All posts by johnsommersflanagan

It’s Not Unusual: John’s Weekend Reflections

john-rapA stranger posted a comment on my blog today. As Tom Jones might say, “It’s not unusual” for my blog to stimulate reader commentary. After all, I’m expressing my opinion, distributing professional information, and often I specifically ask for reader feedback.

Mostly I get positive feedback. Occasionally, I touch a nerve with someone and get pushback or criticism. What’s most interesting to me is that the nerves I touch are nearly always nerves related to White privilege or feminism. I suppose that’s not unusual either.

Today’s comment started with, “Wow. All u do is wafle here. . .” and went on to provide a rambling critique of White privilege (I think). Three thoughts on this: First, to find my several year-old White privilege blog post requires significant effort and searching. Second, with the advent of spellcheck, typically it’s very hard for your computer to let you misspell “waffle” as “wafle.” Third, the critique, as is not unusual, didn’t seem to have much to do with the content of my blog post. Instead, the commenter was clearly focusing in on his own personal issues and history and not so much on what I had written.

The next part of all is also not unusual. In response, I felt disappointment, hurt, and defensiveness. To be perfectly honest, I wanted to counterpoint or counterpunch my commenter. I managed to stop myself. Instead, I labeled his comment as spam and moved on.

Upon reflection, my “spamming” his comment was probably passive-aggressive. And, it was (and is) clear that I haven’t moved on. Funny how criticism has a way of hanging on long after the party has ended and everyone should go home.

In conclusion, here’s the sort of thing I wish I’d written . . .

“Hello beloved fellow human. I’m grateful that you took the time to read my blog and make a comment. Thank you for that. Based on your comment, I think you and I probably disagree on this topic. Rather than arguing and trying to convince you that I’m right and you’re wrong (which likely wouldn’t work anyway), I want to say that I respect your right to a perspective and opinion that’s different from mine. I’m sure we’ve lived very different lives and so it’s not unusual that we would disagree on White privilege. Although I feel defensive about what I wrote, I can also feel a part of myself that’s way down deep and not defensive. That part of me wants to reach out and say ‘Hey. No big deal that we disagree. It wasn’t my intent to write something that offended you. I wish you health and happiness. I wish us a better and deeper mutual understanding. Wherever you feel hurt or pain, I wish you healing. I hear your disagreement with me and, in the future, although I know I won’t be perfect, I will try to be more sensitive and compassionate in what I write.’

If you like, you can read the offending blog post here: https://johnsommersflanagan.com/2012/09/14/a-white-male-psychologist-reflects-on-white-privilege/

Have a fantastic Saturday night.

John SF

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News Flash: The 3rd Edition of Counseling and Psychotherapy Theories in Context and Practice is Now Available!

Theories III Photo

Hello Theories Fans.

I have exciting and good news! The third edition of Counseling and Psychotherapy Theories in Context and Practice is NOW AVAILABLE. Here’s the publisher’s link: https://www.wiley.com/en-us/Counseling+and+Psychotherapy+Theories+in+Context+and+Practice%3A+Skills%2C+Strategies%2C+and+Techniques%2C+3rd+Edition-p-9781119473312

The “less good” news (as the MI folks like to say) is that I wrote up a promotional piece for our publisher to distribute, but they thought it was TOO POSITIVE:) . . . so I’ll do what I can to temper my enthusiasm here.

What’s new in the Third edition?

Other than a massive reference overhaul, empirical updating, and re-writing and editing in response to reviewer feedback, the biggest news is that we added sections Sexuality, Neuroscience, and Spirituality.

The other good news is that our book (2nd edition) already had the highest average Amazon customer rating of all Counseling and Psychotherapy Theories texts, a whopping 4.6 out of 5.0 stars! [for comparison, 4.6 is the same rating as John Grisham’s “The Firm” and higher than Mary Pipher’s “Reviving Ophelia” . . . although, not surprisingly, Grisham’s and Pipher’s works tend to get a few more reviews]

It’s also important to note that our textbook is still relatively inexpensive (compared to other Theories textbooks).

This text also has excellent ancillaries. There is an accompanying video, test bank, online instructor’s resource manual, and a student study guide. The video clips are imperfect and spontaneous demonstrations of specific counseling skills that include counselors and clients with various cultural backgrounds.

