This afternoon, Rita and I are doing a short lecture for the University of Montana Honors College course (HONR 391) titled “Love.” Dr. Timothy Nichols, Dean of the Honors College is teaching the course. They’ve covered a ton of very cool stuff (academic speak here) and Rita and I are getting a chance to throw 2 of our cents in.
While putting together the powerpoints, I also discovered and captured a 4 minute video of my parents talking about love and their relationship. The video was produced on Valentine’s Day of 2008 by Regence Blue Shield of Oregon. I contacted them and they said, of course, I could share the video . . . so, here it is:
Today I’ve been putting together my powerpoints for the upcoming Nate Chute Foundation workshop. The NCF workshop is on two consecutive Tuesday evenings, starting this coming Tuesday.
While reviewing content for the ppts, I tried to pull all the intervention strategies from my brain, and failed. My excuse is that there are too many possible interventions for my small brain to memorize. As a consequence, I was forced to check out the “Practitioner Guidance and Key Points to Remember” sections at the end of all the intervention chapters. To give you a taste, here’s a photo of the “summary” page at the end of the cognitive chapter.
The Cognitive Dimension – Chapter Summary
Each of these bulleted items represents a potential method or strategy for intervening in the cognitive dimension with clients or students who are experiencing suicidality. I’m looking forward to talking about these strategies at the Nate Chute workshop, but rather than trying to commit them to memory (like Ebbinghaus would have), I’ll be using my powerpoint slides as a memory aid.
In partnership with Montana Pediatrics and the Nate Chute Suicide Prevention Foundation, the Montana Happiness Project is launching its “Geographically Exclusive” strengths-based suicide assessment and treatment planning workshop series. The purpose of this workshop series is to work with mental health and school counselors from specific geographic regions to further develop community-based professional competence in suicide assessment, treatment planning, and intervention. Our goal is to train professionals to provide excellent care to students, clients, and patients who are experiencing suicidality. At the same time, similar to Dr. Marsha Linehan’s dialectical behavior therapy model, we hope to build professional communities that will support one another in facing this challenging and stressful professional activity. We believe that if practitioners within a single community feel more competent AND more supported, they’ll be able to be more effective, more available, and better able to handle the stress associated with suicide assessment and intervention work.
Our first geographically exclusive workshop is scheduled for two consecutive Tuesday evenings: April 13 and 20 from 4:15pm-7:15pm. Here’s the description:
Interested in learning a new approach to suicide assessment and treatment? John Sommers-Flanagan, professor of counseling at the University of Montana, will be leading an innovative professional development opportunity on strengths-based suicide prevention.
Founded on current research and national best-practices, this workshop will help you: Understand the limits of suicide risk factor assessment
Use creative approaches to connect with distressed clients, while collecting useful assessment information
Respond compassionately and effectively to client hopelessness, irritability, passive suicidality, and more
Initiate collaborative safety and treatment planning protocols
If you’re interested in hosting a geographically exclusive suicide workshop in your region (via Zoom or in-person), please email me at john.sf@mso.umt.edu
Earlier today I had a 90-minute Zoom meeting with the staff from Bridgercare of Bozeman, Montana. Bridgercare is a medical clinic focusing on sexual and reproductive health. Our meeting’s purpose was to provide staff with training on how to integrate a strengths-based approach to suicide assessment and treatment into their usual patient care.
It’s probably no big surprise to hear this, but even through Zoom, the Bridgercare staff was fabulous. They’re clearly dedicated to the safety and wellbeing of their patients. I enjoyed meeting them and wish I could have been there live and in-person (but, having gotten my second vaccine shot today, more live and in-person events are in my future!).
One member of the medical staff asked if I had material on how to enhance the safety planning process with patients. After fumbling the question for a while, I remembered that I included a safety planning case example in Chapter 8 of our suicide book. I’ve included the excerpt below. Although the case is written in my voice, as you read through, think about how you might put it into your voice.
