This morning I had the honor of spending two hours with counselors from the Western Tidewater Community Services Board in beautiful Virginia. Unfortunately, I wasn’t in Virginia, but the magic of Zoom made the connection and collaboration possible.
The presentation focused on how to integrate assessment and relational factors into an initial clinical interviews. The powerpoints are here:
Before signing off, I want to emphasize how much I enjoyed the short and Zoom-based interactions I had with the Western Tidewater clinicians. They were focused, interested, and engaged. Being with them (over 120 people) increased my belief that there are good people in the world. Thanks!
For many counseling students, September brings with it the question, “What’s my theoretical orientation?” This is a big question . . . and its bigness is probably the reason why many of our old “theoretical orientation” blog posts suddenly get hot this time of year.
Below, I’ve excerpted a section from the end of chapter 1 of our Counseling Theories textbook. If you’re exploring your theoretical orientation, reading this section might be useful.
Here’s the excerpt
If you want to be an excellent mental health professional, then it makes sense to closely study the thinking of some of the greatest minds and models in the field. This text covers 12 of the most comprehensive and practical theories in existence. We hope you absorb each theory as thoroughly as possible and try experiencing them from the inside out. As you proceed through each chapter, suspend doubt, and try thinking like a practitioner from each theoretical orientation.
It’s also important for you to discover which theory or theories are the best fit for you. You’ll have opportunities reflect on the content of this text and hopefully that will help you develop your own ideas about human functioning and change. Although we’re not recommending that you develop a 13th theory, we are recommending that you explore how to integrate your genuine self into these different theoretical perspectives.
Some of you reading this book may already have considerable knowledge and experience about counseling and psychotherapy theories. However, even if you have very little knowledge and experience, you undoubtedly have some preexisting ideas about what helps people change. Therefore, before reading chapters 2 through 14, we encourage you to look at your own implicit ideas about people, and how they change.
Your First Client and Your First Theory
Pretend this is the first day of your career as a mental health professional. You have all the amenities: a tastefully decorated office, two comfortable chairs, a graduate degree, and a client.
You also have everything that any scarecrow, tin man, or lion might yearn for: a brain full of knowledge about how to provide therapy, a heart with compassion for a diverse range of clients, and courage to face the challenge of providing therapy services. But do you have what it takes to help a fellow human being climb from a pit of despair? Do you have the judgment to apply your knowledge in an effective way?
You walk to the waiting room. She’s there. She’s your first client ever. You greet her. The two of you walk back to the office.
In the first 20 minutes, you learn quite a lot about your client: She’s a 21-year-old college student experiencing apathy, insomnia, no romantic interests, carbohydrate cravings, an absence of hobbies, and extremely poor grades. She’s not using drugs or alcohol. Based on this information, you tentatively diagnose her as having some variant of clinical depression and proceed with counseling. But how do you proceed? Do you focus on her automatic thoughts and the core beliefs about herself that might be contributing to her depressive symptoms? Do you help her get a tutor, thinking that improved grades might lift her depressive symptoms? Do you recommend she begin an exercise routine? Do you explore her childhood, wondering if she has a trauma experience that needs to be understood and worked through? Do you teach her mindfulness skills and have her practice meditation? Do you have her role play and rehearse solutions to her problems? Do you focus on listening, assuming that if you provide her a positive therapy environment, she’ll gain insight into herself and move toward greater psychological health? Do you help her recast herself and her life into a story with a positive ending more adaptive identity? Do you ask her to sit in different chairs—speaking from different perspectives to explore her here and now feelings of success and failure? Any or all of these strategies might help. Which ones seem best to you?
You have many choices for how to proceed, depending upon your theoretical orientation. Here’s our advice: Don’t get stuck too soon with a single theoretical orientation. It’s unlikely that all humans will respond to a single approach. As suggested in Putting it in Practice 1.3, experiment and reflect before choosing your preferred theory. (Complete the ratings in Table 1.2 and then look through Table 1.3 to see which major theoretical perspectives might fit best for you).
