Category Archives: Counseling and Psychotherapy Theory and Practice

Becoming a Reality Therapist: The Reality Therapy Lab

Let’s say you want to practice reality therapy. Maybe more than any other approach, you’ll need to use reality therapy on yourself to become a reality therapist. Here’s what I mean.

You could consider channeling a little William Glasser, because he’s the developer of reality therapy. Then again, you might not want to channel Glasser, because, as Robert Wubbolding has written, to become a reality therapist, “You need not imitate the style of anyone else.”

The point is that you get to do the choosing . . . and a great start is to choose to use Wubbolding’s summary of the delivery system of reality therapy. Wubbolding used the letters, WDEP to summarize reality therapy, and these letters also happen to appear on Wubbolding’s car license plate. If you’re getting the feeling that Wubbolding is committed to reality therapy principles, you would be absolutely right. WDEP stands for Wants, Doing, Evaluation, and Planning. The following four questions capture WDEP:

What do you want?

What are you doing?

Is what you’re doing working? [Evaluation]

Should you make a new plan?

Before enacting reality therapy, you’ll need to adopt a positive, engaged, courteous, enthusiastic, counselor demeanor. You also need to be ready to use your excellent active listening skills. Avoiding toxic relational strategies like arguing, blaming, and criticizing is crucial. Think of yourself as a mentor or coach, and then practice the following strategies to see if they fit for you.

Begin by helping your client (or role-play partner) identify what he/she/they want. You could use any of the following questions:

If we could work on something that feels important to you, what would that be?

What do you want from our meeting today?

This is a big question, but I’m going to ask it anyway: What do you want from life?

If we have a good session and accomplish something that feels good to you, what will we have accomplished?

After you’ve gotten a sense of what your client is wants, you can move onto an inquiry about how your client is currently trying to get those wants. Questions like the following might help:

How are you currently trying to get what you want?

What have you tried?

I imagine you’ve tried various strategies for getting what you want to happen in your life. Tell me about all those things you’ve tried and how they’ve worked.

You can see from this last question, that asking about what clients are doing naturally leads to what Wubbolding considers to be the most important step in reality therapy: Evaluation. Wubbolding hypothesizes that many clients don’t get taught how to self-evaluate and/or may not have much practice at self-evaluation. He uses questions like the following to prompt client self-evaluation.

Is what you’re doing helping or hurting?

Is want you want realistic and attainable?

Does your self-talk help or hinder you in your efforts to get what you want?

Wubbolding has many additional questions about how to help clients self-evaluate in his book, Reality Therapy for the 21st Century. Check it out.

This brings us to the final question: Should you make a new plan? I think one of the most important insights that reality therapy brings to the counseling table is its emphasis on active and smart planning. Although SMART plans originated in the business world, Wubbolding has an extensive guide for how to help clients make effective plans. In my experiences doing counseling and psychotherapy, I’ve been astonished at how often clients go off in search of goals with either no plans or bad plans. For Wubbolding, client plans should be: Simple, Attainable, Measurable, Immediate, Involved, Controlled, Committed, and Continuous (Wubbolding’s acronym for planning is SAMI2C3). For more information on how to create SAMI2C3 plans, see Wubbolding’s book or the chapter in our Counseling and Psychotherapy Theories in Context and Practice textbook.

All planning that happens in counseling should be collaborative planning. Your job, as you engage in this important planning step, is to come alongside clients, brainstorm small tweaks or big changes in how clients might attain their goals, and to give them constructive feedback about whether their plan is a smart plan while providing encouragement and collaboratively evaluating the plan’s effectiveness. I have no doubt that reality therapy can be effective, partly because the first three reality therapy questions are so central to human functioning, but also because a good plan is a beautiful thing.

Note: the content of this blog is primarily adapted from the section that Robert Wubbolding wrote for our theories textbook.