This case description illustrates a positive working relationship and outcome. Just to make sure you know that I’m not too Pollyannaish about suicide-related work, the whole book also includes cases and situations with less positive scenarios and outcomes.
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Below, the counselor is discussing a safety plan with a 21-year-old cisgender female college senior named Kayla. Kayla was attending a large state university and living off campus in a small apartment. In this case, Kayla was social distancing in compliance with state stay-at-home orders; the session was conducted remotely, via an online video-based HIPAA-compliant platform (e.g., Doxy.me, SimplePractice, etc.).
The Opening and Unique Suicide Warning Signs
Counselor: Kayla, I’m putting your name on the top of this form [holds form up to camera]. It’s called a safety planning form. Some very smart people made up this form to help people stay safe. There are six questions. We’re supposed to fill it out together. If you hate it when we’re done, we can toss it in the trash. Okay?
Kayla: Okay. That’s possible.
Counselor: That would be fine. Here’s the first question. I’m just going to read them to you. Then you answer, I’ll write down your answers, and then we talk about your answer. What are the signs, in yourself or in your environment that will be a warning that tells you that you need to do something to keep yourself safe?
Kayla: I just like feel a wave of sadness and defeat. Like my life means nothing. Like I’m a damaged, bad person who should die.
Counselor: Okay. A wave of sadness and defeat. How will you know that wave has come? What do you feel in your body or think in your brain?
Kayla: I feel a physical ache. I think about being abused. I think horrible thoughts.
Counselor: I’m writing down, “Wave of sadness and defeat, and physical ache, and thoughts of being damaged, bad, and abused.” Those are all signs that you should follow this safety plan.
Kayla: Also, being home alone at night.
In this initial exchange the counselor empowers Kayla to reject the plan if she wants to. Offering to let Kayla reject the plan probably makes it more likely for her to take ownership of the plan. If Kayla ends up rejecting the plan, that information becomes part of the overall assessment and guides treatment decision-making.
Kayla immediately engages in the process. Specifically, her trauma-based thoughts of being damaged and bad could be fruitful therapeutic grist for cognitive processing therapy or EMDR, both of which address trauma and focus on beliefs about the self. However, when using the SPI, it’s best to stay focused on the SPI, and save the deeper therapeutic content for later. The counselor could (and should) have said, “For now, we’re working on this plan. But later on, if you want, we can start working on your feelings of being damaged and bad.”
Personal Coping Strategies
Counselor: What can you do in the moment to cope with suicidal thoughts and feelings?
Kayla: Look. I could cut myself to feel better, but nobody wants me to do that.
Counselor: I’m sure it’s true that people don’t want you cutting. I also think it’s true that people would rather have you cut yourself than kill yourself. If cutting keeps you alive, we should put it in the plan, at least for now.
Kayla: I think it should be there then.
Counselor: Okay. So, cutting goes on here as a method for calming or soothing yourself. Have I got that right?
Kayla: Yeah. It calms me down when I’m upset.
Counselor: What else could calm you down or distract you from suicidal thoughts?
Kayla: I could listen to music or call a friend.
Counselor: Great. I’m writing those ideas into the plan right now.
Brainstorming coping responses is similar to other processes discussed in chapter 5 (problem-solving and alternatives to suicide). One key principle is to accept all responses before evaluating them later. In the preceding interaction, the counselor accepts that cutting might be a viable (even if not preferred) short-term coping strategy, and then continues to nudge Kayla to generate additional coping ideas. Although cutting isn’t addressed in this case example, after developing the safety plan, therapeutic conversations about cutting and alternatives to cutting, should become a part of ongoing counseling (see Kress et al., 2008; Stargell et al., 2017).
Social Contacts and Settings
Counselor: I’m wondering about those times when you’re alone. Who could you be with to stay safe? Even if it’s only for you to distract yourself?
Kayla: I have a friend named Monroe. He’s crazy. He’s always happy. Sometimes he annoys me, but he’s a good distraction.
Counselor: Monroe sounds like a great distraction. He’s in the plan. Are you able to see him in person, or would you do Facetime or a Zoom call.