On September 24, I’m doing a full-day online-only Strengths-Based Suicide Assessment and Treatment Planning workshop. The workshop is on behalf of the Association for Humanistic Counselors . . . a cool professional organization if there ever was one.
Just in case you want two-days of Strengths-Based Suicide Training or you want to come to the U of Montana or you need some college credit, we’ve got a full two-day version of the workshop happening in Missoula on November 19 and 20. In addition, if you’re wanting a continuing education smörgåsbord, this link also includes two day trainings with the fabulous Dr. Kirsten Murray (Strong Couples) and the amazing Dr. Bryan Cochran (LGBTQI+ Clients). Here’s that link: https://www.familiesfirstmt.org/umworkshops.html
There’s more happening too . . . but for now, this is probably enough for one post.
Have a fantastic week, and don’t be afraid to be the early bird.
Fall semester is quickly approaching. For some of you, it may have already arrived.
This post includes my usual free offer of theories resources. Even though Rita and I have our own Theories textbook, and we would love for you use it, the resources below are free and will work for you regardless of whether you use our textbook. My general philosophy on textbooks is that I’d rather be helpful than try to coerce people to buy books.
I’ve got a set of theories lab activities. I tried posting them here, but technology wasn’t helping. If you want them, email me and I’ll send them out as an attachment. email@example.com
You can access several theories-related counseling demonstration videos through my YouTube page. Also, I’ve posted a bunch of links previously, and you can access them with brief descriptions here: https://johnsommersflanagan.com/2020/03/14/free-video-links-for-online-teaching/ If you want access to the complete set of all of our theories videos, you have to use the text, but the preceding link has several potentially useful videos.
Theories is my favorite course to teach. I hope these resources will help you have a fun, engaging, skills-based, and inclusive theories teaching experience.
In our Counseling and Psychotherapy Theories in Context and Practice book, we include short sections on spirituality for each of the major theories. Previously, I’ve posted all the others (just search spirituality on this blog to find them), but discovered this evening that I forgot to post the Gestalt one. Maybe I forgot because it’s especially short and enigmatic . . . meaning, I didn’t find much out there on the crossroads between Gestalt theory and spirituality. If you know of something, please enlighten me!
Here’s the very short excerpt:
Although not always visible or palpable, Gestalt theory and therapy have deep spiritual roots. Laura Perls studied with Martin Buber and had interests in Taoism. Fritz Perls studied Zen Buddhism. Paul Goodman had interests in Taoism, and Gestalt writer, Dave Mann (2010) contended that Goodman’s book, Nature heals, is consistent with his Taoist beliefs about living with nature in accordance with nature. It may be that Gestalt experiments are consistent in style with the Zen Buddhist koan, a puzzle orriddle designed to open Zen novices to deeper levels of consciousness. At the very least, Zen Buddhism and Gestalt therapy share an attitude of acceptance of the now and an exploration of experience.
There are, of course, differences between Gestaltists regarding the role and nature of spirituality in Gestalt theory and practice. For some, the I-Thou connection is where the transcending and spiritual contact happens. Boundaries dissolve and deeper connections and insights blossom. This may have been what led Jesse Thomas (1978) to publish an early Gestalt-spiritual work titled, “The youniverse: Gestalt therapy, non-western religions, and the present age.” Spirituality, from the Gestalt perspective, is both personal and universal (or youniversalJ).
At the other end of the continuum are individuals who don’t see spirituality as warranting a place in Gestalt theory and practice (Mann, 2010). Mann (2010) recommended that Gestalt therapists, like clients, need to decide where they stand on religion and spirituality, recognizing, at the same time, that where they stand may well change. This brings us to perhaps the most famous words Fritz Perls ever wrote, the Gestalt prayer:
I do my thing and you do your thing.
I am not in this world to live up to your expectations,
And you are not in this world to live up to mine.
You are you, and I am I,
and if by chance we find each other, it’s beautiful.
As most of you know, I recently published an article in Psychotherapy Networker on my long-term experience of coping with the death of a client by suicide. In response to the article, I’ve gotten many supportive responses, some of which included additional published resources on coping with client death by suicide.
