition/Suicide_Assessment_and_Treatment_Plannin/bOQUEAAAQBAJ?hl=en

Here’s the excerpt:

Working in the Emotional Dimension

When clients are depressed and suicidal, everyone—including family, friends, co-workers, counselors, and clients—wish for an improved emotional state. But often the process is slow, and as a result, the very people upon whom the client relies for support may lose patience. Supportive people, even counselors, may feel urges to say things that are emotionally dismissive, like, “Cheer up” or “Come on, you need to exercise!” or “Why can’t you do something to make your life better?”

Moving clients out of despair and into the light is difficult; if it were otherwise, clients would resolve suicidality on their own. Directly or indirectly suggesting to clients in suicidal pain to “cheer up” often backfires, creating anger, hostility, and resistance to treatment; this resistance is a powerful phenomenon called, psychological reactance(Brehm & Brehm, 1981).

Psychological reactance occurs when clients perceive their ultimate freedoms as threatened. If clients sense that clinicians want to coerce them to stay alive, in response, they may dig in their heels and engage in behaviors designed to restore feelings of autonomy. Psychological reactance is one explanation for why clients who are suicidal sometimes vehemently resist help, insisting on their right to think about and act on suicidal impulses. Repeated empathic acceptance of the client’s emotional pain is one way to avoid activating reactance; empathic acceptance also allows clients to begin exploring and addressing key emotional issues in counseling.

Key Emotional Issues to Address

Many emotional issues are relevant to suicide treatment planning. These include: (a) excruciating distress, (b) specific disturbing emotions, such as, acute or chronic shame and guilt, anger, or sadness, and (c) emotional dysregulation. In this next section, we briefly review core emotional issues that you may guide your treatment planning. Later in the chapter we provide case examples and vignettes illustrating methods for working in the emotional dimension.

Excruciating Distress

Shneidman referred to the emotional state surrounding suicide as “psychache” or unbearable distress. He wrote: “The suicidal drama is almost always driven by psychological pain, the pain of negative emotions—what I call psychache. Psychache is at the dark heart of suicide; no psychache, no suicide.” (2001, p. 200, italics added).

Even when using a strength-based or wellness model, exploring the “pain of negative emotions” or excruciating distress is usually your first focus. Sometimes, to avoid activating reactance or resistance, you’ll need to stay with your client’s emotional pain longer than you’d prefer. Staying with your clients’ pain not only helps bypass resistance, it also models that facing negative affective states without fear, avoidance, or dissociation requires personal strength. Even so, as you focus on suicidal pain, you might wish the client would immediately adopt a more positive mindset, or find the process difficult to bear. You also might need to turn to colleagues or your self-care plan for support. Nevertheless, job one in the emotional dimension is to recognize and resonate with your client’s emotional pain.

Acute or Chronic Shame and Guilt

Shame and guilt are non-primary emotions because they involve significant self-reflection. Shame connotes beliefs of being unworthy, defective, or bad. Shame is often directly linked to core beliefs about the self, and activated by particular life situations. In contrast, guilt is more specific, often associated with certain actions or lack of actions (e.g., “I should be doing more to fight racism” or “I shouldn’t have been so critical of my professor”). Generally, guilt can lead to shame, and shame is more likely to ignite suicidality. Reducing or resolving shame or guilt may be a crucial therapeutic goal.

Suicidal thoughts are often accompanied by shame. Cultures around the world have historically judged death by suicide as a shameful or sinful event, and many still do. Your client’s experience may be something like, “Not only do I have suicidal thoughts—which are terrible in their own right—but the fact that these thoughts exist in my mind also make me a bad person.” This double dose of negative judgment, emotional pain plus self-condemnation, often needs to be addressed in counseling. One strategy that may fit into your treatment plan is to help clients develop greater self-compassion as a method for countering their self-condemnation.

Anger

            In graduate school, we had a professor who suggested we consider this question: “Who is this client planning to commit suicide at?” Often, people who are suicidal carry great anger toward one or more friends, lovers, or family members and thus think of suicide as an act of revenge. Counselors should listen for underlying themes that involve using suicide as a behavioral goal for getting even or intentionally hurting others (Marvasti & Wank, 2013).