Kayla: He lives in the apartment building and we could meet up outside.
Counselor: That sounds great. Who else?
Kayla: I can always call my parents, but when I do, I feel like failure. I’m an adult.
Counselor: If you’re feeling suicidal, would your parents want you to call?
Kayla: Yeah.
Counselor: Okay then. Let’s put your parents down. We can talk more later about how calling them might make you feel.
The counselor does a good job of getting Kayla to be specific about how she could connect with Monroe. Overall, Kayla doesn’t have an extensive social support network. Expanding that network will likely become an important goal for counseling.
People Whom I Can Ask Help
Counselor: This question is similar to the last one, but a little different. Instead of people who are distracting, now I’m wondering who you can turn to if you’re in crisis?
Kayla: Monroe wouldn’t be the right person for that.
Counselor: Not Monroe. But who would be right for that?
Kayla: My parents, I guess. And my aunt, Sarah. She’s always been there for me. I could call her if I need to. And my grandma.
Counselor: Good. That’s four. Your mom, your dad, your aunt Sarah, and your grandma. Are they around here, or would you call or text them?
Kayla: My parents and aunt live close by, but we’d probably just Facetime because they’re older I don’t want them to get COVID. My grandma lives in Minnesota.
While generating lists, it’s useful to draw clients into being even more specific than illustrated in this exchange. For example, as Kayla identifies people to call, getting specific about texting or calling, where the person might be, and what to do if there’s no answer, is good practice. Role playing a call or text can be useful, because rehearsing behaviors make them more likely to occur.
Mental Health Professionals or Agencies to Contact
Counselor: How about professionals or agencies that you can call if you’re in a crisis?
Kayla: I don’t have anyone.
Counselor: Wait. You need to put me here. I should be on the list. I can be available for short calls Sunday through Thursday evenings up until 9pm.
Kayla: Okay.
Counselor: And there’s 9-1-1, right? You can always call 9-1-1. In an emergency, that’s what you do. There’s also a new suicide hotline number, 9-8-8. I’m going to write that number down too. You don’t have to call any number, but it’s good to have them just in case you do want to call for professional help during a crisis. The other thing to remember about calling hotlines is that you may get someone you don’t like or don’t connect with. If that happens, keep trying, but also, jot down a few notes so you can tell me about it.
In the preceding exchange, the counselor offers to be a limited option. Whether you provide a personal contact number is up to you. Whatever you do, spell it out in your informed consent and have boundaries around the times when communications with you are acceptable. Because calling hotlines may or may not feel helpful, empowering Kayla to critique her hotline experience and then report it to the counselor might increase her willingness to call.
How Can I Make My Environment Safe?
Counselor: This last question has to do with how you can make your environment safe. We’ve talked about various things, like how you can cope and who you can call. Now we need to talk about whether there’s anything dangerous in your home, anything that could be used to kill yourself if you were suddenly suicidal.
Kayla: Yeah. Well I bought a hand-gun last year. That’s how I would do it.
Counselor: Right. Thanks for telling me about the gun. Can I just tell you what I’m thinking right now?
Kayla: Sure.
Counselor: With guns and suicide, there are two good options. One is for you to give it to someone for now, until you’re feeling better. The other is for you to safely store the gun or get a trigger lock. I’m just being totally honest with you about this. The reason we should get your gun locked up or given to your parents or someone else, is because most of the time, people are intensely suicidal for only 5 or 10 or maybe 30 minutes. During that intense time, people can do things they later regret. Most people who make a suicide attempt don’t make another attempt. It’s usually a one-time thing. My main goal is for you to be safe.
Kayla: But I’m not planning to use the gun or anything.
Counselor: Right. That’s great. But let’s say your Aunt Sarah was suicidal and she had a gun, would you be willing to keep it for her if it made her safer?
Kayla: Of course I would.
Counselor: So, whether it’s you or your Aunt Sarah, we want to make sure suicide doesn’t happen because of one terrible moment.