My Birthday Wish (and Request)

Yesterday, in anticipation of my 63rd trip around the sun, I started feeling a slow creep of melancholia. At my age, because all movements are slower than frozen molasses, I now have the luxury of spotting doom early on, as its ambling my way. Last night’s gloominess was mostly about aging, but amplified by my nightly dose of watching the evening news. As usual, the news inevitably featured Donald J. Trump being Donald J. Trump, and saying things that can’t—without the aid of a delusional disorder—be framed as anything other than mean, nasty, and dangerous. After yet again witnessing Mr. Trump’s malevolence, I turned to Rita and murmured, “I think he might be evil.”

As soon as the word evil escaped my mouth, I immediately thought of Carl Rogers. Rogers was an amazing American psychologist who, from the 1930s to the 1960s, developed a profoundly empathic way of working with people. Rogers was raised in a rigid fundamental conservative Christian family. He wasn’t allowed to dance or play cards. During college, at age 20 (the year was 1922), Rogers took a sharp ideological left turn while on a slow boat to China. He stepped away from his fundamentalist roots, and began embracing a broad and encompassing belief in the goodness of all people. Rogers stepped so far away from judgmentalism, and believed so deeply and persistently in the innate goodness of all humans, that many philosophers and psychologists in the 1950s and 1960s (like Rollo May and Martin Buber), viewed Rogers as dangerously naïve.

After realizing back in the 20th century that I would never be “Like Mike” (Michael Jordan), I started fancying myself as being like Carl Rogers instead. The match seemed perfect. Just like Rogers, I believe in everyone’s positive potential. Also like Rogers, I don’t really believe in evil. However, after four years of listening to someone with immense power mock the disabled, disparage the military, demean women, remorselessly lock migrant children in cages, stoke hate, division, and conspiracies, and threaten to blow up our democratic process . . . I’ve begun reconsidering my naïve Rogerian perspective on evil. Last night’s news snippet included Mr. Trump’s continued attack on the Michigan governor. As far as I can tell, the only times Mr. Trump manages to use his words to show empathy is when he’s reading—rather haltingly—off of a teleprompter.

Rogers might blanch at my judgment of Trump, but I think not. He wrote a book “On Personal Power” and his bottom line was that you should give it away. And when I interviewed his daughter, Natalie Rogers, in 2006, she made it clear that her dad was in favor of accepting and prizing all human feelings, but that he could be quite firm when people (and his children) behaved in unacceptable ways. I’m pretty sure that Carl Rogers, one of the most profoundly influential psychologists of all time, would be horrified by Mr. Trump’s behavior, and he would use his power to bring back civility, decency, and empathy.

A couple years ago I had the honor of meeting Joe Biden, face-to-face. He greeted me with flourish and enthusiasm. He oozed empathy, compassion, kindness, and a commitment to service. He spoke and acted without a whiff of arrogance. I’m convinced that he’s the sort of person who will use his power for good.

Here’s my birthday wish (and request). Instead of sending me all the lavish gifts you had planned to send me, just go out and spread the word that decency, empathy, respect, kindness, and love are making a HUGE comeback. And if you know someone whom you think isn’t voting, consider this: reach out with respect and kindness and ask them to vote for Joe Biden. That would be amazing . . . a little frosting on my birthday wish.

Thanks for reading this and for helping make my birthday wish come true.

Essential Information about Counseling and Psychotherapy Theories

A good summary is a beautiful thing. But summaries are always unfair and limited representations of that which is bigger. Nevertheless, below, I’ve tried to summarize the primary listening focus and the primary change mechanisms for each of 13 theoretical orientations included in our textbook, Counseling and Psychotherapy Theories in Context and Practice (John Wiley & Sons, 2018). In addition, yesterday I filmed myself using a memory-palace strategy while describing all 13 perspectives below. You can read the summary below and/or watch me try to pull off this 15 minute theories overview on YouTube: https://youtu.be/VJFK6cCHCU8