            Thoughts of dying by suicide sometimes emerge as a revenge fantasy. Thoughts like, “I’ll show them” or “they’ll suffer forever” represent anger, along with the desire to punish others. It can be tempting to point out to clients that death is an irrationally high price for fulfilling revenge fantasies. However, helping clients express, accept, and understand the depth of their anger will usually reduce suicidality more efficiently than pointing out that death is a maladaptive revenge strategy. If revenge is central and forgiveness isn’t a viable option, then an apt philosophy to gently infuse into your clients is that the best revenge is a well-lived life.

Sadness

            Major depression is the psychiatric diagnosis most commonly linked with suicide attempts, especially among older adults (Melhem et al., 2019). Clients who present with sadness as a dominant emotion may or may not meet diagnostic criteria for major depression. However, when sadness and the associated emotions and cognitions of irritability, regret, discouragement, and disappointment are central sources of distress, we recommend targeting those symptoms with evidence-based counseling interventions. Weaving positive psychology or happiness interventions into treatment planning is especially appropriate for clients struggling with sadness and depression (Seligman, 2018; Rashid & Seligman, 2018). More information about evidence-based approaches and positive psychology interventions is provided later in this chapter and in upcoming chapters.

Emotional Dysregulation

Clients who are suicidal may exhibit emotional dysregulation during counseling sessions and in their everyday lives. Clients may be emotionally labile, shifting from expressing anger to feelings of affection, appreciation, and deep connection. Clients may share stories of repeated maladaptive emotional overreactions to life’s challenges. Although unstable relationships, emotional swings, and explosive anger fit with the diagnostic criteria for borderline personality disorder, when clients are experiencing excruciating distress, they may behave in ways that resemble borderline personality disorder. However, instead of pathologizing clients with a personality disorder diagnosis, we recommend framing client behaviors using a social constructionist strength-based orientation, such as: Given enough situationally-based stress, including, as Linehan (1993) noted—emotionally invalidating environments—nearly everyone becomes dysregulated and appears unstable. Normalizing dysregulation as a natural response to intense distress helps maintain a strength-based perspective.

Treatment plans for clients who are suicidal often include teaching emotional regulation skills; this translates to helping clients become more capable of regulating themselves in the face of emotionally activating circumstances. Linehan’s (1993, 2015) protocols for working with clients with borderline personality characteristics are recommended for emotional regulation skill development. However, alternative approaches exist, some of which come from positive psychology, happiness, and well-being literature (Hays, 2014; Lyubomirsky, 2007, 2013; see Wellness Practice 4.1).

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice, Suicide Assessment and Intervention

Free Informational Stuff on Suicide in Honor of Suicide Prevention Month

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Rita has slipped away with a friend to go to a Tippet Rise (https://tippetrise.org/events/36201) concert. IMHO, Tippet Rise has amazing concerts. As a means to cope with my jealousy, I’ve decided to pass along a couple of freebies I found in my email inbox. Given that most of the freebies I receive in my inbox are related to someone who wants to trick me into becoming a few hundred million bucks richer, rest assured, I’ve screened out the fake-freebies, and have vetted these.

First, from Dr, Thomas McMahon of Yale University. He wrote about a free eBook:

Youth Suicide Prevention and Intervention offers a comprehensive review of current research on the public health crisis and best practices to prevent youth suicide.  The volume was edited by John P. Ackerman, PhD from the Center for Suicide Prevention and Research at Nationwide Children’s Hospital and Lisa M. Horowitz, PhD, MPH from the National Institute of Mental Health.  It includes 18 chapters organized into five sections on (a) foundations for suicide prevention, (b) prevention and postvention in school settings, (c) screening and intervention with suicidal teens, (d) prevention and intervention for special populations, and (e) the development of more effective systems of prevention.

With support provided by Nationwide Children’s Hospital Foundation and Big Lots Behavioral Health Services, the volume is available in an open access format.  An electronic copy of specific chapters or the entire volume can be downloaded free of charge here.