This blog post has two parts. First, I’m promoting the Networker article again to get it more widely shared as one resource for counselors and psychotherapists who have lost a client. Below, is an excerpt from the article. . . followed by a link. Please share with friends and colleagues as you see fit.
Second, at the end of this post I’m including additional resource articles that several people have shared with me over the past two weeks.
Here’s the excerpt . . .
The Prevention Myth
I’d worked with Ethan for about 20 sessions. Stocky, socially awkward, and intellectually gifted, he often avoided telling me much of anything, but his unhappiness was palpable. He didn’t fit in with classmates or connect with teachers. Ethan felt like a misfit at home and out of place at school. Nearly always, he experienced the grinding pain of being different, regardless of the context.
But aren’t we all different? Don’t we all suffer grinding pain, at least sometimes? What pushed Ethan to suicide when so many others, with equally difficult life situations and psychodynamics, stay alive?
One truth that reassures me now, and I wish I’d grasped back in the 1990s, is that empirical research generally affirms that suicide is unpredictable. This reality runs counter to much of what we hear from well-meaning suicide-prevention professionals. You may have heard the conventional wisdom: “Suicide is 100 percent preventable!” and, “If you educate yourself about risk factors and warning signs, and ask people directly about suicidal thoughts or plans, you can save lives.”
Although there’s some empirical evidence for these statements (i.e., sometimes suicide is preventable, and sometimes you can save lives), the general idea that knowledge of suicide risk, protective factors, and warning signs will equip clinicians to predict individual suicides is an illusion. In a 2017 large-scale meta-analysis covering 50 years of research on risk and protective factors, Joseph Franklin of Vanderbilt University and nine other prominent suicide researchers conducted an exhaustive analysis of 3,428 empirical studies. They found very little support for risk or protective factors as suicide predictors. In one of many of their sobering conclusions, they wrote, “It may be tempting to interpret some of the small differences across outcomes as having meaningful implications, . . . however, we note here that all risk factors were weak in magnitude and that any differences across outcomes . . . are not likely to be meaningful.”
Franklin and his collaborators were articulating the unpleasant conclusion that we have no good science-based tools for accurately predicting suicide. I hope this changes, but at the moment, I find comfort in the scientific validation of my personal experience. For years, I’ve held onto another suicide quotation for solace. In 1995, renowned suicidologist Robert Litman wrote, “When I am asked why one depressed and suicidal patient dies by suicide while nine other equally depressed and equally suicidal patients do not, I answer, ‘I don’t know.’”
Here are the additional resources people have shared with me:
Ellis, T. E., & Patel, A. B. (2012). Client suicide: what now?. Cognitive and Behavioral Practice, 19(2), 277-287.
Jorgensen, M. F., Bender, S., & McCutchen, A. (2021) “I’m haunted by it:” Experiences of licensed counselors who had a client die by suicide. Journal of Counselor Leadership and Advocacy. DOI: 10.1080/2326716X.2021.1916790
Knox, S., Burkard, A. W., Jackson, J. A., Schaack, A. M., & Hess, S. A. (2006). Therapists-in-training who experience a client suicide: Implications for supervision. Professional Psychology: Research and Practice, 37(5), 547-557.
Ting, L., Jacobson, J. M., & Sanders, S. (2008). Available supports and coping behaviors of mental health social workers following fatal and nonfatal client suicidal behavior. Social work, 53(3), 211-221.
As always, thanks for reading, and have a great day!
This Friday, July 16, Rita and I are doing a professional video shoot in Billings, MT. Due to some minor scheduling changes, we suddenly have openings for two last minute volunteers, who are willing to talk about personal issues in the role of clients. Below, I’ve written a short description of what we need. If you happen to be an open-minded person interested in a little psychological discovery, read on . . . .
