Category Archives: Clinical Interviewing

Cultural Specificity and Universality: An Indigenous Example

These days mostly we tend to orient toward the culturally specific, and that’s a good thing. Much of intersectionality, cultural competency, and cultural humility is all about drilling down into unique and valuable cultural and individual perspectives.

But these are also the days of Both-And.

In contrast to cultural specificity, some theorists—I’m thinking of William Glasser right now—were more known for their emphasis on cultural universality. Glasser contended that his five basic human needs were culturally universal; those needs included: Survival, belonging, power (recognition), freedom, and fun.

Although Glasser’s ideas may (or may not) have universal punch, he’s a white guy, and pushing universality from positions of white privilege are, at this particular point in history, worth questioning. That’s why I was happy to find an indigenous voice emphasizing universal ideas.

I came across a quotation from a Lakota elder, James Clairmont; he was discussing the concept of resilience, from his particular linguistic perspective:

The closest translation of “resilience” is a sacred word that means “resistance” . . . resisting bad thoughts, bad behaviors. We accept what life gives us, good and bad, as gifts from the Creator. We try to get through hard times, stressful times, with a good heart. The gift [of adversity] is the lesson we learn from overcoming it.

Clairmont’s description of “the sacred word that means resilience” are strikingly similar to several contemporary ideas in counseling and psychotherapy practice.

  • “Resisting bad thoughts, bad behaviors” is closely linked to CBT
  • “We accept what life gives us, good and bad, as gifts from the Creator” fits well with mindfulness
  • “We try to get through hard times, stressful times, with a good heart” is consistent with optimism concepts in positive psychology
  • “The gift [of adversity] is the lesson we learn from overcoming it” and this is a great paraphrase of Bandura’s feedback and feed-forward ideas

In these days of cultural specificity, it makes sense to work from both perspectives. We need to recognize and value our unique differences, while simultaneously noticing our similarities and areas of convergence. Clairmont’s perspectives on resilience make me want to learn more about Lakota ideas, both how they’re similar and different from my own cultural and educational experiences.

Talking with Clients about Previous Suicide Attempts from a Strengths-Based Perspective

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

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,

Nothing helped. Nothing ever helps (Sommers-Flanagan & Sommers-Flanagan, 2017, p. 373).

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

Free Wiley-Sponsored Webinar

Hi All,

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. 

To check out all the specific webinar events throughout the day, click here.

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     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

A Strengths-Based Suicide Assessment and Treatment Model

Bikes Snow 3

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.

Below is a short excerpt from chapter 1 of our upcoming book. This excerpt gives you a glimpse at the strengths-based model. You can also check out this link for an alternative description: https://johnsommersflanagan.com/2020/12/11/coming-in-january-the-strengths-based-approach-to-suicide-assessment-and-treatment-planning/

If you’re interested, the book is now available through the publisher, as well as through other booksellers: https://imis.counseling.org/store/detail.aspx?id=78174

You can get it in eBook format via Amazon.

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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.

Thanks for reading!

John S-F

The Long Version of our Theoretical Orientation Test: Which Direction will our Hogwarts Theories Hat Point you?

I keep getting a steady stream of requests for the “long version” of our Theoretical Orientation Test. The TOT-Long is from our Study Guide, pictured here:

And here’s a link to the test:

When taking our TOT-Long, keep some or all of the following in the back (or front) of your mind.

  1. This questionnaire is for self-exploration; it’s not an “assessment” with established psychometrics. What that means–in the spirit of Adler–is that this so-called test is an idiographic assessment process.
  2. I’m not a big fan of counselors and psychotherapists pigeon-holing themselves into strict theoretical positions. Instead, finding a compatible theory can help you align with ways you can transform your ideas into practical ways of being and ways of working with clients. Don’t let your theoretical orientation stop you from flexibly providing clients with the services they need and want.
  3. All theory-based approaches work best from a relational foundation. If you question this basic assumption, try doing cold CBT with ambivalent or reluctant teenagers. . . or just imagining how that would go might be enough.
  4. I hope you enjoy contemplating where our theoretical “sorting hat” sends you. As with all assessments, you’re the final authority of whether the shoe (or hat) fits.

Please let me know what you think of the test and, if you’re so inclined, post your theoretical orientation as a comment here. I look forward to hearing and seeing your reactions and results.

Be well!