TheoryWhat to Listen For. . .Change Mechanisms
Psychoanalytic PsychodynamicOld maladaptive intrapersonal conflicts and repetitive, unconscious, and dysfunctional interpersonal patterns.Make unconscious conscious, catharsis, and working through new intra- and interpersonal dynamics.
AdlerianBasic mistakes imbedded in the style of life, including excess self-interest and inferiority/superiority.Awareness, insight, and encouragement (courage) to face the tasks of life.
ExistentialAnxiety over and avoidance of core existential life dynamics like death, isolation, meaninglessness, and freedom.Feedback and confrontation to help clients gain awareness and face life’s ultimate existential demands.
Person-CenteredEmotional distress, incongruence (discrepancies between real and ideal selves), and conditions of worth.A relationship characterized by congruence, unconditional positive regard, and empathic understanding.
GestaltUnfinished emotional and behavioral baggage from the past that blocks awareness or disturbs self-other boundaries.Guidance on using here-and-now experiments to deal with unfinished emotional and behavioral experiences.
BehavioralDisturbing emotions (e.g., anxiety), maladaptive behavior patterns, and environmental contingencies.New learning or re-learning via operant, classical, and social processes.
CBTDisturbing emotions (e.g., anxiety, anger), maladaptive thinking, maladaptive behaviors, and triggers/contingenciesCollaborative and empirical tasks that modify maladaptive or distorted cognitive information processing.
Choice Theory/Reality TherapyWhat clients want, what they’re doing, whether that’s working, and planning.Commit to and enact adaptive plans that are aligned with quality world goals.
FeministWhere is the client experiencing anger or dissatisfaction due to gender-based limits or oppressive situations?Relational connection and empowerment to actively seek personal goals and mutually empathic emotional relationships.
ConstructiveWhere clients are stuck and how existing client strengths, exceptions, and solutions can fuel change.Re-shaping, reframing, and reconsolidating old narratives and problem-based patterns through solutions and sparkling moments.
Family SystemsFamily dynamics, transactions, hierarchy, roles, and boundaries that contribute to personal or systemic dysfunction.Shift family dynamics and transactions via in-session and outside session assignments.
MulticulturalWhere is the client experiencing distress due to limiting or oppressive socio-political factors?Cultural acceptance, empowerment, and culturally-based rituals.
IntegrativeWhat are the client’s unique problems, strengths, and consistent ways of thinking, acting, and feeling?Match a therapeutic process to the client’s unique problems and strengths.

My Cache of Unprofessional Counseling and Psychotherapy Theories Videos

In a surprising turn of events, this semester, I’ve decided to make a series of unprofessional theories videos to accompany my counseling and psychotherapy theories course (and text). When I say surprising, I mean surprising in that I’m surprised about feeling open to spontaneously video recording myself and making it available via YouTube. Could it be that as I grow older, I care less about how I look and sound, and care more about showing myself openly to others as an imperfect being who’s just trying to offer up something that might be educational? Alternatively, maybe I just caught the narcissistically-leaning, reality television, constantly-make-videos-of-myself, YouTube, Instagram, Facebook, Tiktok, virus that’s infecting so many people. We may never know.

And I say unprofessional because I’m filming these all by myself, not using a script, and making side comments and using props that might involve embarrassing myself as I talk about counseling and psychotherapy theories. One form of these unprofessional videos includes me doing “dramatic readings” and commentary from the works of Freud, Adler, and other original theories thinkers and writers. Although I intended these readings to be dramatic, I can see how they also might just be dull.

With my explanations and caveats out of the way, here are the offerings, thus far, for this semester.

Week 1 – An Intro to Counseling and Psychotherapy Theories

Hypnosis for Warts: A Story – https://youtu.be/9FR4PyTcsKw

Psychotherapy Math – https://youtu.be/ZqMW0SNekY0

Week 2 – Psychoanalytic Approaches

Freud Dramatic Reading – https://youtu.be/L-fkveRk7B0

Week 3 – Individual Psychology and Adlerian Therapy

Adler Dramatic Reading, Take 1 – https://youtu.be/_sVysgm1UiY

Adler Dramatic Reading, Take 2 – https://youtu.be/xCQd6i_CWAI

Week 4 – Existential Theory and Therapy . . . coming soon!