The preceding is an example of psychoeducation around suicidality and safety planning. If you have a good rapport and connection with your client, the psychoeducation is likely to be well-received. If your rapport and connection is less good, then you’ll either need to work on the relationship, or take a more directive and authoritative role to promote your client’s safety.
Counselor: All right. I’ve written down your ideas for the safety plan. Now, I’m going to scan it and send it to you through our secure portal. As we’ve already discussed, we’re going to make a bigger plan for your counseling. But in the meantime, we need to keep you safe so we can do the counseling. Right now, you’ve got this safety plan you can use, and we can revise it if we need to. Okay?
Kayla: Okay.
Counselor: Kayla, thank you very much for working with me on this safety plan. I think we made a good plan together.
Kayla: Me too. I guess I won’t throw it in the trash.
Counselor: You’re pretty funny.
Please excuse any typos or bad grammar. The preceding is a pre-published (and pre-copyedited) version from my computer. To check out and possibly purchase the whole darn book, you can go here: https://imis.counseling.org/store/detail.aspx?id=78174
In this blog I often focus on factors that contribute to suicidal thinking and suicidal actions. One theme I repeatedly emphasize (and Rita and I hammer away at in our suicide book), is that suicidal thoughts are often natural and normal human responses to difficult or distressing life circumstances. When painful and disturbing things happen outside of the self, it’s not unusual (and not abnormal) for individuals to feel the pain and then notice suicidal thoughts popping into their minds.
Another theme we repeat is the post-modern, constructive method of linguistically moving personal distress outside of the self. Moving personal distress outside of the self is useful because it allows mental health and school professionals to join with clients and students to strategize on how to cope with or reduce the painful distress contributing to suicidal thoughts and impulses.
Ongoing events, including, but not limited to, the death of George Floyd in Minnesota, abduction and murder of indigenous women in Montana, hateful targeting of Asian people around the U.S., and this week’s murders of Asian women in Georgia, are all stark reminders of how events external to the self can reverberate and cause immense feelings of helplessness and hopelessness within people vulnerable to systemic oppression. Even in cases where specific individuals have not been directly or explicitly threatened, if they identify with victims (which is a perfectly normal human phenomenon), they can experience deep emotional and psychological distress. Although many factors can add to the distress people feel around racism, cultural oppression, and an unsafe dominant culture, in particular, feeling helpless to enact change and hopeless that positive change will ever occur, adds substantially to what we’ve intellectually labeled in our book as “Contextual distress.” Addressing contextual distress requires, at minimum, that oppressed people are empowered to contribute to positive change and hopeful that positive changes can and will occur.
In the film, Good Will Hunting, Robin Williams (the therapist) repeatedly tells Matt Damon (the client) that the abuse he experienced is not his fault. Although I’m not a big fan of the therapeutic methods that Robin Williams employs in the film, the message is salient, powerful, and important: “It’s not your fault!”
“It’s not your fault” is also salient for Asian, Black, Indigenous, and other oppressed minority populations. The “fault” is within the dominant U.S. culture. Nevertheless, minority populations may feel internal distress and desperation . . . and sometimes they’ll feel so helpless and hopeless that they also naturally experience thoughts related to suicide. Again, the core messages we need to offer as egalitarian allies include: “How can we empower you?” and “How can we help our whole society feel more hopeful about creating a new dominant culture that includes honoring, equity, and safety for all minority groups?”
Because it’s relavant to this topic, and how often society and individuals blame people for being oppressed, below, I’m including a short excerpt from our suicide book. This excerpt comes from Chapter 10, where we explore larger contextual factors that can and do contribute to suicidal thoughts and behaviors. I know my approach here is intellectual and clinical, but I also hope to convey the need to address the palpable fear and oppression that’s happening in far too many places within American society.
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The purpose of depathologizing suicide and externalizing suicide-related problems is not to relieve individuals of personal responsibility. Instead, depathologizing and externalizing are social constructionist tools to alleviate shame; these tools also allow clients to gain enough psychological distance from their problems or symptoms to view them as workable. When depathologizing and externalizing work well, clients feel uplifted and inspired to participate even harder the battle against the internal and external stressors contributing to their suicidal state.