Second, Amanda DiLorenzo-Garcia, Ph.D, of the University of Central Florida shared info about a free virtual symposium. Here’s what she wrote:

In honor of suicide prevention month, the Alachua County Crisis Center hosts a free mental health symposium. It is an incredible resource for counseling students, counselors, parents/guardians, teachers, first responders, etc. Therefore, it is open to the community at large. 

This year the symposium is titled Holding Space Together: Addressing the Mental Health Needs of 2022. Topics vary and include suicide prevention, parenting, mindfulness, black mental health, burnout, tapping skills, ADHD, etc. The sessions will take place September 12-15th, 2022 between 5:30-8:30pm EST virtually. Sessions are facilitated by Alachua County Crisis Center staff, community agency mental health providers, and Counselor Education faculty from various institutions. The information is geared toward the general community; however, there are sessions that counselors and counseling students may benefit from attending as well.  

  1. A schedule of the sessions can be found here.
  2. Registration is FREE.
  3. Symposium website.
  4. Flier to share.

Third and last, I’m pasting a copy of a section on “Working in the Behavioral Dimension” from our book, Suicide Assessment and Treatment Planning: A Strengths-Based Approach (for the whole book, which is sadly not free, see here: https://imis.counseling.org/store/detail.aspx?id=78174 or here: https://www.amazon.com/Suicide-Assessment-Treatment-Planning-Strengths-Based-ebook/dp/B08T7VNCMK/ref=sr_1_2?qid=1662160075&refinements=p_27%3ARita+Sommers-Flanagan&s=digital-text&sr=1-2&text=Rita+Sommers-Flanagan)

That’s all for now. The book section is below. Have a great holiday weekend . . .

John S-F

Working in the Behavioral Dimension

When times are difficult and life feels intolerable, many people think about suicide as an alternative to life. But most individuals, despite intense emotional and psychological pain, don’t act on their suicidal thoughts. In fact, people often cling to life even in the face of great pain. Philosophers, suicidologists, and evolutionary biologists all point to the likelihood that humans are genetically predisposed toward survival (Glasser, 1998).

For a variety of biological, psychological, and environmental reasons, it’s usually easier to get people to experiment with new behaviors than it is to get them to stop engaging in their old, habitual behaviors. As children, you may have been repeatedly told “don’t smoke, don’t drink, don’t date that person, and don’t you dare miss your curfew again.” But often, those admonitions didn’t stick. Given how difficult it is to successfully get people to comply with prohibitions makes the “don’t act on suicide impulses” goal of this chapter an arduous task.

This chapter isn’t so much about telling people what not to do, as it is on helping them identify and act on alternative behaviors. Our aim is to stay primarily strength-based, helping clients flood their personal lives with positive behaviors. We’ll review and describe methods for building healthy behavior patterns, developing positive safety plans, and more.

Key Behavioral Issues to Address

The empirical research is thin, but several near-term predictors of suicidal behavior have been identified. These include: (a) active suicide planning or intent, (b) dispositional pain insensitivity and acquired suicide capability, (c) impulsivity, and (d) access to lethal means (Joiner, 2005; Klonsky & May, 2015; O’Connor, 2011).

            Suicide Planning or Intent

Suicide ideation is common—especially among clients and students who are experiencing depressive symptom. But early everyone who thinks about suicide, chooses not to act on their thoughts.

Suicide planning is a step closer to action. When clients have suicide plans, their ideas have taken shape into potential behaviors. Typically, clients who have plans that include greater specificity, higher lethality, more accessibility, and less chance of being prevented are at higher risk. Nevertheless, most clients who have suicide plans don’t act on them.

Suicide intent—although still in the realm of thought—implies enactment of a plan. Suicide intent is especially disturbing when associated with repeated suicide attempts or rehearsal of specific suicide methods. Mentally rehearsing or physically practicing suicide behaviors makes the manifestation of those behaviors more likely. However, when intent is high, planning and rehearsing may not be required; given an opportunity, clients with extremely high intent may spontaneously and impulsively jump from moving cars, dash into heavy traffic, throw themselves into bodies of water, or find whatever means they can to end their lives.