Rita and I are humbled and happy to have the opportunity to publish the third edition of our Theories text with John Wiley & Sons. As in previous editions, our primary goal has been to translate complex theoretical material into prose that is engaging, reader friendly, easy to understand, and has a practical/skill-building emphasis. Most, but not all, of the reader reviews on Amazon are affirming and give us hope that we’ve accomplished this goal. To capture some of the positive responses, I’m sharing several Amazon reviews below:

  • The best text book I’ve ever read! Thoroughly enjoy the humor. Each chapter is written slightly different to capture the feel of the theory it describes. Laughed out loud at the final fantasy writing.
  • I love the writers of this book, it is like a conversation and sometimes humorous. Got the book right away.
  • Absolutely amazing read! Every line has important information and I actually enjoy when chapters are assigned for my theories class in this book!
  • While this was purchased for a class, I am really enjoying the information and case studies the author’s present. I do not mind reading this material and think this is one textbook I will not sell back to the bookstore, instead using it for reference throughout my new career.
  • This book was incredibly helpful to me as a counseling student. This is my first semester in the counseling program and this book was full of useful information, very easy to read and understand, and provided a vast overview of the different theories. I will definitely be keeping this book to use as a resource on future papers.

To see all 43 reviews, you have to go to the 2nd edition: https://www.amazon.com/Counseling-Psychotherapy-Theories-Practice-Resource/dp/1119084202/ref=sr_1_1?ie=UTF8&qid=1527631412&sr=8-1&keywords=John+Sommers-Flanagan

And here’s the 3rd edition on Amazon: https://www.amazon.com/Counseling-Psychotherapy-Theories-Context-Practice/dp/1119473314/ref=pd_cp_14_2?_encoding=UTF8&pd_rd_i=1119473314&pd_rd_r=229a780b-638c-11e8-890c-a735446468c0&pd_rd_w=A4Hos&pd_rd_wg=zISf0&pf_rd_i=desktop-dp-sims&pf_rd_m=ATVPDKIKX0DER&pf_rd_p=80460301815383741&pf_rd_r=SY3RS8RHYZYD8HPR7W7Y&pf_rd_s=desktop-dp-sims&pf_rd_t=40701&psc=1&refRID=SY3RS8RHYZYD8HPR7W7Y

As always, let me know if you have questions or comments on this post or on our third edition of Counseling and Psychotherapy Theories in Context and Practice.

Sincerely,

John SF

 

Memories of Memorial Day: How to Use Memory Re-consolidation to Cope with Pain from the Past

Green Shadow II

Back in the 1970s, I remember singing the lyrics to, The Way We Were, along with Barbra Streisand. Using my best falsetto, Barbra and I crooned, “Memories, light the corners of my mind.”

These lyrics aren’t technically correct. But then Barbra and the song’s lyricists, Alan and Marilyn Bergman, didn’t have access to modern brain scans. Based on neuroscience research, it would have been more accurate for Barbra and I to sing, “Memories, light the center of my mind.”

Memories live deep within the brain. If you could magically poke your index finger down through the top center of your skull, you still couldn’t quite reach your brain’s memory structures, the hippocampus and amygdala.

Memories are a fascinating electrical, molecular, cellular, and inter-structural phenomenon. I won’t be providing scientific details about memory, because then I’d have to write something about how the interaction of glucocorticoids and noradrenaline in the basolateral region of the amygdala can modulate the strength of memories in the hippocampus and other brain areas . . . and by then our fascination with memory would doubtless give way to boredom and sleepiness.

Speaking of sleepiness, it’s metaphorically accurate to say that most of our memories typically just lay around dozing in their hippocampal bed until awakened. Not surprisingly, some memories are lighter sleepers than others; they can be easily awakened. Sometimes, when sleeping memories are rudely awakened (triggered) they tend to be rather grumpy and unpleasant.

Here are three examples:

Say you’re creeping around on Facebook. You see an old high school photo from 25 years ago. The visual stimulus of the photo is a memory trigger; several related images and narratives pop into your mind. These images and narratives aren’t grumpy or unpleasant. Instead, you feel warmly nostalgic. This is an example of a visual trigger that activates a mildly pleasant set of associated memories.

In contrast, if you’re a veteran who has experienced war trauma and you hear firecrackers on the 4th of July, your consciousness may flood with vivid, multisensory memories. These memories could link to deep emotional pain. This is an example of an auditory trigger that awakens or activates disturbing memories—memories that you might prefer to put back to sleep.

Now, think of the smell of coffee in the morning. For me, the scent of coffee is neutral. No clear memories are activated. But, when coffee smells are combined with the aroma of bacon on the griddle, I have instant flashbacks to my Grandma Lucy making breakfast. This is an olfactory stimulus triggering a pleasant memory. I see my grandma’s grey hair, pulled back with bobby pins. I can see my own small hands touching and feeling the textured floral pattern on her white milk glass china as I wait for breakfast, watching her. I hear the pop of bacon sizzling. I can imagine the pain I might feel if I get too close to grandma’s griddle. I instantly know the past and future of this memory. First, Grandma Lucy peeled the bacon apart, dangling each piece before laying them on the griddle. Later, she’ll save the bacon grease, for another purpose. She was like that. Another emotion emerges. I feel sad. I miss her.