In this chapter, it seems odd that we would need to mention that contextual factors driving suicide can originate outside of the self. However, society tends to blame individuals for their oppressive living conditions or stressful life circumstances. Surely, the narrative goes . . . people living in poverty or drinking lead-laced water in Flint, Michigan, must be lazy, criminal, or somehow defective, otherwise they would lifted themselves up by their bootstraps and profited from the American dream. Of course, this narrative is false. In fact, as we think about the depth and breadth of contextual factors that contribute to suicide, we recall the words of Cassius in Shakespeare’s Julius Caesar: “The fault, dear Brutus, is not in the stars, but in ourselves.” As we look at the 7th dimension, this message is flipped, “The fault, dear Brutus, is not in ourselves, but in our stars” (or systemic socioeconomic disparity, racial inequality, and oppression). (Sommers-Flanagan & Sommers-Flanagan, 2021, p. 236)
As many of you know, the class generated a pretty cool song playlist. Typically, I select a song from the playlist, download it into my powerpoint, and start the music at 12:55pm. I say typically in that optimistic—see the glass half-full—sort of way, because, in reality, sometimes I struggle to get the music video to play, other times I start it a bit late (and begin to hear my Zooming students query, “What’s happening? Where’s the music?”), and still other times I go rogue and pick an off-list song that I happen to think fits the topic perfectly.
Last week, before we explored spirituality and forgiveness, I couldn’t resist playing “Heart of the Matter” by Don Henley . . . and now I can’t stop the tune and lyrics in my head . . . “Forgiveness, forgiveness, even if, even if, you don’t love me anymore.” For your immediate listening pleasure, here’s the Henley music link: https://www.youtube.com/watch?v=Rxni_Icyjj8&list=RDRxni_Icyjj8&start_radio=1&t=213
Usually I consider it best practice to keep my camera and microphone off during the opening music. You can imagine why. Holding on to the small shreds of respect that I’ve not yet squandered seems like good judgment, because if I let go, things might look like this: https://www.youtube.com/watch?v=W0Nju66rif4&feature=youtu.be
After the opening music I burst into the Zoom scene with energetic and pithy commentary designed to get everyone focused in on our topic of the day. Then, after a few orienting announcements, I send students into Zoom break-out rooms where they ask and answer the questions: “What do you remember from our last class” and “What about our last class seemed important to you and your life?”
My sense—based on our immediate debriefing after the break-out rooms—is that some students are finding joy in their five-minute one-on-one Q & A time. However, recently I heard from a few students that they particularly dislike the Zoom break-out experience. This leads me to a conundrum (why are there so many conundrums?). Should I continue with the opening class break-out rooms, or should I find another pedagogical strategy? Please enlighten me on whether you think I should continue with the break-out rooms or find a suitable alternative.
Following the break-out rooms and debriefing, I (sometimes accompanied by Rita), launch into lecture content. We talked about spirituality for three class meetings, and have also hit gratitude, kindness, cognitive methods for dealing with pesky negative thoughts, and much more. In order to not completely bore anyone, I shift in and out of the powerpoint slides, inserting side commentaries, forcing students to imagine their part of research studies, and facilitating experiential activities. My favorite two activities (so far) were having students engage in an on-camera Gestalt two-chair with themselves (the visuals were hilarious) . . . and having everyone shout out the word “fail” over and over again for 60 seconds. The “fail” activity is based on research on deconstructing particular words so they lose their power over us, and begin just sounding like funny sounds. The best part of that activity was having students report back that when they yelled “fail” repeatedly into their computers, their roommates thought they were having serious existential meltdowns.
Class usually closes with a large group discussion, during which I’m humbled by the depth and breadth of student commentary. On occasion, I’ve pushed quieter students to comment, and in every case, they’ve delivered. I’d share some examples, but the student comments are theirs to share. Let me just say, on their behalf, it’s good to listen to students.