Although this post focuses on my unprofessional videos, that doesn’t mean I’ve completely stopped behaving professionally. For example, recently, I was a guest on the podcast, “A New Angle” hosted by Justin Angle and Bryce Ward (both of the University of Montana College of Business). In this podcast, we talk about COVID, suicide in Montana, happiness, and why the College of Business supports the teaching “Essential” interpersonal and psychological skills. It’s a pretty cool (and professional) podcast, even if I do say so myself. You can find “A New Angle” on Apple Podcasts at:

https://podcasts.apple.com/us/podcast/i-i-happiness-with-john-sommers-flanagan/id1336642173

Or at: anewanglepodcast.com

I hope you’re all having a great run-up to the weekend.

Counseling Theories — Week One — Hypnosis for Warts

Theories III Photo

Being holed up in our passive solar Absarokee house made an interesting venue for blasting off this semester’s University of Montana Counseling Theories class. I’m mentioning passive solar not to brag (although Rita did design an awesome set-up for keeping us warm in the winter and cool in the summer using south-facing windows and thermal mass), but to give you a glimpse of our temperature-related passivity: we have no working parts (as in air conditioning). And I’m mentioning holed up because we’re in a stage 1 air pollution alert from California smoke and consequently weren’t able to use our usual manual air conditioning system (opening up the windows in the night to cool off the house). Our need to keep the windows shut created a warmer than typical room temperature and, based on my post-lecture assessment of the armpits of my bright yellow shirt, yesterday just might have been my sweatiest class since 1988, when I was teaching at the University of Portland, and started sweating so much during an Intro Psych class that my glasses fogged up. In case you didn’t already know this about me, I’m an excellent sweater. You haven’t seen sweat until you’ve seen my sweat. Top-notch. The sort of sweating most people only dream about. I’d rate myself a sweating 10.

Aside from my sweating—which I’m guessing you’ve had enough of at this point—the students were pretty darn fantastic. Attendance was virtually perfect, which, given that everything was virtual, exceeded my expectations.

Speaking of expectations, because I’m teaching online via Zoom, one thing I’m adding to the course are a few pre-recorded videos. Yesterday’s pre-recorded video featured me telling my famous “Hypnosis for Warts” story. My goal with the pre-recorded video—aside from letting my students see me and my yellow shirt in a less sweaty condition—was to break up the powerpoints. I could have told the story live, but instead, I clicked out of the powerpoints, told my students we were going to watch a video, and then showed a video of myself . . . telling a story I could have been telling live. I thought I was hilarious. However, mostly, the sea of 55 Hollywood Squares faces just stared into the sea of virtual reality, and so I couldn’t see whether the students appreciated my pre-recorded video of myself teaching strategy. I know I’ve got too many “seas” in that preceding sentence, but redundancy happens. Really, it does. I’m totally serious about redundancy.

Back to expectations . . .

One of Michael Lambert’s four common factors in counseling and psychotherapy is expectancy. He estimated that, in general, expectation accounts for about 15% of the variation in treatment outcomes. But, of course, treatment outcomes are always contextual and always variable and always unique, and so, as in the case of “Hypnosis for Warts,” sometimes the outcome may be a product of a different combination or proportion of therapeutic ingredients. If you watch the video, consider these questions:

  • What do you think “happened” in the counseling office with the 11-year-old boy to cause his eight warts to disappear?
  • Do you think the therapeutic ingredients that helped the boy get rid of his warts were limited to Lambert’s extratherapeutic factors, relationship factors, technical factors, and expectancy factors (his four big common factors) . . . or might something else completely different have been operating?
  • What proportion of factors do you suppose contributed to the positive outcome? For example, might there have been 50% expectancy, instead of 15%?

Here’s the video link to the Wart story: https://www.youtube.com/watch?v=9FR4PyTcsKw

That’s about all I’ve got to share for today. However, if you happen to know of some nice 1-5 minute theories-related video clips that I can share with my students, please pass them on. I’d be especially interested if you happen to have video clips of me, but relevant videos of other people would be nice too. Haha. Just joking. Please DON’T send video clips of me. My students and I—we already have far too much of the JSF video scene.