In honor of memory science, it’s important to note that each of the preceding memories may be more or less historically accurate. Even more important is the likelihood that these memories, like all memories, have changed, shifted, and evolved over time.

How can memories change? Isn’t it true that humans have an experience and then store a record of it in their brain, ready for later retrieval? Not exactly.

As it turns out, new memories are more fluid than solid. Following a memorable experience, memories stay unstable for somewhere between a few minutes and a few hours. New memories are in flux and shaped or degraded by additional new experiences that immediately follow. More remarkable is the fact that, even after storage, every time memories are pulled out (or retrieved) they return to an unstable or vulnerable state, until they re-stabilize or reconsolidate. And when they reconsolidate (a process that involves cellular protein synthesis), they can include new, different, or less information. This is how and why memories change over time.

For many Americans, Memorial Day is an intentional memory day. For example, yesterday there were flowers, speeches, and flag waving. Yesterday, you were probably in the company of family, possibly kneeling at a gravesite, perhaps celebrating the life of someone whom you loved and lost.

Memorial Day is a memory trigger. It’s a time set aside to honor the lives of men and women who died in service of our country. It’s natural and good to engage in this honoring ritual. People also honor non-military family members with flowers and graveside visits. But, amidst the celebrations, as is often the case, the emotional side of life gets short shrift. Typically, we celebrate and move on, despite the fact that it’s equally natural and good to honor the grief that we feel in response to Memorial Day celebratory rituals.

It might have been the 21 gun salute or the color of the flowers or the taste of the potato salad or the smell of your uncle’s cologne. Whatever the case, yesterday you probably had old memories awaken and stroll past you in an internal memory parade. Some of these memories may have been neutral. Others may have been pleasant. Still others, felt angry, sad, guilty, or lonely.

But memories are open to change, and that fact begs for intentionality. What I mean is that we should all have a plan for Memorial Day (and then a plan for Memorial Night). Not only do we need plans for how to celebrate, we need plans for dealing with the raw emotions that Memorial Day can trigger.

I wish I could offer up a simple method for helping you to deal effectively with Memorial Day memory activation and reconsolidation. But you (and everyone) are a unique entity with layers of fantastic idiosyncrasy. Nevertheless, here’s a quick glimpse into the emerging science of memory reconsolidation.

In one research study, participants were exposed to negative emotional memories from watching a trauma film. The next day, these memories were re-activated using a trauma-photo from the film. Then, after a 10 minute-break some participants played a game of Tetris, while others didn’t. The results: Over the next seven days, the participants who played Tetris after having traumatic memories re-activated, experienced significantly fewer intrusive trauma-related memories. The implications? Maybe the Memorial Night solution is to establish a Tetris-playing ritual.

But painful memories are complex and unique. What works for one person, might not work for another. As Drexler and Wolf (authors of a 2018 scholarly review) were inspired to write, “Indeed, when the activation of selective L-type voltage-gated calcium channels or GluN2B-containing NMDA receptors in the hippocampus was prevented before retrieval, thus blocking memory destabilization . . . the interfering air puff had no effect” (p. 15). Reading this led me to conclude that reading more of Drexler and Wolf’s article might serve as another possible memory disrupting intervention to employ during the reconsolidation period. I’m guessing, if you’ve made it to this point in this blog, that you’re inclined to agree.

From a practical perspective, it’s good to know that, generally, memory reconsolidation can take up to six hours. And so, in addition to Tetris and reading intellectual research papers, there are other reasonable strategies you can use to facilitate healthy memory reconsolidation, not just on Memorial Day (or Night), but any time of the year—as long as you’re within the six hour memory consolidation window.

  • Talk with a trusted friend or counselor about the emotions you’re experiencing. Even better, don’t just talk about your emotional pain, but also talk about and focus on the strengths you have for coping with your challenging emotions.
  • Engage in a physically strenuous activity. This could involve some sort of strenuous physical activity like cycling, running, yoga, or weight-lifting.
  • Ritual is good. This could involve a culturally appropriate spiritual activity like going to a sweat lodge or attending a religious service.
  • Writing is a common and effective method for expressing emotions. In particular, writing about your loss in ways that are meaningful to you can be therapeutic.
  • There may be no better way to deal with problematic emotions than engaging in positive helping behavior. Alfred Adler called this social interest. When you’re triggered, consider ways in which you can shift the spotlight away from yourself and toward fostering wellness in others.