John and Rita Sommers-Flanagan, authors of Clinical Interviewing, Tough Kids, Cool Counseling, and other professional books, are doing a video shoot on Friday, July 16. The video content will be used for educational purposes, primarily to accompany textbooks and for training mental health professionals. John and Rita have openings for volunteers to participate in two demonstrations in the afternoon of July 16. Each demonstration will involve about 30 min of on-camera time, with additional time for prepping and debriefing. Volunteers will be paid a one-time stipend of $100. A description of the two demonstrations follow:
John will engage a volunteer in a brief (single-session) nightmare treatment. The volunteer should have a real problem with nightmares. The therapeutic demonstration will focus on coping with nightmares and changing or reducing their frequency and intensity.
Rita will demonstrate how current emotions are linked or related to past emotions. The volunteer should have experience with some problematic emotions in their present-life and be willing to explore past connections to current distressing emotions. Anger, sadness, and anxiety are three emotions that work well for this demonstration.
Volunteers should be open and interested in exploring psychological issues. Potential volunteers (we only need two!) should contact John Sommers-Flanagan ASAP at firstname.lastname@example.org
Here’s a glimpse of what the garden looks like this morning.
In most of life, most of the time, there’s not much completely new or original. People tend to gather inspiration from others and build on or rediscover old ideas. This my way of acknowledging that, although I wish I always had a boatload of original ideas to share in the blog, more often than not, I’m embracing the green new deal and . . . re-using, recycling, and repurposing old ideas.
The following Table describes the seven dimension model that Rita and I use to aid clinicians in conducting assessments and interventions with clients or patients who are suicidal. These seven dimensions aren’t original, but the idea that suicide drivers (and risk/protective factors) can emerge and influence people from any or all of these dimensions is helpful in a more or less original way. Check out the Table to see if it’s useful for you.
Dimension:In this column, we define the dimensions
Evidence-Based Suicide Drivers: In this column, we identify risk factors or suicide drivers that can push or pull individuals toward suicidality. The key to this model is to identify and treat the main sources of distress (aka psychache). In the next columns (not included here), you would find wellness goals and specific interventions.
Emotional: all human emotions.
Excruciating emotional distress
Specific disturbing emotions (guilt, shame, anger, sadness)
Cognitive: All forms of human thought, including imagery.
Negative core beliefs
Interpersonal: All human relationships.
Social disconnection and perceived burdensomeness
Interpersonal loss and grief
Social skill deficits
Repeating dysfunctional relationship patterns
Physical: All human biogenetics and physiology.
Biogenetic predispositions and physical illness
Sedentary lifestyle; poor nutrition
Agitation, arousal, anxiety
Trauma, nightmares, insomnia
Spiritual-Cultural: All religious, spiritual, cultural values that provide meaning and purpose.
Religious or spiritual disconnection
Cultural disconnection or dislocation
Behavioral: All human action and activity.
Using substances or self-harm for desensitization
Suicide planning, intent, and preparation
Contextual: All factors outside of the individual that influence human behavior.
No connection to place or nature
Chronic exposure to unhealthy environmental conditions
Socioeconomic oppression or resource scarcity (e.g., poverty)
You may have a form to screen clients for a trauma history. However, more often than not, you’ll need to ask directly about trauma, just like you need to ask directly about suicidality. In many cases, as discussed in Chapter 3, it may be beneficial to wait and ask about trauma until the second or third session, or until there’s a logical opportunity. Although insomnia and nightmares don’t always signal trauma, when they co-exist, they provide an avenue to ask about trauma.
Counselor: Miguel, I’d like to ask a personal question. Would that be okay?
Counselor: Almost always, when people have nightmares about guns and death, it means they’ve been through some bad, traumatic experiences. When you’ve been through something bad or terrible, nightmares get stuck in your head and get on a sort of repeating cycle. Is that true for you?
Miguel: Yeah. I went through some bad shit back in Denver.
Counselor: I’m guessing that bad shit is stuck in your brain and one ways it comes out is through nightmares.
Miguel: Yeah. Probably.
Even when clients know their trauma experiences are causing their nightmares, they can still be reluctant to talk about the details. Physical and emotional discomfort associated with trauma is something clients often want to avoid. To reassure clients, you can tell them about specific evidence-based approaches—approaches that don’t require detailed recounting of trauma or nightmare experiences. Two examples include eye movement desensitization reprocessing (EMDR; Shapiro, 2001) and imagery rehearsal therapy (Krakow & Zadra, 2010).