Be well,

John SF

Reality Therapy: Developing Effective Plans

With Wubbolding

Thanks to Molly Molloy, the Montana Office of Rural Health, the Montana Flex Program, and the Montana Hospital Association, I had a chance to present as part of a “Rethinking Resiliency” series this morning. One question that came up had to do with how we can make better plans to facilitate our self-improvement. The best answer I could come up with was to follow Robert Wubbolding’s guidance on effective planning, from a reality therapy perspective. All of the preceding leads me to posting a section from our Counseling and Psychotherapy Theories textbook on Reality Therapy and Planning.

Here we go:

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Wubbolding (1988, 1991, 2000, 2011 . . . and pictured above) has written extensively about how reality therapists help clients develop plans for making positive life changes. Therapists help clients make positive and constructive plans. Wubbolding (1988) uses the acronym SAMI2C3 to outline the essential ingredients of an effective plan:

S = Simple: Effective plans are simple. If a plan generated in reality therapy is too complex, the client may become confused and therefore not follow through.

A = Attainable: Effective plans are attainable or realistic. If the plan is unattainable, the client can become discouraged.

M = Measurable: Effective plans are measurable. Clients need to know if the plan is working and if they’re making progress.

I = Immediate: Effective plans can be enacted immediately, or at least very soon. If clients have to wait too long to implement a plan, motivation may be compromised.

I = Involved: Helping professionals can be involved with their client’s or student’s planning. This should be done ethically and in ways that promote client independence.

C = Controlled: The planner has exclusive control over effective plans. Avoid having clients develop plans that are contingent on someone else’s behavior.

C = Committed: Clients need to commit to their plans. If a client is only half-heartedly invested in the plan, the plan is less likely to succeed.

C = Continuous: Effective plans are continuously implemented. When the process is going well, reality therapy clients have continuous awareness of what they want and of their plan for getting what they want. This high level of awareness reminds us of mindfulness or conscious-raising therapeutic techniques.

Wubbolding (1988) also recommended that individuals learning to conduct reality therapy develop a plan for themselves. He noted that to be effective reality therapists, practitioners should obtain consultation and/or supervision from certified reality therapists (in addition, we recommend that you practice living your life using choice theory rules; see Putting it in Practice 9.3).

Putting it in Practice 9.3

Living Choice Theory: The Four Big Questions

Four questions have been developed to help students and clients live the choice theory lifestyle (Wubbolding, 1988). These questions are derived from Wubbolding’s WDEP formula. During one full week, do your best to keep these four reality therapy questions on your mind:

  1. What do you want? (Wants)
  2. What are you doing? (Doing)
  3. Is it working? (Evaluation)
  4. Should you make a new plan? (Planning)

Every day you’re operating with a personal plan. The plan may or may not be any good and it may or may not be clear. The point is this: You’re thinking and doing things aimed toward getting your basic needs met. Therefore, consistently ask yourself the four preceding questions. This will help make your plan and choices more explicit.

Wubbolding’s four questions are powerful and practical. Think about how you might apply them when doing therapy with a teenager. Now think about how you might apply them as a consultant for a local business. Whether you’re consulting with a teenager or a business leader, there are hardly any other four questions that are more relevant and practical.

In the space that follows each question, answer the four questions for yourself today.

  1. What do you want? ________________________________________
  2. What are you doing? _______________________________________
  3. Is it working? _____________________________________________
  4. Should you make a new plan? _______________________________

After you’ve answered the questions, go back and think about what you’ve written as your answer for Question 1.

To Mask or Not to Mask: Making America Rational Again

Make America Rational Again

About 4 years ago, I made a MARA hat. MARA stands for “Make America Rational Again.” My hat was in honor of the late Albert Ellis, a famous psychologist who relentlessly advocated for rational thinking. Given that some folks are doubting Covid-19, while others are passionately accusing health officials of infringing on their God-given liberties, I’m thinking my MARA hat from the last presidential election is still in style.

Way back when I was a full-time therapist working mostly with teenagers, I developed a method for talking with my teen-clients about their freedoms. When they complained about their parents infringing on their rights—those damn parents were pronouncing unreasonable curfews, alcohol prohibitions, and other silly mandates—I’d say something like this:

“Really, you only have three choices. You can do whatever your parents think you should do. That’s option #1. Or, you can do the opposite of what your parents think you should do. That’s option #2. Those are easy options. You don’t even have to think.”