John SF

Seven Dimensions and Suicide Assessment and Treatment

To help practitioners focus on wellness within the whole person, Rita and I have been writing about seven life dimensions as they pertain to suicide assessment and treatment. Although treatments for individuals who are suicidal should focus on suicide, it’s also true that there’s much more to whole person in the room than suicidality. The seven dimensions we’re using include the following:

  1. The emotional dimension
  2. The cognitive dimension
  3. The interpersonal dimension
  4. The physical dimension
  5. The cultural/spiritual dimension
  6. The behavioral dimension
  7. The contextual dimension

The visual excerpt from chapter 4 included with this post (above) focuses on the emotional dimension. In chapter 4 we discuss how to use empathy to emotionally connect with clients, but also on a variety of strategies for helping clients (and students) develop strengths, resiliency, and wellness within the emotional dimension.

The book is primarily available the the American Counseling Association. Here’s the ACA link: https://imis.counseling.org/store/detail.aspx?id=78174

Coming In January: The Strengths-Based Approach to Suicide assessment and treatment Planning

As many of you know, Rita and I have been working on a suicide assessment and treatment planning manuscript to be published by the American Counseling Association. Today, we received a photo of the full (front and back) cover. Although we know you’re not nearly as excited about this book (coming in mid-January!) as we are, below, I’ve pasted the photo of the cover and the first part of the Preface.

Preface

Writing a book about suicide may not have been our best idea ever. Rita made the point more than once that reading and writing about suicide at the depth necessary to write a helpful book can affect one’s mood in a downward direction. She was right, of course. Her rightness inspired us to pay attention to the other side of the coin, so we decided to integrate positive psychology and the happiness literature into this book. As is often the case when grappling with matters of humanity, focusing on suicide led us to a deeper understanding of suicide’s complementary dialectic—a meaningful and fully-lived life–and that has been a very good thing.

Before diving into these pages, please consider the following.

Do the Self-Care Thing

            In the first chapter, we emphasize how important it is to practice self-care when working with clients who are suicidal. Immersing ourselves in the suicide literature required a balancing focus on positive psychology and wellness. While you’re reading this book and exploring suicide, you cannot help but be emotionally impacted, and we cannot overstate the importance of you taking care of yourself throughout this process and into the future. You are the instrument through which you provide care for others . . . and so we highly encourage you to repeatedly do the self-care thing.

What is the Strengths-Based Approach?

            Many people have asked, “What on earth do you mean by a strengths-based approach to suicide assessment and treatment planning?” In response, we usually meander in and out of various bullet points, relational dynamics, assessment procedures, and try to emphasize that the approach is more than just strength-based, it’s also wellness-oriented and holistic. By strengths-based, we mean that we recognize and nurture the existing and potential strengths of our clients. By wellness-oriented we mean that we believe in incorporating wellness activities into counseling and life. By holistic we mean that we focus on emotional, cognitive, interpersonal, physical, cultural-spiritual, behavioral, and contextual dimensions of living.

You will find the following strengths-based, wellness-oriented, and holistic principles woven into every chapter of this book.

  1. Historically, suicide ideation has been socially constructed as sinful, illegal, or a terribly frightening and bad illness. In contrast, we believe suicide ideation is a normal variation on human experience that typically stems from difficult environmental circumstances and excruciating emotional pain. Rather than fear client disclosures of suicidality, we welcome these disclosures because they offer an opportunity to connect deeply with distressed clients and provide therapeutic support.
  2. Although we believe risk factors, warning signs, protective factors, and suicide assessment instruments are important, we value relationship connections with clients over predictive formulae and technical procedures.
  3. We believe trust, empathy, collaboration, and rapport will improve the reliability, validity, and utility of data gathered during assessments. Consequently, we embrace the principles of therapeutic assessment.
  4. We believe that counseling practitioners need to ask directly about and explore suicide ideation using a normalizing frame or other sophisticated and empathic interviewing strategies.
  5. We believe traditional approaches to suicide assessment and treatment are excessively oriented toward psychopathology. To compensate for this pathology-orientation, we explicitly value and ask about clients’ positive experiences, personal strengths, and coping strategies.
  6. We believe the narrow pursuit of psychopathology causes clinicians to neglect a more complete assessment and case formulation of the whole person. To compensate, we use a holistic, seven-dimensional model to create a broader understanding of what’s hurting and what’s helping in each individual client’s life. 
  7. We value the positive emphasis of safety planning and coping skills development over the negative components of no-suicide contracts and efforts to eliminate suicidal thoughts.

Understanding Suicide – A Video/Podcast Interview with Paula Fontenelle

The word suicide, all by itself and regardless of context, can elicit anxiety, grief, anger, and other raw emotions. One of my goals as a mental health professional, is to advocate for open discussions of suicide. Why? Because I want to actively role model how facing, embracing, and discussing suicide directly can shrink the threatening nature of the word—and also shrink the anxiety, grief, and anger that people feel when they hear the word.