Clients with high suicide intent sometimes require hospitalization and may need to be on safety watch. Pulling clients back from the suicidal edge and modifying their intent is frightening, but potentially gratifying. If you work with clients who have extremely high intent, remember to focus on your own safety and find support for potential vicarious traumatization.

            Suicide Desensitization or Acquired Capability

Some individuals are unusually fearless and sensation-seeking from birth. O’Connor (2011) refers to this as dispositional pain insensitivity. In contrast, other individuals, born with normal pain sensitivity and a normal aversion to death can, over time, achieve what Joiner (2005) called acquired capability; this process is also called suicide desensitization. Joiner wrote: “The capability to act on (suicidal) desire is acquired over time through exposure to painful and provocative events” (2005, p. 3).

The predisposition to fearlessness and high pain tolerance likely has biogenetic roots (Klonsky & May, 2015). In such cases, psychosocial therapeutic strategies are limited. Identifying high-risk and high-vulnerability situations and activities and then working collaboratively with clients on appropriate coping strategies may be the best treatment option.

Clients who have acquired capability have become desensitized to suicide over time (Joiner, 2005). Desensitization can be unintentional or intentional. Repeated trauma or exposure to chronic physical pain can produce desensitization. Alternatively, self-mutilation and substance abuse and dependence are intentional behaviors that produce numbness and can reduce fear of pain and suicide.

Impulsivity

            Clients who are highly impulsive tend to act suddenly, without planning, and without reflective contemplation. Impulsivity can be examined as a trait—individuals who display a pattern of acting without planning and do so across time and different circumstances have trait impulsivity. Impulsivity can also be situationally triggered; ingesting alcohol, being around certain people, or being in particular situations can magnify impulsivity.

            Clients diagnosed with bipolar disorder, borderline personality disorder, and substance use disorders are more inclined toward impulsive behavior patterns and suicide. Effective treatments of impulsivity are limited. Some possibilities include (a) dialectical behavior therapy (Linehan, 1993), (b) lithium (Cipriani et al., 2013), and (c) individual or group treatment for substance abuse (López-Goñi et al., 2018).

            Access to Lethal Means

            Easy availability of lethal means increases suicide risk. Firearms are far and away the most lethal suicide method. Although firearms can quickly become a politicized issue, access to firearms unarguably magnifies suicide risk (Anestis & Houtsma, 2018). Other common and lethal suicide methods include poisoning (using pills or carbon monoxide) and suffocation/asphyxiation. Reducing access to lethal means or enhancing firearms safety are common strategies that reduce immediate suicide potential.

Happiness, Writing

Redundancy, Again

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One of my long-time friends from graduate school in the 1980s had lots of corny, pithy, and funny commentary on life. He was adept at noticing when professors repeated themselves, often snarking that particular professors had graduated from the “Department of Redundancy Department.” I enjoyed his commentary so much that I forgot to snarkily notice the redundancy of his jokes.

Somewhat later, another colleague told me of his educational motto: “Redundancy works!” After years of counseling and doing presentations, he decided that most people aren’t listening very well and so saying things over and over gives teachers and counselors a better chance of being heard and remembered.

Back when we lived in Great Britain for several fortnights, we learned that the Brits used the term redundant to refer to employee layoffs. For example, when employers cut staff, they referred to staff as having become redundant (or unneeded), and consequently, unemployed.

I bring up redundancy today because I’m posting two things here that are almost exactly the same as what I posted earlier this week. Yesterday and today, I had and have the honor of presenting to STEM graduate students from Montana Tech (yesterday) and the University of Montana (today) on how to integrate a few happiness skills into their lives. The handouts (below) are virtually identical to those I provided on Monday (for the Belgrade Teacher presentation) . . . and so you should bear in mind that I’m clearly a graduate of the Department of Redundancy Department because I’ve learned that Redundancy Works! . . . and I’m hoping I’ve not quite become redundant myself.

To summarize (again). . .