Hoping to pique the teen’s interest, I’d pause and to let my profound comments linger. Sometimes I got stony silence, or an eye-roll. But usually curiosity won out, and my client would ask:

“What’s the third choice?”

“The third choice is for you to make an independent decision. But that’s way harder. You probably don’t want to go there.”

Actually, most of my teenage clients DID want to go there. They wanted to learn, grow, develop, and become capable of effective decision-making. Sadly, that doesn’t seem to be the case today. All too often, Americans are basing their decision-making on poor information. For example, when people are gathering the 411 on whether they should mask-up in public settings, to where do they turn? The rational choice would be medical professionals and virologists. But instead, people are turning to Facebook, Twitter, and even worse, Fox News, where misinformation from Tucker Carlson, Laura Ingraham, and Sean Hannity is offered up with nary a shred of journalistic ethics or integrity (for a fun and fabulous SNL Parody with Kate McKinnon as Laura Ingraham, check out this link: https://www.youtube.com/watch?v=XezLiezWN0E).

A related question that’s especially pressing right now is this: “How should we respond to coronavirus deniers and rabid anti-maskers?” Speaking for myself, I’ve been struggling to find the right words. Saying what I’m thinking—which usually starts with “WTF!? Have you been listening to Tucker Carlson instead of Dr. Fauci?”—seems too offensive and unhelpful. Instead, I’m making a commitment to letting go of the outrage, putting my 2016 campaign hat back on, and making myself rational again. Instead of being angry, my plan is to retreat to rationality. I’ll say things like this: “Hey, I’m curious, have you read the latest article in the New England Journal of Medicine titled, “Observational study of hydroxychloroquine in hospitalized patients with Covid-19?” or, “What are your thoughts about the chilblain-like lesions doctors are finding on patients with Covid-19?” or “According to the CDC and Dr. Fauci and the American Medical Association, the cloth face coverings—although imperfect—statistically reduce the likelihood of spreading the coronavirus.”

I invite you to join me in gathering good data for our personal and social decision-making. Together, we can Make America Rational Again.

Individualizing Suicide Risk Factors in the Context of a Clinical Interview

Spring 2020

In response to my recent post on “The Myth of Suicide Risk and Protective Factors” Mark, a clinical supervisor from Edmonton, wrote me and asked about how to make individualizing suicide risk factors with clients more concrete/practical and less abstract. I thought, “What a great question” and will try to answer it here.

Let’s start with two foundational prerequisites. First, clinical providers need to be able to ask about suicide in ways that don’t pathologize the patient/client. Specifically, if clients fear that disclosing suicide ideation will result in them being judged as “crazy” or in involuntary hospitalization, then they’re more likely to keep their suicidal thoughts to themselves. This fear dynamic is one reason why we emphasize using a normalizing frame when asking about suicide.

Second, both before and after suicide ideation disclosures, providers need to explicitly emphasize collaboration. Essentially, the message is: “All we’re doing is working together to better understand and address the distress or pain that underlies your suicidal thoughts.” In other words, the focus isn’t on getting rid of suicidal thoughts; the focus is on reduction of psychological pain or distress.

With these two foundational principles in place, then the provider can collaboratively explore the primary and secondary sources of the client’s psychological pain. In our seven-dimensional model, we recommend exploring emotional, cognitive, interpersonal, physical, cultural-spiritual, behavioral, and contextual sources of pain. Collaborative exploration is fundamental to individualizing risk factors. The general statistics showing that previous attempts, social isolation, physical illness, being male, and other factors predict suicide are mostly useless at that point. Instead, your job as a mental health provider is to pursue the distress. By pursuing the distress, you discover individualized risk factors. The following excerpt from our upcoming book illustrates how asking about “What’s bad” and “What feels worst?” results in individualized risk factors.