Miguel: If I talk about the nightmares, they get more real. I have enough trouble keeping them out of my head now.
Counselor: That’s a good point. But right now your dreams are so bad that you’re barely sleeping. It’s worth trying to work through them. How about this? I’ve got a simple protocol for working with nightmares. You don’t even have to talk about the details of your nightmares. I think we should try it and watch to see if your dreams get better, worse, or stay the same? What do you think?
Miguel: I guess maybe my nightmares can’t get much worse.
Evidence-Based Trauma Treatments
In Miguel’s case, the first step was to get him to talk about his insomnia, nightmares, and trauma. Without details about his experiences, there was no chance to dig in and start treatment. The scenario with Miguel illustrates one method for getting clients to open up about trauma. Other clinical situations may be different. We’ve had Native American clients who were having dreams (or not having dreams, but wishing for them), and we needed to begin counseling by seeking better understanding of the role and meaning of dreams in their particular tribal culture.
Counselors who work with clients who are suicidal should obtain training for treating insomnia, nightmares, and trauma. Depending on your clients’ age, symptoms, culture, the treatment setting, and your preference, several different evidence-based treatments may be effective for treating trauma. The following bulleted list includes treatments recommended by the American Psychological Association (2017) or the VA/DoD Clinical Practice Guideline Working Group (2017), or both (Watkins et al., 2018).
Cognitive Processing Therapy (Resick et al., 2017).
Trauma-Focused Cognitive Behavioral Treatment (Cohen et al., 2012).
Although the preceding list includes the scientifically supported approaches to treating trauma, you may prefer other approaches, many of which are suitable for treating trauma (e.g., body-centered therapies, narrative exposure therapy for children [KID-NET], etc.).
Specific treatments for insomnia and nightmares are also essential for reducing arousal/agitation. Evidence-based treatments for insomnia and nightmares include:
Cognitive-Behavioral Therapy for Insomnia (CBT-I; Cunningham & Shapiro, 2018).
Targeting trauma symptoms in general, and physical symptoms in particular (e.g., arousal, insomnia, nightmares) can be crucial to your treatment plan. Addressing physical symptoms in your treatment instills hope and provides near-term symptom relief.
What follows is an excerpt from, Suicide Assessment and Treatment Planning: A Strengths-Based Approach (American Counseling Association, 2021). We address insomnia and nightmares in Chapter 7 (the Physical Dimension). This is just a glimpse into the cool content of this book.
Insomnia and nightmares directly contribute to client distress in general and suicidal distress in particular. In this section, we use a case example to illustrate how counselors can begin with a less personal issue (insomnia), use empathy, psychoeducation, and curiosity to track insomnia symptoms, eventually arrive at nightmares, and then inquire about trauma. Focusing first on insomnia, then on nightmares, and later on trauma can help counselors form an alliance with clients who are initially reluctant to talk about death images and trauma experiences.
Focusing on Insomnia
Miguel was a 19-year-old cisgender heterosexual Latino male working on vocational skills at a Job Corps program. He arrived for his first session in dusty work clothes, staring at the counselor through squinted eyes; it was difficult to tell if Miguel was squinting to protect his eyes from masonry dust or to communicate distrust. However, because the client was referred by a physician for insomnia, he also might have just been sleepy.
Counselor: Hey Miguel. Thanks for coming in. The doctor sent me a note. She said you’re having trouble sleeping.
Miguel: Yeah. I don’t sleep.
Counselor: That sucks. Working all day when you’re not sleeping well must be rough.
Miguel: Yeah. But I’m fine. That’s how it is.
To start, Miguel minimizes distress. Whether you’re working with Alzheimer’s patients covering their memory deficits or five-year-olds who get caught lying, minimizing is a common strategy. When clients say, “I’m fine” or “It is what it is” they may be minimizing.
But Miguel was not fine. For many reasons (e.g., pride, shame, or age and ethnicity differences), he was reluctant to open up. However, given Miguel’s history of being in a gang and his estranged relationship with his parents, the expectation that he should quickly trust and confide in a white male adult stranger is not appropriate.