Memorial Day is an intentional memory day. We created it and we celebrate it. But you can have other, self-created memory days. And what we know about memory and the disturbing emotions that can accompany memories, is that they present us with an opportunity. Some researchers call this an opportunity for “updating.” Recognizing this opportunity and intentionally engaging in healthy and soothing behaviors when difficult memories are activated is good guidance. This might be Tetris. It might even involve singing along with Barbra Streisand in your best falsetto. The point is that we have power, albeit limited, to update our activated memories . . . and so I wish you the best in finding intentional and healthy ways to soften your painful memories. It’s the honorable thing to do.

Suicide Assessment: Mood Scaling with a Suicide Floor

IMG-2759

The following material is adapted from an article in the Journal of Health Service Psychology. You can access the whole article here: https://www.nationalregister.org/pub/the-national-register-report-pub/journal-of-health-service-psychology-winter-2018/conversations-about-suicide-strategies-for-detecting-and-assessing-suicide-risk/

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My favorite suicide assessment procedure is to ask about suicide in the context of a mood assessment (as in a mental status examination). This procedure utilizes a scaling question to explore patient mood and possible suicide ideation (Sommers-Flanagan & Shaw, 2017). As you read through these steps, think about how you might apply this procedure with a recent or current patient of yours.

  1. Is it okay if I ask some questions about your mood? (This is an invitation for collaboration; patients can say “no,” but rarely do.)
  2. I’d like you to rate your mood right now, using a zero to 10 scale. Zero is the worst mood possible. Zero would mean you’re totally depressed and so you’re just going to kill yourself. At the top, 10 is your best possible mood (you might hold your hand up high to illustrate the top of the scale). A 10 would mean you’re as happy as you could possibly be. Maybe you would be dancing or singing or doing whatever you do when you’re extremely happy. Using that zero to 10 scale, what rating would you give your mood right now? (Each end of the scale must be anchored for mutual understanding.)
  3. What’s happening now that makes you give your mood that rating? (This is what psychoanalysts call binding affect; it links the internal mood to an external situation.) At this point, you might ask questions to have your patient elaborate, in greater detail, the reason for the current mood rating.
  4. What’s the worst or lowest mood rating you’ve ever had? (This question informs you about the patient’s lowest lows.)
  5. What was happening back then to make you feel so down? (This question binds the sad affect to an external situation; it may lead to discussing previous attempts.) Again, you might take time here to explore a previous attempt, in an effort to understand the (a) dynamics that led to it, (b) the seriousness of suicide intent, and (c) what happened to help the patient live and be with you to work on suicide.
  6. For you, what would be a normal mood rating on a normal day? (You can insert this question at any point where it fits. Often, the best point is after the first mood rating because patients will immediately tell you whether they’re a little more up or a little more down than normal. The purpose is to get your patients to define their normal.)
  7. Now tell me, what’s the best mood rating you think you’ve ever had? (The process ends with a positive mood rating.)
  8. What was happening that helped you have such a high mood rating? (The positive rating is linked to an external situation.)

This procedure is a general map that can be used more or less creatively. No doubt, when you start the process with an individual patient, there will be opportunities to stray from the procedure. For example, when exploring the low end of her mood, your patient may begin sharing a traumatic experience. If so, you are at a key choice point. Should you continue with the next step in the procedure or focus in more detail on the trauma? Either option may be appropriate and will depend on one or more of the following factors:

  • Based on your best judgment, does your client want to talk about trauma in more detail? If so, you should move in that direction and come back to the procedure later.
  • Do you have time to immediately explore the trauma? If not, then you should say so and let your patient know that when you do have time, you will be interested in hearing details.
  • Do you sense that your rapport is minimal and your client is uncomfortable sharing details? If so, then the best option is to continue with the procedure, making a mental note to check back later when your client is more comfortable.

Numbers can be useful in rating patient mood, but because every patient is unique, the meaning of specific numbers will be subjectively variable. I have interviewed teenagers and young adults who emphasize their distress by saying something like, “I’m a negative three!” Despite the fact that having a negative three rating on the suicide scale indicates—in a quantitative sense—suicide certainty, these patients are typically making a point, and may or may not be an especially high suicide risk. In contrast, I have also worked with cases where adult patients burst into tears and admit to suicide ideation after giving themselves a current mood rating of 8 or 9. One patient who rated herself as “9” explained that she always thought of herself as being a 10. For her, anything outside of a perfect mood rating as terribly disturbing.