Class ends with a flurry of good-byes, as well as expressions of gratitude and affection.
Although I’m not completely certain students are feeling the joy, I can say with confidence that I am. I’m loving the experience and deeply appreciating how often my students are making the Zoom version of happiness class . . . magical.
Working with suicidal clients often involves working two sides at the same time. . . as in a dialectic or paradox. For example, it’s crucial to be able to move back and forth between empathic acceptance and active-collaborative problem-solving.
When working from a strengths-based model, clinicians shouldn’t shy away from focusing on pain, sadness, anger, or other aversive emotions and experiences. At the same time, we need to also focus on potential strengths. The following excerpt from our new suicide book illustrates how to explore previous attempts, while also looking for strengths.
Previous attempts are often considered the most significant suicide predictor (Brown et al., 2020; Fowler, 2012). You can gather information about previous attempts through your client’s medical or mental health records, from an intake form, or during the clinical interview. During clinical interviews, clients may spontaneously tell you about previous attempts; other times you’ll need to ask directly. Again, using a normalizing frame can be facilitative:
It’s not unusual for people who are feeling very down to have made a suicide attempt. I’m wondering if there have been times when you were so down that you tried to kill yourself?
Once you have knowledge about a client’s previous suicide attempt, you can explore several dimensions of the attempt:
What was happening that made you want to end your life?
When you discovered that your suicide attempt failed, what thoughts and feelings did you experience?
Some people report learning something important from attempting suicide. Did you learn anything important? If so, what did you learn?
Although the preceding questions are important for assessment, once you’re ready to move beyond exploration of a previous attempt, you should ask a therapeutic solution-focused question, similar to the following:
You’ve tried suicide before, but you’re here with me now . . . what has helped? (Sommers-Flanagan & Sommers-Flanagan, 2017, p. 373).
Asking “What helped?” is central to a strength-based or solution-focused model and sometimes illuminates a path forward toward living. However, if your client is depressed, you may hear,
In the context of an assessment protocol, the “What helped?” question and its side-kick, “What have you tried?” are important because they assess for two core cognitive problems associated with suicidality: hopelessness and problem-solving impairment. Clients who respond with “nothing ever helps” are communicating hopelessness. Clients who claim, “I’ve tried everything” or “There’s nothing left to do” are communicating hopelessness, plus the narrowing of cognitive problem-solving that Shneidman (1996) called mental constriction. Hopelessness and problem-solving impairments should be integrated into your suicide treatment plan.
You can read more excerpts of our book in other posts on this blog, via Amazon or Google. You can also purchase it as an eBook through Wiley, Amazon, or as a paperback through the American Counseling Association: https://imis.counseling.org/store/detail.aspx?id=78174
On March 3, the publisher, John Wiley & Sons is offering a free day-long webinar. They’re calling it a “Psychology Thought Leadership Summit.”
Full disclosure, I’m presenting at the 2:30pm-3:15pm (Eastern) time-slot. My presentation is titled: “Interviewing for Happiness: How to Weave Positive Psychology Magic Into the Interview Process.” Here’s my presentation description:
Freud once said that “words were originally magic.” In this interactive presentation, John Sommers-Flanagan will describe how clinical interviewing involves a process of using word magic to shift clients from a locked constructivist state to receptive social constructionism. This presentation focuses on systematically integrating positive psychology (aka happiness interventions) into a standard initial clinical interview protocol. Intentionally and systematically weaving happiness interventions into initial interviews is especially important because many people are being adversely affected by social isolation and challenges associated with the global pandemic.
Some of the other presenters are very notable. For example, Derald Wing Sue is presenting “Microintervention Strategies: Disarming Individual and Systemic Racism and Bias” during the at the 9:45am to 10:45am (Eastern) time slot. Here’s Dr. Sue’s presentation description:
Microinterventions are the everyday words or deeds—whether intentional or unintentional—that communicate the following concepts to targets of microaggressions:
Validation of their experiential reality
Value as a person
Affirmation of their racial or group identity
Support and encouragement
Reassurance that they are not alone
More importantly, they serve to enhance psychological well-being, and provide targets, allies, and bystanders with a sense of control and self-efficacy.
