All posts by johnsommersflanagan

Clinical Interviewing, Suicide Assessment and Intervention

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

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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.

 

Cool Counseling, Counseling and Psychotherapy Theory and Practice, Suicide Assessment and Intervention, Therapy with Adolescents, Writing

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

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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.

 

Boys and Men, Love, Parenting, Personal Reflections, Politics, Writing

2020 Dreams from My Mother

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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.

 

Happiness

Happy Habits . . . Episodes 7 and 8

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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 Listen — https://coehs.umt.edu/happy_habits_series_2020/hhs_module_seven.php

Here’s Episode 8: Persistence, Resilience, and Joy — https://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.

Happiness

Happiness Homework: Emotional Journaling

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Tippet Rise

After taking a detour away from my happiness class and toward the Happy Habits series, I’m circling back to this week’s assignment for my Art and Science of Happiness course at the University of Montana

Emotional Journaling

What if there was a simple procedure that could help you obtain the following benefits?

  • A reduced need to go see a physician
  • Improved immune functioning
  • Fewer physical ailments or symptoms
  • Less distress
  • Less negative affect
  • Less depression
  • Improved GPA
  • Less absenteeism from work

According to social psychologist and prominent researcher, James Pennebaker, a simple procedure to provide you with these benefits is right at your fingertips. Literally. All you have to do is write about hard, difficult, or traumatic experiences. Here’s an example (summarized) of his instructions:

For the next three days write about your very deepest thoughts and feelings about an extremely important emotional issue that has affected you and your life. When writing, really let go and explore your deepest emotions and thoughts. You might want to tie your writing into your relationships with others or to your past/present/future, or to who you’ve been, who you are, and who you’d like to be in the future. You can write about the same topic every day or a new one every day. Keep your writing confidential. Don’t worry about spelling, grammar, etc., just write for 15-30 minutes straight. (adapted from Pennebaker, 1997)

I’ve been impressed with Pennebaker’s research for three decades. However, I also think it’s important to remember that Pennebaker is a social psychologist; he isn’t a clinical or counseling psychologist, a clinical mental health counselor, or a clinical social worker. As a consequence, I’m not asking you to leap right into his assignment without support. In fact, most researchers, including Pennebaker, believe you can gain the same benefits by talking about painful emotional experiences with a counselor or psychotherapist. One additional caveat: Pennebaker has also found that when writing or talking about traumatic experiences, often people feel distressed or emotionally worse to start, but over time they begin feeling even better than they did at the beginning.

To do this assignment, I just want you to think about Pennebaker’s method and his claims, and then tell me (a) what you think of his idea, (b) whether you would ever like to try his technique, and (c) if you would prefer writing or talking about your emotionally difficult events.

If you eventually decide to try Pennebaker’s method, be sure to remember that you could feel worse first, and that having someone you trust to confide in about how you’re feeling through the process might be a good idea.

If you want to dive into Pennebaker’s method, you should use one of his books as a guide. Here’s one example: https://www.abebooks.com/Opening-Writing-Down-Expressive-Improves-Health/22531442075/bd?cm_mmc=ggl-_-US_Shopp_Trade-_-new-_-naa&gclid=CjwKCAjw4pT1BRBUEiwAm5QuR4ZmBWoiw2FhWHexwZiPtAnyDc9frTptZr9dimZhEWcsE4HUl70gzxoCd60QAvD_BwE

Thanks and happy Sunday.

John S-F

 

 

Happiness, Writing

Happy Habits for Hard Times: Gratitude and Inspiration

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Snow Angel

Episode 6 of the Happy Habits for Hard Times series was posted yesterday on the College of Education of the University of Montana’s website.

But it’s probably still relevant today.

The written portion of episode 6 is below.

You can get to the video via this link: https://coehs.umt.edu/happy_habits_series_2020/hhs_module_six.php

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You are what you focus on. When you remember what you’re grateful for and notice what inspires you, your day will be much better.

Humans tend to repeat behaviors that work out well for them and tend to stop doing things that don’t turn out well. Usually, when you get rewarded for something, you keep doing it. Of course, it’s more complicated than that, but today’s topic is all about introducing two new behaviors that we hope you’ll find rewarding.