Rather than pursuing anything personal, the counselor communicated empathy and interest in Miguel’s insomnia experiences.
Counselor: Not being able to sleep can make for very long nights. What do you think makes it so hard for you sleep?
Miguel: I don’t know. I just don’t sleep.
When asked directly, Miguel declines to describe his sleep problems. Rather than continue with questioning, the counselor fills the room with words (i.e., psychoeducation). Psychoeducation is a good option because sitting in silence is socially painful and because multicultural experts recommend that counselors speak openly when working with clients from historically oppressed cultural groups (Sue & Sue, 2016). The reasoning goes: If counselors are open and transparent, culturally diverse clients can evaluate their counselor before sharing more about themselves. As Miguel’s counselor talks, Miguel can decide, based on what he hears, whether his counselor is safe, trustworthy, and credible.
Counselor: Miguel, there are three main types of insomnia. There’s initial insomnia—that’s when it takes a long time, maybe an hour or more, to get to sleep. They call that difficulty falling asleep. There’s terminal insomnia—that’s when you fall asleep pretty well and sleep until maybe 3am and then wake up and can’t get back to sleep. They call that early morning awakening. Then there’s intermittent insomnia—that’s like being a light sleeper who wakes up over and over all night. They call that choppy sleep. Which of those fits for you?”
Miguel: I got all three. I can’t get to sleep. I can’t stay asleep. I can’t get back to sleep.
Counselor: That’s sounds terrible. It’s like a triple dose of bad sleep.
As Miguel begins opening up, he says “I haven’t slept in a week.” Although it’s obvious that zero minutes of sleep over a week isn’t accurate, for Miguel, it feels like he hasn’t slept in a week, and that’s what’s important.
After Miguel yawns, the counselor asks permission to share his thoughts.
Counselor: Miguel, if you don’t mind, I’d like to tell you what I’m thinking. Is that okay?
Miguel: Sure. Fine.
Counselor: When someone says they’re having as much trouble sleeping as you’re having, there are usually two main reasons. The first is nightmares. Have you been having nightmares?
Miguel: Shit yeah. Like every night. When I fall asleep, nightmares start.
Counselor: Okay. Thanks. I’m pretty sure I can help you with nightmares. We can probably make them happen less often and be less bad in just a few meetings.
The counselor’s confidence is based on previous successful experiences, including using a nightmare treatment protocol that has empirical support (Imagery Rehearsal Therapy; Krakow & Zadra, 2010). Although evidence-based treatments aren’t effective for all clients, they can establish credibility and instill hope. Nevertheless, Miguel doesn’t immediately experience hope.
Miguel: Yeah. But these aren’t normal nightmares.
Counselor: What’s been happening?
Miguel: I keep having this dream where I’m sticking a gun in my mouth. People are all around me with their voices and shit telling me, “pull the trigger.” Then I wake up, but I can’t get it out of my head all day? What the hell is that all about?”
Counselor: That’s a great question.
When the counselor says, “That’s a great question,” his goal is to start a discussion about all the reasons why someone (Miguel in this case), might have a “gun in the mouth” dream. If Miguel and his counselor can brainstorm different explanations and possible meanings for the dream images, it’s less likely for Miguel to interpret his dream as a sign that he should die by suicide. What’s important, we tell our clients, is to look at many different possible meanings the unconscious or God or the Great Spirit or the universe or indigestion might be sending to the dreamer. To help clients expand their thinking and loosen up on their conclusions about their dream’s meaning, we’ve used statements like the following:
You may be right. Your dream might be about you dying or killing yourself. But our goal is to listen to the message your brain sent you and be open to what it might mean. It’s perfectly normal to think your dream was about you dying by suicide—but that’s not necessarily true. That’s not the way the brain and dreams usually work. Some counselors use self-disclosure about dreams or nightmares they’ve had themselves. Others offer hypothetical or historical dream examples. Either way, normalizing nightmares helps clients become more comfortable talking about their bad dreams and nightmares.
To be continued . . . NEXT TIME . . . we ask about trauma.