The HOPES Powerpoints are here:

happiness-for-hopes-2022Download

The HOPES Handout is here:

hopes-happiness-handout-2022Download

Have a great weekend!

John SF

Happiness

Evidence-Based Happiness for Belgrade Schools: Advice is Cheap, but Knowledge is Power

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Tomorrow I’ll be in Belgrade, Montana.

Back in May I received an email from a Belgrade High School AP Biology teacher asking if I could present to Belgrade teachers on mental health. The details have worked out. I’m super-excited to do this for several reasons:

  • I’m very passionate about supporting teacher mental health and well-being. For as long as I can remember (but especially during these past three years), teachers have been over-stressed, over-worked, under-paid, and under-appreciated. I even happen to have a grant proposal submitted that would give teachers access to very low-cost graduate credit on an Evidence-Based Happiness course. Happiness knowledge and mental health support for teachers is essential.
  • Education is the central “plank” on my personal political platform. IMHO, to quote myself, “The road to economic vitality, the road to environmental sustainability, the road to excellence in health care and social programs, and the road to good government always has and always will run through education.” We need excellent teachers and we need excellent public education. We need it now more than ever.
  • Belgrade is conveniently located just off I-90, a freeway that I regularly drive on my way from Missoula to Absarokee and back again.
  • And best of all, I’ll get to see the famous Nick Jones. Nick is a cool Aussie transplant, a former Carroll College basketball player, and a graduate of our M.A. program at the University of Montana. He also happens to be a school counselor at Belgrade High School.  

The ppts for tomorrow’s presentation are here:

happiness-for-belgrade-2022Download

And here’s a one-page handout/summary:

belgrade-happiness-handout-2022Download

My big theme will be that although advice is cheap, knowledge is power. We all benefit from knowing more about mental health and happiness. One of my main topics will involve information on understanding sleep. . . because we all have better mental health when we sleep well.

See you in Belgrade tomorrow!

Happiness

Upcoming Happiness and Strengths-Based Suicide Events

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This is the flyer/registration form for Montana Tech in Butte. The link for the UM – Missoula workshop is below in the blog post.

Next week, the Montana Happiness Project and the Families First Learning Lab have a variety of educational offerings. I’ve listed them below, along with links that can provide additional information.

If you’re a STEM grad student at the University of Montana, and you want to attend a short (2.5 hour) evidence-based happiness workshop on Friday, August 26 (and get a free lunch), click on this link for more information and to register. https://umt.co1.qualtrics.com/jfe/form/SV_3yjFgwKqfmE7Qt8

As you can see below, I’m doing the same workshop for Montana Tech in Butte on Aug 25.

If you’re working with an organization that might want a speaker on happiness or strengths-based suicide assessment and treatment, you should check out the Montana Happiness Project “Speaker” page: https://montanahappinessproject.com/speakers . . . and contact us to let us know of your interest.

Okay. Here’s the list of events for Aug and Sept.

August 23, 2022 – John Sommers-Flanagan presents on “The art and science of happy teachers” to the Belgrade School staff. Belgrade, MT.

August 25, 2022 – Dylan Wright presents on “Parent Engagement” to the Youth Dynamics staff. Webinar.

August 25, 2022 – John Sommers-Flanagan presents on “Evidence-based happiness skills” to the Montana HOPES Project at Montana Tech. Butte, MT.

August 26, 2022 – John Sommers-Flanagan presents on “Evidence-based happiness skills” to the Montana HOPES Project at University of Montana. Missoula, MT.

September 1, 2022 – Dylan Wright presents on “The Art, Science, and Practice of Meaningful Happiness” for Mountain Home staff. Missoula, MT.

September 20, 2022 – John Sommers-Flanagan presents on “Suicide assessment and treatment: A strengths-based approach” for the Wallowa Valley Center for Wellness. Enterprise, OR.