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     The opening exchange with Sophia is important because it shows how clinicians—even when operating from a strength-based foundation—address emotional distress. In the beginning the counselor drills down into the negative (e.g., “What’s making you feel bad?”), even though the plan is to develop client strengths and resilience. By drilling down into the client’s distress and emotional pain, and then later identifying what helps the client cope, the counselor is individualizing risk and protective factor assessment, rather than using a ubiquitous checklist.

Counselor: Sophia, thanks for meeting. I know you’re not super-excited to be here. I also know your parents said you’ve been talking about suicide off and on for a while, so they wanted me to talk with you. But I don’t know exactly what’s happening in your life. I don’t know how you’re feeling. And I would like to be of help. And so if you’re willing to talk to me, the first thing I’d love to hear would be what’s going on in your life, and what’s making you feel bad or sad or miserable or whatever it is you’re feeling?

The counselor began with an acknowledgement and quick summary of what he knew. This is a basic strategy for working with teens (Sommers-Flanagan & Sommers-Flanagan, 2007), but also can be true when working with adults. If counselors withhold what they know about clients, rapport and relationship development suffers.

The opening phrase “I don’t know. . .” acknowledges the limits of the counselor’s knowledge and offers an invitation for collaboration. Effective clinicians initially and intermittently offer invitations for collaboration to build the working alliance (Parrow, Sommers-Flanagan, Sky Cova, & Lungu, 2019). The underlying message is, “I want to help, but I can’t be helpful all on my own. I need your input so we can work together to address the distress you’re feeling.”

The opening question for Sophia is negative (i.e., What’s making you feel bad or sad or miserable or whatever it is you’re feeling?). This opening shows empathy for the emotional distress that triggers her suicidality and clarifies the link between her emotional distress and the triggering situations. By tuning into negative emotions, the counselor hones in on the presumptive primary treatment goal for all clients who are suicidal—to reduce the perceived intolerable or excruciating emotional distress (Shneidman, 1993).

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Collaborative exploration is the method through which risk and protective factors are individualized. If Sophia had a previous attempt, the reason to explore the previous attempt would be to discover what created the emotional distress that provoked the attempt, and how counseling or psychotherapy might address that particular factor. For example, if bullying and lack of social connection triggered Sophia’s attempt, then we would view bullying and social disconnection as Sophia’s particular individualized risk factors. We would then build treatments—in collaboration with Sophia and her family—that directly address the unique factors contributing to her pain, and provide her with palpable therapeutic support.

I hope this post has clarified how to individualize suicide risk factors and use them in treatment. Thanks for the question Mark!

A Strength-Based Suicide Assessment and Treatment Model

Bikes Snow 3

Over the past couple years, with feedback from workshop participants, supervisees, clients, and people with lived experiences around suicide, we’ve continued to refine our strength-based suicide assessment and treatment model. Below is a short excerpt from chapter 1 of our upcoming book. This excerpt gives you a glimpse at the strength-based model.

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

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

Spring Sunrise and Hay

Rita and I are spending chunks of our social distancing time writing. In particular, we’ve signed a contract to write a professional book with American Counseling Association Publications on suicide assessment and treatment planning. We’ll be weaving a wellness and strength-oriented focus into strategies for assessing and treating suicidality.

Today, I’m working on Chapter 6, titled: The Cognitive Dimension. We open the chapter with a nice Aaron Beck quotation, and then discuss key cognitive issues to address with clients who are suicidal. These issues include: (a) hopelessness, (b) problem-solving impairments, (c) maladaptive thinking, and (d) negative core beliefs.

Then we shift to specific interventions that can be used to address the preceding cognitive issues. In the following excerpt, we focus on collaborative problem solving and illustrate the collaborative problem-solving process using a case example. As always, feel free to offer feedback on this draft content.

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Collaborative Problem-Solving

Though not a suicide-specific intervention, problem-solving therapy is an evidence-based approach to counseling and psychotherapy (Nezu, Nezu, & D’Zurilla, 2013). Components of problem-solving are useful for assessing and intervening with clients who are suicidal. As Reinecke (2006) noted, “From a problem-solving perspective, suicide reflects a breakdown in adaptive, rational problem solving. The suicidal individual is not able to generate, evaluate, and implement effective solutions and anticipates that his or her attempts will prove fruitless” (p. 240).