Just yesterday, Paula Fontenelle, author of “Understanding Suicide” (see Amazon: https://www.amazon.com/Understanding-Suicide-Living-loss-prevention/dp/1691504831), posted a podcast and video of her and I discussing suicide. As always, when I look at and listen to myself, I feel a bit shy about sharing this. The mirror (or video recording) is never as flattering as I wish it to be. However, I love that Paula is so dedicated to this topic and that she was willing to have me as a guest on the 1st anniversary and 40th episode of her show.

You can access a video of the show here: https://www.youtube.com/watch?v=RDmY8kgf6Zc

You can access the audio (podcast) of the show here: https://bit.ly/3muZ2eD

If you want to know more about Paula and her interests and expertise, you can link to her in all of the methods listed below:

WebsitePodcast | YouTube | LinkedIn | Facebook | Instagram

Thanks for reading, listening, and watching. I wish you all the best this weekend and beyond!

John

Suicide Assessment Should be Therapeutic Assessment

This morning (or afternoon, depending on your time zone), I’ll be participating on a panel discussion titled, “Treating and Preventing Suicide.” Although the event has reached maximum capacity, the link for more information is here: https://catalog.pesi.com/sq/pn_001386_essentialstreatingpreventingsuicide_panel_aca-139059?fbclid=IwAR2QYfDxVFjdnnDHV1JwKUYh54JqKzvhpneB98FF-yNrk5fcbFfPMdtyuWs

As a resource to complement the panel discussion, I’m posting some information on suicide assessment. Below is the opening from the suicide assessment chapter in our forthcoming book with the American Counseling Association. We emphasize that suicide assessment isn’t purely data collection. Instead, professionals need to simultaneously keep their eye on how to be therapeutic. Here’s the excerpt:

Suicide assessment integrates science and art. Assessment science helps practitioners determine what information is most important during a clinical interview and how to best obtain reliable and valid assessment data (Sommers-Flanagan et al., 2020; Wygant et al., 2020). The art of assessment includes how and when to ask questions, relational methods for offering empathy, and how clinicians can partner with clients to explore symptoms and strengths in ways that facilitate trust and stimulate honesty (Ganzini et al., 2013). Because suicide is a painful and provocative topic, advanced assessment skills are essential.

When clients or students experience suicidality, exposure to an assessment process can feel threatening. As a consequence, we believe counselors should embrace principles of therapeutic assessment (Fischer, 1970, 1985). Therapeutic assessment originated in the late 1960’s, when Constance Fischer began practicing and publishing about a radical new assessment approach. Unlike traditional objective and unilateral approaches to assessment, Fischer (1969, 1970) began viewing clients as “co-evaluators.” Stephen Finn has extended Fischer’s ideas; the approach is now called therapeutic assessment (Finn et al., 2012).

Therapeutic assessment principles are consistent with the professional counseling paradigm (Capuzzi & Stauffer, 2016); they include collaboration, compassion, openness, honesty, and a commitment to valuing clients as ultimate experts on their lived experiences. Although information gathering remains important, relationship connection during assessment interviews takes priority. Every assessment finding needs to be validated and understood within each client’s unique personal context. Collaboration is the cornerstone; assessments are done with clients, not on clients (Martin, 2020; Sommers-Flanagan & Sommers-Flanagan, 2017). As Flemons and Gralnik (2013) wrote, when conducting suicide assessments, “Our goal is not to remain objectively removed but, rather, to become empathically connected” (p. 6).

There are several “therapeutic” strategies for suicide assessment interviewing. Jobes’s (2016) book is a great resources, as is Freedenthal’s (2018). You can also check out our Clinical Interviewing suicide assessment chapter, or read this free blog post on using a mood scaling method: https://johnsommersflanagan.com/2018/05/25/suicide-assessment-mood-scaling-with-a-suicide-floor/

Obviously, there’s not enough time and space to go into great depth on suicide assessment in a little blog like this. And so, if you looking for depth, check out the video series I did with Victor Yalom and Psychotherapy.net. You can even watch a short demonstration video clip: https://www.psychotherapy.net/video/suicidal-clients-series

I wish you all the best as you face the challenge of engaging with and treating clients who are suicidal with the therapeutic respect they deserve.

Sweet Home Alabama — Suicide Workshop Handouts

See below for links to the handouts for the Alabama Counseling Association workshop on 8/21/20, titled, “Suicide Assessment and Treatment Planning: A Strength-Based Approach.” Although I wish I could be there in-person in Alabama, instead, we’ll get an exciting, live, and interactive Zoom workshop!

Powerpoint Slides are Here: Suicide Workshop Alabama

Extra Handouts are Here: Alabama Handouts 8 21 20