            Several of my supervisees who work with teenagers have creatively transformed the scaling method to eliminate numbers. One supervisee engaged a patient in mood scaling using musical genres. After a collaborative conversation, they established that listening to opera 24/7 was equivalent to zero and imminent suicide, while listening to heavy metal was a solid 10. When working with a middle school boy, another former student used Yoga as zero and pizza as 10. The point of these examples is that practitioners can collaborate with patients to identify a method to discuss mood. Collaborative rating systems makes the method personally meaningful to the patient; it also involves interpersonal connection, implying that the assessment method has become simultaneously therapeutic.

The mood scaling procedure offers several advantages. First, it is a process that facilitates engagement, and engagement or interpersonal connection is central part of suicide interventions. Second, when patients bind their low and high moods to concrete external situations, you gain knowledge about the themes and triggers that lift and depress your patient’s mood. Third, as illustrated in the case where a client begins talking about trauma, the mood scaling procedure can be abandoned (temporarily or permanently) in favor of more salient therapeutic opportunities. Fourth, mood scaling flows smoothly into safety planning or other suicide interventions (e.g., “When you say that being a zero always involves you being alone, it tells me that one thing we should talk about now or later is how you can reach out to others, and we should talk about who you want to reach out to, during those times when you’re feeling like a zero. It also tells me that we should talk some more about other methods you can use to move from a zero to a one.”).

One final note: The mood scaling technique is an indirect method for assessing suicidality. As such, it is not a replacement for using a normative frame and asking directly. In fact, you should be thinking about if and when you will weave asking directly into your mood scaling process. For example, if your client says “I’m a 3” you might follow that with a normative-based direct question: “It’s not unusual for people who rate themselves as a three to sometimes have thoughts about suicide. Has that been the case for you?”

The Graduation Speech They Didn’t Let Me Give (again)

Roni Aubrey John Grad 18 Better

This year, like all other years in the history of planet Earth, no one asked me to do a college or university commencement speech. I thought I had a shot at the University of Montana, but they settled on a Nike executive instead.

I puzzled over my lack of commencement speech invites, but only briefly. After all, at my most recent keynote (the Montana School Counseling Association), I spontaneously told my “Just Shut Up” story. It just so happens that my “Just Shut Up” story references a body part that typically isn’t mentioned in keynote speeches.

In my own defense, the “Just Shut Up” story is about adolescent development, and, because the entire experience of adolescent development is inappropriate, it’s impossible to say anything inappropriate when talking about adolescent development. This is so obvious that if you saw a Jeopardy answer saying, “A topic about which it’s impossible to say anything inappropriate” the correct question would, of course, be, “What is adolescent development?” I think I’m on solid ground here.

My point is that I’ve come to accept not getting asked to do commencement speeches. After all, they’re rigorous speaking gigs where you have to be ready to offer sage and complex advice like, “Be yourself” and “Don’t forget to give back.” That sort of sage advice might be somewhat outside my wheelhouse.

But then, the week before last Saturday’s University of Montana commencement, I found out that our graduating M.A. students in Counselor Education had requested a microphone for their post-commencement reception. I didn’t realize it immediately, but upon embarking on my one-mile walk to line up for the commencement ceremony, it hit me. My students were sending me a special indirect message. The microphone was for me. Knowing my penchant for speech-giving, they leaked the microphone intel, so I’d have time to prepare a fancy commencement speech, just for them.

When it comes to graduation speeches, preparation is key, so I spent the 15 minutes of my walk in a state of profound inspiration. I prepared a formal opening and closing, and then wrote two special graduation songs, practicing them along the way. The passerby seemed appreciative, even though they probably couldn’t understand why I was singing “Move your eyes” to the tune of “Shake it Off” or what inspired me to include the main refrain of “A date with Sigmund Freud” instead of “A partridge in a pear tree” when singing “The Twelve Weeks of Theories.”

Being uncertain as to whether I should focus exclusively on songs, I outlined an additional speech. This extra speech was all about the Gestalt of be-here-now and self-awareness, as I integrated the rising (and flooding) spring waters of the Clark Fork River as a metaphor for how over-activity contributes to the opaqueness of the self. To be sure that my commencement message would get through, I also included warnings about Narcissus and his fatal projection of the self. That’s the sort of mythical anecdote that can bring down the house.

Sadly, that afternoon, I discovered that the leaking of the microphone rental was nothing more than the flirtation of a ruse. During the WHOLE Counselor Education reception, the students completely hogged the microphone. All they did was go On and On and On and On (like Jack Johnson) saying nice things about each other and the faculty and the doc students, not leaving me a minute with the mic to get up there with my Poker Face (like Lady Gaga) to perform my freshly written songs.