This session provides participants with the opportunity to learn, practice, and rehearse microintervention strategies and tactics to disarm and neutralize expressions of bias by perpetrators while maintaining a respectful relationship.
In the following paragraph I’ve pasted the Wiley promo, which includes a link to sign yourself up. . . or just REGISTER HERE. It looks like you’re supposed to register very soon, so check it out.
Wiley Psychology Thought Leadership Summit
March 3, 2021
As one of the world’s leading psychology publishers, Wiley offers trusted and vital resources written by leading subject matter experts in the field. Join colleagues from across North America for the Wiley Psychology Thought Leadership Summit featuring some of our top authors. Speakers will give inspiring talks and conduct breakout sessions where you’ll gain insight and ideas to bring back to your classroom or practice. Choose from multiple sessions on March 3, 2021.Sign Me Up
Because I’ve been getting plenty of questions about the Strengths-Based Approach as applied to suicide assessment and treatment, I’m re-posting a revised version of this blog from June, 2020. My apologies for the redundancy. On the other hand, as a friend and mental health professional has repeatedly told me, “Redundancy works.” So . . . I guess his redundancy worked on me.
Seven Dimensions of Being Human: Where Does It Hurt and How Can I Help?
We began this chapter describing the case of Alina. Mostly likely, what you remember about Alina is that she displayed several frightening suicide risk factors and openly shared her suicidal thoughts. However, Alina is not just a suicidal person—she’s a unique individual who also exhibited a delightful array of idiosyncratic quirks, problems, and strengths. Even her reasons for considering suicide are unique to her.
When working with suicidal clients or students, it’s easy to over-focus on suicidality. Suicide is such a huge issue that it overshadows nearly everything else and consumes your attention. Nevertheless, all clients—suicidal or not—are richly complex and have a fascinating mix of strengths and weaknesses that deserve attention. To help keep practitioners focused on the whole person—and not just on weaknesses or pathology—we’ve developed a seven-dimension model for understanding suicidal clients.
Suicide Treatment Models
In the book, Brief cognitive-behavioral therapy for suicide prevention, Bryan and Rudd (2018) describe three distinct models for working with suicidal clients. The risk factor model emphasizes correlates and predictors of suicidal ideation and behavior. Practitioners following the risk factor model aim their treatments toward reducing known risk factors and increasing protective factors. Unfortunately, a dizzying array of risk factors exist, some are relatively unchangeable, and in a large, 50-year, meta-analytic study, the authors concluded that risk factors, protective factors, and warning signs are largely inaccurate and not useful (Franklin et al., 2017). Consequently, treatments based on the risk factor model are not in favor.
The psychiatric model focuses on treating psychiatric illnesses to reduce or prevent suicidality. The presumption is that clients experiencing suicidality should be treated for the symptoms linked to their diagnosis. Clients with depression should be treated for depression; clients diagnosed with post-traumatic stress disorder should be treated for trauma; and so on. Bryan and Rudd (2018) note that “accumulating evidence has failed to support the effectiveness of this conceptual framework” (p. 4).
The third model is the functional model. Bryan and Rudd (2018) wrote: “According to this model, suicidal thoughts and behaviors are conceptualized as the outcome of underlying psychopathological processes that specifically precipitate and maintain suicidal thoughts and behaviors over time” (p. 4). The functional model targets suicidal thoughts and behaviors within the context of the individual’s history and present circumstances. Bryan and Rudd (2018) emphasize that the superiority of the functional model is “well established” (p. 5-6).