As you know from previous episodes, there are behaviors (strategies) you can engage in that are likely to boost your mood. In this episode of Happy Habits, we elaborate on two strategies, but we’re confident you can think of more on your own. We are also aware that for some strange reason, even though these behaviors are rewarding, it’s still hard to get started doing them. That’s a topic for another day. For now, trust us and try these. There’s a reasonable chance that when you do them, you’ll feel better, and you’ll want to keep doing them.

Happiness Habit: Expressing Gratitude

Although it’s true that nearly everyone experiences gratitude, most of us don’t intentionally create time and space to express it. Expressing gratitude is a smart thing to do. It reminds you that you have positive things you are grateful for, it feels good to say “Thanks” and often, you make someone else feel good. Expressing gratitude makes for a nice, positive loop.

Along with the COVID-19 pandemic, it can be tempting to think we have little to be grateful for. While this may be true, it won’t help to dwell on the negative and feel sorry for yourself. Someone once said, “Oh, you think you have nothing to be thankful for? Take your pulse.” Now is a good time to use your brain to force yourself to think and behave with positivity.

Try the following steps:

  1. Identify someone toward whom you feel or have felt appreciation and gratitude. You may have plenty of options. It’s helpful to choose someone toward whom you believe you haven’t yet expressed enough gratitude.
  2. Write a gratitude note to that person. Include in the note why you feel gratitude toward to the person. Include specifics as needed, as well as words that best express your sincere heartfelt feelings toward the person.
  3. Find a way to express your feelings directly to your gratitude target. You can read the note in person, over the phone, or send it in whatever way you find best.

Your plan is to express gratitude. That means you need to drop any expectations for how the recipient of your gratitude should or will respond. Don’t focus on their response, instead, focus on doing the best job you can expressing the gratitude that you sincerely feel.

If the person loves hearing about your gratitude, cool. If the person is uncomfortable, or not positive, or silent, that’s okay. Your goal should be within your control—meaning: all you can control is your end of the communication and not how the communication is received.

If you get inspired, feel free to repeat this gratitude experiment a second or third time. You may find that gratitude begets gratitude.

Happy Habit: Notice Something Inspiring

Inspiring things are always happening. People are caring for the infirmed and elderly, risking their own health. People are volunteering, donating, and doing what they can. The word inspire comes from the Middle English enspire, from the Old French inspirer, and from the Latin inspirare ‘breathe or blow into’ from in- ‘into’ + spirare ‘breathe.’ The word was originally related to a divine or supernatural being, in a sense, ‘impart a truth or idea to someone’.

You can go pretty much anywhere on the internet right now and find inspiring stories. But instead, if possible, we want you to go live, in real time. We want you to watch for and then closely observe something inspiring that’s happening in your daily life.

The inspiring action that you notice may be small or it may be big. It might give you a tiny lift, or be jaw-droppingly inspiring. The key is that it involves intentionally watching for that which will inspire. Keep all your sensory modalities open for inspiration. Then, if you’re up for it, jot down what inspired you, or share it with someone else. What was it like to intentionally pay attention to things that might inspire you? The key is attitude. For whatever time you devote to this exercise, you’re focused on noticing positive actions and events. You’ve given yourself a little respite from the bad news lurking in every corner right now.

Inspiration can lift you up. Try it out. See what it can do for you.

Happiness, Personal Reflections, Writing

Happy Habits for Hard Times: Your Best Possible Self

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Burned Tree

They say that failure is good for the soul, or maybe they say it’s good for developing character. I don’t know who “they” are, but they forgot to say that failure is good for learning. I think that’s the best thing.

My favorite football season of all time was my senior year in high school, when my team when 0 – 10. That’s right. We lost every game, and we lost most of them very badly. The next year, my team, Mount Hood Community College, went 10 – 0. It was great; almost as good as the year before.

I don’t LOVE failure, because I’m not that weird. But I do like failure. I like it because of the learning that comes along with failure.

Today, Episode 5 of the Happy Habits series goes live. You can click on it below. The topic is: Your Best Possible self. Keep in mind that only by failing and improving ourselves can we begin to approach the best possible version of ourselves.

Onward!