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice, Ethics, Personal Reflections, Writing

Informed Consent in Counseling and Psychotherapy: Problems and Potential

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A quick review of recent informed consent research leads me to think that informed consent should be a perfect blend of evidence-based information about the benefits, risks, and process of psychotherapy. Like all good hypnotic inductions, informed consent, has the potential to stir positive expectations or activate fear. But when I look at all that we’re supposed to include in informed consents I wonder, does anyone really read them? Informed consent could have significant effects on treatment process and outcome. But only if clients actually read the written document.

The alternative or a complementary strategy is a good oral description of informed consent. Again, as someone trained in hypnosis and sensitive to positive placebo effects, I’m inclined to use informed consent to set positive expectations. I think that’s appropriate, but it’s also easy for us, as practitioners, to become too enthusiastic and unrealistic about what we have to offer. The truth is that no matter how much passion I may have for a particular intervention, if there’s absolutely no scientific evidence to support my niche passion, and there is evidence to support other approaches, then I could come across like someone promoting ivermectin for treating COVID-19. If you think about the people who promote ivermectin, it’s likely they’re either (a) uninformed/misinformed and/or (b) profit-driven. To the extent that all professional helpers or healers aim to be honest and ethical in our informed consent processes, we should strive to NOT be uninformed/misinformed and to NOT be too profit-driven. I say “too profit-driven” because obviously, most clinical practitioners would like to make a profit. All this information about being balanced in our informed consent highlights how much we need to read and understand scientific research related to our practice and how much we need to check our enthusiasm for particular approaches, while remaining realistic, despite potential financial incentives. 

Informed Consent: Who Reads Them? Who Listens?

If informed consents are difficult to read and comprehend, they may be completely irrelevant. On the other hand, in their obtuseness, they may function like the confusion technique in hypnosis and psychotherapy. Although the confusion technique is pretty amazing and I’ll probably write more about it at some point, it’s inappropriate and unethical to use the confusion technique in the context of informed consent.

In medical and some therapy settings, informed consent often feels sterile. If you’re like me, you quickly sign the HIPAA and informed consent forms, without taking much time to read and digest their contents. The process becomes perfunctory. 

I recall a particularly memorable pre-surgery informed consent experience. After hearing a couple of low probability frightening outcomes and experiencing the sense of nausea welling up in my stomach, I stopped listening. I even recall saying to myself, “I can choose to not listen to this.” It was an act of intentional dissociation. I knew I needed the surgery; hearing the gory details of possible bad outcomes only increased my anxiety. Here’s a journal article quote supporting my decision to stop listening, “Risk warnings might cause negative expectations and subsequent nocebo effects (i.e., negative expectations cause negative outcomes) in participants” (Stirling et al., 2022, no page number)

Informed consent flies under the radar when clients or patients stop listening. Informed consent also flies under the radar because many people don’t bother reading them. In our theories textbook we have nice examples of how therapists can write a welcoming and fantastic informed consent that cordially invites clients to counseling. Do these informed consents get read? Maybe. Sometimes.

Informed consent has the potential to be powerful. To fulfill this potential, we need to contemplate on big (and long) question: “How can we best and most efficiently inform prospective clients about psychotherapy and maintain a balanced, conversational style that will maximize client absorption of what we’re saying, while appropriately speaking to the positive potential of our treatment and articulate possible risks without activating client fears or negative expectations?”

Here’s an abbreviated guide: Provide essential information. Use common language. Be balanced.

For example:

“Most people who come to counseling have positive responses and after counseling, they’re glad came. A small number of people who come to counseling have negative experiences. If you begin to have negative experiences, we should talk directly about those. Sometimes in life, confronting old patterns and talking about emotionally painful memories will make you feel bad, sad, or worse, but these negative feelings should be temporary. Getting through negative or difficult emotions can open us up to positive emotions. My main message to you is this: No matter what you’re experiencing in counseling, it’s good and important for you to share your thoughts, feelings, and reactions with me so we can make the adjustments needed to maximize your benefits and minimize your pain.”

I could go on and on about informed consent, but that might reveal too much of my nerdiness. These are my reflections for today. Tomorrow may be different. I just thought I should inform you in advance that consistency may not be my forte.