Our approach differs from the functional model in several ways. Due to our wellness and strength-based orientation, we studiously avoid presuming that suicidality is a “psychopathological process.” Consistent with social constructionist philosophy, we believe that locating psychopathological processes within clients, risks exacerbation and perpetuation of the psychopathology as an internalized phenomenon (Hansen, 2015; Lyddon, 1995). In addition to our wellness, strength-based, social constructionist foundation, we rely on an integration of robust suicide theory (we rely on works from Shneidman, Joiner, Klonsky & May, Linehan, and O’Connor). We also embrace parts of the functional model, especially the emphasis on individualized contextual factors. Overall, our goal is to provide counseling practitioners with a practical and strength-based model for working effectively with suicidal clients and students.
The Seven Dimensions
Thinking about clients using the seven life dimensions can organize and guide your assessment and treatment planning. Many authorities in many disciplines have articulated life dimensions. Some argue for three, others for five, seven, or even nine dimensions. We settled on seven that we believe reflect common sense, science, philosophy, and convenience. Each dimension is multifaceted, overlapping, dynamic, and interactive. Each dimension includes at least three underlying factors that have theoretical and empirical support as drivers of suicide ideation or behavior. The dimensions and their underlying factors are in Table 1.1.
Insert Table 1.1 About Here
Table 1.1: Brief Descriptions of the Seven Dimensions
The Emotional Dimension consists of all human emotions ranging from sadness to joy. Empirically supported suicide-related problems in the emotional dimension include:
Excruciating emotional distress
Specific disturbing emotions (i.e., guilt, shame, anger, or sadness)
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.
Although automated quiz grading is awesome, two of your 25 quiz items need manual grading.
Click on item 24 of Student 1, to initiate manual grading.
Scroll everywhere without finding any place to manually enter grade.
Scroll again.
Find link to “manual override”
Click on manual override.
Enter grade.
Look for “save” button.
Notice that the Moodle screen doesn’t quite fit your laptop screen.
Begin muttering.
Plug laptop into larger external screen.
Move visual to larger screen.
Click on “save changes.”
Feel satisfaction from effective Moodle problem-solving.
Notice that nothing happens.
Swear.
Try clicking on next item that needs manual override.
Notice that nothing happens.
Swear again.
Click on item heading (in hopes of accessing ALL ungraded items)
Notice that instead of taking you into the item, Moodle takes you back to the whole list of student quiz scores.
Scroll sideways to re-locate items to grade.
Notice that item 24 for Student 1 IS NOW GRADED!
Smile to yourself at your Moodle success.
Follow identical process to grade item 24 for Student 2.
Notice the process no longer works.
Move to F-word in profanity cache.
Search “How to override an individual quiz item” in Google.
Almost find the right answer.
Try using the almost right answer.
Fail.
Continue with F-bombs, now in close combination with Moodle.
Write email to University IT help, trying not to type F-Moodle as Subject Line.
Wait.
Get tired of waiting.
Try grading again.
Notice that Moodle no longer recognizes you as having grading privileges.
Give yourself grading privileges.
Begin grading again.
Begin wishing you had used crayons to administer and grade quiz.
Step away from Moodle.
Begin an email invoicing Moodle or IT or the Universe for your lost time.
Delete email.
Consider describing your problems with Moodle in your next email to students, because you need to apologize to them for the delay in quiz-grading.
Delete paragraph of email to students where you described all your Moodle problems.
Send email.
Realize that Moodle timed out while you were composing your email, and consequently your email did not send.
Realize (again, because this has happened before) that Moodle has no automatic back-up for emails and consequently you have to re-write what was likely the most eloquent email you’ve ever written.
Recall that you had previously sworn to yourself to never again write a long email in Moodle.
Exercise risk management by stepping away from the computer.
Consider resigning from the University because of continued problems with Moodle, Qualtrics, Box, and repeated difficulties recalling your passwords.
Recognize, through a finely honed capacity for self-awareness and self-reflection, that you need to take a nap before engaging in any rash decision-making.
Take a nap.
Awake refreshed and optimistic.
Consider logging into Moodle.
Procrastinate, hoping Moodle will upgrade itself by the time you’ve finished writing a snarky blog about Moodle.
Post blog.
The place to click if you want to learn about psychotherapy, counseling, or whatever John SF is thinking about.