Grad 18 Awards

In the end, truth be told, the Nike guy was pretty darn good, and likely a better choice than me. But, more importantly, our students were like they usually are . . . AWESOME. These graduates will be heading out to schools, mental health agencies, and intercultural destinations, where they’ll connect with and counsel youth and adults and make the world a healthier place.

Other than my amazing vocal performance, there’s one thing I wish I’d had a chance to say. It might have been something like this:

Take a moment to look around the room. See your classmates, your supportive families, and your faculty. Don’t just see them, SEE them as the multi-layered and profound beings that they are. In this irretrievable sparkling moment of the now, let’s remember a few things together. Remember your decision. You walked in this building to become a counselor. You dedicated yourself to learning how to help others. How cool is that? Feel the power of that memory. Remember our first times together. Remember when your professors kept having you awkwardly introduce yourselves to your new classmates. Feel that awkwardness and anxiety. Let it be with you, remembering that you OWN your future awkwardness and anxiety, because you worked through it, conquering it for now and later. Remember the painful viewing of video recordings of yourself doing counseling. Remember the painful feedback. Remember the tears and joys you experienced together. Remember getting to know the people in this room in ways you never could have imagined, until it happened. Remember growing in respect for yourself, growing your counseling skills, and deepening your respect for your classmates. Remember the late nights, the early mornings, the six straight hours of class, and that assignment (or two) that you pretty much hated. And most of all, remember this moment, right now, surrounded by friends and family. Remember the joy of right now. Remember why you chose this path and why you’re here today. Remember it all, and put it in your heart. Then, in the future, which might be now and might be later, commit yourself to combine your counseling skills, your empathic heart, and your thirst for continued learning. Let the joy of now flow back to the memories of then and the future of what will be. Recognize your new power; it’s like the Force; it’s in your hands, it’s in your heart, it’s in your brain. You take it from here, remembering also, that we are honored to have had time with you and to send you out to shape a healthier and happier society.

Oh. Yeah. I almost forgot. Remember this too, and be grateful: Never again will you have to date Sigmund Freud.

An Early Peek at the Suicide Assessment and Intervention Video Project

Helicopter CroppedBack in March, 2012, I settled into a Starbucks in Vancouver, Washington to reflect on my experiences at the annual American Counseling Association conference in San Francisco. Memories of Dr. Irvin Yalom’s keynote bubbled up in my mind, so that’s what ended up in my fingers, on my screen, and in my blog.

Several days later, I got an email from a “Dr. Yalom.” Seeing the name, I immediately felt anxiety and anticipation. First thoughts, “I meant to be positive. I hope I didn’t write anything offensive?”

The email was from Dr. Victor Yalom. It was nice . . . and supportive . . . and positive . . . and a big relief.

Victor is the owner/publisher/president or grand sultan of psychotherapy.net. Psychotherapy.net is a publisher of psychotherapy training and continuing education materials, mostly videos. Over the past 6 years Victor and I have struck up a collegial friendship. He is the biggest fan and proponent of our Clinical Interviewing video series (which he sells through psychotherapy.net). After viewing the Clinical Interviewing video, he has repeatedly asked Rita and I about doing a video for psychotherapy.net. Unfortunately, the timing never worked out, until this past fall, when we agreed to collaborate on a six-hour suicide assessment and intervention training video.

As they say in the film industry, everything is in the can. We’re down to final editing and other details. We filmed in Missoula and Mill Valley. Rather than working directly with imminently suicidal clients, we got volunteers to channel previous or potential suicide-related experiences. All this is just my way of introducing this sneak peek into this upcoming video.

Of course, reading isn’t the same as watching, but the next 2,000 words can give you a glimpse of one of the cases featured on the video. The client is a young Native American man and veteran. Many cultural issues emerge during the session, along with suicide ideation. Here’s the clip, along with my side “commentary” in bold:

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John:            Cory, I know a little bit about you, but not very much. And so maybe the best place to start is for you to tell me some things about yourself, some things about how you’ve been feeling in your life, some things about the situations that you’ve been in, and maybe help me get a sense of how I might be of help.

Cory:            Yeah, I come from a small reservation in Eastern Montana, and I was kind of – it was a comfortable life growing up. I didn’t know anything different. And I remember sitting there with my family watching the war and kind of spurred us to want to help bring honor to our tribe. So, I signed up at 17.

John:            Yeah, what tribe?

Cory:            I’m from the Lakota Sioux tribe from the Fort Peck Indian Reservation.

John:            Okay. Great, thank you. Sorry.