Happiness, Personal Reflections

Five Buck Friday Consults: Tips on Presenting to an Organization that Works with Parents

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Albert Ellis used to offer “Five Buck Friday” night presentations in New York. What a cool idea. People would show up and he would teach them Rational Emotive Behavior Therapy (REBT).

I do lots of presentations. I like to think I do lots of presentations because I’m good at doing presentations, but I also know I’m not a perfect presenter and need to be consistently open to feedback and new learning. Anyway, lately I’ve been doing more consultations with young professionals on how to do presentations. This humbling new “gig” is related to our work on the Montana Happiness Project (click here for to see the MHP website: https://montanahappinessproject.com/). Our MHP vision is: “To help create a world where people listen to and value one another while also living lives that are personally meaningful and saturated with eudaimonic happiness.” To help move toward our vision, Rita and I are doing more training of young professionals who want to help infuse more positivity and happiness into the challenges of life.

The young professionals are amazing. Sometimes I wonder when they sleep. Today, as part of supervising and consulting one of our amazing presenters, I responded to some specific questions he posed in an email.

This is my free blog-version of Ellis’s Five Buck Friday consultation.

Dear John

The staff of this organization works directly with parents. Some things they struggle with are listed below:

  1. The staff struggles with self-regulation
  2. The staff would like to be able to be curious (and not activated) when a parent is yelling at their kid, etc.

I’m glad you got this information. One key to a great presentation is to dovetail the process and content to meet the group’s specific goals.

Issues 1 and 2 are great topics to focus on in a staff training/presentation. Self-regulation is almost always adversely affected when there are surprise triggers. Although break-out groups would be good for discussing staff triggers, because the director said the staff doesn’t like break-out groups, you could do live polling on the staffs’ “buttons” or triggers. The goal would be for staff to become very familiar with personal triggers so they can develop a plan for their “best possible responses” to their triggers, and then practice their best possible responses with imagery and rehearsals or role plays. You can’t be curious (Item 2) unless you’re READY for the trigger and have a plan for what your curiosity will look like.

The other issue is that sometimes the staff will need to enforce behavioral limits. When presenting, you are the parent/role model; when working with parents, the staff members are the parent/role model figures. They need to be clear on inappropriate parental behaviors and have a plan for setting and enforcing limits will help them (and possibly the parents) with self-regulation. As I sometimes say about nightmares and tantrums, it helps when the adult “looks forward” to the dreaded incident/trigger. I know that sounds weird, but the incident is inevitable anyway and when it occurs, it provides an unparalleled opportunity to try out the new plan.

In the context of Family Based Services, the staff could use help with:

  1. How to engage when parents don’t want to be there.
  2. Going to be transitioning to going back into the homes of clients – this could be hard on clients and counselors.

Using a positive or meaningful frame for parents who are “involuntary” or un-enthused about therapy is essential. Below I’ve listed and described some positive framing ideas and a couple strategies that might help.

  • Thank the parent for being there.
  • If the parent appears negative or reluctant, thank them even more sincerely and with empathy by acknowledging the reality in the room (e.g., “I REALLY appreciate you being here especially because I can see you don’t feel like being here.” – Obviously tweak that wording and all other wordings to fit your own style.)
  • Identify at least one positive reason why the parent showed up (e.g., “You must really love your son/daughter to get yourself here to work with me even when you don’t feel like it.” Or, “Lots of parents don’t follow through on the commitment to show up for these sessions. I really appreciate you showing up. It tells me how committed you are to doing the right thing and being here to do the work.”)
  • Bring gifts. Find out the parents’ favorite non-alcoholic drinks and bring them along. Find out their favorite salty snack and bring it along. Hardly anything calms irritability better than sincere positive gestures that include food😊.
  • Listen, listen, and listen to the parent’s perspective and complaints and paraphrase the heck out of them before moving on to issues of substance.
  • Before, during, and after you share these ideas in your presentation, be sure to be prompting the group to add to the list, while acknowledging how much insight there is in the room.
  • Consider helping the staff to establish a positive family-based therapy dynamics checklist to think about before doing family sessions.

I hope this info is helpful!

JSF