Extended Case Example: Sophia – Problem-Solving

In Chapter 5 we emphasized that clinicians should initially focus on and show empathy for clients’ excruciating distress and suicidal thoughts. However, there often comes a moment when a pivot toward the positive can occur. Questions that help with this pivot include:

  • What helps, even a tiny bit?
  • When you’ve felt bad in the past, what helped the most?
  • How have you been able to cope with your suicidal thoughts?

In response to these questions, clients who are suicidal often display symptoms of hopelessness, mental constriction, problems with information processing, or selective memory retrieval. Statements like, “I’ve tried everything,” “Nothing helps,” and “I can’t remember ever feeling good,” represent cognitive impairments. Even though your clients may think they’ve tried everything, the truth is that no one could possibly try everything. Similarly, although it’s possible that “nothing” your client does helps very much, it’s doubtful that all their efforts to feel better have been equally ineffective. These statements indicate black-white or polarized thinking, as well as hopelessness and memory impairments (Beck et al., 1979; Reinecke, 2006; Sommers-Flanagan & Sommers-Flanagan, 2018).

Pivoting to the Positive

Picking up from where we left off in Chapter 5, after exploring the distress linked to Sophia’s suicide ideation in the emotional dimension, the counselor (John) pivots to asking about the positive (“What helps?”) and then proceeds into a problem-solving assessment and intervention strategy. One clearly identified trigger for Sophia’s suicidal thinking is her parent’s fighting. She cannot directly do anything about their fights, but she can potentially do other things to shield herself from the downward cognitive and emotional spiral that parental fighting activates in her.

John: Let’s say your parents are fighting and you’re feeling suicidal. You’re in your room by yourself. What could you do that’s helpful in that moment? [The intent is to shift Sophia into active problem-solving.]

Sophia: I have a cat. His name is Douglas. Sometimes he makes me feel better. He’s diabetic, so I don’t think he’ll live much longer, but he’s comforting right now.

John: Nice. My memory’s not perfect, so is it okay with you if I write a list of all the things that help a little bit? Douglas helps you be in a better mood. What else is helpful?

Sophia: I like music. Blasting music makes me feel better. And I play the guitar, so sometimes that helps. And volleyball is a comfort, but I can’t play volleyball in my room.

John: Yeah. Great. Let me jot those down: music, guitar, volleyball, and being with your cat. And volleyball, but not in your room! I guess you can think about volleyball, right? And how about friends? Do you have friends who are positive supports in your life?

Although the fact that Douglas the cat has diabetes includes a depressive tone, the good news is that Sophia immediately engages in problem-solving. She’s able to identify Douglas and other things that help her feel better.

Throughout problem-solving, regularly repeating positive coping strategies back to the client is important. In this case, John summarizes Sophia’s positive ideas, and then asks about friends and social support—a very important dimension in overall suicide safety planning.

Sophia: Yeah, but we’re all busy. My friend Liz and I hang out quite a bit. I can walk into her house, and it will feel like my house. But we’re both in volleyball, so we’re both really busy. But our season will end soon. Hopefully that will help.

John: Ok, the list of things that seem to help, especially when you’re in a hard place with your parents fighting: Douglas the cat, music, guitar, and volleyball, and friends. Anything else to add?

Sophia:  I don’t think so.

Often, the next step in collaborative problem-solving is to ask clients for permission to add to the list, thus turning the process into a shared brain-storming session. At no time during the brainstorming should you criticize any client-generated alternatives, even if they’re dangerous or destructive. In contrast, clients will sometimes criticize your ideas. When clients criticize, just agree with a statement like, “Yeah, you’re probably right, but we’re just brainstorming. We can rank and rate these as good or bad ideas later.”

Overall, the goal is to use brainstorming to assess for and intervene with mental constriction. During brainstorming, Sophia and John generated 13 things Sophia could do to make herself feel better. Sophia’s ability to brainstorm in session is a positive indicator of her responsiveness to treatment.