Cory:            So, I left at 17, and it was kind of a big deal. We had a big honor, big gathering for me, big sendoff, and it was pretty great and feeling pretty good. Deployed when I was 18 years old over to Iraq. It was going great. I felt like I was doing something. I didn’t get to talk to my family much, maybe every three months. And I didn’t know what was going on at home. Had a fiancée when I left. Life was great. Eventually time to come home and came home. And my family’s kind of in disarray. My grandma died. I didn’t get to go to her funeral. They didn’t tell me.

John:            Yeah.

Cory:            So, kind of tore me up. My fiancée left me for one of my best friends, so that was the shock of my life.

John:            Yeah. So, at least at this point I’m hearing that you were on kind of a high and feeling good at 17, get a big sendoff from your tribe, from your family, and you go, and you go to Iraq. And you get back, and things are a mess.

Cory:            Yeah. Meth kind of hit our reservation pretty hard. And family members on meth and prison and kind of whole world changed, I guess. Eventually, I didn’t – just came back and started drinking. Not sure who I was anymore. So, that was difficult, didn’t have very many people to turn to anymore. Never had a father growing up. My mom was always raising us with a couple jobs. And eventually her and her boyfriend got into drugs, so that’s kind of pretty difficult. And I didn’t know what to do anymore. And I was kind of feeling down and just kept drinking, and I kind of don’t know what to do anymore. For us it’s a honor to serve and kind of makes us who we are.

John:            Yeah.

Cory:            We view it as becoming a warrior man.

John:            Yeah.

Cory:            And I felt like I did that, and I’d bring honor back to my culture, my tribe. Yeah, just I came home. Everything’s in disarray, and I thought I was pretty stable. Eventually – and one thing, on the reservation we don’t – or culturally we don’t talk about our feelings or emotions. So, every time we do, feel pretty shame. A lot of shame comes from it. So, it’s kind of you just deal with it.

John:            Yeah, yeah. Yeah, so a couple of cultural pieces. One is that sense of honor of serving, and you hooked onto that and were living that. And then another cultural thing is, it’s a little shameful to express emotions, sadness, that kind of emotion or others.

Cory:            Yeah, I mean, I guess I could just describe it as shame. Like I feel guilty talking about it because we’re supposed to be men.

John:            You’re warriors. You’re strong.

Cory:            Yeah.

John:            And so you keep it all –

Cory:            Yeah, it’s part of who we are, death, fighting, honor, celebrating together, just part of who we are.

John:            Yeah, yeah. And then as you get back, and you’re in this disarray, and the meth on your reservation is prevalent, and you start drinking, and it sounds like that could be connected with the emotional warrior. Is that one of the ways that you might cope?

Cory:            I guess I just – kind of just helped me feel nothing.

COMMENTARY: Cory has covered lots of ground quickly. He has articulated his collectivist identity. Knowing about his collectivist identity early in the session is a very good thing. He has also mentioned multiple stressors and losses; these stressors and losses are traditional risk factors and load onto the various risk dimensions. These include: coming back from war, being a veteran, loss and betrayal by his girlfriend, his grandmother’s death, the disarray of his tribal community from meth, and other issues. In addition, one immediate challenge that’s coming into my mind is how to address alcohol, because it’s a suicide desensitizer, but it’s also helping him “feel nothing” which is consistent with his cultural value of not expressing his feelings. At this point I’m choosing to build a relationship with Cory before jumping in and discussing alcohol directly.

John:            Okay.

Cory:            Just kind of, I guess, how I dealt with it because I couldn’t talk about stuff that happened over there, and I didn’t have no male role models in my life to kind of talk about culturally with or anything.

John:            Yeah. So, I’m aware of the fact that you’ve told me, and I really appreciate it, some cultural things about you, about being a Lakota Sioux, about the reservation that you grew up on and some of the things you experienced, about the honor, about the shame, about the warrior mentality. And I’m going to do my best to track all those things. Occasionally if you think I’m just not getting it from your cultural perspective, I would love it if you would tell me, but I don’t want to put all that responsibility on you. So, I will probably every once in a while just check in to see, am I getting this right? Is that okay with you if we –

Cory:            Yeah, that’s fine.

John:            Yeah, because I just don’t want to misunderstand things because of my lack of the same cultural experience as yours. And so as I’m imagining it, you’re back. You’re drinking. It’s part of being numb.

Cory:            Uh-huh.

John:            And getting rid of those emotions. And as you talk, one question that comes to mind to me, and my guess is that this would be a dishonorable thought to have, although not an abnormal thought because it’s not unusual when people come back and life is disappointing and hard, and you’re drinking, and you’re managing those emotions, it’s just not unusual to have a thought about suicide or about killing yourself. And my guess is that would be in opposition to your culture, too, but I don’t know.

Cory:            Yes and no. One way we look at is from we’ve had everything taken from us. That’s one thing you can’t take from us. Our life is ours to give to the Creator, to Wakan Tanka which is our God. So, when it’s our time, it’s kind of our choice.

John:            Okay.

Cory:            The sad thing about it is, I’m feeling down, and a lot of times like as I grew up I had – I was probably nine years old. My first friend committed suicide. And it brings the community together. We have big honoring, big feast for his family, for him, and just days of celebrating. It’s kind of like bring the family back together. I had another friend do it after that because he was – couldn’t graduate high school and didn’t have nobody there, and he wanted his family to come back together, so he committed suicide, just felt like it’s going to bring his family back together. And it did for a bit, but meth came in again, so it kind of tore it apart.

John:            Uh-huh.

John:            So, I’m hearing two suicides of people that you knew well around the time that you graduated high school?

Cory:            Oh, one was when I was 9, and a good friend was 16. And by the time I was 18, I probably lost maybe 7 friends from drinking and driving, drugs, stabbings. So, I guess to us, I mean, death is death, so it wasn’t really a big deal, kind of a celebration and we’ll see them again.

John:            Yeah. So, for each one the family celebrates, the community celebrates –

Cory:            Uh-huh.

John:            – the life. And sometimes it almost sounds like somebody might choose suicide as an effort, it sounds like, to pull the family together to get everybody closer.

Cory:            Yeah, I guess, too, they know people will care. Pretty big sense of hopelessness there. Not many people know where to turn.

John:            Yeah. Yeah, so that’s a lot of death that you saw even by the time you graduated high school. Have you had some thoughts of suicide yourself?

Cory:            Originally when I first came back, I did. I just didn’t know what to do anymore. Then I came to college, thought I was going to – wanted to do something honorable again. Again, big celebration and sent us off to college. And I get here, and things are going well at first. Then just the culture differences, like nobody understood me, didn’t know what to do. I was doing all right in classes, but I just kind of couldn’t fit in, didn’t feel like anybody understood me. I mean, they’re all pretty nice guys and gals. I could tell they were trying to, but just something I knew they didn’t.

And then now things are getting bad again. I’m trying to sleep at night. Yeah, just every time I go to sleep, I remember one time in Iraq we were sitting there, and they decided – well, I guess Al-Qaeda, they blew a whole street, whole city block, and it just – I mean, every building came down. And we were there trying to help, and you had kids with missing arms and missing eyes and moms with no legs and crying, screaming. We were trying help as best we can, and same time people shooting at us and just didn’t know what to do.

My friend’s crying. Like why the fuck are we here? Like what are we doing here? Like this isn’t what we – not what we’re here for. Yeah, I just remember a mom with no leg carrying her helpless child just in her arms, and the child was dead. I mean, just every time I go to sleep, I just remember that kid helpless laying there. And so I’m not sleeping much, a lot of drinking still. I guess I don’t know what to do anymore.

COMMENTARY: It’s not unusual for suicidal clients to present with a vast array of psychological pain. That can be overwhelming to the client and to the therapist. Cory has shared several layers of unresolved grief, traumatic war memories. The number of people whom he has known who have died by suicide is immense. Additionally, because of his cultural norms of stoicism, I’m wanting to address these parts of his experience, while not activating intense emotions. my strategy has been and will be to use reflection of content, to avoid reflecting back strong emotions like sadness or anger, to keep his collectivist perspective in mind, and to take notes in a way so that he and I can take a more intellectual and problem-solving approach to working with him on his experiences.

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If you made it this far, a big congratulations. Acquiring skills to work effectively with clients who are suicidal is challenging, but dealing with the emotions that come up is probably even more difficult. The purpose of this training video (when it becomes available) is to help practitioners obtain knowledge, learn skills, and refine their awareness of the inner and interpersonal dynamics associated with suicide assessment and intervention. When I have more information on the video’s availability, I’ll let you know.

Working with Parents Across Cultures

This morning I have the honor and privilege to present an ACA Education session on working with culturally diverse parents. Part of the presentation is business as usual. Sara Polanchek and I will take turns talking about some of the ways in which we work with parents. This content is mostly linked to the “How to Listen so Parents will Talk and Talk so Parents will Listen” book.

But what’s exciting this morning is that two of our U of Montana doc students will intermittently offer cultural commentary on how to work with parents who are culturally diverse. Maegan Rides At The Door and Salena Beaumont Hill are the doc student co-presenters. I have already learned much from them . . . and will be learning more this morning. To share the learning, the powerpoints are here: ACA Parenting 2018 REV #274